PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Subdivisions of Program Areas, these track general higher level sub-classifications of expenditure.
Subdivisions of Major categories, these are the most detailed expenditure data.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008
In COP07, APIN supported PMTCT services at 32 sites. COP08 funding will support a comprehensive
PMTCT program in line with the revised National PMTCT Guidelines (2007), at 36 service outlets in 9 states
(Benue, Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). "Opt-out" counseling and testing
(HCT) with same day test results will be provided to all pregnant women presenting for ANC including labor
and delivery. The current level of PMTCT opt-out testing and counseling uptake from women presenting for
ANC or delivery is 90%. All women are provided posttest counseling services on prevention of HIV infection
including the risks of MTCT. They are encouraged to bring partners and family members for HCT. The
program has a target of providing HCT with 70,000 receiving results. A full course of ARV PMTCT
prophylaxis will be provided to approximately 5,475 women. All ART ineligible women will be enrolled into
long term palliative care following the completion of ART prophylaxis. Palliative care services include onsite
enrollment or referrals for family planning services. In addition, for all women, PMTCT services are
integrated into a system of OB/GYN services designed to promote maternal and child health. 2,190 ART-
eligible HIV-infected women will be provided with ART treatment for their own disease following the National
PMTCT Guidelines (2005). As a result, APIN+ will provide basic care and ART prophylaxis to 5,475 HIV-
exposed infants. Children who remain uninfected following the completion of ART prophylaxis will be
provided with care services under OVC activities. Infant follow-up care linked with PMTCT activities
includes Early Infant Diagnosis (EID), nutritional support, growth monitoring, cotrimoxizole prophylaxis and
other preventative care services.
ART sites will provide downward referrals to secondary and primary sites for continuity of care. Counseling
on infant feeding options begins in the antenatal period following the National PMTCT and Infant Feeding
guidelines. Infant feeding counseling will be performed in an unbiased manner and women will be supported
in their choice of method. Clients will also be counseled on the beneficial effect of couple/partner
HCT/disclosure on adherence to infant feeding choice. A follow-up team consisting of counselors and a
support group of PLWHAs will assist in home and community tracking of positive mothers to provide
nutritional support and ascertain infant diagnosis. Infants at all sites are diagnosed and monitored for ART
eligibility by HIV DNA PCR and CD4 testing respectively, which are performed at tertiary care sites. APIN
will actively participate in the National Early Infant Diagnosis Initiative and scale-up by providing DNA PCR
testing of dried blood spots (DBS) at APIN supported laboratories. The source of DBS samples will include
APIN and non-APIN supported PMTCT sites. Through implementation of the 2007 National PMTCT
Guidelines, APIN+ aims to reduce MTCT substantially from the current 10-12% rate. This funding will
support the ANC, labs, ARV prophylaxis intervention to mothers and babies (not HAART), and personnel
involved in PMTCT.
In addition to program monitoring through electronic data capture, during COP08 APIN+ will develop and
implement a QA/QC program. The program will utilize electronic data captured through the SI activities to
measure the quality of services provided and associated patient outcomes.
A regular training program will be established at all sites to train and retrain health personnel (430) involved
in the PMTCT program in the National PMTCT curriculum. Indirect targets include training Traditional Birth
Attendants (TBAs) (using an adapted curriculum) in local areas near sites in PMTCT counseling, training
PMTCT counselors in the National PMTCT program, providing technical assistance for the development of
the National Infant Feeding counseling manual, and providing a zonal training of trainers with this manual.
This training supports PMTCT efforts at all National PMTCT centers; APIN proposes that all pregnant
women tested and receiving results at National PMTCT sites are indirect targets.
APIN will partner with other IPs in the implementation of the PEPFAR-Nigeria LGA coverage strategy in the
program areas of PMTCT and TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in
at least one health facility in every local government area (LGA) of 6 identified states. Per patient costs
reflect the expansion to at least 8 new sites and scale up as a part of this LGA coverage strategy in Plateau
and Lagos states. Under the coverage strategy, these facilities are all linked with primary health facilities
which provide HCT and referrals for PMTCT services for HIV infected mothers. Harvard will leverage
UNICEF support in capacity building/training in identifying new PMTCT sites in its scale up plans.
CONTRIBUTIONS TO OVERALL PROGRAM AREA
Through the PMTCT program, APIN will provide HCT with test results to 70,000 pregnant women.
