For COP 10, ICAP's goal is to work closely with the Swaziland Ministry of Health (MOH) at the national, regional and site level to support the strengthening of systems, programs, facilities, healthcare workers and the respective communities to offer quality adult and pediatric HIV care and treatment services with an integrated family-centered approach to people living with HIV and AIDS (PLWHA). This will focus on decentralizing HIV treatment services, initiating HIV care services on the primary care level and better linking the community to the facility. Ultimately, ICAP will shift many of its current activities (re: technical leadership, clinical mentoring and supervision, and community systems) to local governmental and non-governmental responsibility and ownership.

In COP 10, ICAP is funded under three mechanisms: CDC-care/treatment service provision cooperative agreement, CDC-technical assistance for Strategic Information use (UTAP) and HRSA - building capacity to support nurses training. This narrative applies to activities under the CDC-service provision funding.

In January 2006, ICAP, with PEPFAR support, began providing support to the MOH to support PMTCT-Plus programs and ensure that HIV-infected pregnant women were rapidly enrolled into HIV care and treatment services with the goals of reducing peri-natal HIV transmission and ensuring that HIV-infected women, their children and partners had access to HIV care and treatment services. In FY09, ICAP re-focused its support to implement family-centered HIV Care and Treatment services in ART centers and clinics, with a focus on de-centralizing services and supporting the Comprehensive Package of Care for HIV/AIDS/TB (CCP). ICAP Swaziland receives technical and programmatic support from the ICAP New York office.

The primary aim of the ICAP program is to collaborate synergistically with the MOH, at the national and site level, and other partners to improve on the ability of healthcare workers (individual level), the multidisciplinary team (group level) and health service (system level) to provide quality family-centered care and treatment (C&T) services through the CCP approach.

ICAP's goals support and contribute directly to the principle goals of the GOKS-PEPFAR Partnership Framework (PF): " to decentralize and improve the quality of treatment services within a CCP in order to increase access and improve outcomes for PLWHA". Also, through community linkages to HIV care, ICAP will support the Impact Mitigation five-year PF goal by increasing the percentage of orphans and vulnerable children receiving basic support (health) services on a regular basis. Finally ICAP's program supports the Human and Institutional Capacity Development five-year PF goal by working to Strengthen the HR capacity of the national government, through strengthening pre-service and in-service training for key cadres, and strengthening the capacity of community level workers to deliver HIV-related services.

The ICAP program provides substantial support to the whole national program in the areas of policy, planning, information systems, laboratory, and pharmaceutical management/supply. ICAP's clinic level support targets MOH and other health care facilities in three of the four regions of the country, Hhohho, Manzini and Lubombo. Medecins san Frontiers covers the 4th region although in collaboration with ICAP. The target population of the three regions is an estimated 140,000 people who are affected by HIV and AIDS and their family members, the national government and local community groups.

ICAP is planning to strengthen the national and regional systems in the country to be able to provide quality clinical site support and to phase out our direct site supervision. ICAP also plans to undertake renovations and equip key facilities early in the PF period to enable them to expand services more efficiently, without further donor support. Early investments in pre-service institutions and continuing medical education systems should reap long term benefits in terms of sustainable systems where workers are more capable and do not need frequent retraining. ICAP will work closely with the MOH to develop cost effective and sustainable programs using existing personnel more effectively to support the national systems. ICAP will contribute technical inputs and provide support to MOH leadership in a National planning and costing exercise around HIV Care and treatment services.

ICAP is moving quickly to enlist and fund the collaboration of three indigenous community-based implementers. The Nazarene Compassionate Ministries (NMI), World Vision (WVI), and Cabrini Sisters of St Phillips Mission all have strong, historic links in the community in the provision of HIV Care and treatment.

