This activity is linked to activity 8567. The philosophy of the International Training and Education Center for HIV (I-TECH) is to support the ongoing development of health care worker training systems that are locally-determined, responsive and self-sustaining in countries hardest hit by the AIDS epidemic. The primary activities of I-TECH include assessing needs and capacity for training and clinical care; designing clinical management and workforce training systems; supporting knowledge transfer through instructional design and on-site training; measuring access to quality care through monitoring and evaluation; and strengthening organizational capacity through development assistance and strategic planning. I-TECH has been working internationally on training and capacity development activities for health care providers around HIV, TB, and STIs for the past 4 years. Since 2003, the USG in Mozambique has supported PMTCT activities through the adaptation of the WHO-CDC PMTCT curriculum and in the establishment of two PMTCT reference centers. Columbia University (CU) has supported the development of both of these centers; one at Jose Macamo Hospital in the Maputo Province that serves the southern region of the country and a second at the 25th of September health clinic in Nampula that serves the northern region. From October 2005 through March 2006, both centers collectively trained 820 PMTCT providers. To date, trainings are based on a national curriculum and have been classroom-based with no practicum associated. I-TECH provides a special expertise in developing clinical mentoring programs. In 2007, I-TECH will be asked to work together with PMTCT staff at CU to provide technical assistance and support for translating and adapting clinical mentoring materials for PMTCT service providers who have undergone the classroom training. In particular, I-TECH will be asked to establish a standardized process for preparing supervisors to offer practica in a consistent way. In addition, I-TECH will work with CU to develop a plan for rolling out PMTCT training activities nationally. Deliverables that will be provided include: standardized elements for PMTCT practica the number of providers undergoing practica, and a plan for rolling out training activities -including practica - nationally. In addition, I-TECH willl strengthen linkages between community based activities and clinic based PMTCT activities. In Mozambique, linkages between facility- and community-based PMTCT activities as well as between health care workers and community volunteers are weak. There has been some success in mobilizing and using community volunteers, including Traditional Birth Attendants, peer educators and/or PLWHA, to provide and strengthen PMTCT-related health education that includes counseling, tracing of defaulters, and promotion and use of PMTCT services at existing individual PMTCT service sites. However, in discussion with the Mozambique MOH PMTCT program and USG-funded PMTCT implementing partners, the need to develop a comprehensive community framework to formalize, guide, and standardize these efforts has been identified. This can include development of guidelines, job descriptions, training materials, and job aids for community based volunteers. Plus Up funding will allow I-TECH to provide technical assistance to the MOH PMTCT team, and work with PMTCT partners in-country, to design the framework, identify needed materials and tools, develop a plan and timeline, and develop the first set of materials ready for piloting at selected sites. Similarly, while several PMTCT partners are currently supporting the establishment and coordination of mother-to-mother support groups at the sites, no standardized guides, scripts or tools exist to conduct and sustain these groups. The mother-to-mother support groups are composed primarily of HIV-infected pregant women and mothers who gather on a regular basis to discuss various topics of interest. The discussions are generally led and facilitated by MOH nurses, volunteer peers or PLWHAs with few materials to facilitate and stimulate discussion. Funding proposed under this activity will allow I-TECH to gather existing in-country and regional materials for mother-to-mother support groups, translate, adapt and pilot materials in collaboration with the MOH PMTCT team and PMTCT partners. I-TECH will subcontract a portion of the technical assistance to the FXB Center of University of Medicine and Dentistry of New Jersey, a group well-known for its work in PMTCT material development. Deliverables for this second activity will be a proposal and timeline for the development of the framework for community-based follow-up and promotion activities, a needs assessment of existing in-country and regional materials and tools, and the adaptation of selected materials for mother-to-mother support groups in Mozambique. In addition, I-TECH will coordinate piloting of mother-to-mother support group materials with in-country partners, to be determined.

Funding will be used to support adaptation of cotrimoxazole guidelines for Mozambique, curriculum development, content review, evaluation of the pilot training and one review after training. Training will be undertaken in accordance with an implementation plan to be developed by the MOH. The number and type of participants in the pilot training will be finalized in collaboration with the MOH.

