This activity is linked to 8571, 8567, 8630, 8638 and 8580 activity sheets. Since the formal establishment of the Ministry of Health (MoH) PMTCT program coordination office in 2003, the USG has supported the development of national PMTCT program guidelines and training materials, as well as the geographical expansion of PMTCT services, including the training of PMTCT program trainers and PMTCT service providers. Funding proposed under this activity will contribute to and support the following activities: 1) PMTCT training for trainers: Funding for FY07 will support the training of 60 new PMTCT program trainers and 60 existing PMTCT program trainers, using the new/revised PMTCT program curricula, incorporating Counseling and Testing (CT) in ante/postnatal and maternity settings, couples counseling and support for discordant couples as well as a revised overall counseling contents. These trainers will in turn conduct training for PMTCT service providers at existing and newly established PMTCT service sites in FY07. 2) In addition to training of trainers, plus up funding proposed will support the training of 150 PMTCT service providers (i.e. 6 courses) that the Ministry of Health PMTCT program is planning to conduct for PMTCT service sites, with priority to sites receiving little or no NGO support so far and may lack funds to support adequate training of PMTCT providers. 3) Production and distribution of 1,500 PMTCT kits for PMTCT trainers and providers: These kits contain key PMTCT program materials such as the PMTCT operational guidelines, the PMTCT training manual, the PMTCT providers' pocket guide, and other job aids and educational materials that have been developed by the PMTCT program over the past two years. 4) Community Health Agent Trainings: the MoH PMTCT program priorities and plans for FY07 include an increased effort in community mobilization and enhanced linkages between community-based and facility-based PMTCT activities. As part of these efforts, the MoH proposes to train 60 PMTCT trainers on how to train, facilitate and supervise PMTCT activities conducted by Community Health Agents, focusing on PMTCT service promotion, PMTCT-related BCC (Behavior Change Communications), promotion of adherence to ante/postnatal care consultations and institutional births in general as well as adherence to ARV prophylaxis or treatment where applicable, and support to HIV+ pregnant women, mothers and families at community level. USG funding for these activities will complement funding for PMTCT program expansion and training support provided by other agencies such as WHO, UNICEF, and the Global Fund Initiative.

This activity is linked to activity sheets 8516 and 8228.

Since the beginning of USG support for Injection Safety (IS) and Infection Prevention and Control (IPC) under PEPFAR in 2004, some direct support and funding has been provided to the Ministry of Health (MoH) biosafety program to allow MOH biosafety program staff to conduct IS and IPC training activities and to supervise adequately the implementation of IS, IPC and Universal Precautions at health facilities and sites without partner support. The MoH biosafety program staff have been able to use guidelines, norms and standards, and training materials developed with assistance of USG-supported partners such as JHPIEGO and JSI, to implement these activities on their own at selected health facilities. Increasing capacity of MoH staff to conduct these activities will contribute to long-term sustainability and a strong sense of local ownership.

Funding proposed under this activity will contribute to and support the following activities: 1) IPC and IS trainings: Funding proposed for FY07 will support 5 IPC and IS courses, one in each of the following provinces: Sofala, Gaza, Niassa, Zambezia and Manica. Each course will have around 24 participants selected from health facilities that have no external partner support for IS and IPC activities. Two courses that will be realized in the 2007 focus provinces Sofala and Zambezia.

2) Supervision visits: With support provided in FY07, the MoH team plans to conduct supervision visits to four provinces (Zambezia, Nampula, Sofala and Tete), where facility staff have been trained in 06/07 and IS and IPC activities are currently implemented. During these visits, the MoH central and provincial level supervisors will work with facility staff to assess progress made in implementation of the IS and IPC activities, identify further opportunities for improvement, and help the facility staff to plan further activities accordingly.

Please note that substantial support for procurement and distribution of IPC/biosafety equipment and supplies has been funded in FY06 and will contribute to the training of MoH facility staff (as explained above) necessary to implement the activities.

This activity is linked to the I-RARE (International Rapid Assessment, Response and Evaluation) activity 8632.

The I-RARE activity in Mozambique will provide Ministry of Health (MoH) and civil society researchers/workers with skills to conduct and analyze qualitative data on hard-to-reach, vulnerable populations. Upon completion of training by the US-based team, researchers and field workers will collect and analyze qualitative data to assess and respond to local health needs. In particular, this information will be used to reduce stigma and descrimination by improving access to and uptake of HIV services among vulnerable populations.

