Model Center for Maternal and Family ART/Care

In FY07, the Johns Hopkins University-Bloomberg School of Public Health (JHU-BSPH), with collaborative

assistance from JHPIEGO, proposed to develop a Maternal and Family HIV Center of Excellence to model

delivery of PMTCT and ART services, and to facilitate care for family members of HIV-positive persons. The

proposed site was Gandhi Hospital in Addis Ababa, a specialized facility known for excellent maternal care,

which has not functioned to full potential due to severe material and staff shortages. However, Gandhi has

provided excellent antenatal (ANC) and PMTCT care. In FY06, a model voluntary counseling and testing

(VCT) center opened, and currently serves pregnant women, their partners, and children with a full-time

general practitioner to care for HIV patients and a pediatrician to care for HIV-exposed infants. Great efforts

are underway to further develop Gandhi Hospital as a model center providing integrated PMTCT, VCT, and

ART services.

To date in FY07, JHU-BSPH has: developed a workplan for this activity in collaboration with Gandhi and the

Addis Ababa regional health bureau (RHB); conducted an on-site PMTCT training for all ANC and labor and

delivery personnel; hired a PMTCT case manager and nurse assistant to facilitate the extra workload

involved in this project; and worked with the facility to relieve perceived work burden for overstretched

hospital personnel.

In FY08, Gandhi Hospital will continue to take the lead in solidifying the implementation of the revised

national PMTCT guidelines, which support opt-out HIV counseling and testing and aggressive referral of

family members. In the ANC setting, the opt-out approach will continue to include group education and rapid

testing by trained lay counselors. HIV-positive women will be encouraged to have partners and children

tested. JHU-BSPH will support an innovative, family-focused approach at Gandhi using PMTCT as the entry

point. Gandhi pioneered starting HIV-positive pregnant women on ART within the same clinic, and now

plans to expand services to provide care for the entire family. Moreover, Gandhi will provide screening for

other family-focused clinical problems, such as TB. Evidence shows that referring a pregnant woman from

PMTCT to an ART clinic for treatment is inefficient in the Ethiopian context; in reality, most eligible women

do not receive evaluation or ART until after delivery. Other pregnant women are never properly screened for

therapy, or are referred back to PMTCT programs, due to clinician inexperience in treating pregnant

mothers with ART. Referrals may also over-burden ART providers, contributing to burn-out and attrition.

JHU-BSPH proposes to optimize delivery of ART to pregnant women who meet treatment criteria. Based on

preliminary data from the Nigat Project, a PMTCT clinical-trial collaboration between JHU-BSPH and Addis

Ababa University, approximately 30% of HIV-positive pregnant women have CD4 counts <200/mm3.

Pregnant women with advanced clinical AIDS, or with CD4 counts <200/mm3, are at greater risk of

transmitting infection to their infants and at greater risk of serious morbidity or death. Maternal illness and

death have been shown to affect neonatal/infant health and survival adversely, even when mothers have no

HIV infection. Women with more advanced HIV require ongoing combination ART for their own health. Use

of single-dose nevirapine (SD-NVP) for lower CD4 counts is associated with increased NVP resistance,

which has the potential to affect community rates of nonnucleoside reverse transcriptase inhibitor (NNRTI)

resistance and reduce future maternal treatment options.

As part of the training programs of the Gandhi Hospital center of excellence, JHU-BSPH will continue to

train ANC providers and OB/GYN in ART management during pregnancy, clinical staging, and CD4

interpretation. JHU-BSPH will implement the revised Ethiopia PMTCT guidelines, which include extended

ARV prophylaxis options. These range from full ART to AZT during pregnancy, NVP and combivir

intrapartum and combivir postpartum, to SD-NVP, where facilities do not permit more complex regimens.

This transition in regimens will continue to require intensive staff training and measures to ensure

medication accessibility for pregnant women. In FY08, JHU-BSPH and Gandhi will share their experience in

training healthcare workers (HCW) on the extended regimens, and will use their experience in implementing

the revised guidelines to develop training materials and as a basis to develop a training-center program to

train HCW from other hospitals.

PEPFAR feels that the continuum of care for positive pregnant women starts at the ANC visit, followed by

HIV counseling, testing, and appropriate ARVs throughout pregnancy, as recommended by the MOH, with

the goal of reducing HIV transmission to the infant. As ART is scaled up in many low-resource settings,

providing highly active antiretroviral therapy (HAART) to HIV-positive pregnant women will benefit both

mothers and infants. HAART has been associated with the lowest rates of MTCT and has become standard

care for infected mothers in the US and abroad. Improvement in maternal health with ART will result in

healthier infants and reduced neonatal/infant mortality. General obstetrical antenatal practices will also be

strengthened, focusing on those most relevant to PMTCT (e.g., malaria prophylaxis in endemic areas,

syphilis screening, prevention/treatment of anemia, antenatal discussion of family planning). JHU-BSPH will

partner with the JHPIEGO-supported ACCESS Program at Gandhi Hospital that aims to improve maternal

obstetrical care.

The center of excellence will also provide general postpartum and newborn/infant care, including family

planning, counseling/monitoring of infant-feeding options, growth monitoring, and child immunizations. After

18 months, care for mother and family will be transferred to the nearest ART clinic. Pediatricians will be

trained in infant diagnosis and will provide infant management. The center will co-manage the partners of

the HIV-positive women, as treatment of the family as a unit has been shown to help keep the households

together, which in turn, minimizes mother and infant morbidity and mortality.

Care and treatment burden-sharing among a wider range of medical specialties will be a great strength of

this center and a marker of quality comprehensive care for the entire family unit. It is expected that this will

also have a positive influence on the retention crisis for trained health providers and the human resource

shortage challenges plaguing ART provision. Quality of services will be guaranteed when reliable

consultative linkages to internal medicine and infectious-disease services are established at Tikur Ambassa

or Zewditu Hospitals for complicated or advanced cases. JHU-BSPH plans to facilitate the transfer of

knowledge through international subject-matter-expert exchanges, supportive supervision and mentoring,

distance learning, and scheduled in-service training in the management of HIV-positive pregnant mothers.

In FY08, JHU-BSPH will continue to support the model site at Gandhi Hospital and will expand certain

activities, such as developing a training center and training capacity for practical PMTCT and ART

Activity Narrative: attachments, and involving family-focused cases in the ongoing telemedicine case conferences supported

by JHU-BSPH. If the model center proves successful in improving follow-up of infants, timely initiation of

ART for pregnant and postpartum women, and inclusion of all members of the family in HIV screening and

care, JHU-BSPH aims to extend this model to additional sites within its operational zone.

Proposed activities for FY08 include:

1) Annual assessment and review of activities: number of pregnant HIV-positive women seen in ANC clinic

and referred to ART clinic and number of pregnant women seen in ART clinic

2) Training of ANC providers to do clinical staging and perform and interpret CD4 counts

3) On-site and practical training for other hospital-based PMTCT programs; support to develop local training

center

4) Telemedicine for complicated HIV-positive pregnant cases

5) Training of ANC/labor and delivery physicians in ART management and follow-up

6) Introduction of counseling and testing at ANC and labor and delivery using the opt-out strategy

7) Introduction of counseling and testing to postpartum women who missed HIV testing in the prepartum

period

8) Early infant diagnosis with dried-blood-spot DNA PCR testing

9) Creation of the exposed infant clinic for all children born to HIV-positive mothers

10) Strengthening and increased functionality of referral linkages between ANC, labor and delivery wards,

exposed infant clinics, ART clinics and the HIV laboratory

11) Support for mothers' support groups at Gandhi

12) Support for case managers and nurse assistants at site level to ensure proper follow-up, tracking, and

comprehensive care for the entire family

13) Introduction of this model to another site in the JHU-BSPH-supported operational zone

14) Assistance for two US-based university partners to establish model centers at Jimma and Gondar

University hospitals

This is a continuing activity from FY07. In FY07, Johns Hopkins University/ Technical Support for the

Ethiopia HIV/AIDS ART Initiative (JHU TSEHAI) supported PMTCT services in 30 hospital networks in

Addis Ababa, Benshangul- Gumuz, Gambella and the Southern Nations, Nationalities, and Peoples

Regions (SNNPR). JHU TSEHAI expanded and enhanced interventions to prevent prenatal and

postpartum transmission, and to link HIV-positive pregnant women and their families to comprehensive HIV

care and treatment services. In FY08, JHU will extend these services to a total of 42 health facilities,

working to dramatically reduce the number of infants born with HIV, in collaboration with the Federal

Ministry of Health (MOH) and regional health bureaus (RHB) of target areas.

Accordingly, JHU will provide PMTCT services at five hospitals in Addis Ababa, two hospitals and 11 health

centers in Benshangul-Gumuz, one hospital and six health centers in Gambella, and 17 hospitals in

SNNPR. JHU uses antenatal care (ANC), maternal/neonatal/child health (MNCH), and PMTCT programs as

entry points to HIV care and treatment for women, children, and families. The Government of Ethiopia has

recently issued revised national PMTCT guidelines, and JHU, in collaboration with JHPIEGO, will support

the rollout of the new PMTCT guidelines in these regions. Major areas of emphasis include: integration of

PMTCT with MNCH services and HIV prevention, care, and treatment programs; provider-initiated, routine,

opt-out HIV testing and counseling at ANC and labor and delivery; implementation of more potent and

complex PMTCT regimens; prompt clinical and immunologic staging of HIV-positive pregnant women and

rapid initiation of ART for eligible patients; enhancing the quality of infant-feeding initiatives; strengthening

systems for PMTCT service delivery; and supporting human resources by providing high-quality training and

clinical mentoring.

