The PROGRAM GOAL is focused on increasing access to quality evidence-based HIV prevention, care and treatment services. In MAPUTO CITY and INHAMBANE PROVINCE: Columbia will provide health systems strengthening support to the DPS, Districts and local NGO partners through: Training and mentoring of District Health management teams in clinical competency, M&E, planning and data quality; Pre-service courses, infrastructure renovations; and sub agreements to Maputo City Health Directorate, Inhambane DPS and a Mozambican Clinical NGO-Centre for Collaboration in Health (CCS). In NAMPULA province Columbia will partner with EGPAF to provide technical assistance and health systems strengthening support. Columbias role will be provision of technical support to all 21 Districts. PF Goals achieved: 1) Scale up CT, PMTCT and ART; 2) Community mobilization and linkages 3) Increase Provincial and District Health capacity; 4) Quality assurance and quality improvement activities. GHI FOCUS AREAS: Expanded access and uptake of quality MNCH services and Strengthening Governance in the Health Sector. Target beneficiaries:7,531 pregnant women receiving ARVs for PMTCT; CT for 62,600 people; and ART to 28,582 patients.

Program costs will reduce by transition of USG programs to provinces and local partners. Transition of CLINICAL services support from Columbia to CSS has begun in Maputo City and Inhambane province. An M&E system captures standard data related to quantity, quality and impact of HIV clinical services, systems strengthening activities, financial accountability and admin management.

Columbia has to date purchased 37 vehicles. In FY12, CDC will monitor and keep records of all vehicle acquisitions. Pipeline analysis showed that this IM is in line with the 18 month standard.

In FY 12, the International Center for AIDS Care and Treatment Programs (ICAP) of Columbia University, Mailman School of Public Health, will continue to provide technical assistance to the Ministry of Health and implementing partners, to ensure the deliver of high quality HIV related services in four provinces of Mozambique, namely, Maputo city, Inhambane, Nampula and Zambezia.

ICAP will leverage existing resources, promoting cost efficiencies, integration of services and capacity building of the health system in these four provinces.

The strategic approach will be to capacity building to CCS (Maputo City and Inhambane) and the DPSs to improve program management and performance of HIV care and support programs to ensure scale-up of services, early access to care and treatment, high quality of services and retention.

To ensure that Pre-ART and ART patients are retained in care, funds provided to Columbia University will be used for:

1. Roll out the Pre-ART package of care and support services to HIV infected patients. This activity will allow better follow-up of patients in care in standardized manner. The objective is to ensure all patients in care, either pre-ART and ART benefit from a comprehensive set of intervention such as diagnosis of opportunistic infections (OIs), provision of cotrimoxazole prophylaxis, TB screening, INH prophylaxis, STI diagnosis and syndromic management, nutrition assessment and counseling (NAC), psychosocial support, adherence support, positive prevention and other services that will contribute to link to and retain patients in care.

To ensure that HIV prevention services are delivered to HIV-infected persons as part of their routine care, funds provided to Columbia University will be used for:

2. Integration of Pre-ART with positive prevention (PP) interventions. In line with the MoH vision, Pre-ART and PP interventions will be integrated. PEPFAR recommends a whole range of interventions that should be offered to all patients in care. Efforts will be done to ensure that at health facility the following 7 interventions are provided(including the data reporting as long as the monitoring and evaluation systems are in place) within the pre-ART package: 1)Condom assessment and risk reduction education ;2) Partner testing and referral;3) STI screening, treatment and partner referral; 4) Family Planning assessment and referral; 5) Adherence assessment and support provision/referral (ie:home-based care, support groups, post-test-clubs);7)Alcohol use assessment and counselling

3. Provincial trainings and supervision to improve the syndromic management of STIs

4. Provide Technical assistance to CCS to scale up `screen and treat` cervical cancer program

5. Train nurses and medical agents in OIs (new guidelines) to ensure appropriate and early diagnosis of and provision of CTX prophylaxis

6. Implementation of universal access of peer educators (PE) support. At central level, ICAP will support the standardization of PE role across all partners, harmonization of the national strategy, curricula development, and reproduction of manuals, guidelines, and tools

All USG-supported treatment partners, including Columbia University, will be funded to implement TB/HIV activities in HIV and TB treatment settings for adults and children. These proposed activities are in line with the MoH priorities and at a minimum will include: 1) Strengthening the implementation of the 3 Is- intensified TB case finding (ICF), Isoniazid preventive therapy prophylaxis (IPT) and infection control (IC); 2) provision of cotrimoxazole preventive therapy (CPT); 3) universal anti-retroviral treatment (ART) for all HIV-infected person who develops TB disease (irrespective of CD4); 4) integration of TB and HIV services including scaling up the implementation of one stop model 5) strengthening of the referral system and linkages with other services (ATS, PMTCT) to ensure that TB suspects are diagnosed with TB and successfully complete TB treatment under DOTS, 6) IC assessment and developing to reduce nosocomial TB transmission in health facilities; 7) ensuring that all key clinical receive training on TB/HIV, and MDR-TB including management of pediatric TB..