An ICAP M&E unit was established in January 2009. This new team has worked hard to forge a good working relationship with key MOH stakeholders in monitoring and evaluation of HIV/AIDS care and treatment. M&E staff will continue to provide technical support to all ICAP-supported facilities and participate in relevant technical working groups at the national level. The M&E unit is supported by Monitoring, Evaluation and Research department at ICAP headquarters New York (MER-NY). This technical support ensures that ICAP's global wealth of experience is shared with the ICAP-Swaziland M&E staff to ensure compliance to programmatic and funding partners reporting requirements. Recently, ICAP has been working in collaboration with HIVQUAL, UNICEF, and the MOH to establish a national QA/QI system around care and treatment and related services.

The overarching goal of the M&E unit of ICAP-Swaziland program implementation is to develop and conduct high-quality, timely, and sustainable monitoring and evaluation of ICAP supported activities for program evaluation and improvement. This is a collaborative effort, with local, national, and international partners to routinely collect, analyze, and disseminate data to assess program quality, as well as program impact within the Kingdom. In Swaziland, ICAP will implement the nationally approved monitoring and evaluation system and tools. ICAP participates in PEPFAR and national committees to review and revise M&E tools.

An M&E expert joined ICAP in January 2009 as the Program Monitoring Director and head of the M&E unit. He is assisted by three data officers who also joined ICAP in January and May 2009 and a fourth officer who joined in late 2009.

All ART sites have an electronic medical record systems (developed by MSH for the MOH called RX Solution Program Monitoring System) that captures and manages patient level data. At each main care and treatment site, data clerks maintain the PMS, perform routine data quality checks, monitor patients on ART, produce monthly reports on hard copy and send (both electronically and on hard copy) to MOH headquarters through the regional health offices. ART sites' monthly reports are aggregated at the central level and distributed to partners-including ICAP.

The lack of national requirement to routinely report on HIV care indicators represents a major handicap in monitoring HIV services. With MOH approval, ICAP has assisted nine main care and treatment sites to use the Pre-ART registers, and has developed a routine monthly report tools for key care indicators. ICAP is currently piloting this new tool with the main objective to adapt it as a national care monthly reporting form. The findings will be discussed with MOH in October 2009.

Each site sends hard copy monthly reports to the national M&E headquarters. Then the national M&E unit shares hard copies with implementers. As a consequence, there are long delays in data transmission and dissemination. ICAP will provide technical support to strengthen the national M&E system for HIV/AIDS at all assisted sites. ICAP will also work with other PEPFAR partners in assisting the national M&E leadership to develop standard operating procedures, conduct routine data quality assurance at care and treatment sites, and develop analysis approaches to track key treatment outcome measures.

Lastly, ICAP M&E in collaboration with the PEPFAR team, will support the development of CCP costeffectiveness analysis capacity at the MOH. As national ART guidelines move in the direction of improved quality of care, integrated services, and change in CD4+ threshold (<350), it is important that PEPFAR and partners assist the MOH in raising awareness regarding the cost-coverage implications of policy change. Routine analysis of cost parameters in relation to coverage and quality are key to enhanced planning and implementation of sustainable service delivery models.

ICAP will focus activities for care and support in 50 facilities in four main areas; community linkages and programming, adherence and psychosocial support, pre-ART programs and supportive supervision and quality improvement. This focused support is within the larger context of the CCP framework.

Through sub-agreements with WVI, NCMI and the Cabrini Ministries, ICAP will create a national model for strengthening the continuum of care for PLWHA through community linkages in three regions using the Rural Health Motivators (RHM) as the central building block for activities.

ICAP will continue to support the national, regional and site level APS programs in the country including the expert client program. The integration of APS into the overall service delivery at sites will be improved by training site multi-disciplinary teams in APS. By assisting to create a regional structure for APS supervision, ICAP will be able to reduce hands-on work at the facilities.

Following a successful pilot of the pre-ART program in 2009, ICAP will support the MOH to roll-out pre-ART systems as part of the CCP at all facilities in the three regions of ICAP support. These pre ART systems provide a structure for the delivery of quality HIV care (including clinical, preventive, and psychosocial services) and monitoring of HIV positive clients who are not eligible for ART. This will improve the quality of life, ensure that patients start HAART at the right time and are well prepared to ensure a more seamless continuum of care for patients.