Additionally, treatment and prophylaxis will be provided to 5,475 pregnant women. Implementation of the
National PMTCT Guidelines in 36 sites (old and new) contributes to the PEPFAR goal of expanding ART
and PMTCT services. Site numbers have increased by adding secondary and primary level sites in the
radius of APIN+ tertiary care institutions which will continue to build the network capacity and coverage in of
target states. Counseling will encourage mothers to bring their partners and family members for testing, to
reach discordant couples and expand the reach of HCT, based on the PEPFAR 5-year strategy. This
program is implemented in geographically networked sites to optimize training efforts and provide
collaborative clinic/lab services as needed. APIN+ will train and retrain 430 health care personnel from the
PMTCT sites, including doctors, nurses, and counselors. Training will build capacity at local sites to
implement PMTCT programs and provide essential treatment support to pregnant women with HIV/AIDS.
Capacity building efforts are aimed at future expansions of PMTCT programs. Quality assurance and
control will be carried out through personnel training, data collection from sites for monitoring and evaluation
and supervisory visits from key program management staff, which may include representatives from the
USG and GON.
LINKS TO OTHER ACTIVITIES
This activity is also linked to counseling and testing (5424.08), OVC (5415.08), ARV Services (6715.08), AB
(15652.08), condoms/other prevention (9216.08), blood safety (6489.08), injection safety (6818.08) and SI
(#3.3.13). Pregnant women who present for HCT services will be provided with information about the
PMTCT program and referred to the PMTCT program if they are eligible for these services. ART treatment
services for infants and mothers will be provided through ART Services. Basic pediatric care and support,
including TB care, is provided for all infants and children through our OVC activities. All exposed infants
identified through PMTCT services will be linked to these OVC services. Pregnant women are at high risk
for requiring blood transfusion. Personnel involved in patient care will be trained in universal precautions as
a part of injection safety activities. Additionally, these activities are linked to SI, which provides support for
monitoring and evaluation of the PMTCT activities and QA/QC initiatives.
Activity Narrative: POPULATIONS BEING TARGETED
In addition to providing PMTCT services for HIV infected pregnant women and girls on HAART for testing
and prophylaxis, this program also targets women who may not know their HIV status and may be at
greater risk for MTCT. Furthermore, it seeks to target infants, who are most at risk of becoming infected
from an HIV positive mother during the antepartum, intrapartum and postpartum periods. Through the
counseling and testing components, APIN seeks to target a broader group of adults by encouraging women
to bring their partners and family members in for HCT. Furthermore, training activities will train public and
private health care workers on the implementation of PMTCT protocols and HIV related laboratory testing.
KEY LEGISLATIVE ISSUES
The program will increase gender equity by specifically targeting pregnant women, girls and their male
partners for HCT and PMTCT prophylaxis. Data collection on PMTCT regimens provides a basis for
developing strategies to ensure that all pregnant women have access to needed and optimally effective
PMTCT services. This program addresses stigma and male norms and behaviors through the
encouragement of partner notification and bringing other family members in for HCT. Infant feeding
counseling, including on the appropriate use of exclusive breastfeeding or BMS where AFASS is available,
will be in line with the National PMTCT Guidelines. Referrals to Income Generating Activities (IGAs) will also
be provided to women as a part of palliative care and counseling activities.
This activity will place major emphasis on the development of networks through expansion into more local
areas through a network of secondary or primary PMTCT clinics with rural outreach to community
healthcare workers involved in home delivery, which are linked to tertiary health care facilities. In addition,
major emphasis will be placed on building organizational capacity in order to work towards sustainability of
PMTCT centers and further expansion of the Nigeria PMTCT program. These system strengthening
activities are led by local investigators at current PMTCT sites who participate in new site assessments,
overseeing QA/QC, capacity development and training for new PMTCT centers. Minor emphasis is placed
on performing targeted evaluations of PMTCT interventions, to estimate the rate of transmission with each
of the ART treatment and prophylaxis courses.
Harvard/APIN+ will be a new partner in the program area of Abstinence/Be Faithful (AB) in COP08. APIN+
will implement its AB programming activities in line with the overall PEPFAR Nigeria goal of providing a
comprehensive package of prevention services to individuals reached (thereby improving the effectiveness
of this messaging) through a balanced portfolio of prevention activities including condoms and other
prevention(funded under that area). Through the involvement of APIN+ as a new partner in this activity
PEPFAR Nigeria will extend its reach with AB services as APIN+ will be active in 8 states (Benue, Borno,
Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe) by the end of COP08. Through its other program areas APIN+
has a large population of HIV+ adults, adolescents and children to which it is already providing services; this
group forms part of the core target population for AB messaging that is provided by APIN+ through its
prevention with positives activities funded under care. In addition, APIN+ will target activities to HIV negative
persons in its catchment areas in order to minimize their risk behaviors and contribute to an overall
reduction in HIV prevalence. A key age group for AB activities is youth/young adults aged 15-24 years as
this encompasses the highest prevalence age group. The 2005 ANC survey in Nigeria indicates that among
age cohorts in Nigeria, the 20-29 year old age group has the highest HIV prevalence (4.9% compared to a
national prevalence of 4.4%). In addition, the 2005 National HIV/AIDS and Reproductive Health Survey
(NARHS) demonstrated a low risk perception (28%) among the general population and significant reports of
transactional sex (11%) among young women aged 15-29 years. This age cohort for both men and women
represents the working age group in Nigeria; it is expected that a combination of prevention messaging
approaches will ensure they are reached with prevention interventions.