Columbia University will develop linkages with the community groups and TB programs and other USG partners to ensure that adherence support is provided to co-infected individuals, and that monitoring and evaluation systems are in place to track HIV-infected patients at the clinics who are screened, diagnosed, and treated for TB.

As part of provincial team Columbia University will continue to participate in the provincial planning, provincial and district technical working groups and in monitoring the implementation of the activities with the DPS and other partners in respective geographic area.

Additionally Columbia University will collaborate with existing TB diagnostic and treatment facilities to ensure that:

1) Minor renovations in out-patients, wards with TB and/or MDR-TB patients, waiting areas, laboratory and X-ray departments to improve cross ventilation will be carried out in selected health facilities.

2) A good laboratory system for sample referral for GeneXpert and including in communication and information system are in place.

3) Clinicians and nurses at provincial and district/rural hospitals are trained to perform sputum induction in children and strengthening evaluation and management of pediatric TB.

4) Motorcycles will be purchased to support supportive supervision to peripheral health facilities, community based DOTs volunteers/activists and to trace defaulters and contacts of TB.

5) Print and disseminate IEC materials

6) Implementation of surveillance of TB among health workers

7) Continuing coordination and collaboration with key partners in the province to identify gaps, avoid duplication and make the rational use of resources.

During FY12 Columbia will support Pediatric HIV care services in Maputo City (for TA and Capacity building to CCS, DPS and DDS), Inhambane and Nampula provinces.

Support for the provision of comprehensive care and support services to HIV exposed and infected children includes: Early infant diagnosis; cotrimoxazole prophylaxis; management of opportunistic infections; growth and development monitoring; nutrition assessment, counseling and support; psycholo- social support. In FY12 Columbia will provide cotrimoxazole prophylaxis to 6326 HIV exposed infants.

The systems strengthening and capacity building activities that will be supported in Fy12 include: in-service training on comprehensive pediatric HIV care, supportive supervisions and mentoring; provision of job aids; and strengthening of commodity, drug and reagent distribution systems within the province

Routine supervision, monitoring and collection of data on infant diagnosis, cotrimoxazole prophylaxis and enrollment in ART programs will be ensured through implementation of QI activities.

Activities promoting integration and linkages of pediatric services with other routine care will be implemented and include:

1) Expanding PICT: - to all hospital admitted children, TB clinics and nutrition services; systematic testing of children of adult patients enrolled on ART;

2) Strengthening the HIV DNA PCR infant diagnosis logistic system, use of cell phone printers technology to transmit test results and reduce the waiting time to HIV diagnosis.

3) Improving referral systems between pediatric Care and treatment and child at risk consultation clinics (CCR):- using escorts (peer educators) for mother/baby pairs between maternity and CCR; in EPI/MCH services, verification of HIV status/ exposure in the child health card and referral for testing and follow up in CCR clinics

4) Integration of HIV in MCH services by including MCH nurses in ART management committee meetings, reviewing patient flow to reduce loss to follow and conducting home visits for HEI within the first month of delivery.

5) Supporting access to malaria and diarrhea prevention assuring storage and distribution of basic care commodities (water purification, IEC materials and soap) and access to ITNs for all children < 5 years;

5) Nutritional assessment and counseling and provision or referral to access therapeutic and supplementary food that is provided through other partners and donors (e.g WFP and UNICEF)

6) Strengthen referral systems between clinic and community services including OVC programs;

Columbia has implemented a few adolescent HIV care activities such as support groups and youth friendly services. The USG will develop a comprehensive strategy on adolescent HIV care including disclosure which will be implemented by clinical partners.

Clinical outcomes are tracked routinely on paper and electronically. Monthly reports are submitted to MoH. Columbia also reports quarterly, semi and annual PEPFAR reports. USG Clinical partners meetings take place every 6-8 weeks to review and analyze performance data.