Target Populations: Doctors Nurses Public health care workers Other Health Care Worker

Table 3.3.07: Program Planning Overview Program Area: Palliative Care: TB/HIV Budget Code: HVTB Program Area Code: 07 Total Planned Funding for Program Area: $ 3,513,682.00

Program Area Context:

Mozambique has a high TB burden and in 2006, was ranked 19th in terms of high burden countries with an estimated incidence of 460 cases/100,000 population and an annual increase of 2.6%/year (WHO 2006). In 2004, Mozambique reported 31,150 TB cases, and estimated that 48% of adult TB cases (aged 15-49 years) were HIV infected. Mozambique adopted the DOTS Strategy through technical assistance from the International Union Against TB and Lung Disease (IUATLD) in the 1980s, and has had 100% DOTS coverage since 2000. However, health infrastructure is extremely limited in Mozambique and an estimated 40% of the population has access to DOTS services (defined as a health facility within 10km of a patient's residence). TB case detection was 35% in 2004; well below the global target of 70%. For the 2003 cohort, treatment outcomes remained inadequate, with a 76% successful treatment completion rate (global target 85%). Key donors to the national TB control program include the USG and the Global Fund. Mozambique was awarded $15.2 million for TB in Round 2 of the Global Fund. As of June 2006, $7.2 million has been disbursed, but very little of this has been spent on programmatic activities. Key goals for the Global Fund support are to expand and strengthen DOTS coverage to achieve 70% case detection and 85% treatment success by the end of 2007. Mozambique recently completed an application for additional TB funding to Round 6 of the Global Fund. Case finding relies on smear microscopy, but laboratory infrastructure for TB diagnosis is limited. At present, there is only one national lab (in Maputo) capable of performing mycobacterial culture and drug susceptibility testing.

Mozambique has one of the highest documented rates of multidrug-resistant TB (MDR) in Africa (WHO/IUATLD Drug Resistance Surveillance). A national survey in 1998-1999 found that 3.4% of new patients had MDR TB and that drug resistance (isoniazid and streptomycin) was higher among HIV-infected TB patients. This is of great concern since HIV-infected patients with MDR have exceedingly high mortality rates, even in settings where they have access to HIV treatment (including ART). Nosocomial transmission of MDR TB to susceptible patients (especially persons with HIV) has been well-documented in both high- and low-resource settings, including in Africa (South Africa).

Since Mozambique has a more recent (and still growing) HIV epidemic, it is estimated that the proportion of TB patients who are HIV-infected will continue to rise. The National TB Program (NTP) recognizes the importance of expanding TB/HIV services in Mozambique, but progress in implementing these activities has been slow. The MoH endorses routine HIV testing to all TB patients using a provider-initiated model, provision of cotrimoxazole at TB clinics to all HIV-infected TB patients, including referrals for ART services and screening HIV+ patients for TB in all care settings: VCT, home-based care, and HIV day hospitals. Several partners (including Health Alliance International (HAI)), with MOH endorsement, are planning to scale up ART initiation in TB facilities in Sofala Province in FY07.To date, TB/HIV policies, training materials, and new reporting formats have been developed. Implementation on a national scale is planned in the coming months.

USG efforts are consistent with the MoH and WHO TB/HIV Framework which highlights the need for integrated programming, decreasing the burden of TB among PLWHA and increasing the HIV care available for TB patients. The emphasis of USG support is to provide HIV counseling and testing to all TB patients, to screen all HIV-infected patients for TB, to link all HIV-infected TB patients to HIV care and treatment and to link all HIV-infected TB suspects to TB diagnosis and DOTS therapy.

In FY 2006 USG resources and technical assistance supported TB activities by USG-supported Treatment Partners as well the development of a provider-initiated counseling and testing curriculum for TB settings, which has been adapted and translated into Portuguese, pilot-tested and AIDS/TB/Malaria Coordinators from all provinces were trained in August 2006. Further trainings and a rollout of these activities are planned.

USG-supported HIV treatment partners are implementing TB/HIV activities at integrated health network

sites which includes TB screening for all HIV patients and linkages to TB diagnosis and treatment under DOTS. Treatment partners are also working with TB services in their catchement areas to ensure that all TB patients are offered HIV testing, cotrimoxazole, and referral to other HIV-related services, including ART.

In addition to USG support through PEPFAR, USAID also will provide $1 million to the TB program in FY 2007 through the TB-CAP (administered by FHI). These funds were planned for use in FY 2006, but these activities have not yet been implemented due to delays at the MOH. These funds will be used for (1) TB laboratory strengthening and expansion of culture to Beira and Nampula, (2) Community DOTS expansion, and (3) TB/HIV activities.

