Elizabeth Glaser Pediatric AIDS Foundation's (EGPAF) Family AIDS Initiatives (FAI) Program works to support the Ministry of Health and Child Welfare (MOHCW) to increase access to comprehensive, high quality PMTCT services linked to treatment, care and support of families, including children living with HIV and AIDS. This is achieved through direct support to the national AIDS&TB Unit to implement the national PMTCT program, guided by the national PMTCT and Pediatric Care and Treatment Strategic plan 2006-2010. Since 2001, EGPAF has seconded staff to the National AIDS&TB Unit to ensure overall technical leadership, coordination and development of the national PMTCT program. The FAI program also provides support at district and health facility levels through three partner organizations the JF Kapnek Charitable Trust, the Zimbabwe AIDS Prevention Project, and the Organisation of Public Health Interventions and Development -- guided by the Foundation's country team.

The program's strategic objectives are: 1) to advance research that increases access to and uptake of high quality integrated services of prevention, care and treatment for HIV/AIDS in Zimbabwe; 2) to support the expansion and provision of quality PMTCT and care and treatment services for children and their families affected by HIV/AIDS; 3) to advance the Family AIDS Initiative consortium's leadership role in influencing public health policy and serve as a national advocate to seek the eradication of pediatric HIV/AIDS; 4) to enhance the Family AIDS Initiative partnership's capacity to operate in an effective, efficient, accountable and responsive manner.

The FAI program has been supported by USG since 2004. Between January 2004 and June 2009, the program reached over 582,075 pregnant women attending antenatal (ANC) clinics at a total of 595 USG supported PMTCT sites. Of these women, 409,774 were tested for HIV and 384,187 received their results. Through June 2009, the program identified approximately 72,325 women living with HIV and of these 55,387 women and 36,489 infants received ARV prophylaxis. As the program has matured, EGPAF has collaborated with the MOHCW and other partners to pilot a number of enhanced PMTCT interventions including short-course combined ARV "more efficacious regimens" (MER) and early infant diagnosis (EID).

EGPAF is improving Zimbabwe's Human Resources for Health through training national, provincial and district trainers who have cascaded training to healthcare workers at a site level in a number of modules including PMTCT, MER, EID, infant feeding counselling, OI/ART, psychosocial support and HIV rapid testing. The FAI partners provide both direct technical support to these trainings and mentoring to national trainers. EGPAF has ensured that family planning (FP), and maternal and child health issues are integrated within the trainings and site support visits, with growing attention to FP and emergency obstetric care. EGPAF has worked with MOHCW to continually update the national training materials and job aides to support these activities. Gender issues, including increasing gender equity in HIV/AIDS activities and addressing male norms are included via EGPAF and partner family centered approach to encourage access to program services. In particular the benefit of male participation is highlighted during community mobilization activities and initiatives such as sending out of letters to invite men to accompany their partners to routine maternal and child health services. This has led to increasing numbers of male partners being tested for HIV in an ANC setting.

EGPAF's core activities funded under PEPFAR are complemented with additional resources from DFID, Gates Foundation, Johnson and Johnson, and UNFPA, particularly for operational research. In addition, EGPAF is expecting to receive funds under Global Fund Round 5 and UNICEF to support activities for children living with HIV.

The program relies on already existing national structures and works closely with provincial and district nursing officers through peer support and mentorship. In addition, EGPAF continues to build the capacity of the national PMTCT unit to coordinate and lead the overall process according to national strategic plans. Over time, these cadres become more proficient to undertake the responsibility to manage and monitor the program, enabling partners to support poorer performing districts and sites. Efficiency of the program is maintained by working at national, provincial, district and site level ensuring that national standards are applied and coordination efforts are not duplicated.

The FAI partners monitor the program according to national indicators and using national reporting formats. As new interventions have been scaled up e.g. MER, EGPAF has worked closely with MOHCW to revise existing registers and monitoring tools. Training on their use is then integrated into the training courses. Data from sites is collected by the sites and implementing partners on a quarterly basis using monthly reporting formats. These are then consolidated by EGPAF in quarterly reports submitted to both PEPFAR and the national PMTCT unit. Data validation assessments are an integral part of the program. Site support visits are undertaken by EGPAF and the partners to ensure that data is analyzed and utilized for decision making and improvement in the quality of the program.

Most adult treatment activities will be undertaken with FY09 supplementary funding. Specifically FAI will support the introduction of point of care CD4 testing in PMTCT sites (machines to be procured by CHAI and UNICEF) at medium/low volume sites and ART initiation for eligible pregnant women at an initial 25 sites. In addition, the program will strengthen linkages between high volume PMTCT sites and ART clinics using application of standardized referral forms to improve access to CD4 and ART. Specific activities include: 1) Organizing an exchange visit for senior policy makers to review successful roll out of ART initiation in MCH in the region (leveraged funding from DFID). 2) Development of national protocols and tools including revision of national ART registers. 3) Updating national ARV guidelines; 4) Finalization of referral forms and national scale up of these to strengthen linkages between PMTCT, laboratory and OI/ART clinics training to be integrated. 5) Training of MCH staff on adult OI/ART management and on-the-job training of CD4. 6) Support to scale up of the national mentorship pilot to improve ART delivery. 7) Support to MOHCW to mobilize resources to procure BD stabilizing tubes and introduce these at additional sites. 8) Intensive on-site supervision at the learning sites; 9) Strengthening coordination at national level. 10) Detailed documentation and review to inform policy changes and advocacy.