Proposed FY07 funding will be used to, based on findings from I-RARE (evaluation described under Strategic Information), for a team of MOH technical staff from the HIV/AIDS/STI program, the health education department and the Mozambican National Health Institute, to design, pilot and implement first training and Information Education and Communication (IEC) interventions targeting vulnerable populations, such as drug users and commercial sex workers in Mozambique. Effective interventions targeting these groups in Mozambique to-date are very limited, and this activity will assist the MOH team to gain first experience in designing and implementing interventions, measuring effectiveness and potentially expanding them to larger groups and geographical areas in FY08.

This activity provides additional funding to the Ministry of Health (MOH) and is aimed at enhancement of diagnosis, management, and treatment of opportunistic infections at health facilities in Mozambique. The main activities include: support a national technical working group on opportunistic infections that will recommend and advise the Ministry of Health Department of Clinical Services on issues related to improved monitoring and evaluation, supervision and training related to Opportunistic Infections.

This activity is linked to activities 8566, 8595 and (USAID) 9133 which support clinic based HIV palliative care; and activity sheets 8570, 8631 and 8637 for HIV-STI integration.

Through requested FY07 funding, the Home Based Care (HB) Program will continue to receive support for improving monitoring and evaluation (M&E) tools at the central level, and updated training, supervision and policy materials for the delivery of palliative care at the community level.

The HBC program will also continue to work in conjunction with the Traditional Medicine Section to train provincial trainers who will, in turn, train Traditional Healers to improve referral links between them and the modern health care system and to improve their practice. Training will emphasize changing harmful practices and respecting neutral or positive practices. Some of these practices include the use of certain plants for symptom relief while avoiding those that interact with ARVs and other important medications, promoting traditional counseling practices while encouraging the protection of the rights of women and children regarding inheritance issues, and health education for prevention around HIV and TB transmission. Correcting or modifying harmful practices and clarifying harmful beliefs also serve to decrease stigma in the community.

In addition to these two activities, the HBC team will provide in-service training to improve health workers skills for provision of HIV health care. The National Nursing Department in coordination with the Department of Medical Assistance (DAM) has implemented Basic HIV and Opportunistic Infections trainings for mid- to basic-level cadres (medical technicians, general nurses, medicine agents and basic nurses) who are involved in the provision of health care to adults. USG-funds in the previous years supported the development of training materials for a Basic Course in HIV and Opportunistic Infections based on the generic WHO Integrated Management of Adolescent and Adult Illness (IMAI) and existing in-country materials. Manual contents include broad aspects of HIV/AIDS prevention, Biosafety, and HBC, including how to identify signs and symptoms and treat Opportunistic Infections (OIs). Those materials have been used in all training activities throughout the country by MOH staff and implementation partner agencies and organizations resulting in 253 health workers and 52 facilitators trained from 9 provinces in the country. Training activities proposed for FY07, include: 1) Reproduction of updated training materials to facilitate the process of standardization of OI case management 2) Provincial courses for 100 health workers in 5 provinces. 3) Supervisory visits from the central level to five provinces to ensure the training quality and follow up trainees Niassa, Cabo Delgado, Sofala, Zambezia and Nampula provinces.

In addition to the support for the above described support for HBC and OI management, the following HIV-STI interventions are proposed for FY07 which build off of FY05 and FY06 activities:

1) Training for 300 STI service providers using the new/revised guidelines and training materials, including HIV counseling and testing, STI treatment for HIV-positive clients and partner notification: FY07 funds will support 2 trainings per province to be conducted in six provinces. National clinical STI guidelines and STI training materials where reviewed so as to introduce and appropriately address a) HIV counseling and testing to be provided during outpatient and STI consultations; b) treatment algorithms, drug prescriptions and dosages for HIV-positive patients affected by STIs; and c) partner notification and testing for HIV-positive and STI patients. 2) Reproduction of the above described revised STI clinical guideline and training manual, as well as basic job aids and IEC materials for STI service providers trained. 3) Supervision visits (22 visits or 2 visits to each of the 11 provinces) conducted by central level STI program technical staff and supervisors to monitor the integration of STI

management at HIV/AIDS treatment sites as well as visit STI providers trained and provide further on-the-job guidance. 4) M&E support visits (11 visits or 1 visit to each of the 11 provinces) from central level STI data management staff and M&E staff to supervise the use of integrated HIV and STI reporting, data compilation, analysis and use at provincial level. 5) Recruitment and hire of two MoH STI and HIV data management staff to support the revision and further improvement of STI program registers and forms with integrated HIV and testing data; as well as recording and compilation of STI data at HIV/AIDS treatment sites.