FY06 funds are also being used to hire a TB/OI Coordinator as part of the CDC team who will work closely with the MOH, TB-CAP partners, other USG-supported partners, to ensure that TB/HIV activities are scaled up and are well-harmonized.

In FYO7, USG (through PEPFAR and TB-CAP resources) will assist in providing technical assistance to MoH in the following areas: (1) TB drug resistance surveillance and treatment, (2) laboratory strengthening, and (3) monitoring and evaluation. In partnership with the National TB program, USG will support completion of a TB drug resistance survey that includes HIV testing of all patients enrolled. Funding is available through the Global Fund, but MoH would benefit from technical assistance to ensure timely completion of a nationally representative survey. USG will also provide technical assistance with development of a treatment plan for MDR TB (through assistance with an application to the Green Light Committee). Given the weak laboratory infrastructure for TB diagnosis, USG will support strengthening of these services through in-service training of existing laboratory staff (through APHL), support for 2 new regional TB labs capable of performing culture and drug susceptibility testing (through TB-CAP), and through strengthening of the National TB Reference Lab in Maputo. Finally, USG will support Monitoring and Evaluation of TB/HIV activities through assistance in proper use of new recording and reporting formats that are being distributed. In addition, in FY06, the Electronic TB Register has been translated into Portuguese. With USG support, the NTP will pilot the use of the ETR in a number of select districts (in the focal provinces) in FY07. MoH has funding for computers for this activity through the Global Fund.

All HIV USG funded treatment partners (Columbia/ICAP, HAI and EGPAF) will be funded and expected to provide a minimum package of TB/HIV services. This includes strengthening linkages with community organizations in TB case finding and improved linkages to TB care. In addition, efforts will be made to scale up TB/HIV activities in the two provinces (Zambezia and Sofala) where USG will be concentrating its efforts in FY 2007. This will include close collaboration with the Provincial Health Directorates. Treatment partners working in these provinces (HAI in Sofala and Columbia in Zambezia) will work to scale up TB/HIV activities, and to develop innovative best practices, including ART initiation in TB clinical settings and improved diagnosis of smear-negative TB.

The USG meets regularly with all TB/HIV donors to coordinate planning, oversee program implementation and ensure rational use of resources. Additionally, small teams from the TB/HIV donor coordination group will conduct joint supervision of TB/HIV service sites, laboratories and M&E activities.

Program Area Target: Number of service outlets providing treatment for tuberculosis (TB) to 98 HIV-infected individuals (diagnosed or presumed) in a palliative care setting Number of HIV-infected clients attending HIV care/treatment services that are 8,730 receiving treatment for TB disease Number of HIV-infected clients given TB preventive therapy 3,600 Number of individuals trained to provide treatment for TB to HIV-infected 575 individuals (diagnosed or presumed)

Table 3.3.07:

International Training and Education Center for HIV (I-TECH)'s philosophy is to support the ongoing development of health care worker training systems that are locally-determined, responsive and self-sustaining in countries hardest hit by the AIDS epidemic. The primary activities of I-TECH include assessing needs and capacity for training and clinical care; designing clinical management and workforce training systems; supporting knowledge transfer through instructional design and on-site training; measuring access to quality care through monitoring and evaluation; and strengthening organizational capacity through development assistance and strategic planning.

At the request of the Minister of Health (MoH), the USG will continue to work on at the central level, while beginning to focus activities on the USG's two focus provinces: Sofala and Zambezia. In late spring, the MoH developed an accelerated training plan to develop health care providers more rapidly. Currently, 50-60% of the population do not have access to health care and the system's ability to respond is being further stressed by HIV/AIDS. The accelerated training plan focuses on preparing health care providers, lab technicians and pharmacists more quickly by increasing the number of classes at each training institution and by shortening the total amount of time for pre-service coursework. The accelerated training plan challenges the capacity of the training institutions as they work to double their work load.