In FY 2012, ICAP will prioritize health systems strengthening assistance in Maputo City and Inhambane province in the following ways:

Support Pre-Service training for clinical officers, general nurses, MCH nurses, laboratory technicians, and pharmacy technicians from both basic and middle level training programs at the provincial Health Institutes. The goal of this activity is to increase the production of healthcare workers and decrease the numbers who drop out of training due to financial constraints. This activity supports the implementation of the National Ministry of Health Human Resources Development National Plan (2008-2015) and PEPFAR goals of increasing the number of qualified healthcare workers.

Continue to pay for provincial pharmaceutical supply chain advisor positions to support supply chain management of medicines and reagents in the province including improvement of site- and district-level stocks management; incorporate pharmacy supervision visits into joint integrated supervision visits; coordinate with the provincial advisors in other areas, CMAM, MoH laboratory section, and SCMS around bottlenecks or problems with essential commodities, including laboratory reagents; help coordinate and support trainings in collaboration with the DPS and CMAM; collaborate with SCMS and CMAM at central level and participate in CMAM-led pharmacy supervision visits at provinces, districts and sites.

Lab provincial advisors

Continue to pay for provincial Laboratory Technical Advisors positions to support optimal care and treatment to HIV patients. The laboratory advisor will liaise with and coordinate activities with NGOs and partners, MoH, SCMS, APHL, and others. The advisor will identify weaknesses in laboratory processes, procedures, and logistics, propose adequate strategies for improvement, and contribute to a plan towards building capacities at provincial and district levels.

Conduct Minor renovations and rehabilitation of existing infrastructure to support scale up of CT, PMTCT and Care and treatment services including renovations of facility and district pharmacies for improved storage conditions for medicines

Support supply chain & commodities by providing additional support to the supply chain system below provincial level, in collaboration with SCMS and SIAPS. Columbia will provide general support to strengthening quality of pharmaceutical management services, including ARV dispensing services through improved monitoring of the MMIA system, monitoring pharmacies and adherence to standard operating procedures, and participating in joint supervision visits with the DPS/DDS. . Partners will support the expansion of the logistics management information system (SIMAM) to additional districts in line with the SIMAM implementation strategy. This support will also include technical assistance in use of data for decision-making. Columbia will receive funds to support distribution in Inhambane province.

Prevention of medical transmission of HIV is addressed through the MOH Infection Prevention and Control program, which goal is to reduce the risk of transmission of HIV and other blood borne pathogens at health facilities. Activities include: compliance with Infection Prevention and Control/Injection safety (IPC/IS) standards; reinforce of biomedical waste management; Post Exposure Prophylaxis (PEP) to HIV and work place safety. The program started in 2004 with PEPFAR technical and financial support. Since 2010 USG/PEPFAR supported Clinical partners are requested to mainstream IPC/ARE activities at their sites.

In alignment with PEPFAR FY 2012 goals, Columbia will continue to reinforce IPC implementation at their geographic area, including: compliance with IPC standards and guidelines; adequate sharps and other infectious waste disposal; PEP scale-up and M&E; dissemination and implementation of the National waste management plan.

FY 12 Key activities include: 1) Strengthen and expand implementation of PEP services including monitoring and evaluation 2) Strengthen implementation and compliance of IPC standards and support regular measurement of good performance using Standards-Based Management and Recognition approach, and improve M&E system for IPC and work place safety 3) improvement of the waste management system including assessment, implementation and supervision of a non burning waste management system using autoclaves

As part of provincial team ICAP will continue to participate in the provincial planning and district technical working groups and in monitoring the implementation of the activities with DPS and other existing partners in their geographic area.

ICAP will continue its support to MOH through an alignment of FY 2012 activities with overall PEPFAR Counseling and Testing goals and strategies, with a focus on strengthened linkages from HTC to other services.

ICAP will target populations for HTC in health-care setting: provider Initiated testing and Counseling (PICT) for all patients accessing health care services and their partners as well Voluntary CT for all patients wanting to access Ct services with a special focus on men, adolescent girls, partners of PLHIV and couples

ICAP will also be instrumental in the regional CT campaigns planned for FY12 in terms of an efficient and quality driven response to the demand which will be created by the campaign. The target population for the HTC regional campaigns will be mainly partners of PLHIV, couples and men, as these particular groups have had low coverage in years past.

SYSTEM STRENGTHENING AND CAPACITY BUILDING:

Quality assurance is a priority and ICAP will continue using on-going supportive supervision including direct observation approach to be sure that each counselor performs HTC service delivery correctly. Additionally, all of Columbia Universitys counselors will participate in a training designed by the National health Institute to improve the quality of HIV rapid diagnostic testing.