Funding will be provided to the Mozambique National TB program of the Ministry of health (MOH) to support the following specific activities 1) Strengthen infection control at health facilities to prevent nosocomial transmission of TB and drug-resistant (MDR, XDR) TB through the procurement of equipment (respirators, fans, etc.) 2) Strengthen monitoring and evaluation of TB/HIV activities through the rolled out implementation of the Electronic Tuberculosis Register (ETR) including supervision and training activities. and 3) Support renovation of the National TB reference laboratory, establishment of supervised quality assurance programs and specialised TB training for 4 biologist in the area of TB laboratory management

This activity is linked to Activity ID Numbers: 8568, 8572, 8620, and 8633.

Early in 2006, the Ministry of Health (MoH) started a process of redefining and revising national policies and program directions for counseling and testing (CT) services. Where CT services have traditionally been provided through Voluntary CT (VCT) centers co-located at health facilities, the MoH is moving toward a system of routine counseling and testing that is integrated into a package of existing health services (e.g. tuberculosis, antenatal care, hospital, youth-friendly, and sexually transmitted infections). Existing VCT services will continue, however, their scope will be broadened to include other diseases and health promotion areas. Community-based CT is being piloted and will be expanded in FY07.

The requested funds will contribute to and support the following activities:

(a) Reproduction of CT program materials: Support the transition of traditional VCT services to routine CT in health facilities: Print and disseminate revised guidelines and training materials for CT in clinical settings and community based CT.

(b) CT training for trainers and health workers: Health workers will undergo a basic CT training course to provide CT in their respective health services. This will include a 24 hour classroom training and 20 hours in-service training under supervision. Proposed FY07 funds will support 4 training courses for trainers that will help to establish a pool of 100 CT trainers for roll-out of CT training for health workers in clinical settings. Following the training-of-trainers, participants will return to conduct trainings for health workers within their respective provinces. Funds proposed will support 11 training courses (1 in each of Mozambique's 11 provinces) for 275 health workers located in tuberculosis (TB), inpatient-hospital, maternity settings, youth-friendly health clinics (YFHC) and outpatient consultations.

(c) CT service promotion and communication: There is an urgent need to increase public awareness about the importance of CT in the general public as well as in specific populations (couples, young people, rural population, vulnerable populations etc.). Communication campaigns are planned in coordination with the National AIDS Council Communications Unit and the MoH health education department as well as NGOs that work in the field of social communication. Radio spots and written materials (leaflets) will be designed. These efforts will address issues of gender, discordant couples, and young people. Additionally, materials directed to health workers about the importance of CT will be produced.

(d) Improvement of basic CT management practices through Monitoring and Evaluation (M&E) training: In line with new CT program directions, the existing computerized CT database needs to be updated and improved to incorporate aggregate CT data collected in clinical and community settings. This improvement will also help simplify and improve the management of individual client records from VCT centers and Youth-Friendly Health Centers. Funds will be utilized for the procurement of computer equipment for provincial level data entry and analysis as well as for 2 courses to train 30 key MoH and NGO personnel involved in managing CT program data.

(e) Procurement of a vehicle for central level CT Program personnel for supervision visits to CT sites located in the Southern region, i.e. Maputo City, Maputo Province, Gaza and Inhambane Provinces where sites can be accessed by road.

(f) Support for CT program supervision: Funding proposed for FY07 will continue to support travel of the central level CT staff and provincial CT trainers and supervisors for supervision of training activities. These supervisors will monitor the quality of service provider training and accreditation of newly trained CT trainers, and give feedback to staff at existing and newly opened CT service sites to help to improve services.

(g) Support for provincial counselors' meetings: Funding will support 11 provincial level CT meetings (one meeting per province, 25 health workers/counselors per meeting) for health workers and counselors from selected sites to exchange experiences and lessons learned, and to help prevent burn-out by coping with the emotional and psychological burden associated with the work conducted. These meetings will also contribute to the

dissemination of revised role and job description of staff providing counseling services in light of the new CT policies and roll-out of integrated services.

This activity is linked to activities 8516, 8582 for prevention of medical transmission, and 8569 for early diagnosis in HIV exposed infants.

