The World Food Program (WFP) Urban HIV/AIDS Nutrition and Food Security Project (UHNFSP) overall goal is to improve household food security and nutritional status of PLHIV, OVC and households affected by HIV/ AIDS. This program will improve services in 23 urban and peri-urban areas with high HIV prevalence and poverty in SNNPR, Oromia, Tigray, Amhara, Dire Dawa and Addis Ababa regions. The program will be rolled-out to the emerging regions of Somali, Afar, Benishangul Gumuz and Gambella in COP 2012. The NACS approach will be used to assess and link clients to food security programs and support according to standardized criteria. Existing CMAM concepts and materials will be integrated into NACS programs to improve linkages between the community and health facility. Specific objectives are to: 1) improve the nutritional status and health of malnourished PLHIV, PMTCT clients and OVC; 2) improve household food security of these clients and their households; 3) strengthen the evidence-base for nutrition and food security programming; and 4) strengthen the capacity of the health system to provide nutrition care. Targeted populations include: 1) malnourished PLHIV on pre-ART/ART, 2) malnourished PMTCT clients and their children, 3) all malnourished and food insecure OVC regardless of HIV status. Targeted populations will "graduate" from food and nutrition support once they reach food security criteria. Activities are aligned with the GHI strategy to prevent and treat malnutrition with an integrated response and the PF goal to support nutrition for PLHIV and OVC. The programs geographical coverage will complement other nutrition programs in country. Though no COP12 funds are being requested for this project, the project will continue as described using pipeline funds.

UHNFSP will provide food and nutrition services to address the needs of malnourished PLHIV enrolled in ART, Pre-ART and PMTCT clinics and health facilities and OVC in Afar Benshangul, Gambella and Somali regions. PLHIV and OVCs nutritional status will first be assessed by Mid-Upper-Arm-Circumference (MUAC) or Body Mass Index (BMI) measurements, then counseled regarding appropriate nutrition and, if eligible according to MUAC and/or BMI criteria, they receive treatment in accordance with the National Guidelines for HIV and Nutrition. Those receiving treatment will have their nutritional status assessed monthly. Clients will be graduated if they attain targeted improvements in MUAC or BMI for two consecutive measurements. Malnourished individuals will also be referred for a household (HH) food security assessment and food insecure HHs (based on set criteria) will be linked to food assistance.

UHNFSP will utilize existing Community Resource Persons (CRPs), volunteers who are appointed by the GOE to work with HEWs to provide primary health care at the community level, to provide linkages between the community and health facilities. CRPs will provide HH level follow-up for the program, including counseling and assistance with nutrition and ART adherence. This will improve client retention, adherence to treatment and early detection, diagnosis and initiation of treatment.

UHNFSP will also conduct the following activities to ensure quality NACS is provided: 1) training on NACS for community-based CRPs; 2) equipping facilities with equipment and NACS materials; 3) developing NACS job aids for health workers; 4) improving nutrition M&E at health institutions; and 5) on-site supportive supervision and mentorship for NACS staff and volunteers.

This program will create and improve community and facility linkages for nutrition services, including referrals from other programs, in collaboration with the FMoH. Nutrition indicators will be integrated into existing clinical and community M&E systems and tools. Quarterly urban and peri-urban review meetings and bi-annual/annual regional and nutrition TWG meetings will be held to monitor the progress and challenges of the program.

HKID funding allocations will address vulnerable children and households affected by HIV/AIDS, with a focus on food insecure households. Program provision of nutritious food vouchers to guardians of OVC for maintenance of normal nutritional status in OVC will continue in the previously targeted 23 woredas in SNNPR, Oromia, Tigray, Amhara, and Dire Dawa regions and will be expanded to selected project areas of Somali, Afar, Benishangul, Gumuz and Gambella regions. OVC will be selected through the established community process and receive support through local sub-grantees at the community level, such as Early Childhood Care & Development (ECCD) organizations, NGOs, CBOs and PLHIV associations.

Existing Community Resource Persons (CRPs), recruited and managed by the GOE, will be trained in community NACS, with a focus on community management of acute malnutrition (CMAM) and how to do a household food security assessment. Simplified community job aids and reference materials will be developed to assist the CRPs to provide counseling and support in the community. CRPs will conduct monthly home visits to assess OVC for nutritional status, conduct growth monitoring, and counsel guardians regarding nutritional and psychosocial needs of OVC. CRPS will refer OVC to health facilities for treatment if there is evidence of OVC growth faltering, stunting or malnourishment.

In areas where USG nutrition programs do not provide specialized foods, OVC clients will be linked to UNICEF sponsored food programs for children under five. In addition, the program will collaborate with the GOE to improve the ability of other HIV/AIDS programs to link to and from UHNFSP services. This includes strengthening the linkages of UHNFSP with other community and facility-based partners for appropriate care and support services referrals. Sub-grantees (TBD) will be monitored through quarterly urban and peri-urban meetings. Sub-grantees will participate in bi-annual regional meetings with HAPCO/FMOH and implementing partners to facilitate collaboration and integration.