INTEGRATION AND LINKAGES:

Whereas in previous years, counselors simply gave referral slips to HIV positive clients, with COP 12 funds, ICAPs counselors and health care service providers will have a stronger role supporting newly diagnosed clients by personally introducing them to existing peer educator/peer navigator/case manager volunteers who will navigate or escort clients to enroll or register for follow up services, including positive prevention or the new MOH pre-ART service delivery package and support groups. For those newly diagnosed who do not enroll in HIV care and treatment services, CT counselors will continue using the door to door approach to re-visit already diagnosed HIV positive to monitor their enrollment and adherence to recommended treatment and care through the positive prevention or pre-ART support groups. HIV negative clients will be encouraged to bring their partners in for testing and reduce their risk through condom use and partner reduction. Where available, counselors will refer HIV negative men to medical male circumcision services.

MONITORING AND EVALUATION

ICAP will work closely with the USG and partner Strategic information teams to develop and utilize instruments to document and measure CT service uptake as well as service-to-service and facility-to-community linkages to ensure follow-up, retention and adherence of clients diagnosed with HIV.

The USG portfolio on MARPs has been growing in the last year with interventions focused on different population groups, particularly female sex workers and their clients, men who have sex with men, incarcerated populations and injection drug users (IDUs). These population groups (with the exception of IDUs) have been reached through a comprehensive package of information and services that include behavior change, risk reduction activities and bio-medical interventions. In the coming year, more attention will be given to exploring innovative ways to increase the number of MARPs using care and treatment services in order to ensure linkages between prevention and clinical partners including humanization of care and treatment services for MARPs through dissemination of national guidelines for care, treatment and follow-up with the goals of reducing and removing barriers to the access of services and information and decreasing stigma and discrimination of MARPs. In coordination with the prevention partners in the province of Inhambane, the activities will include the strengthening of linkages between community and care and treatment facilities through the establishment of effective referral mechanisms with functioning tracking systems in place (referral charts, monitoring instruments). Activities might also include support the implementation of surveillance system at designated night clinics (to be determined by Ministry of Health after approval of protocol and data collection forms) for FSW and other MARP groups in order to provide much needed qualitative and quantitative information around specific MARPs needs in the clinical setting. In addition, collaborate in the training of clinical partners and health center staff on appropriate STI diagnosis, treatment and MARP friendly services and provide support to the clinical interventions for HIV/STI prevention and care, based on local protocols.

Additionally, this IM receives Central GBVI funds.

Columbia priorities in FY 2012 is coordination with MOH for accelerating the scale up of effective PMTCT interventions within an integrated maternal, neonatal and child health (MNCH) system towards the goal of virtual elimination of mother-to-child transmission of HIV by 2015.

In FY2012 Columbia will support the following activities:

1) Prevention of HIV in women of childbearing age:

a. Re-enforce provider initiated counseling and testing for women and couples in all components of MCH services;

b. In coordination with community partners, develop IEC activities and promote health fairs focusing in areas with high concentration of women.

2) Prevention of unwanted pregnancies among HIV+ women:

a. Re-enforce targeted family planning and contraception for HIV+ women in both HIV care and treatment as well as FP settings;

b. Integration of family planning component in routine mobile brigades;

3) Prevention of mother-to-child transmission

a. Scale up training of Option A;

b. Scale up exposed child follow up to all facilities with PMTCT services;

c. Develop strategies to increase institutional delivery.

4) Care and support for HIV+ women, infants and families:

a. Training of MCH nurses for provision of ART in ANC settings;

b. Increase delivery of ART to eligible HIV+ pregnant women and infected children;

c. Support positive prevention and family planning at HIV care and treatment sites;

d. Scale up mothers support groups interventions and community involvement.

Additionally, Columbia will support implementation of the following cross cutting activities:

5) Develop interventions to strengthen capacity of networks, civil society and support groups of women living with HIV. Collaboration with communities and traditional birth attendants to increase facility-based deliveries.

6) Develop interventions to ensure continued availability of supplies and commodities for PMTCT;

7) Support PMTCT related training activities;

8) Nutrition - safe infant nutrition interventions integrated into routine services;

9) Support dedicated personal with M&E expertise to directly work with DPS and health facilities for ensuring quality M&E system; support roll out of new M&E tools; support implementation of supervision, QA/AI cycles, strengthening data flow and data entry at facility level.

Columbia supports adult ART services in Maputo City, Inhambane and Nampula provinces.

Priority areas are increased treatment access; ART retention; ART Quality assurance; program linkages and integration especially with CT, TB, PMTCT, nutrition, pre-ART services, and prevention with positives

Programmatic efficiencies are increased by deployment of multi-disciplinary teams of clinicians, psychosocial support, M&E to provide technical assistance in ART program management and capacity building in finance and administration management to site and district health teams. Each team is assigned to 3-4 districts.