This activity will support the Ministry of Health (MOH) to continue treatment-related activities that will (a) contribute to safety and quality of services at antiretroviral treatment sites in the '07 focus provinces Zambezia and Sofala; and (b) increase the number of women tested for HIV and syphilis, the number of HIV-positive pregnant women accessing CD4 count laboratory services to determine treatment eligibility, and HIV exposed infants diagnosed at PMTCT and pediatric treatment sites.

FY07 funds (US$100,000) will support central and provincial level MOH biosafety staff to visit all ART treatment and HIV/AIDS service sites in the two '07 focus provinces Zambezia and Sofala, conduct a complete inventory of all sterilization and biosafety equipment and supplies at these facilities, procure new equipment and supplies where needed and repair equipment where possible.

In addition proposed FY07 funding (US$100,000) will support the training of 600 Mother-to-Child Health Care nurses and other health professionals (150 nurses and health care workers to be trained per quarter, course duration 2-3 days) providing PMTCT services on collection of blood samples for CD4 counts, HIV and syphilis rapid testing for pregnant women and women delivering at maternities, as well as collection of Dried Blood Spots for early infant diagnosis. Funding will also contribute to transport costs for blood specimen and DBS samples from service sites to reference laboratories for peripheral PMTCT sites where laboratories are not available. This activity will contribute to an increased number of women eligible for treatment being identified as well as decreased infant mortality through early diagnosis and initiation of treatment for infants needing ART.

This activity is related to activity 8532, and 8540 and is a continuation of activities initiated in FY06 for support to the Ministry of Health (MoH) in the development of the network of public health laboratories in Mozambique.

The MoH's overall objective for laboratory services is to strengthen and provide state-of-the-art technology to ensure the quality of services provided to complement and support health care services. The main areas that the MoH aims to improve include: expansion of access to quality serological HIV diagnosis, provision of appropriate technical laboratory support needed for quality ART including in peripheral zones; creation of sustainable and effective specimen referral and laboratory logistics systems in order to establish locally an internationally accredited quality laboratory diagnostics.

Funding during FY07 will continue to support these broad objectives through implementation of the following activities:

1) Planning and coordination of trainings for all laboratory personnel in the country including participation in international meetings and conferences

2) Development and updating standard laboratory operating procedures and guidelines and undertake supportive supervision

3) Procurement of laboratory units including supplies and equipment for five to-be-defined district health centers.

In addition to these activities, these funds will be used to help maintain and support skilled expatriate staff needed to develop the referral network through strengthening laboratory support at provincial level.

The USG team provides significant financial and technical assistance to the Ministry of Health (MoH) to support health information technology (IT) infrastructure. This support is not only provided to the central MoH but also to surrounding hospitals and provincial health offices to promote stable computing systems and a platform for data reporting in the national HMIS. The process of supporting IT in the MoH is in a state of transition. Prior to 2006, sections of the MoH, including the HIV/AIDS program staff, contracted only for ISP support while covering all basic maintenance and user support through existing MoH IT staff. Using reprogrammed USG IT funds in 2006, the MoH opted to bid out their IT services to a single contractor because they have not been able to attract qualified IT staff. The MoH will select a contractor by December and existing IT staff in the MoH will begin overseeing the contract in 2007.

To address these changing needs, funds in this COP are specifically requested to further strengthen and expand the IT infrastructure at the provincial level as well as to improve user support centrally, primarily through contractual agreements. Specifically, the MoH will continue to use USG funds to assure Internet access centrally and in the 4 provincial health offices. Additionally, these funds will be used to partially fund and oversee (via 4 provincial site visits by 3 IT staff) an IT contract for maintenance of computers and the network and to purchase and upgrade software and hardware. Finally, the MoH IT and provincial IT staff will identify training in South Africa on Microsoft systems that will allow them to better technically oversee the contract. Additional funding for these contracts will be identified from the MoH, which is increasingly recognizing the opportunity costs of a weak IT infrastructure.

The lack of health care infrastructure in Mozambique is discussed throughout the USG five-year strategy. In reality, it is one of the biggest challenges for the Government of Mozambique in effectively responding to the HIV/AIDS epidemic.