Strategic Information activities in this program will strengthen the data collection and M&E system for nutrition. The revised Urban HIV/AIDS Information system (UHAIS) will capture all nutrition and food security outputs, outcomes and impacts. After rollout and implementation of this system, results will be documented and disseminated to inform planning and decision-making with an evidence-base. The program will focus on the following SI activities:

1) Documentation of nutrition best practices through systematic recording of lessons learned.

2) Conduct operations research with local and international universities (Ben-Gurion University in Israel) examining nutrition outcomes to provide evidence for refining and designing programs Potential research areas include: a) appropriateness of BMI as an indicator of nutritional status for PLHIV enrollment in specialized food support; b) nutritional outcomes when food support focuses on local nutritious diets for PLHIV; c) comparison of economic strengthening activities designed to increase household food diversity for PLHIV to identify changes in nutritional and HH food security status; and d) the impact of Neglected Tropical diseases (NTD) on the nutritional status of PLHIV.

3) Documentation of nutrition outcomes with an improved data information system, including UHAIS database training for community and facility-based service providers and MoH and HAPCO focal persons.

4) Establishing and setting up UHAIS database centers in all regions of the country and equipping them with the necessary IT equipment.

5) Conducting regular partner reviews to assist all implementers with jointly assessing performance and readjusting their programs to align with existing gaps, thus increasing the efficiency of program implementation. These reviews will include documentation of lessons learned.

Health system strengthening will be a major part of the WFP Urban HIV/AIDS Nutrition and Food Security Project (UHNFSP). The program will strengthen the capacity of communities and health facilities to provide Nutrition Assessment, Counseling and Support (NACS) and improve household food security. The previously developed M&E tool kit will be revised in collaboration with the Nutrition TWG to ensure all needed nutrition indicators are included. These revisions will be captured in the newly designed Urban HIV/AIDS Information system (UHAIS) database and then rolled-out to all project sites. UHAIS is aligned with the HMIS and CIS and will capture all nutrition and food security outputs, outcomes and impacts. It is planned that the database will become a national FMOH system to inform planning and decision-making with evidence. During UHAIS roll-out, nutrition and food security service providers from all implementing partners, along with key GOE focal points, will be trained how to use both the database and the data for improved decision-making in nutrition programs (including HIV nutrition).

Health care providers (HCP) in targeted NACS health facilities will be trained on NACS, including: 1) taking anthropometric measurements, 2) nutrition counseling techniques and information, 3) prescription of specialized foods, and 4) nutrition M&E.

Use of the new database by CRPs and implementing partners will allow identification and tracking of clients, including those lost to follow-up. Malnourished PLHIV or OVC clients at the health facility who are prescribed specialized foods will be referred to a CRP for follow-up and tracking of food adherence. At the community level, PLHIV and OVC will be screened by CRPs and HEWs and referred to a health facility for NACS and treatment of severe malnutrition. CRPs will be trained on Community NACS and CMAM including adherence counseling, screening for malnutrition, IYCN, growth monitoring, healthy diets, ANC and IYCN for PL-PLHIV, the Basic Preventive Care Package (BPCP) for child survival, nutrition for PMTCT and pregnancy, and referral. Efforts will be made to coordinate with other USG-supported nutrition partners.

MTCT funding for UHNFSP will target malnourished pregnant and lactating women living with HIV (PL-PLHIV) and their babies with dietary support to meet nutritional requirements and contribute to better pregnancy outcomes. PL-PLHIV will receive NACS including: 1) counseling on improved infant and young child feeding practices (IYCN) using the National IYCN materials and guidance; 2) guidance on how to access the Basic Preventive Care Package (BPCP) for babies; and 3) referrals for FP and other care and support services.

Community resource persons (CRPs) will be trained on community NACS, ANC, IYCN, BPCP for child survival, and PMTCT focused nutrition for pregnancy. CRPs are community focal persons who identify clients together with HEWs, provide follow-up home visits and ongoing counseling and refer malnourished clients to appropriate facilities. The program will focus on using existing community and facility based mechanisms to strengthen referrals to and from other HIV/AIDS programs in alignment with national referral protocols. CRPs will track mother-infant pairs before and after birth with a focus on improving maternal nutrition and providing basic child survival interventions for the first 24 months of life. This will include malnutrition assessment and treatment of PL-PLHIV by PMTCT service providers. Malnourished clients enrolled inPMTCT services will be referred for a HH food security assessment and linked to HH food assistance if found insecure. Food vouchers for insecure HH are partially funded with support from other donors. Childrens nutritional status will be assessed at 18 and 24 months of age. If the childs nutritional status is normal at the 24 month assessment, mothers of HIV negative children will graduate from the project, while mothers with HIV positive children will be reassessed for linkages to household food security activities. Nutritional status of all children under five will be followed through GOE HEW primary health care program (which recruits, trains and oversees the CRPs and HEWs).

This program will also coordinate with other USG-supported PMTCT, ANC, and FP partners, as well as facility and community-based partners and programs (such as mother support groups).