JHU will work to support PMTCT programming at the national, regional, and site levels. At the national level,

as a member of the National Technical Working Group on PMTCT, JHU will contribute to the development

of training materials, clinical support tools, guidelines, formats, and standards. JHU will continue to provide

technical input and guidance to the MOH and RHB, supporting initiatives to expand PMTCT beyond single-

dose nevirapine (SD-NVP) where appropriate, enhancing PMTCT-plus training, and supporting links

between PMTCT programs, HIV care and treatment programs, and pediatric services. At the facility level,

the JHU-supported package of PMTCT Plus/family-focused care includes:

1) Support for linkages between healthcare facilities and community-based implementing partners, including

PLWH organizations, to promote uptake of antenatal and PMTCT services and to support follow up of

infants enrolled in early infant diagnosis (EID) programs

2) Enhanced linkages between ANC, MNCH, PMTCT, family planning (FP), STI, and HIV care and

treatment clinics at the facility level

3) Promotion of partner testing and a family-centered model of care, using PMTCT as an entry point to HIV

services for mothers, children, and families

4) Routine, opt-out HIV testing and counseling at ANC, labor and delivery according to national guidelines

5) Active case-finding within families and households using a simple, validated tool—the Family Enrollment

Form

6) Adherence and psychosocial support and enhanced follow-up and outreach services for pregnant women

testing positive for HIV to encourage retention in care. In collaboration with JHPIEGO, implementation of

peer-educator programs and Mothers' Support Groups (MSG) at selected sites, to maximize adherence to

care and treatment among pregnant HIV-positive women, and to strengthen their links to psychosocial

support and community resources.

7) Provision of a basic care package for all HIV-positive pregnant women, including patient education, TB

screening, prophylactic cotrimoxazole (CTX) when indicated, nutritional support (see below), insecticide-

treated bed nets, condoms, and safe water in coordination with the Global Fund to Fight AIDS, Malaria, and

Tuberculosis (Global Fund) and other partners

8) Routine assessment of all HIV-positive pregnant women for ART eligibility using clinical staging and CD4

testing, and provision of prophylaxis and treatment as appropriate, including ART when indicated

9) Nutritional education, micronutrient (MVI) supplementation, and "therapeutic feeding" for pregnant and

breastfeeding women in the six-month postpartum period

10) Enhanced postnatal follow-up of HIV-positive mothers and HIV-exposed infants

11) Promotion of infant-feeding initiatives and healthy infant-feeding practices by facilitating on-site trainings

and mentoring of MNCH staff (including traditional birth attendants) on safe infant-feeding practices in the

context of HIV, developing infant-feeding support tools, and establishing infant-feeding MSG

12) Linkages of all infants born to HIV-positive women to the HIV-Exposed Infant Clinic to ensure EID by

DNA PCR using dried-blood spot (DBS) testing. Enhanced laboratory capacity for infant diagnosis at

selected facilities and strengthened linkages with regional labs at remaining facilities (see the laboratory

narrative). Initiation and expansion of the clinical and health-management information systems (HMIS)

needed to implement EID services

13) Ensuring that HIV-exposed infants are enrolled in care and receive prophylactic CTX, immunizations,

nutritional support, careful clinical and immunologic monitoring, monitoring of growth and development, and

ongoing assessment of eligibility for ART

14) Determination of infection status at 18 months of age for HIV-exposed infants not found to be HIV-

positive via EID

15) Facilitate availability of supplies for PMTCT services

16) Support for site-level staff to implement national performance standards and the JHPIEGO-supported

Standard-based Management Program

17) Provision of PMTCT-Plus training to multidisciplinary teams at the facility level

18) Provision of ongoing clinical mentoring and supportive supervision in partnership with RHB

19) Ongoing development and distribution of provider job aids and patient-education materials

20) Routine monitoring of PMTCT-plus programs, reporting of progress against targets, and ongoing

assessment of linkages within facilities (from PMTCT to ART clinics, for example) and uptake of services by

family members

21) Support for the availability and correct usage of PMTCT registers and forms, HIV-exposed infant

registers and follow up cards, timely and complete transmission of monthly reports to regional and central

levels, and appropriate use of collected data

22) Minor renovation, refurbishing, and repair (as needed) of ANC, labor and delivery rooms, and maternity

wards at JHU-supported sites

23) Radio and TV outreach campaigns and use of information-education-communication/behavior-change

communication (IEC/BCC) materials in local languages to enhance public awareness and use of ANC,

MNCH, PMTCT and HIV care & treatment services

In FY07, JHU-TSEHAI also implemented an initial pilot program to support infant-feeding practices in the

postpartum period. In FY08, this activity will continue as before, but will incorporate the following expanded

activities: (1) Expansion to SNNPR by linking with Intrahealth/JHPIEGO to introduce MSG at hospital level

Activity Narrative: for ongoing feeding support; (2) Supporting institutions to become baby friendly hospitals that promote

exclusive breastfeeding; (3) Training counselors and nurses in this activity; and (4) Training HIV-positive

mothers and family members in optimal feeding at all hospital sites.

JHU, in collaboration with Addis Ababa University, had followed more than 1,000 HIV-positive women and

their infants who were in a clinical trial for PMTCT. Review of feeding practices showed that although good

infant-feeding counseling was provided by trained healthcare staff, less than 50% of those who chose to

breastfeed were exclusively breastfeeding beyond three months. Appropriate ongoing counseling by

healthcare providers, mother-to-mother support groups, and involvement of family members would provide

a vehicle to promote and support optimal breastfeeding practices for mothers who are breastfeeding. The

proposed FY08 continuation activities include: (1)Assessment and improved current breastfeeding

counseling practices; (2) Targeting pregnant women in the antenatal period to counsel on infant-feeding ;

(3) Collaborating with partners on revising and updating current infant-feeding guidelines and manuals; (4)

Assessing and supporting factors that promote optimal breastfeeding such as maintaining breast health and

appropriate breastfeeding (positioning, attachment, etc.), developing IEC materials on exclusive

breastfeeding, ensuring maternal health and nutrition status, and family support; and (5) Training MSG to

ensure ongoing support for optimal infant-feeding and support for exclusive breastfeeding. JHU proposes

to train 150 counselors and nurses and 300 mothers and family members on optimal feeding options.

Additional narrative to COP08 narrative: This activity will provide support for outreach ANC/PMTCT

services. It will train health care workers to provide ANC and PMTCT services to the hard-to reach rural

communities. Trained nurses based at a hospital and health center and Health extension workers will be

involved to provide outreach PMTCT services. Community level PMTCT activities will be linked to the near-

by Hospital or Health center PMTCT programs through referral linkages and establishment of catchments

area networks. Experiences elsewhere and in Ethiopia (JHU and IntraHealth) have shown that outreach

PMTCT services can effectively be utilized to improve the uptake of PMTCT services. JHU will be involved

in the expanding outreach PMTCT services in Addis Ababa, Gambella, Benishangul and SNNPR regions.

Strengthening STI Services for MARPs

This funding will be used to strengthen the existing prevention intervention by Johns Hopkins University

Bloomberg School of Public Health. Mainly the program will focus on mainstreaming IEC and Behavioral

Change Communication programs with care and treatment programs.

Johns Hopkins University Bloomberg School of Public Health in collaboration with regional health bureaus,

regional HAPCO's, US University partners and CDC-Ethiopia will establish a national and respective

regional taskforce to research, design and develop, produce and mounting billboards centrally and

regionally on new thematic areas that will be endorsed by the task force. These billboards will replace the

central and regional billboards which were mounted in 2004 and 2005 under the theme "the Role of

Leadership in the fight against HIV/AIDS". JHU-CCP will provide the necessary technical assistance in the

production processes of the educational billboard. University of Washington will mainly work with three

regional health bureaus in this regard.

Prevention of sexually transmitted infections (STI) among most-at-risk populations (MARPs) and people

living with HIV (PLWH) is a critical activity in preventing new HIV infections and slowing the pace of the

epidemic.

During FY07, Johns Hopkins University Bloomberg School of Public Health (JHU-BSPH) has taken full

responsibility for supporting STI activities at 44 sites found in Operational Zone 2 (Addis Ababa,

Benishangul-Gumuz, Gambella, and Southern Nations, Nationalities, and Peoples (SNNPR) regions). The

support includes: development of a workplan and an assessment tool to identify the sources of STI

treatment and prevention activities at the hospital level; participation in PEPFAR-funded trainings; and

communication with Population Services International (PSI) regarding accessing and deploying pre-

packaged STI treatment doses at the hospital ART site level.

FY08 activities at the regional level will include:

1) Coordination with Regional Health Bureaus (RHB) to help facilitate and coordinate linkages between STI

and HIV/AIDS services, and strengthen external referral linkages between hospitals, health centers, and

community service organizations (CSO), faith-based organizations (FBO) and PLWH support groups and

associations. Regional linkages will be supported so that patients who do not respond to syndromic

management of STI symptoms at the health-center level are referred to appropriate care at the hospital

level.

FY08 activities at the hospital/facility level include:

1) Expansion of STI services to six additional sites, for a total of 76 sites supported by JHU-BSPH (including

hospitals and emerging region health centers)

2) Continuing collaboration with uniformed health services coordinating offices to conduct needs

assessments of the capabilities of hospital-based STI services. This will be followed by joint action planning

with facility staff to improve STI services and linkages between STI and other services (counseling and

testing, care and treatment, antenatal care, etc.).