In FY 06, very little direct funding was provided to Ministry of Health (MoH) due to the large amount of unspent FY05 money. The funds were unspent due to the transition within the government after national elections, which were held in late 2004. However, in the past six months, USG-supported funding was reprogrammed into various MoH activities. The Human Resources department redirected money to support an accelerated training plan that: 1) Covered student costs for a specific number of classes; 2) Paid part-time faculty to teach the additional classes and to private training institutions to prepare lab technicians; 3) Supported an annual meeting for faculty from training institutions; and 4) Purchased computers, printers and furniture for human resource directors and training institutions; and conduct supportive supervision visits to provinces.

In FY 07, the following two areas and related activities will be funded with USG-support

1) Pre-Service and In-Service Training ($550,000) - The USG will provide funds to the Human Resources Department to compliment activities of other implementing partners in the areas of pre-service and in-service training. There are three specific pre-service strengthening activities being funded in FY 07:

a) Multimedia equipment and furniture procurement for training institutions libraries, training faculty on HIV topics and quality improvement in training institutions. Purchasing library equipment and furniture ($100,000) is vitally needed. Many of the libraries in the training institutions have limited media resources and little furniture. It is not uncommon to see students sharing a desk that is designed for one person to use. Of equal importance, is access to multi-media educational materials especially in Portuguese or Spanish.

b) Individual training accounts: Funds are being provided to MoH to pay for the costs, including per diems and travel expenses, of participants attending at least one training. This activity compliments I-TECH's activity of providing faculty and content for training institution faculty in HIV topics such as ART, PMTCT, counseling and Opportunistic Infections ($120,000). (Linked with 8802)

c) Quality assurance/improvement at training institutions ($180,000). (Linked with 8575) With JHPIEGO designing the quality assurance process and training materials, these funds will go to support MISAU costs associated with sending participants from 13 training institutions and supportive supervisory visits to select institutions after the trainings occur.

FY 07 support for strengthening in-service includes three activities: a) Equipment purchase for in-service department: Equipment purchase will provide needed computer tables and shelves for the computer equipment recently purchased using FY 05 redirected funds for 11 provinces. ($25,000) b) Supportive supervision visits: With MOH's move to decentralize their decision-making and financial responsibilities from central to provinces, supportive supervisory visits are all the more important for mentoring provincial level in-service staff as they take on these new responsibilities ($65,000). c) Training Information Management System (TIMS) salary support and ongoing technical assistance to the Human Resources department: Support for TIMS staff salary and office equipment is critical as the database expands to a web-based model ($45,000). (Linked with 8575) Lastly, CDC continues to support a technical advisor in the Human Resources department to provide continuity and support for organizational elements of MoH.

2) Strengthening systems to reach health care workers and minimize/mitigate the impact of HIV/AIDS on their personal and professional lives. ($50,000)

One of the key objectives of the MoH Strategic Plan to Combat STIs, HIV, and AIDS is to reduce the impact of HIV/AIDS on health care workers. To date, there are few activities existing that support health workers in dealing with HIV/AIDS. It is unknown how many

health workers themselves have undergone testing and counseling. According to anecdotal information, concerns around confidentiality of information and fears of discrimination within one's work environment are concerns of health care workers when considering whether to access counseling and testing services. These concerns represent barriers to accessing services, seeking accurate information and examining the risk associated with their personal and professional behaviors. It is unlikely that HIV risk among health workers can be overcome without significant changes to attitudes and behaviors. In FY06, USG funding has been supporting the development of an assessment of health workers' current behaviors, attitudes, norms and knowledge around primary prevention of HIV and uptake of counseling and testing services, to determine how to better design interventions promoting structured opportunities for educating and assisting health workers to better deal with HIV/AIDS in their work and home environment. This activity is a continuation of funding in FY06 and is linked to 8628 and 9064.

FY 07 funds are being requested for expenditures related to MoH staff piloting and conducting first interventions targeting and supporting health workers. Technical assistance for quantitative and qualitative Public Health Evaluations, such as the above described study, that will inform the design of the interventions and methods to be used will be provided by the CDC team and a TBD technical assistance partner (linked to 9064, 8635, 8639). Funds will assist the MoH team, composed of staff from the human resources, training, health education departments and the HIV/AIDS/STI program, to conduct weekly training and discussion sessions using innovative and participatory methods, to be delivered to a health centers team composed of both health professionals and support staff at the respective facility. FY07 funds will also support the development of HIV informational materials: 1) materials that can be used as HIV/AIDS reference materials by health professionals and 2) materials that health facilities can take home and share with family members, neighbors and friends to facilitate discussion and raise awareness in their personal life environment.