In COP08 APIN+ will implement this activity at both the facility and community levels to reach its target
group with a minimum of three interventions. APIN will ensure that each beneficiary is reached through
community awareness campaign, peer education models and peer education plus activities within the year.
Activities conducted at the local level by APIN+ will be reinforced through national level mass media
campaigns by other USG partners such as the successful Zip-Up campaign. APIN+ will target the general
population within catchment areas of current care and treatment services. AB messages promoting
abstinence, mutual fidelity and addressing issues of concurrent and multiple sexual partnerships will be
balanced with concurrent condoms and other prevention messaging where appropriate and will be
integrated with treatment and care services in current and proposed expansion sites totaling 40 sites (facility
based comprehensive care sites, PMTCT sites, and HCT sites with their surrounding communities) in 9
states. Targets to be counted will be those individuals that were reached on a regular basis with the three
strategies APIN+ will employ .The target for this intensive AB messaging campaign is 6,400 individuals. In
addition, age appropriate abstinence only messaging and secondary abstinence messaging will be
conveyed to 3,200 children and adolescents, particularly focused on those orphans and vulnerable children
receiving both facility and home based support. A total of 380 health care providers, counselors, and peer
educators will be trained to conduct effective prevention interventions inclusive of AB messaging.
APIN+ collaborates with a community based organization (CBO) and with PLWHA support groups at its
facilities and surrounding communities in other PEPFAR programming activities. These support groups and
this CBO will also serve as appropriate partners in the dissemination of ABC messaging to other PLWHA
utilizing the peer education model, and to wider audiences through the peer education plus model and
community awareness campaigns. To address stigma issues and in compliance with the GIPA principle,
approximately 10 PLWHA from the pool of those receiving treatment at facilities who are living openly and
positively will be trained using the peer education model on dissemination of ABC messaging. They will
serve as peer educators to extended family members and members of their support groups. These trained
PLWHA will in turn reach individual cohorts of at least 10 other persons from among their social peers. With
36 treatment facilities (including PMTCT sites), this will serve as an effective tool for reaching individuals in
at least as many communities with balanced ABC messages.
A community awareness strategy will also be employed to serve the catchment areas of the hospital
facilities which will be linked with community mobilization efforts promoting HCT. During static and mobile
HCT services, counselors will be disseminating balanced ABC messages to recipient communities and
clients through focused group discussions and interpersonal communication. With an HCT target of 78,500
clients getting counseled, tested and receiving their results, a minimum of this many clients will receive
balanced ABC messaging through this approach. The key messages that will be conveyed are delay in
sexual debut, secondary abstinence, mutual fidelity, prompt and complete treatment of all STIs and
promotion of need to ascertain HIV serostatus through HCT.
APIN+ will also implement the peer education model targeting job peers who are healthcare workers.
Healthcare workers at each site will be trained (the exact number will vary based on facility size) using
established National peer education curricula and each will be requested to form peer groups of
approximately 10 members from the healthcare worker community for dissemination of balanced ABC
messaging. It is anticipated that these healthcare workers will continually serve as conduits for age
appropriate prevention messaging not only for their work peers but also for their social peers and for all
clients with whom they come in contact.
A focus of the program in COP08 will be improvement of the integration of prevention activities into the HIV
care and treatment settings; specifically, healthcare providers and lay counselors in care and treatment
settings will be trained to appropriately deliver integrated ABC prevention messages and incorporate the
messages into routine clinic visits using IEC materials and job aids. An appropriate balance of abstinence,
be faithful, and correct/consistent condom use education will be tailored to the needs and social situation of
each individual client in its presentation. In addition to the integration of such services into the HIV-specific
treatment setting, prevention activities will be assimilated into other points of service in each health facility
(general outpatient clinics, emergency services, etc.), particularly into reproductive health services
including, family planning counseling, sexually transmitted infection management and counseling, and risk-
CONTRIBUTIONS TO OVERALL PROGRAM AREA:
APIN+ AB activities emphasize integration of prevention activities with treatment and care services. Use of
the community awareness campaigns, the peer educator model, and peer education plus activities
(community drama, dance events, etc.) allows dissemination of AB messaging, including integration with
condom messaging, from society-attributed sources of credible information - healthcare workers and
Activity Narrative: PLWHA. This program will contribute to the Global HIV/AIDS Strategy by reaching 6,400 people with AB
messaging and 3,200 people with abstinence only messaging in a comprehensive approach. The activities
will also address issues of stigma and discrimination through the education of individuals and communities
LINKS TO OTHER ACTIVITIES:
AB activities relate to HCT (5424.08), by increasing awareness of HIV. It also relates to care and support
activities (5369.08) through dissemination of information by home based care providers and ultimately by
decreasing demand on care services through decreased prevalence. Linkages also exist to condoms and
other prevention (9216.08) as a complementary prevention strategy and to OVC programming (5415.08) by
targeting orphans and vulnerable children.