3) Provision of on-site technical assistance to improve STI diagnosis and treatment following national

syndromic management guidelines

4) Training, supportive supervision, and mentorship of 300 providers (including physicians, health officers,

and nurses) on STI prevention, diagnosis, and treatment, with a focus on the linkages between STI and HIV

infection, as per national guidelines

5) Training of facility-based peer educators on STI prevention and treatment for PLWH and their partners,

as well as community education regarding STI symptoms and the need to seek care

6) Development of linkages with the Global Fund for AIDS, Malaria, and Tuberculosis and other PEPFAR-

funded partners to ensure adequate supplies of STI drugs at all facilities

7) Development of linkages to HIV counseling and testing (HCT) services, promoting a provider-initiated,

opt-out approach for all STI patients, and linkages to care and treatment services for those who are HIV-

infected

8) STI education focused on risk reduction, screening, and treatment for patients enrolled in HIV/AIDS care

and treatment at the hospitals

9) Provision of condoms, and education on how to use them, to patients enrolled in care and treatment, with

a special focus on MARPs

10) Integration of STI services into antenatal and PMTCT services. This will ensure that all pregnant women

are educated on and/or treated for STI, and receive education on STI prevention during pregnancy

(according to national STI management and antenatal care guidelines)

11) Development of linkages to community-based organizations that promote risk reduction and HIV/STI

prevention and early/complete treatment in communities surrounding ART sites supported by Columbia

University's International Center for AIDS Care and Treatment Programs.

Palliative Care and Nutrition Support at Hospitals

In FY06, Johns Hopkins University - Bloomberg School of Public Health (JHU-BSPH) introduced a basic

palliative care approach to 20 ART facilities and then in FY07 expanded this activity to 44 sites in

Operational Zone 2 (Addis Ababa, Benishangul-Gumuz, Gambella, and SNNP). Initial work included: a

baseline assessment of the palliative care activities at sites; development of site-level training materials for

palliative care and the prevention care package in cooperation with the national leadership; development of

national pain management guidelines and training materials; and supervision of palliative care activities.

Training and supervision focused on identifying pain and discomfort among HIV patients, ensuring

cotrimoxazole (CTX) prophylaxis (pCTX)for all eligible patients, conducting tuberculosis (TB) screening for

HIV-positive patients, and targeting elements of the preventive care package (e.g., multivitamins, nutrition

assessments, condoms, and links to programs that distribute insecticide-treated bed nets (ITN) to HIV-

positive patients. To date in FY07, this project has provided palliative care to 3,995 people, and has

distributed 22,000 condoms, 1.2 million tablets of CTX, 33,000 bottles of cotrimoxazole and 630,000

multivitamins to ART sites. Four programs have linked ART clinics with the regional ITN distribution,

reserving 1,200 nets for HIV-positive persons of all ages. As the lead for nutritional programs among

university partners, JHU-BSPH has initiated collaborative meetings with Food and Nutrition Technical

Assistance (FANTA) and the HIV/AIDS Prevention and Control Office (HAPCO) to facilitate the introduction

of "food by prescription" programs at hospital level. Initial site visits have been conducted at St. Peter's

Hospital by JHU with FANTA.

In FY08, JHU will support palliative care activities at 50 sites providing HIV/AIDS care and treatment

(hospital and emerging regional health centers), via a multidisciplinary, family-focused approach to

providing the preventive care package for both adults and children. This approach will incorporate best

practices for health maintenance and the prevention of opportunistic infections for people living with HIV

(PLWH), slowing disease progression and reducing morbidity and mortality.

JHU will assist the 50 facilities to provide the preventive care package, complementing the Global Fund for

AIDS, Tuberculosis, and Malaria (Global Fund), the Federal Ministry of Health, and other PEPFAR Ethiopia-

funded activities when possible. JHU will focus on providing the basic care package for adults, which

includes: pCTX; micronutrient and nutrition supplements and counseling; ITN (through linkage with the

Global Fund malaria control program); water disinfectant at community and hospital level; condoms and

education for prevention among positives; and TB screening and pain management for all patients. The

basic care package for children includes: pCTX to prevent serious illnesses like Pneumocystis carinii

pneumonia, TB, and malaria; prevention and treatment of diarrhea; nutrition and micronutrient supplement;

and links to national childhood immunization programs.

JHU will work closely with other university partners to ensure complementary of activities with, for example,

the implementation of national pain management guidelines and the development and implementation of

the Palliative Care Training curriculum.

JHU support to facilities will be continued or expanded as follows:

1) Strengthen the internal and external linkages required at facility level to identify HIV-positive individuals

and provide them with access to care. Internal linkages include referrals to the HIV/AIDS/ART clinic from

antenatal clinics, TB clinics, under-5 clinics, inpatient wards, out-patient departments, and voluntary

counseling and testing. External linkages include referrals to and from community-based resources

providing counseling, adherence support, home-based care, and financial/livelihood and nutritional support.

2) Provide on-site implementation assistance, including staff support, implementation of referral systems

and forms, and support for monthly HIV/AIDS team meetings to enhance linkages.

3) Provide training on palliative care and the preventive care package to multidisciplinary teams.

4) Provide clinical mentoring and supervision to multidisciplinary teams related to the care of PLWH,

including those who do not qualify for, or choose not to be, on treatment, in partnership with regional health

bureaus in the respective regions.

5) Continue to develop and distribute provider job aids and patient education materials related to palliative

care and positive living.

6) Identify and sensitize community-based groups to palliative care, to the importance of adherence to both

care and treatment for PLWH, and to the palliative care services available at the facility level.

7) Improve nutrition assessment at health facilities.

8) Promote interventions (pharmacologic and non-pharmacologic) to ease distressing pain or symptoms.

9) Continue patient management after hospital discharge, if pain or symptoms are chronic.

10) Link patients with community resources after discharge.

JHU will: ensure that all supported sites have reliable stocks of CTX tablets and syrups; provide emergency

supplies when essential for quality and continuity of care; promote TB screening; and provide and promote

INH prophylaxis for HIV+ adults and children. (See also the activity section on TB/HIV activities.) Supportive

supervision and the institution of standard operating procedures and national guidelines will improve the use

of CTX and INH prophylaxis. Attention will be given to the issue of HIV/malaria co-infection, and the routine

provision of ITN in HIV/AIDS and PMTCT programs in collaboration with Global Fund. Health education and

behavior-change communication for HIV-positive individuals will be provided by facility and lay staff,

complementing Global Fund and other USG-funded activities. Health education, counseling, and support

will encourage positive living to forestall disease progression and promote prevention among positives to

prevent further HIV transmission.

In FY08, JHU will continue to support and expand nutritional activities to:

1) Assist in development of guidelines for nutrition assessment.

2) Improve dietary and nutrition assessment at the point of care and evaluate the effectiveness of the

assessment technique.

3) Improve nutrition counseling by assessing current practices and implementing identified best practices for

nutrition counseling.

4) Assess and address micronutrient supplement needs and examine and address therapeutic and

supplemental feeding needs.

5) Integrate therapeutic "food-by-prescription" with ART and PMTCT programs.

6) Support implementation of "food-by-prescription" in at least 20 hospitals, based on criteria agreed upon

by PEPFAR Ethiopia.

Activity Narrative: 7) Evaluate therapeutic and supplementary feeding programs with adaptation of WHO criteria for eligibility

and exit criteria for programs.

8) Support dietary assessment and supplementation of micronutrients to pregnant and lactating women and

children.

9) Assess and recommend effective ways to improve dietary intake in patients with weight loss due to

appetite loss and inadequate intake.

10) Integrate infant feeding counseling and maternal nutrition in PMTCT programs.

11) Assess effect of ART in chronically malnourished populations.

12) Develop capacity and skill of hospital staff in nutritional assessment.

13) Examine the use of lay counselors (i.e., PLWH) to assist with nutritional counseling so that clinic staff is

not overburdened.

14) Share information regarding nutritional assessment guidelines and experiences gained through pilot

implementation programs with the other university partners.

TB/HIV Linkage Support at Hospital Level

An integrated tuberculosis (TB)/HIV program is an essential component of the comprehensive HIV care

preventive package. With this program, Johns Hopkins University-Bloomberg School of Public Health (JHU-

BSPH) aims to strengthen the linkages between TB and HIV services in hospitals of operational zone 2

(which encompasses Addis Ababa, Benishangul-Gumuz, Gambella, and Southern Nations, Nationalities,

and Peoples Region (SNNPR).

In FY07, JHU-BSPH was funded to support and expand activities to 40 ART sites. To date, in FY07, JHU-

supported sites have provided HIV counseling and testing to 1,305 TB patients, treated or screened 393

HIV patients for TB, placed 165 persons on isoniazid preventive therapy (IPT) and trained 34 persons in

TB/HIV collaborative activities. Sensitization has been initiated at St. Peter's TB Hospital to serve as a

training and demonstration site, and plans are underway to review the TB curriculum, conduct a review of

multi-drug-resistant (MDR) TB cases, establish culture activity at St. Peter's laboratory, and implement

infection control measures in the inpatient setting. On-site trainings are planned for the second through

fourth quarters of FY07.

In FY08, JHU-BSPH will continue with all previous activities, supporting 50 sites in Operational Zone 2

(hospitals and emerging region health centers), and will focus on expanding activities to improve monitoring

and evaluation (M&E) and improved use of the current and revised TB/HIV recording system. Widespread

on-site training for TB/HIV activities will address the human resource attrition in the field. Improved TB

diagnostics (e.g., chest x-ray (CTX), concentrated acid-fast bacilli (AFB) staining methods, fluorescent

microscopy, fine-needle aspirations, culture and sensitivity, and—eventually—molecular diagnostics) will

improve site-level capacity to diagnose active TB. JHU-BSPH will support the phased implementation of

World Health Organization guidelines on smear-negative disease and extra-pulmonary TB, and will assess

TB relapse and failure rates as a proxy for resistance (MDR-TB).