ICAP is a key member of the Quality Assurance TWG and has spearheaded the quality improvement process for pre-ART and ART indicators. ICAP will work with the MOH and SNAP to adapt and roll out its Clinical Systems Mentorship approaches, including the Standards of Care (SOC) quality improvement tool to ensure that facilities continue to evaluate the quality of their work and implement programs to address gaps. Additionally, ICAP will train supervisors in Integrated Management of Adult Illness (IMAI) so they have the technical knowledge to supervise HIV care, and work with them to model supportive supervision techniques. ICAP is also planning to work with the Chief Nursing Officer to support her plan to develop more appropriate and useful supervision tools. Lastly, ICAP is collaboration with HIVQUAL and UNICEF to develop and implement a QA/QI system for use by the MOH in its quality of care oversight role.

ICAP Swaziland has been the key treatment partner in the country since 2006. ICAP will continue to support the 8 main ART centres in hospitals and health centers and peripheral sites to improve the quality of ART care through supporting the multidisciplinary teams in:

Clinical Systems Mentoring (Clinical care and health systems strengthening patient flow, drug supply, adherence counseling and support, follow up)

Ongoing Quality Improvement

ICAP will build on the successful implementation of appropriate decentralized models of ART refills and initiations in several clinics since 2007. The further decentralization of Adult treatment will improve access, quality of care and community involvement.

ICAP Swaziland will work with the MOH to develop a regional approach to C&T services:

A Regional team will provide coordination, clinical systems mentoring and support to all facilities in their region

Hospitals and health centers will continue to provide adult treatment at their ART units. Their outreach role at the clinics will change from providing services (refills and ART initiation) to a more supportive supervision/mentoring role.

At clinic level, ART refills will become a routine service provided on a daily basis. ART initiation will at first be provided by an outreach doctor. ICAP Swaziland in collaboration with WHO will work with the MOH to develop a task shifting policy that will enable nurses to initiate patients on ART. ICAP and WHO will support the MOH in piloting and implementing this new strategy.

The following activities will support decentralized Adult treatment at clinic level

Supply of mobile/temporary structures and renovation of existing clinics to ensure adequate space for the expansion of services at clinics

Supply of equipment and furniture, and appropriate patient information tools (patient files, registers, appointment books)

Support for an appropriate patient information system (in collaboration with MSH/SPS)

Establishment of clinic teams that will meet regularly to discuss operational and clinical issues

IMAI training for clinic staff

Site support: clinical systems mentoring (clinical care and health systems strengthening patient flow, drug supply, task shifting, adherence counseling and support, follow up, and site training

Further development of facility-based tracking mechanisms and community based linkages and follow up of patients who miss appointments.

In addition to main areas of support described under HBHC, ICAP will focus specifically with regard to pediatrics in the following areas.

Ensuring appropriate care and follow up of HIV exposed children and to ensure early infant diagnosis with DNA PCR testing at six weeks. Follow up of exposed infants using facility-based tracking systems and community linkages will ensure that HIV infected infants start HAART soon after diagnosis.

Developing a better understanding of how orphans and vulnerable children are accessing care and working to eliminate any identified hindrances

Working on developing APS messages that counselors can use with children and parents can use to talk to children about their status

Ensuring that the pre-ART program is extended into the PHUs (in cooperation with EGPAF) to ensure uniform tracking of children while they are in care at these facilities

Ensuring that indicators for pre-ART and ART QA/QI and the ICAP SOCs have a focus on pediatric issues

Infants and children will receive the same services as described mentioned for adult treatment above within the framework of family-centered care. Specific attention will be given to:

Ensuring that infected infants below 12 months are started on HAART within a month of diagnosis

Focus on the child's development, including referral/facilitation to schooling

Actively enquiring with adult patients on HAART about their children and their HIV status

Developing training modules and skills on adherence issues specific for children/teenagers: dosing, gradual disclosure, sexuality