EGPAF has been working to improve follow up of HIV-exposed infants by integrating postnatal activities within the expanded program of immunization (EPI_ as well as developing a national follow-up register. The program intends to improve prescribing of Cotrimoxazole prophylaxis at 6 weeks to HIV-exposed infants from 9,000 to 14,000 infants using PEPFAR funding. Using FY09 Supplemental funds along with leveraged funding from DFID and UNICEF with the following to be undertaken:

1) Finalize and print a national implementation guide and job aides to improve follow up services and integrate application within existing training courses. 2) Distribute the national follow up register and include training on this into existing courses. 3) Support PSS groups for children and carry out exchange visits (leveraged funding from UNICEF). 4) Evaluate the child health card and provide on-the-job training to ensure cards are appropriately filled in to identify HIV-exposed infants (leveraged funding from DFID). 5) Carry out community mobilization activities to raise awareness on infant feeding issues and care for children living with HIV (leveraged funding from UNICEF). 6) Develop a community based follow up register (leveraged funding from UNICEF). 7) Support and train community cadres on PSS (leveraged funding from UNICEF and Global funds). 8) Supplement national stocks of Cotrimoxazole using private funding. 9) Develop materials to support caregivers awareness of pediatric issues (leveraged funding from UNICEF).

FY10 funds will be used to maintain and scale up the activities mentioned above.

Using FY09 Supplemental funding, EGPAF will support the expansion of the national pilot on early infant diagnosis linked to initiation of pediatric ART that is using leveraged funding from CIDA, CHAI and global funds. Expansion from 4 centralized hospitals to more rural areas is underway but slow. EID training is integrated with MER although stand alone trainings on EID will be encouraged with the new FY10 funds . The program will target testing of 4,000 infants at less than two months of age with an additional 5,000 HIV-exposed infants tested at 18 months. EGPAF has mobilized resources through Global Fund to support training on pediatric OI/ART management.

Using PEPFAR funding, EGPAF will continue to strengthen the national ART unit through provision of direct technical support. In addition, the FAI program will:

1) Support the decentralization of pediatric services in Harare and Chitungwiza through supervision, review meetings and development of decentralization standard operating procedure manuals.

2) Integrate EID training within existing PMTCT modules.

3) Provide training in EID and pediatric ART management.

4) Scale up the national mentorship pilot to 2 additional provinces, linked with ART initiation in MCH.

With FY 2009 supplemental and new FY2010 funding, EGPAF will expand the quality of the PMTCT program with a focus to ensure that existing sites can deliver MER and ART to eligible pregnant women. The program will maintain coverage in the existing 31 districts and cities and will expand into 3 new districts with complementary UNICEF funds. EGPAF will provide direct support to 680 PMTCT sites with 215 of these being upgraded to provide MER. In addition, 25 learning sites will be identified to initiate ART in a MCH setting. The program intends to continue to provide: sdNVP to 11,000 identified women; MER to 10,000 pregnant women and ART to 4,000 eligible women. Drugs to support PMTCT will be provided using national stocks (through UNITAID, PEPFAR and Global Funds).

Core activities will include: 1) Provision of technical support to MOHCW to strengthen coordination and management at national and district level including: secondment of existing and additional staff to the national PMTCT unit; hiring of additional EGPAF and partner technical staff; participation in technical working groups; and support to the PMTCT and ART partnership forums. 2) Training and refresher courses for both national/provincial trainers as well as site level healthcare workers in: PMTCT, OI/ART management, HIV rapid testing, Infant feeding counseling, psychosocial support, and integrated FP. 3) Intensive on-site supervision and mentorship at all levels. 4) Exchange visits between poorly and better performing districts. 5) Facilitation of national and district review meetings. 6) Community mobilization and awareness activities including distribution of IEC materials and support to PMTCT psychosocial groups. 7) Provision of essential commodities (using leveraged funding from J&J, DFID, UNFPA). 8) Regular monitoring and evaluation including; training in revised M&E tools, improved documentation and analysis; carry out an evaluation of both the national PMTCT program and a mid-program evaluation of the FAI program. 9) Development and printing of program documents, abstracts and lessons learnt as an advocacy tool to raise the visibility of the PMTCT program. 10) Technical exchange visits within the region and attendance at technical conferences. 11) FAI planning and coordination meetings including performance monitoring meetings