JHU will further expand TB/HIV collaborative activities to those private-sector hospitals providing free ART

and PPM-directly observed therapy services and also expand IPT and cotrimoxazole preventive therapy

(CPT) to co-infected pediatric patients. In FY08, JHU-BSPH will work with Columbia University and the

MOH to assess training needs and curricula related to family-focused TB/HIV activities, including provider-

initiated counseling and testing (PICT) guidelines for children. With ICAP-Columbia University as the lead

TB-implementing partner among university partners, current didactic materials will be modified to reflect

current needs. JHU-BSPH will also support the Federal Ministry of Health (MOH), the HIV/AIDS Prevention

and Control Office (HAPCO), and CDC's efforts to improve the TB/HIV information system by hiring a

TB/HIV M&E expert who can work closely with CDC and MOH.

In FY08, JHU-BSPH will continue to implement previous interventions such as expansion of PICT for TB

patients, referral of HIV/TB patients for HIV-related care including CTX and ART, TB screening in HIV care

and treatment settings with improved documentation of these activities at the HIV clinic, IPT for HIV-positive

patients in whom active disease has been safely ruled out, and support at site level for improved ability to

rule out active TB by providing CXR capacity in rural areas and in network/referral hospitals.

These activities, initiated in FY07, will continue to be closely coordinated with the national TB and HIV

control programs and regional health bureaus (RHB) in the operational zone covered by JHU-BSPH. JHU-

BSPH will continue to work closely with the RHB in strengthening the TB/HIV working groups and review

meetings at regional level, along with providing strategies for: joint supportive supervision for TB/HIV

activities; M&E of TB/HIV activities; programs to improve prevention, diagnosis, and treatment advocacy for

MDR-TB; and human resources training and retention. JHU site-support teams will continue to provide

monthly supportive supervision and clinical mentoring in the field of TB/HIV, and teams will work closely

with the RHB to solve implementation road blocks.

In FY06 and FY07, JHU-BSPH initiated support to strengthen TB diagnostics among HIV-positive patients

through improvement of smear microscopy services, quality assurance of laboratory networks, and support

for regional referral. JHU-BSPH laboratory personnel assisted in the review of new smear microscopy

guidelines, trained on concentrated AFB methods, and disseminated this information to JHU-supported

TB/HIV sites. JHU-BSPH will continue to support improved smear microscopy but will expand this

laboratory support to labs providing culture and sensitivity testing at regional and federal levels, in

collaboration with the Plus-Up fund activities. The goal will be to increase ease of referral and improve

information feedback to patients and efforts to assess the situation of MDR-TB.

Counseling and Testing Support Service at Hospitals

In FY07, Johns Hopkins University - Bloomberg School of Public Health (JHU-BSPH) supported HIV

counseling and testing (HCT) services in 40 ART facilities (36 hospitals and four health centers) in

Operational Zone 2 (Addis Ababa, Benishangul-Gumuz, Gambella, and Southern Nations, Nationalities, and

Peoples Region (SNNPR)). This included: initial site assessment; training in collaboration with JHPIEGO;

refurbishing sites; standardizing data collection and reporting; and supervising HCT services. Site support

aimed to deliver improved quality HCT services for community and patients. So far in FY07, 19,088 people

have been counseled, tested, and received results.

In FY08, JHU-BSPH will support 48 sites (hospitals and emerging regions health centers) by training health

professionals and community counselors on standard voluntary counseling and testing (VCT) and provider-

initiated counseling and testing (PICT). This will be done in partnership with regional health bureaus (RHB).

JHU-BSPH will also provide site-level support for continued provision of integrated HCT activities as part of

ART/VCT/PMTCT/TB/STI activities, and the comprehensive care package will be available at all hospitals in

the four regions.

Major HCT interventions by JHU-BSPH will include:

1) Adopting PICT and opt-out strategies for CTR hospitals and outpatient clinic settings

2) Assessment of current capacity for care, laboratory testing, and nursing support of VCT

3) Support for the sites to provide same-hour HIV testing at VCT sites

4) Strengthening of the referral link between counseling and testing with post-test services

5) Support for site-level refresher trainings and mentoring for HCT personnel with JHU-BSPH experts

6) Support for minor renovation of physical space to ensure infrastructure which is consistent with the

standard

7) Providing necessary laboratory supplies for the VCT labs

8) Improved data management system of HCT and reporting

9) Establishing a quality assurance system for HCT services for both client- and provider-initiated HCT

JHU-BSPH technical assistance will continue to ensure that all relevant HCT protocols are followed

appropriately and consistently. To increase HCT uptake beyond site level, outreach programs will be

expanded to target high-risk populations and various other special populations, such as the disabled,

refugees, and those within other sectors (e.g., schools, universities, factories, and faith- and cultural-based

environments). JHU-BSPH will strengthen family-member screening, with particular focus being given to

couples counseling, pediatric screening, and improving partner notification. After-hours, weekend, and

holiday HCT service will be promoted, and national campaigns such as Millennium AIDS Campaign and

local initiatives to increase uptake of HCT will be supported.

JHU-BSPH will continue support for quality documentation and compliance with national reporting

requirements, including counseling-data management and data utilization at site and regional levels. JHU

will continue to support sites in the preparation and timely submission of reports to zonal, district, and RHB

and the Federal Ministry of Health (MOH). JHU-BSPH will further monitor administrative and technical

coordination mechanisms to build strong management systems at the facility level. Quality assurance

programs and burnout management sessions for HIV/AIDS care providers begun in FY07 will be expanded

and strengthened in collaboration with relevant partners.

JHU-BSPH will collaborate and harmonize HCT activities with partners implementing programs in the same

region. JHU works closely with the International Rescue Committee (IRC) and the United Nations' High

Commissioner for Refuges (UNCHR) to improve VCT services for refugees in Gambella and Benishangul-

Gumuz regions.

Technical Support for ART Scale-up

In FY06 and FY07, Johns Hopkins University - Bloomberg School of Public Health (JHU-BSPH) led

Advanced Clinical Monitoring, initiated and sustained Private Hospital Involvement and supported ART

implementation in Operational Zone 3.

In FY07 to date, JHU-supported sites have initiated 2,290 persons on ART, support 23,755 persons

currently on ART, and have served 34,083 persons ever on ART. Training has been conducted for 533

healthcare workers, and JHU continues to lead with advanced ART workshops and CME telemedicine case

reviews. In addition, 506 infants (45% positive) have been tested with DNA PCR as part of the early infant

diagnosis (EID) program.

In FY08, JHU will continue to support FY07 ART facilities, expanding from 44 to 50 sites (hospitals and

emerging regions health centers) in collaboration with the regional health bureaus (RHB), according to

national guidelines. In FY08, JHU will continue all previous support provided to the ART hospitals and

health centers. Support will be divided among several programmatic activities: direct site-level support,

mentoring, human resources, infrastructure, training, quality care, expansion of ART to the private sector,

pediatric care, laboratory diagnostics, site-level management, community-level support, and monitoring and

evaluation of outcomes. To increase capacity, JHU will invest in personnel to support ART technical

assistance (TA) at sites and will augment support by sponsoring regional meetings, collaborative activities,

and by participating in the RHB ART coordinating and implementation teams. JHU will address region-

specific challenges to scaling up, while preparing new hospitals for free ART provision and maintaining

quality mentorship at established ART sites.

In FY07, as the lead for the post-exposure prophylaxis (PEP) program amongst university partners and

health network, JHU focused on national-level activities in policy development, as well as on regional-level

facility-based training to implement an effective PEP guidelines, targeting healthcare providers and victims

of sexual assault at ten pilot facilities. Specific activities included: ensuring availability of national guidelines

and protocols; ensuring the availability of ARVs for PEP; implementation of awareness programs to

increase uptake of the program by exposed individuals; and training of trainers (TOT) for health workers

and Ministry of Health (MOH) and RHB staff to ensure dissemination of activities to other regions and

partners.

Phase I of this activity addressed the need to increase safety and protection of healthcare workers and the

need for a comprehensive plan of care for victims of sexual assault. Phase II focused on development of

guidelines, policy, and an implementation model for providing comprehensive care to both target

populations. Continuing its activities in FY08, JHU will focus support on a PEP expansion plan in the 50

supported facilities within the four regions, and continue to provide guidance to other university partners.

FY08 activities will also include expansion of activities to the entire health network model in the two

emerging regions of Gambella and Benshangul Gumuz. JHU will further expand the comprehensive HIV

activities in the private sector —in particular TB)/HIV, PMTCT, VCT, linkages to ART clinics in private

hospitals, increased coverage of pediatric ART and DNA testing for EID at all JHU-supported ART sites.

JHU will continue to work with the Ethiopian Orthodox Church and International Orthodox Church Charities,

and expand activities to other faith-based organizations. Using guidelines and training materials, JHU will

work closely with the MOH and RHB to address malaria and HIV co-infection and to provide linkages to

insecticide-treated nets for all HIV patients in malaria endemic areas. JHU will expand peer network

advocacy for people living with HIV/AIDS (PLWH) and tracking systems to improve adherence, follow-up for

care, and community-level support for ART.

JHU will continue to provide expertise at all levels of ART provision, ranging from multidisciplinary team

mentoring and supportive supervision to creation of a cadre of local university mentors. These mentors will

provide clinical stewardship and develop additional expertise in data processing and management at ART

sites. Recognizing the majority of patients are lost between CT and the ART clinic, JHU will continue to

invest resources to improve networking and inter and intra-service linkages with CT, TB, antenatal clinics

(ANC), sexually transmitted infections, PMTCT services, and community-based care, based on the "Referral

Network Model for Ethiopia" project completed by JHU in FY06. JHU will support hospital and RHB activities

in transferring patients from hospital ART clinics to locally networked health centers. JHU will offer TA with

transfer readiness, patient identification, development of standard operating procedures for mentoring, and

case review for difficult cases. JHU will support developing a cadre of nurse specialist mentors to provide on

-site follow-up and mentoring for ART nurses, as well as to train counselors, lay counselors, and peer

educators on adherence. JHU plans to train or identify persons affiliated with PLWH associations in an effort

to promote ownership, communication, policy drafting, and overall sustainability of ART programs.

