Centre for Collaboration in Health (CCS) is a is a newly formed Mozambican organization that first received PEPFAR funding in 2011 to support HIV programs in Maputo City. CCS has taken over TA and support to all sites and (urban) districts that were previously supported by Columbia University via the Track 1 mechanism. FY12 funding will enable CCS to further expand its activities to Inhambane Province as the Clinical TA partner, replacing Columbia University in 9 districts. The GOAL is to increase access to quality HIV prevention, care and Tx using evidence-based approaches. Key activities are: in-service trainings, supportive supervision, case reviews, patient follow up, tracking and implementation of QU activities. The PF GOALS include Scale up CT, PMTCT and ART; Community mobilization and linkages Increase Provincial and District Health capacity; and QA and QI activities.

GHI Focus areas are expanded access and uptake of quality MNCH services. CCS has no prior expenditure analysis. This new agreement is stepping stone towards transitioning programs to local partners which will likely lower costs related to program implementation compared to international partners. However, CCS has no prior experience in managing programs in this area, therefore a phased transition that includes regular assessments of partner performance, and program management capacity and financial accountability has been adopted. Program costs will also reduce by transition of USG programs to provinces and local partners. An M&E system captures standard data related to quantity, quality and impact of HIV clinical services, systems strengthening activities, financial accountability and administrative management.

PURCHASE OF VEHICLES: In Year 1 CCS did not yet purchase any vehicles.

In FY 12, the Center for Collaboration in Health (CCS) will support the Ministry of Health in implementing HIV related services in Maputo city, and Inhambane province.

In line with the GOM, CCS will leverage existing resources, promoting cost efficiencies, integration of services and capacity building of the national health system. The strategic approach for scale-up and sustainability of the programs will focus on strengthening the provision of facility-based continuum of care that is appropriately linked to community based care and support to those in need.

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

1) Roll out the Pre-ART package of care and support services to HIV infected patients. This activity will allow a better follow up of patients in care in standardized manner. The objective is to ensure that 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.

2) Integration 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)condoms (assessment of sexual activity and provision of condoms (and lubricant) and risk reduction counseling);) Partner testing (assessment of partner status and partner testing provision or referral);3) STI (assessment for STIs and (if indicated) treatment/partner treatment provision or referral (including TB);4) Family Planning (assessment of FP/PMTCT needs and (if indicated) family planning services provision or referral);5) Adherence(assessment of adherence and (if indicated) support or referral for adherence counseling;6) Support(assessment of need and (if indicated) refer or enroll PLHIV in community-based program such as home-based care, support groups, post-test-clubs);7)Alcohol (use, assessment and counseling).

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

1) Provincial trainings and supervision to improve the syndromic management of STI

2) Scale up of the `screen and treat` cervical cancer program

3) Trainings on OIs (new guidelines) for nurses and medical agents to improve the diagnosis and provision of cotrimoxazole prophylaxis.

To ensure that patients are linked from facility-based to community-based programs and vice-versa funds provided to CCS will be used for:

1) Implementation of universal access of peer educators (PE) support.

All USG-supported treatment partners, including CCS, 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..

In addition CCS 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 CCS 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 CCS 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 CCS will support Pediatric ART services in Maputo City and Inhambane province. In these geographic regions, Columbia University will provide TA and Capacity building support to CCS.

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 CCS will provide cotrimoxazole prophylaxis to 4,517 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

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. CCS also reports quarterly, semi and annual PEPFAR reports. USG Clinical partners meetings take place every 6-8 weeks to review and analyze performance data.

MOH has placed increasing focus on strengthening human and technical resources at the provincial level to improve the coordination and delivery of services in the province. In FY 2008, MOH developed a standard set of technical advisor positions to be placed at the Provincial level; these four positions included advisors in Clinical Care, Laboratory, Pharmacy, and Monitoring and Evaluation (M&E).

USG was asked to assist with the funding and recruitment of these positions at the provincial level. The primary partner responsible for providing technical assistance in the area of clinical services in a province will also be responsible for the recruitment and support of the four technical advisor positions, including this Monitoring and Evaluation Technical Advisor position. Recruitment has begun for these positions; USG will support training of these Advisors through another USG supported partner (South to South collaboration with Brazil).

The role of the M&E Provincial Advisor is to provide support in the coordination of routine activities related to monitoring and evaluation at the Provincial Directorate of Health, giving priority to endemic diseases, including HIV. This advisor will help to reinforce and support the implementation of the decentralization of HIV services including related data collection systems. S/he will provide leadership in the supervision and management of data to ensure the quality of data at the district and site level, help to strengthen the flow of data to the district, provincial, and central levels. Additionally this person will support the Provincial Directorate of Health in the analysis and dissemination of data (for example, to the site level, Ministry of Health, and partners.) This person will sit within the Provincial Department of Planning and Cooperation at the Provincial Directorate of Health.

In FY 2012, CCS 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.

Support supply chain & commodities by providing additional support to the supply chain system below provincial level, in collaboration with SCMS and SIAPS. CCS 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.

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, CCS 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 CCS 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.

CCS 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.

CCS 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 as Voluntary CT for all patients wanting to access CT services with a special focus on men, adolescent girls, partners of PLHIV and couples

SYSTEM STRENGTHENING AND CAPACITY BUILDING:

Quality assurance is a priority and CCS 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 CCSs 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, CCSs 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

CCS 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.

CCS 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 CCS 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 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, CCS 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.

CCS supports adult ART services in Maputo City and Inhambane province in the following priority areas: 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.

In FY 12, the top three priorities of the Adult treatment portfolio are:

1. Treatment scale-up

2. Improving retention of patients enrolled in care and already on ART

3. Monitoring and improving the quality of services being provided to HIV-infected patients

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

Intensification of testing and recruitment strategies

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

Mobile clinics to bring services closer to patients living in rural isolated areas

Scale-up of Community Adherence and Support Groups

Community drug distribution

Standardizing and universalizing peer educators in all PEPFAR 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

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 reported 12 month retention on treatment at sites previously supported by Columbia University and which CCS will begin to support in FY11 was 80% (SAPR11). 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.

The following are systems strengthening and capacity building activities that will be supported by CCS:

1) Task shifting ART to nurses, middle-level health workers and mentoring of health service providers

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

3) Participate in development and implementation of a national QI system. CCS 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 continue to provide managerial capacity building to CCS in these geographic regions.

In Maputo City and Inhambane province CCS shall provide site level clinical technical assistance while Columbia will provide all Systems strengthening support to the DPS

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

During FY12 CCS will support Pediatric ART services in Maputo City and Inhambane province. In these geographic regions, Columbia University will provide TA and Capacity building support to CCS.

Scale-up of pediatric HIV is a national priority that CCS will support MoH work towards including ensuring implementation of new guidelines within supported provinces, districts and sites. CCS 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%. The following are the expected pediatric treatment targets for the next two years: FY12- 893 new patients and 3,533 ever on treatment and FY13 1,071 new patients and 4,074 ever on treatment.

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) An active case finding model

6) Improved 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.

CCS has implemented a few adolescent ART activities such as support groups and youth friendly services.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.