In Sofala, there are a number of PEPFAR-supported activities that will be coordinated by I-TECH to develop additional cadres of health care workers and lab technicians that can support roll-out of ARV treatment. USG-funded Health Alliance Internation will be providing resources to support student fees associated with the accelerated training plan (Linked to USAID_Treatment_HAI). Catholic University, in twinning with University of Pittsburgh, will be providing a clinical practicum site focus on ARV treatment that can be used by the pre-service and in-service institutions (Linked to 8800). JHPIEGO, at the request of the National Director of Training for MoH, will focus on improving the overall quality of training institutions (Linked to 8575). In particular, they will focus on Sofala's training institutions, with the intent that necessary changes be applied to other provinical training institutions. I-TECH's work in revising the tecnico de medicina (mid-level providers) curriculum and in developing standard elements for clinical practicums will also contribute to the overall effects of this consortium. In addition, I-TECH will offer faculty training in HIV/AIDS and adult learning methods. MoH will continue to secure faculty, support their training institutions, and assure that all activities are in line with the government's plan.

In Zambezia, there have been less PEPFAR investments to date. JICA has invested in the renovation of one training institution although there are other institutions that need further strengthening. Through funding of this proposal, I-TECH would be asked to investigate the needs of that province and propose a plan to increase the number of tecnicos de medicina and nurses that can be graduated through the accelerated training plan. This plan could then be further funded by PEPFAR or other donors in subsequent funding cycles.

To accomplish these activities, funding is requested to support one or two I-TECH staff working fulltime in Sofala and Zambezia and costs associated with their coordination activities. In addition, Ï-TECH would coordinate 1 in-service ARV training using the Columbia-MoH-I-TECH curriculum for tencicos de medicina.

Deliverables: number of students enrolled, needs assessment completed, development of standard elements for practicums and clinical mentoring

International Training and Education Center for HIV (I-TECH)'s philosophy is to support the ongoing development of health care worker training systems that are locally-determined, responsive and self-sustaining in countries hardest hit by the AIDS epidemic. The primary activities of ITECH include assessing needs and capacity for training and clinical care; designing clinical management and workforce training systems; supporting knowledge transfer through instructional design and on-site training; measuring access to quality care through monitoring and evaluation; and strengthening organizational capacity through development assistance and strategic planning.

While all cadres of health care workers are lacking enough providers and have limited faculty to prepare new providers (either through pre-service or in-service), one of most severely under-resourced cadres is lab technicians. Currently, not enough lab technicians are trained to support the increasing demands placed on labs with the introduction of ARV treatment. This limitation in staffing is further exacerbated by the lack of faculty at pre-service institutions who can prepare a new cadre of lab technicians. Currently the Ministry of Health (MoH) is turning to the small number of private training institutions to offer pre-service education in laboratory methods.

To prepare existing lab technicians for ARV related activities in the labs, I-TECH will be working with APHL (American Public Health Labs), the MoH Lab Department and a To-Be-Determined partner to develop a standard clinical mentoring model for lab technicians. Both lab partners have proposed doing on-the-job training to further develop the skills of current lab technicians. With I-TECH developing the clinical mentoring elements for supervisors and lab technicians, it will be possible to have a level of quality assurance that might not be there if each lab partner developed their own clinical mentoring separately.

Deliverables: guidelines and elements for clinical mentoring for lab technicians and supervisors

The Ministry of Health's (MoH) "2006-2010 Human Resources Development Plan" (October 2005) calls for mid-level health providers (tecnicos de medicina) to carry a greater responsibility in HIV care and treatment. The plan also calls for strengthened management at all levels within the health sector.

In FY07, I-TECH will assist the MoH to implement these human capacity development plans. I-TECH will improve the HIV-related training of tecnicos de medicina during their initial training (pre-service) and on-the-job in clinics (in-service). I-TECH will partner with MoH officials to improve the management skills necessary for the roll-out of antiretroviral treatment, targeting local health directors, provincial AIDS coordinators, and training institution directors. All objectives and activities described below are continuations from '06 except support to '07 SMDP participants:

Objective A: New tecnicos de medicina will have competence to provide quality HIV care upon graduation. In 2007, I-TECH will work with 13 training institutions to implement recommendations from the 2006 assessment of tecnicos de medicina pre-service training.