In FY08, JHU will manage high demand at urban centers by: increasing site-capacity through renovation in

coordination with the Regional Procurement Support Office and Crown Agents; training and innovative

methods to improve human resource retention; and by strengthening referral linkages between hospitals,

health centers, and community-based organizations to improve service delivery. JHU will support linking

treatment, care, and support services with PLWH associations. JHU will continue to strengthen provider-

initiated counseling and testing (PICT), referrals for TB/HIV and malaria/HIV.

In FY08, emphasis will be placed on increased pediatric care capacity at all sites. Collaborating with ICAP,

JHU will continue support to all sites in pediatric care, by training pediatricians and other health workers and

integrating pediatric ART into current ART activities. JHU will also focus on improved entry points for

children by supporting family focused care and family testing, PICT, and improved infant follow-up after

PMTCT. It will create linkages with OVC programs and orphanages. JHU will support the regionalization of

DNA PCR testing for early HIV diagnosis and will aim to have 100% of eligible infants placed on

cotrimoxazole preventive therapy. JHU will continue to expand the intensification of PMTCT to ART linkages

and to increase the number of pregnant women on ART at five pilot PMTCT and ART sites initiated in FY07.

In FY08, JHU will place PMTCT case managers and nurse assistants at sites to improve overall screening

for ART and to improve linkages to other programs (ART, pediatrics, TB/HIV).

JHU will work closely with the MOH, the Global Fund for AIDS, Malaria, and Tuberculosis, the Supply

Chain Management System/RPM+, and RHB to ensure drugs purchased to treat opportunistic infections

Activity Narrative: (OI) are distributed rationally, and to develop OI drug access for all HIV-positive patients, especially CTX for

TB patients, pregnant women, and HIV-exposed children. The availability of consistent and quality

laboratory services at all these sites is critical to ensure quality comprehensive HIV/AIDS services (please

see COP Activity 10433 for specifics).

JHU will expand MOH's basic ART Training activities within the hospitals, training inpatient healthcare

personnel, new graduates so that ART services expand accordingly. JHU will continue to supplement basic

training through HIV telemedicine, case review sessions, TheraSim, and work with other partners to expand

services to distant regions through satellite connections and possible portable videoconference capabilities.

In association with JPHIEGO, Standards Based Management and Recognition (SBMR) for all HIV activities

were introduced in FY07 and will be continued in FY08. These measures will assist measurement and

improvement of quality site services; performance on agreed indicators will be measured at facilities and

district and comparative reports produced. JHU will also continue to assess quality of reporting, recording,

and clinical services using Lot Quality Assurance Sampling techniques. These methods provide immediate

feedback to sites on areas requiring improvement and services management change.

Monitoring and evaluation (M&E) training for ART and laboratory technicians will continue to be provided as

part of the basic training package. JHU will work with the MOH to develop and distribute Information-

Education-Communication materials, reporting and recording formats, and all support for accurate

monitoring. M&E specialists will work closely with sites and RHB to analyze ART data and provide feedback

to clinicians. This will coordinate with the rollout of the health management information system and with

other PEPFAR partners.

Finally, JHU will continue to support the MOH in expanding free ART technical support to private sector

facilities in Addis Ababa. JHU will intensify its regional capacity building with greater emphasis on local

university and capacity. JHU will continue to build the capacity of Addis Ababa and Debub Universities in

knowledge-transfer, TA, supportive supervision, and mentoring to their respective RHB and catchments

health networks.

Clinically Focused Record Systems

In FY07, Advanced Clinical Monitoring (ACM) achievements included: protocol submission and clearance;

initiation of cohort enrollment; ongoing support for the governing steering committee structure;

strengthening of clinic-based activities at seven participating university hospitals; development and

implementation of facility-based, project-management standard operating procedures (SOP) to initiate

cohort enrollment, collect data from the targeted sample of HIV+ patients put on ART at the seven

universities, and meet data-transfer and specimen-repository standards.

In FY08, continuation activities will include: ongoing support for cohort enrollment; maintenance of

implemented standardization measures for data collection and patient records management; monitoring of

data quality levels; data and specimen transfer to host institutions: ongoing facility staff training to use

national monitoring and evaluation (M&E) tools; monitoring electronic data management systems at site and

central levels; and Johns Hopkins University (JHU) will continue to support collaborative targeted

evaluations to meet project objectives, facilitate data and specimen requests from daughter protocols as per

steering committee approvals, and increase university hospital capacity to twin with local and international

institutions.

Intensive monitoring and evaluation of approximately 3,000 patients on ART will provide critical information

on large-scale ART distribution without piloting on a small scale. This activity will improve case

management of treatment services at the university hospitals and will enhance the universities' capacity to

provide technical assistance (TA) and training to clinicians, residents, and medical students. Data generated

by this multisite project will inform and improve ART delivery in Ethiopia by providing important information

on ART-associated toxicities and early mortality. The multisite patient database and specimen repository

will facilitate operational research and scientific inquiry pertinent to HIV/AIDS, through in-depth monitoring

of: treatment; acceptance and adherence; assessment of indicators of adherence; clinical and virologic

efficacy of treatment protocols; assessment of monitoring protocols (CD4); evaluation of drug toxicity, drug-

interactions and viral resistance; and investigation of potential barriers to expanding ART access in

Ethiopia.

The project will train staff required for collection of additional data to answer programmatic issues and

perform patient follow-up. JHU will also support building the capacity of health providers and regional health

authorities to record, store, and share information to support providing appropriate services to individual HIV

patients and their families, across the continuum of care. These information systems will be flexible,

adaptable, and compatible with various existing healthcare information systems and will support program

M&E. JHU's team of healthcare informatics experts will provide expert technical input in developing a data

model for HIV care and will work with the CDC informatics group and national committee to develop an

infrastructure for installation of electronic health records to support the longitudinal care needed to combat

HIV over the long-term. When an electronic patient record system for HIV care or for overall hospital care is

developed, the JHU team will guide its implementation for the hospitals in its four regions. This activity will

include provision of the CDC medical record folders if supported.

Added 10/21/08

This is approved country specific PHE activity. Reprogramming is taking place to reflect change of Prime

Partner and Agency. Prime Partner is changed from To Be Determined to the Ethiopian Public Health

Association (EPHA) and agecy is changed fro State Department/OGAC to HHS/CDC.There will be no

change in emphasis, coverage area or target population.

The narrative of this activity remains the same. The only change will be that it was initially proposed as a

potential multi country protocol, but now, it is approved and will be undertaken as a country specific Public

Health Evaluation (PHE).

-------------------

PARTNER: Johns Hopkins University Bloomberg School of Public Health

Title

Identifying Groups with Poor Access to ART - potential Multi Country Protocol

Time and Money Summary:

Expected timeframe: 1 year, Total projected budget: $ 100,000

Local Co-Investigators: In Ethiopia, this study would be carried out by Johns Hopkins University (JHU)

Technical Support For The Ethiopia HIV/AIDS ART Initiative (TSEHAI) as a supplement to the JHU/TSEHAI

Advanced Clinical Monitoring (ACM) of ART in Ethiopia project, which is governed by a Memorandum of

Understanding with 10 Ethiopian institutions.

Primary evaluation question:

What patient factors affect whether patients initially enroll in the national ART program at an early or late

clinical stage of disease?

Project Description:

This case-control study is designed to identify target groups with comparatively poor access to enrollment in

a country's national ART program. It takes advantage of the insight that hospitalizations for conditions

amenable to primary care can be used as indicators of poor access to primary care. The relationship of

access to demographic characteristics, risk behaviors, attitudes to HIV and pathways to care will be

assessed.

Programmatic importance:

Both WHO and the Institute of Medicine report evaluating PEPFAR have expressed great concern about

possible inequities in access to care for women, rural populations, the poor, and other vulnerable groups.

WHO said in April 2007 that in monitoring progress toward universal access to HIV/AIDS prevention,

treatment and care, "Higher priority must be given to promoting, monitoring and evaluating equity in access

to services. …special studies will be needed in order to help to understand uptake patterns, factors which

inhibit or facilitate access to services for men and women, and potential differences in clinical outcomes."

After these factors are identified, interventions targeting them can be developed.

Population of interest:

This study uses case-control methodology to compare the characteristics of three groups: (1) Cases:

Patients with "late" access to care, who are admitted to hospital wards with HIV disease without ever having

received outpatient HIV care. (2) Control group A: patients who enroll in ART "timely," become eligible due

to a CD4<200 without ever having developed WHO stage III or IV clinical disease, and (3) Control group B:

patients with "intermediate" access, who enroll in ART after developing WHO stage III or IV conditions but

without ever having been hospitalized for HIV disease. Cases will be sampled from hospital ward logs.

Controls will be identified from ART clinic registers. They will be matched by facility and month of case

admission matched to month of control ART enrollment. 900 participants per country will be selected: 180

cases, 360 from control group A and 360 from control group B.