The strategies that will be employed to address these challenges are:

Intensification of couple counselling and testing and recruitment strategies to include family members of index cases (spuoses and children)

Universal ART for TB/HIV co-infected patients

Implementation of the 350 cells/mm3 CD4 count threshold

Test and treat strategy for all HIV-infected pregnant women accessing antenatal care at ART sites, irrespective of CD4 count; recruitement of husbands/partners of HIV infeceted pregnant women

Scale-up of Community Adherence and Support Groups

Community drug distribution

Standardizing and universalizing peer educators in all supported health facilities

Standardized quality improvement program

Scale-up of POC CD4 count technology

Implementation of a pre-ART package

Additional task-shifting to include nursing cadres and medical assistants

Gender distribution of access to treatment shows that currently about 66% of patients on ART are female. there are also comparatively more females testing HIV positive than men. Continued efforts to promote family centred approached to treatment and care will be promoted to ensure gender equity in access to service.

On-site peer educators and follow-up of patients using community volunteers, electronic patient tracking systems, diary/agenda systems and home visits are conducted to trace defaulters or lost to follow up cases and to improve retention rates. The peer educator program will be standardized in all sites in FY12.

The following are systems strengthening and capacity building activities supported by Columbia:

1) DPS sub agreements to finance staff priority activities

2) Task shifting ART to nurses, middle-level health and mentoring of providers

3) Hire provincial Clinical Advisors for Maputo City and Inhambane province.

4) Joint Columbia/DPS supervision visits that are linked to Continuous Quality improvement (CQI) program activities.

5) Participate in development and implementation of a national QI system. Columbia participates in the periodic HIVQUAL program activities

In FY12 clinical services management responsibility in Maputo City and Inhambane province shall transfer from Columbia to Centres for Collaboration in Health (CCS). Columbia shall provide managerial capacity building to DPS, districts and to CCS.

In Nampula province Columbia shall provide site level clinical technical assistance while EGPAF will provide all Systems strengthening support.

Clinical outcomes are tracked routinely on paper and electronically. Monthly reports are submitted to MoH. Columbia also reports quarterly, semi and annual PEPFAR reports. USG Clinical partners meetings take place every 6-8 weeks to review and analyse performance data.

During FY12 Columbia will support Pediatric ART services in Maputo City (for TA and Capacity building to CCS, DPS and DDS), Inhambane and Nampula provinces.

Scale-up of pediatric HIV is a national priority that Columbia will support MoH work towards including ensuring implementation of new guidelines within supported provinces, districts and sites. Columbia will support sites to achieve pediatric new ART enrollments rates of at least 15% of all new patients on treatment and ART retention of 85%.

Activities to expand pediatric enrollments and access to diagnostic services include:

1) improving patient flow and specimen referrals to increase access to EID

2) POC CD4 testing

3) Implementation of continuous quality improvement programs

4) early initiation of treatment

5) Active case finding model

6) Improved pediatric testing and linkages between services (i.e.: TB, MCH, inpatient wards etc)

7) Increased community awareness of the importance of testing children and accessing care early

The systems strengthening and capacity building activities that will be supported in FY12 to enhance capacity of sites and health care providers include: in service training on pediatric HIV care and treatment, supportive supervisions and mentoring; provision of job aids, implementation of new national Pediatric Treatment Guidelines; assistance in monitoring stocks of ARV drugs and support distribution systems within the province.

Routine supervision, monitoring and collection of data on pediatric treatment will be ensured through implementation of QI activities, Patient tracking systems and strengthening of district and provincial ART management committees.

The USG will develop a comprehensive strategy on the management of HIV-infected adolescents which will be implemented and supported by the clinical implementing partners.

Adherence and retention strategies are provision of psychosocial support, improved quality of care, caregiver counseling, support groups, and community follow up. There will also be emphasis on the importance of disclosure.

Strategies to ensure increased integration and linkages of HIV services with the existing child health and other programs to reduce loss to follow and improve retention include: prioritization of children in ART clinics, assuring same day consultations for mother and child in PMTCT services, developing formal referral systems between ART clinics with TB, PMTCT, Counseling services, CCR and EPI programs and with the community; ART initiation within CCR clinics.

Clinical outcomes will be tracked routinely on paper and electronically. Monthly reports will be submitted to MoH as well as quarterly, semi and annual PEPFAR reports. USG Clinical partners meetings take place every 6-8 weeks to review and analyse performance data and the TBD partner will also partcipate in these meetings.