Activity 1: Introduce pre-service curriculum changes based on assessment recommendations. ($119,000) I-TECH will work with training institution pedagogy directors to revise the existing course outline to include more detailed material on the most important causes of mortality and morbidity in Mozambique. In some cases, existing in-service training materials could be adapted for pre-service purpose. If needed, I-TECH will draft and introduce one new pre-service module in 2007 related to HIV and associated causes of mortality and morbidity. Deliverable: Revised course plan document; new curriculum module

Activity 2: Develop teaching skills at training institution faculty. ($95,000) Using curriculum developed for this purpose in 2006, I-TECH will conduct training-of-trainer (TOT) courses for faculty and clinical instructors at 5 institutions, reaching 100 persons (5 sites x 20 per site) (Linked to 8628). Deliverable: 100 persons trained, emphasis on Sofala and Zambezia

Activity 3: Improve pre-service and in-service practica through training and resources. ($124,000) I-TECH will pilot the use of learning objectives, best practices guides, and checklists to improve the clinical practica based on theories about effective adult learning. Flowing from the work with institutions, I-TECH will coach national partners (HAI, Columbia, APHL) on best practices. Deliverables: Practicum teaching tools and technical assistance implemented at 5 institutions and by national training partners; improving training for 60 students at each site (300), emphasis on Sofala and Zambezia

Objective B: Current tecnicos de medicina will have competence to provide quality HIV care. In 2007, I-TECH will complete the following improvements to in-service trainings to initiate an on-the-job mentoring program for tecnicos de medicina already serving in clinics:

Activity 4: Update clinical guidelines and establish a process for validation. ($32,000) This activity is a continuation of work began last year. I-TECH will continue processes begun in 2006 with the Ministry of Health and other stakeholders to update the clinical guidelines for the treatment of HIV opportunistic infections. I-TECH will provide technical expertise to the process. I-TECH will develop a proposal for validation research related to the new guidelines. Deliverable: Updated guidelines and validation process

Activity 5: Revise "Basic Course on HIV" based on updated opportunistic infection treatment guidelines. ($82,000) This activity is a continuation of work began last year. I-TECH will revise the existing curriculum as needed, including the development of different course components for different cadres and practice locations. Deliverable: Completed curriculum

Activity 6: Evaluate TARV course. ($88,000) (Activity linked to 8545) I-TECH will conduct an evaluation in clinical sites to observe graduates of the TARV in-service course to see if they are prescribing treatment consistent with the information taught in the course.

I-TECH will revise the course based on the evaluation. Deliverable: Report and recommendations based on evaluation; revised curriculum

Activity 7: Introduce clinical mentoring. I-TECH will pilot a clinical mentoring program for tecnicos de medicina. ($147,000) Through partnerships with day hospitals, I-TECH will organize expatriate and local physicians and experienced tecnicos to serve as mentors for health workers who complete the TARV course. This effort will be linked with Activity 3 to improve clinical learning in a practice setting. Deliverables: 30 persons trained through clinical mentoring; clinical mentoring toolkit translated to Portuguese, emphasis on Sofala and Zambezia

Activity 8: Provide TOT courses for in-service training faculty.($71,000) I-TECH will coordinate and implement TeachBack trainings four times in 2007. The TOT courses will be tailored to specific in-service trainings. Deliverable: 60 persons trained (4 TOT courses x 15 participants), emphasis on Sofala/Zambezia

Activity 9: Design/improve other in-service curricula. ($45,000) I-TECH will have capacity in Maputo and Seattle to work on other curriculum development projects with partners in areas such as PMTCT, adherence, lab. The priorities for curriculum development will be based on the HIV training inventory completed by I-TECH in October 2006. Deliverables: Curricula as determined.

Objective C: Health managers will have improved capacity to support the expansion of HIV treatment in Mozambique. In 2007, I-TECH will mentor and assist Mozambique's three participants in the Atlanta-based Sustainable Management Development Program (SMDP) to transfer knowledge and skills to their peers in Mozambique.

Activity 10: Train institution directors. SMDP and I-TECH will provide in-service management training to institution directors, pedagogy directors, and administrative directors. ($126,000) (Activity linked to 5244). Deliverables: 3 persons at 13 institutions = 39 persons trained; CDC Management for International Public Health curriculum adapted for Mozambican context, emphasis on Sofala/Zambezia

Activity 11: Train district health directors and provincial AIDS coordinators. ($200,000) (Activity linked with 8628) SMDP and I-TECH will provide in-service training and on-the-job mentoring in public health planning, coordination, and management to district health officials in Sofala province and to provincial AIDS coordinators in all provinces. I-TECH plans to partner with the US National Alliance of State and Territorial AIDS Directors (NASTAD) to provide technical assistance. NASTAD provides assistance on decentralized public health planning to local health districts in the US and internationally. Deliverables: 39 persons trained; CDC Healthy Plan-It curriculum adapted for Mozambican context; district health plans completed, emphasis on Sofala