Methods:

The exposures shown in the table below will be abstracted from hospital and clinic records. Not all

exposures may be available for analysis in all countries or sites; they are available in Ethiopian nationally

standard ART clinic forms, and staff at ACM sites ensures that these data elements are captured. A subset

may be available in hospital charts. Conditional and ordinal logistic regression techniques will be used to

assess the association between each exposure and different levels of access to ART. To assess the direct

effect of demographic factors on access, it is necessary to control for the fact that different demographic

groups (e.g. men and women) may have been infected with HIV at different periods of the HIV epidemic in a

given country. Therefore multivariate regressions will be conducted including and excluding proxy variables

for length of infection: CD4 count and time since first positive HIV test.

Exposures:

Demographic: Gender, age, urban/rural residence, income/poverty status, level of education, religion,

employment, marital status, household composition

Behavior: Sex risk behavior, drug use behavior

Attitudes: Disclosure of HIV status, perceived stigma, depression, attitudes toward ART

Pathways to care: referral source, HIV support group member

Sample size calculation:

The sample size was based on the number of cases required to detect a 15% point difference between

cases and controls with rural residence (Power= 0.9, alpha=0.05, 1 case: 2 controls). Based on these

calculations, the total number of cases required was rounded up to 180. They would be matched at a ratio

of 1 case: 2 timely access controls: 2 intermediate access controls; therefore the number in each control

Activity Narrative: group was set at 360 and the total number of participants in Ethiopia at 900. The cases would be divided

evenly among participating facilities that serve both rural and urban patients. If the ACM sites are used for

this study in Ethiopia, there are 5 such sites; 36 cases, 72 timely access controls and 72 intermediate

access controls would be enrolled per site.

Dissemination plan:

The study will be cleared by CDC and the ACM steering committee for publication in professional journals.

Budget justification:

Ethiopian personnel - $ 24,400

Statistical support - $ 12,000

International travel - $ 7,000

Domestic travel - $ 2,250

Computers - $4,000

Supplies/Communications - $5,000

Total - $54,650

Total including indirect costs - $67,470

PARTNER: Johns Hopkins University Bloomberg School of Public Health

Title of Study:

Effectiveness of food by prescription programs for severely malnourished HIV+ patients

Time and Money Summary:

Expected timeframe: 1 year, Budget Year 1: $90,000

Local Co-Investigator:

Dr. Solomon Gashu, Medical Director, St. Peter's Specialized Tuberculosis Hospital

Project Description:

Nutritional support is considered an essential part of a comprehensive HIV/AIDS package. Data indicate

that nutrient intake can improve ART absorption and is associated with medication adherence among ART

patients. Studies have shown that moderate to severe malnutrition (Body Mass Index, or BMI<17) at the

time of starting ART and severe anemia are independent predictors of mortality and likewise screening and

managing malnutrition among PLWH starting ART has survival benefits. USG partner Johns Hopkins

University (JHU) Technical Support For The Ethiopia HIV/AIDS ART Initiative has developed a plan to

introduce a food by prescription program (FBP) at the ART clinic at St. Peters' Specialized Tuberculosis

(TB) Hospital in Addis Ababa. Food by Prescription provides therapeutic and supplemental food to patients

on ART, pregnant or lactating HIV+ women, and HIV exposed children. A baseline nutritional assessment

of ART clients and then follow-up assessment after 6 months of nutritional support will be undertaken.

Change in body mass index, CD4 count, functional status, opportunistic infections and mortality, will be

compared to a historical cohort of patients that did not receive nutritional interventions.

Evaluation Question:

This proposal will address the following questions:

1) What are the baseline nutritional indices for patients about to start ART?

2) How do these indices vary by TB/HIV co-infection?

3) Does an intensive six month FBP intervention for severely malnourished patients improve patient

outcomes as measured by decreased mortality and morbidity?

4) What is the cost-effectiveness and sustainability of the FBP program?

Programmatic Importance:

Achieving food security and appropriate nutritional support is difficult in environments such as Ethiopia that

have been long plagued by food insecurity. This problem is especially evident among patients who are co-

infected with HIV and tuberculosis. For example, registry data of ART patients at St. Peters Specialized TB

hospital indicate that 19% of patients weigh less than 40 kilograms (kg) at the start of ART and 3% of adults

weigh less than 30 kg. In an analysis of survival, underweight patients had an increased risk of dying in the

first year of follow-up after initiating ART.

The currently measured early mortality rate among the Ethiopia national program is close to 10%; however

rates are as high as 14% among TB/HIV infected patients. Follow-up data indicate that this mortality occurs

usually within the first three months; however, a second peak occurs between 8-12 months and is likely due

to immune reconstitution. We believe much of this early mortality may be associated with severe

malnutrition, anemia and co-infections with subclinical opportunistic infections. Once patients start ART,

many report poor adherence due to the lack of consistent food and subsequent gastro-intestinal distress

with the medications. Providing patients with food supplementation and therapeutic feeding during this

early phase of ART initiation is likely to reduce this early mortality rate and will hopefully lead to improved

medication adherence. This is important for the overall program to reduce the development of resistance

from poor adherence and to encourage more patients to accept ART even when severely debilitated. It will,

as well, lead to patients who more quickly return to a functional status and have improved quality of life.

Methods:

1) Baseline nutritional assessment among pre-ART patients ready to start ART at St. Peters: A standard

nutritional questionnaire and nutritional screening tool (including BMI, mid-upper arm circumference and

diet review) will be developed and administered to all patients found eligible for ART, pregnant and lactating

HIV+ women and HIV+ and exposed children. Patients will be coded according to level of malnutrition with

severe malnutrition defined as BMI < 17. For children, standard z-scores will be used to assess

malnutrition. Any person with severe malnutrition will be offered the FBP intervention at the time of initiating

ART. A sample size of 200 is expected over the 12 month period of intervention; however all consecutive

patients who qualify will be enrolled into the study.

2) Food By Prescription Intervention: JHU will partner with the Ethiopian national FBP program with other

PEPFAR partners, UNICEF and other partners. This program will provide intensive therapeutic and

supplemental nutritional support, including ready to use therapeutic foods (RUTF) such as fortified flours

(e.g. First foods, Advantage or Foundation plus), prepared feeding (e.g. F75, F100), and biscuits and

PlumpyNut for children. Additionally, safe water will be secured for all patients in the program to avoid

diarrheal diseases. Counseling and education regarding local foods and nutrition will be conducted.

3) Evaluation of outcomes: After the patients have received 6 months of the food intervention and ART, and

evaluation of outcomes will be made. Comparison of change in weight, BMI, z-scores, CD4, and number of

opportunistic infections, loss to follow-up and death will be made between the patients receiving the FBP

support and a historical cohort at St. Peters with similar low weight who did not receive nutritional

intervention. Likewise, comparisons can be made with other ART programs that have not yet initiated the

FBP program. Factors associated with the outcomes of interest will be compared between the intervention

and comparison groups and independent risks measured using the chi-square and t-test analyses.

Multivariate analyses will be performed to identify independent risk factors while controlling for confounders,

such as TB/HIV co-infection or immune reconstitution inflammatory syndrome (IRIS).

4) Cost effectiveness: Costs for the FBP program will be compared to costs related to early mortality and

morbidity avoided with the intervention program.

Activity Narrative: Population of Interest:

The populations of interest are HIV+ clients, pregnant and lactating HIV+ women, HIV+ and exposed

children attending ART clinic who are severely malnourished and/or eligible for food by prescription

Information Dissemination Plan:

Stakeholders include the Ministry of Health (MOH), Addis Ababa Regional Health Bureau, local non-

governmental organizations and faith-based organizations working in these communities, health care

providers, PEPFAR and other entities involved in the support of health care delivery. In the planning phase

of the evaluation, stakeholders meetings will be organized to describe the goals of the evaluation.

Stakeholders will be involved in review of the assessment form and the indicators to measure malnutrition.

MOH personnel will be involved in the gathering of data and review of findings. Results will be

disseminated in a review meeting for the region and findings will be shared with PEPFAR and other

partners.

Budget Justification for Year One Budget:

Baseline & follow-up survey

Coordinator (responsible for developing assessment, training assistants, standardization)$10,000

Dietary and nutritional assessment survey assistants - $15,000

Materials - $1,500

Transportation (to and from evaluation site) - $1,500

Data collection, management and analysis - $15,000

Intervention

Materials (includes educational and training materials) - $10,000

FBP program covered by other PEPFAR partners

On-site Training (on FBP) - $5,000

Office supplies and forms - $2,500

Transportation (Coordinator to travel to site weekly) - $6,750

Miscellaneous costs, telecommunications - $1,000

Review and stakeholders meetings- $10,000

Subtotal - $75,290

Indirect Costs - 18.8%

Total - $90,000

Site-Level Laboratory Support

In FY07, Johns Hopkins University 's Technical Support for the Ethiopia HIV/AIDS ART Initiative (JHU-

TSEHAI) supported comprehensive high-quality HIV/AIDS services at 44 public and private hospital

networks in Addis Ababa, SNNPR, Gambella, and Benishangul-Gumuz regions which built on previous

activities of FY06. JHU provided on-site and comprehensive HIV laboratory training, developed and

implemented standard operating procedures (SOP) for all HIV laboratory services, and internal quality

assurance (QA) training and recording formats. In FY08, JHU will expand the service to 50 sites (hospitals

and emerging region health centers).

In FY07, JHU expanded these activities by regionalizing national laboratory support to 39 laboratory-sample

transport networks, working closely with national, regional, and site levels to ensure the highest quality of

laboratory diagnostic services. For this, JHU worked with the Ethiopian Health and Nutrition Research

Institute (EHNRI) and regional labs to: deploy sample transport couriers; arrange SOP, registers, and

reports to document sample transport; and provide training for sample handlers. JHU supported

development and dissemination of SOP for all nationally purchased machines (CD4, hematology and

chemistry). In collaboration with EHNRI, CDC, and other laboratory partners, JHU also trained personnel at

national and regional levels. JHU regional lab-support staff also provided regular refresher and on-site

trainings for HIV serology-rapid testing, CD4, chemistry/ hematology, tuberculosis (TB) smear microscopy;

and opportunistic infection (OI) diagnosis. In collaboration with ICAP, JHU supported early infant diagnosis

(EID) services at Addis Ababa and Southern Nation, Nationalities and Peoples Region using dried-blood-

sample (DBS) referral to sites with DNA PCR testing facilities.

In FY08, JHU will continue to implement the strong laboratory support plan initiated in FY07 in collaboration

with EHNRI, CDC, the American Society of Clinical Pathologists, the Clinical and Laboratory Standards

Institute, the Association of Public Health Laboratories, and other laboratory partners. The plan will ensure

regional implementation of national laboratory training and develop on-site training and mentoring for lab

technicians. All training will require practical components and on-going follow-up to ensure adequate

technology transfer and capacity development. Trainings will cover: site and regional trainings on HIV

diagnosis (HIV serology testing, rapid testing); HIV disease monitoring (hematology, clinical chemistry, and

CD4); facility-level lab management; laboratory training on integrated diseases including diagnosis of

common OI. JHU, in collaboration with regional labs, will evaluate the quality of services delivered by lab

personnel after training in different disciplines.

JHU will continue to provide technical assistance and implementation support to referral laboratory services.

This will strengthen the functioning of the reference labs as they supervise QA activities at lower-tier labs

and provide access to more sophisticated diagnostic assays. JHU will also support EHNRI/regional labs to

establish systems for: specimen collection at health centers and/or peripheral hospitals; transportation to

appropriate hospital and regional laboratories; tracking patient samples; reporting of results; and

implementing and ensuring that standard guidelines and procedures are followed.

EHNRI will expand the pilot external quality control (QC) systems, and JHU will work directly with the

regional and hospital labs and with health center personnel to implement and monitor these programs.

QA/QC guidelines will be distributed to additional sites. JHU will continue to support the national QA

programs for blood safety, voluntary counseling and testing, PMTCT, TB prevention, and HIV and OI

surveillance by disseminating guidelines to the regional level and assuring uninterrupted links between

health center, hospital, regional, and national laboratories.

JHU will continue to improve OI diagnostics by introducing simple laboratory diagnostic techniques for OI

such as cryptococcosis, isospora, microsporidia, and cryptosporidiosis. JHU will support the regional

capacity building in different laboratory issues. JHU will provide supportive site supervision and mentoring to

all ART laboratories to improve quality of laboratory management, laboratory safety, lab set-up, specimen

management, test procedures, documentation, reporting, inventory, and stock management of laboratory

supplies at each facility in collaboration with the Supply Chain Management System (SCMS). JHU will

closely work with regional laboratory associates of SCMS and will support the national laboratory reporting

systems and conduct regular mentoring on standard record-keeping and timely and accurate reporting

(including QC forms, lab request forms, and registers) to facilitate monitoring of quality. JHU will work with

partners to ensure uninterrupted quality laboratory services at all 50 hospital networks through: continuous

and sufficient reagent supply; timely provision of preventive and troubleshooting maintenance; regional

capacity building to institutionalize laboratory equipment maintenance capability; develop laboratory

inventory systems at the hospital networks; and ensure availability of adequately trained laboratory

personnel.

In FY08, JHU will continue to provide the comprehensive laboratory support previously outlined, and, as a

new activity, will renovate two regional labs to establish DNA PCR testing for scale-up of EID. JHU will work

to strengthen TB laboratories with concentrated acid-fast bacilli methods, and fluorescent microscopy

methods, treatment monitoring for adults and children. JHUS will continue supporting the establishment of

external quality control and quality assurance at regional and hospital levels

JHU will support the training rollout of HIV rapid testing and the QA program. JHU will work to improve

infection-prevention practice in labs and access to post-exposure prevention. JHU will support the

expansion of the laboratory information systems (LIS) by EHNRI at the pilot ART laboratory sites,

strengthen laboratory layout (process design flow), and laboratory technician training on laboratory

management in collaboration with regional laboratories. In collaboration with EHNRI, regional labs, and ART

laboratories, JHU will also expand on-site lab training on new HIV-testing algorithms and strengthen the

monitoring and site evaluation for implementation of the new algorithms.

The significant increase of budget was necessary to support upgrading two regional laboratories and

hospital laboratories in the three regions and health center laboratories in emerging regions and to support

integration of OI diagnosis.

Clinical Simulation Technology (TheraSim) to support training on ART

In FY07, this was a new activity which links to various HIV treatment services activities supported by

PEPFAR. The capacity for rapid ART scale-up is severely limited by the rapid turnover of trained and

experienced HIV clinicians. To reduce this attrition and improve the knowledge-base of urban and rural

clinicians, JHU will introduce a continuing medical education and clinical-decision support tool via TheraSim

HIV clinical care simulator. To date, in FY07, TheraSim has been deployed to 38 sites, trained nearly 200

persons, and has been used to evaluate training outcomes for a basic ART training conducted by Johns

Hopkins University - Bloomberg School of Public Health (JHU-BSPH).

In FY08, JHU-BSPH will continue to work with TheraSim to provide support to 50 ART clinical sites (hospital

and health centers) to ensure all new physician and nursing staff are oriented to the case-learning program

and receive support to complete the training. The program will also be extended to all medical residents

enrolled in Addis Ababa University and Hawassa's training programs. TheraSim, under the guidance of JHU

-BSPH, will develop three new modules to expand the case learning approach to nurses, and to incorporate

new cases dealing with pediatric HIV care, tuberculosis (TB)/HIV, and advanced cases that deal with

treatment failure and other complications, for clinicians who have completed the basic training program.

Along with increasing the number of sites, the depth of the clinical complexity of cases and extent of the

personnel involved in the training program, JHU-BSPH will design an evaluation system to assess basic

ART training through the JHU-BSPH HIV telemedicine program. The modules will be used pre- and post-

training to assess training activities. A validation study will be developed to compare patient outcomes from

the simulator versus actual patient-outcome data in the clinics. In addition, TheraSim will provide

opportunities for clinicians to submit Ethiopian-based cases to be incorporated into the training program.

Clinicians will be compensated for their efforts, and TheraSim will act as an incentive and possible retention

program.

TheraSim was introduced because the success of the PEPFAR Ethiopia ART program depends on the

skills and stability of the ART team - doctor, nurse, pharmacist, and lab personnel. The stability of

healthcare workers in the Ethiopia HIV program has been challenged since trained clinicians often find

better-paying positions outside the public sector after graduating from medical school, and general

practitioners, who are expected to spend 2-4 years in public hospitals in isolated regions, often leave the

posts prior to completing their contracts. These clinicians report feeling cut off from learning, and they desire

increased clinical decision-making support, as consultations with more experienced clinicians are

impossible due to lack of communication technology. To improve the clinical skills of rural clinicians,

increase their capacity for appropriate decision-making, and address their desire for professional growth,

JHU-BSPH will continue its distance-learning program using TheraSim, a program for clinical-decision

support. For urban physicians, JHU-BSPH will continue to provide training centers and ART clinics with

access to the training programs via CDs or the Web. PEPFAR Ethiopia believes that improving information

transfer about HIV will reduce turnover of geographically isolated clinicians, as well as those from

overwhelmed urban clinics—thus improving HIV/AIDS care.

TheraSim, Inc. is a US-based company providing software and services internationally to measure and

improve the quality of clinical practice for HIV/AIDS and a variety of chronic and infectious diseases,

including malaria, tuberculosis (TB), hepatitis and diabetes. Capacity-building in Ethiopia faces several

challenges, including: a need for rapid scale-up of clinical capacity and expertise in treating patients with

HIV/AIDS; high cost and slow response of classroom-based learning; an ongoing need for clinically-based

mentoring following didactic training; and a general absence of empirical data after drug distribution.

TheraSim monitors and addresses gaps in clinical competence following existing classroom training and

helps improve patient outcomes in the ever-changing therapeutic environment. The TheraSim Clinical

Quality Assurance System has four key components: simulation-based assessment and intervention,

electronic medical records, decision support, and dashboard reports. The system is both Internet- and CD-

ROM-based, providing simulation of hypothetical patients in various stages of HIV/AIDS. The simulated

cases can be adapted for use by nurses, basic-level physicians (those who see few HIV/AIDS patients), and

expert-level clinicians. TheraSim uses guidelines approved by the World Health Organization (WHO) or

country-specific guidelines where they exist, and regionally-appropriate pharmacology and treatment

modalities with authentic "virtual" case studies for diagnosis and treatment of HIV/AIDS and co-morbidities.

It complements other methods, such as formal training, bedside teaching, and case discussions. Simulated

cases are used, for which diagnosis and treatment decisions must be made; the system then gives

feedback on these choices, referring to country and relevant international guidelines.

TheraSim can be adapted for training nurses and allied health professionals as needed. In the next phase

of support, TheraSim will advance existing capacity-building efforts efficiently by improving and measuring

the quality and outcome of clinical practice, including ART delivery for HIV/AIDS and the treatment of TB, in

compliance with published national treatment guidelines. TheraSim will seamlessly augment efforts begun

with CDC and other programs. For example, Washington University/I-TECH has developed training

curricula for ART, management of opportunistic infections (OI), and PMTCT with the support of international

partners and has organized numerous trainings. These training programs primarily reached health

professionals in the public sector. Various institutions have organized 2-5 day basic-training workshops on

HIV/AIDS management, one-day advanced courses for clinicians, and evening seminars on specific topics,

usually attended by clinicians from public and private sectors. However, no reliable and accessible system

exists to: assess individual health workers' skills; assess the overall effect of existing training activities;

provide ongoing mentoring and support; provide clinical support to reduce medical error; or to report clinical

skills and patient outcomes. TheraSim and JHU-BSPH will deploy TheraSim's field-tested Clinical

Performance Management computer-based decision support ("TheraSim CPM") system for rapid and

effective ongoing mentoring of healthcare workers throughout Ethiopia to support PEPFAR Ethiopia goals.

The system will continue to use regionally appropriate pharmacology and treatment modalities with

authentic case studies for diagnosis and treatment of HIV/AIDS and TB.

Site Level Data Support for Hospitals

This is a continuing activity from FY07. The major purpose of this activity is to strengthen the

implementation of the national Health Management Information System (HMIS) for comprehensive

HIV/AIDS services and to optimize the use of data for service and program strengthening in Addis Ababa,

Benishangul-Gumuz, and Gambella regions, and the Southern Nations, Nationalities, and Peoples Region

(SNNPR).

In FY07, the International Johns Hopkins University-Bloomberg School of Public Health (JHU-BSPH)

supported 50 sites in Operational Zone 2 to collect, manage, analyze and use HIV/AIDS services-related

data generated at site level for decision-making to improve clinical and program management. In addition,

JHU-BSPH has trained more than 90 health professionals and data clerks in monitoring and evaluation

(M&E) and assisted regional health bureaus (RHB) to organize experience-sharing workshops.

In FY08, JHU-BSPH will expand its site-level capacity building in M&E to further improve quality data

collection and maximize data use for continuous service quality improvements. JHU will:

1) Intensify support for efforts to fully document information for pre-ART and ART patients on the national

HIV care/ART follow-up by:

a) Continuing routine, data-quality assurance exercises to measure completeness and accuracy of

information on follow-up forms

b) Providing support to clinical teams for accurate completion of follow-up forms

c) Supporting efforts to fully document information for PMTCT, tuberculosis (TB)/HIV, voluntary counseling

and testing (VCT), and provider-initiated counseling and testing (PICT) clients on the appropriate national

HMIS forms

d) Supporting the integration of HIV/AIDS care and treatment data with national comprehensive HMIS

through technical support at site level in archiving, retrieving, and report aggregation, supported by routine

data-quality assurance assessments

e) Train healthcare providers, data clerks, and HMIS personnel on database use, including how to enter

records, query the databases, and produce routine reports

2) Provide support for M&E support tools developed for the national M&E systems and equipment. JHU-

BSPH will work to ensure availability of computers, computer peripherals, and storage equipment and an

uninterrupted supply of the national M&E tools at all the sites

3) Strengthen supportive supervision and mentorship. On-site supervision and mentorship will be provided

to enhance collection of accurate and complete data. JHU- BSPH will also work with site-level staff to build

capacity in data analysis, and in the use of data to manage and improve program delivery.

4) Support institutions to manage and use data fully and effectively. Sites will continue to be assisted in

tabulating and visualizing their data using tables, charts, line and bar graphs and other standard methods;

optional tabulations will include aggregation of data by patient, clinic, and regional levels. Continued FY08

activities will expand the number of facility-based health providers with basic computer skills and data

management skills, including data entry, data analysis, technical paper writing, and presentations.

5) Support the national laboratory information systems to ensure communication of patient results in an

efficient manner. There will be particular emphasis on communicating results to patients whose specimens

were transported to the hospital from another facility, such as a health center. Furthermore, JHU- BSPH will

assist sites in tracking specimens of patients who need more specialized tests, such as viral load, which are

currently performed only at regional labs.

6) Support biannual, regional review meetings to provide fora where facilities can present their data and

share lessons learned. This activity will also continue to support and strengthen the national HMIS

implementation, document best practices, and present findings and experiences at local and international

scientific and programmatic forums. Implementation mechanisms will consist of necessary modeling at site

and RHB levels.

Title of Study: Public Health Evaluation of Training of Health Providers in Health PEPFAR funded health

centers in Ethiopia

Time and Money Summary:

The evaluation will be conducted from April 2008 to March 2009, pending clearance of the revised protocol,

and is expected to cost $150,000 for Year 2.

Local Co-Investigator: Marion McNabb, Mesrak Nadew, Yassir Abduljewad, Anne Pfitzer, Dr Anteneh

Worku, Petros Faltamo

Project Description

The availability of trained and competent service providers in delivering quality HIV/AIDS services is of

utmost importance in the Ethiopian context. Ethiopia's single point HIV prevalence is 2.1%, which translates

into a target of 350,000 eligible for ART in order to obtain the universal access for ART by 2010. The

Ministry of Health's 2005-06 publication "Health and Health Related Indicators" reported that there is one

physician for every 35,493 people and one nurse for every 4,207 people in Ethiopia. The numbers are

significantly below the WHO international standards for physicians with the standards set at one physician

for 10,000 people and near to the nurse ratio of one nurse for every 5,000 people making access to regular

healthcare services by skilled

There have been multiple reports of high attrition of health care providers in Ethiopia. The resources and

efforts put into PEPFAR training have been enormous. It is important to provide measurable information and

assess training effectiveness periodically. In the context of the Ethiopian scale up of ART services, health

centers were recently added as service provision sites. COP08 will be an opportune time to review the

effectiveness of training programs at this health facility-level to refine strategies for the future.

Status of study/progress to date

In FY07, JHPIEGO was funded to conduct an evaluation that will provide feedback to PEPFAR Ethiopia

regarding the effectiveness and cost of investments to train health care workers at facilities. The evaluation

included descriptive review of training processes and methodologies utilized by PEPFAR implementing

partners employing a quasi-experimental data collection methods to assess the performance of trained and

untrained providers(either on the job or in a simulation) on specific knowledge and skills included in the in-

service training they received. Additionally, the evaluation measured the attrition rates and reasons for

attrition.

The main evaluation questions were:

1) What proportion of health care workers who have attended training funded under PEPFAR are still in the

post they were in at the time of training?

2)Where are the providers that left the facilities?

3)How effectively are health care workers performing on specific skills for which they were trained?

4)What was the average training cost per trainee, by category of knowledge and skills of the training event?

What is the anticipated cost for re-training providers?

5)How are the PEPFAR trainers being used within the program and how many training events have they

conducted?

6)What is the perceived risk of HIV infection in providers trained versus providers not trained in providing

HIV services?

JHPIEGO reviewed PEPFAR Ethiopia's Training Information Management Information System (TIMS) for

data on providers trained in HIV/AIDS services to identify the population of health care workers trained by

PEPFAR in all areas of prevention, care and treatment at hospitals. Accordingly, data were collected from

selected but representative cohort hospitals in Ethiopia. Due to funding limitations in COP 07 the sample

only included hospitals.

The skills of trained providers were evaluated by comparing skills that providers are expected to have post-

training versus skills that are displayed at the time of assessment using standardized case study

assessment tools which were developed using competencies agreed upon in Ethiopia and all PEPFAR

Ethiopia Training Partners reviewed and approved the tools.

Surveys were distributed to PEPFAR Ethiopia's university partners to determine the costs of training. The

protocol was finalized and submitted for the CDC Institutional Review Board approval.

Planned FY08 Activities:

In COP08, JHPIEGO proposes another Training Evaluation with a similar study design and the same

objectives, but with a protocol targeting staff at health centers. The evaluation will assess similar elements

as the hospital version collected: including trainers, cost, and competency of providers and attrition rates of

providers at the health center level. The selection of health centers will be confined to those networked to

hospitals. JHPIEGO will work closely and collaborate with implementing partners that have trained staff at

health center level in refining the protocol and evaluation tools, including US agencies and

international/local partners. The evaluation of training effectiveness will provide useful information across all

PEPFAR funded training programs; working closely with PEPFAR partners on the evaluation will bring

greater impact. The availability of trained and competent service providers in delivering quality HIV/AIDS

services is of utmost importance in the Ethiopian context. Ethiopia's single point HIV prevalence is 2.1%

which translates into a target of 350,000 eligible for ART in order to obtain the universal access for ART by

2010. In 2005/06 the Ministry of Health document "Health and Health Related Indicators" that there is one

physician for every 35,493 people and one nurse for every 4,207 people in Ethiopia. The numbers are

significantly below the WHO international standards for physicians with the standards set at one physician

for 10,000 people and near to the nurse ratio of one nurse for every 5,000 people making access to regular

healthcare services by skilled providers limited for a significant proportion of Ethiopians.

Information Dissemination Plan:

The findings can be used by HAPCO and the Human Resource Department of Ministry of Health, Regional

Health Bureaus, and PEPFAR partners that invest in in-service training for capacity building. The study will

also inform retention strategies with a specific focus on the needs of health centers

Activity Narrative: Budget Justification for FY08 monies:

Given experience to date and the breadth of the proposed FY08 scope of work, the study is budgeted at

$150,000 in COP08. The funding will be used for protocol development, recruitment of data collectors,

training of data collectors, data collection and supervision, data cleaning, entry and analysis, dissemination,

salaries of staff, other direct costs and Johns Hopkins University financial and administration costs.

This is a continuing activity in COP 08 originally planned with JHPIEGO-E as Prime Partner. It was

erroneously entered in the databasewith JHU -Bloomberg as prime partner. The activity is to conduct a

targeted evaluation on the effectiveness of Training for staff at Health Centers under PEPFAR -E. The

findings of the evaluation will provide useful information across all PEPFAR funded training programs ,

partners and stakeholders to identify the retention and attrition status of trained health care providers.

JHPIEGO-E is a prime partner which has a strong potential in conducting targeted evaluation. CDC-E will

provide guidance and follow up of the targeted evaluation.