Key populations targeted are the healthcare community in treatment facilities, PLWHA, youths and adults
accessing HCT services at either static or mobile within catchment areas of the treatment sites, support
group members and immediate families of PLWHA. Other target populations include discordant couples,
pregnant women and religious leaders.
AB programming emphasizes local organization capacity building, human capacity development and efforts
to increase gender equity in HIV/AIDS programs.
AB activities promote a rights based approach to prevention among positives and other vulnerable
members of society and equal access to information and services. Reduction of stigma and discrimination
are also key to the program.
This activity will support capacity development for blood safety (training and equipment), blood bank
screening for HIV and other TTIs, universal precautions and good lab practices, waste management, and
QA/QC for HIV serologic testing. The funding will support the building of infrastructure and capacity for high-
quality blood bank and transfusion practices, the support of counseling and laboratory personnel and their
training. Capacity for high-quality blood transfusion services at seven APIN+ supported ARV centers will be
increased through linkages between blood banks at these APIN+ sites and NBTS Zonal Centers. This
activity will support the infrastructure development, laboratory training, HIV counseling training and
replacement laboratory equipment to supported facilities.
In COP08, APIN+ will work closely with the National Blood Transfusion Service (NBTS) and Safe Blood for
Africa Foundation (SBFA) in all aspects of its blood safety program. APIN+ will support the NBTS in
implementing its primary objective of migrating fragmented hospital-based blood services to centralized
NBTS-based blood services nationwide. A key feature of this program is the development of a nationwide
voluntary donor recruitment system (VDRS). At APIN+ supported facilities NBTS will provide TA for blood
donation drives and SBFA will train nurses and medical laboratory scientists in recruitment strategies to
create repeat voluntary blood donors from the ranks of current family replacement donors. In this plan
APIN+ will be instrumental in working with hospital management and staff at all comprehensive sites to
participate in the NBTS blood services program, to create support of blood donor organizers, and to
strengthen health facility and community focused blood drive activities. Each of the 28 APIN+ sites that
have blood transfusion services will be technically supported so that HIV testing using the National testing
algorithm for HCT is conducted in the pre-donation setting. Data on patients provided with HCT through
these activities will be captured and analyzed through APIN+ SI activities. All donors will be prescreened
using the NBTS screening questionnaire and donors may be deferred based on their responses. APIN+ and
its supported facilities will establish and coordinate a regular QA/QC program to ensure that HCT testing in
the blood donor setting meets national and international standards. It is expected that these improvements
in the donor screening and blood collection practices will result in the safe collection of 15,000 units of
Linkages to NBTS Zonal Centers will occur through strengthening of ongoing collaborations. APIN+ works
in a range of secondary and tertiary facilities that do blood transfusions, some of which are already utilizing
a combination of ELISA and rapid testing for the four transfusion transmissible infections (TTIs) of HIV I and
II, hepatitis B, hepatitis C and syphilis and are resistant to moving their current blood screening practices to
NBTS. APIN+, NBTS and SBFA will continue to promote the benefits of NBTS-screening to the
management and hematology departments of these facilities, however they will not be chosen during
COP08 as NBTS-linked blood banks. APIN+ will facilitate the development of an NBTS/hospital blood
exchange program at seven health facilities that will be selected based on supportive management,
proximity to a zonal NBTS office, availability of blood banking facilities, laboratory infrastructure and other
resources. This linkage will include regular delivery of donated units of blood to NBTS for screening in
conjunction with a regular delivery of screened units of blood back to the facility. NBTS will pick up
unscreened blood units that these seven hospitals have appropriately collected and stored and will transport
these units back to NBTS centers where they will be screened for the four TTIs using ELISA techniques. In
addition to collecting unscreened units, NBTS will deliver to these seven hospitals their requested order of
screened units for blood banking and use at the facilities as well as a supply of blood bags for blood
collections. NBTS will also provide monthly feedback on rates of the four TTIs found by ELISA screening of
blood units collected by each facility. It is expected that through this NBTS blood banking system 3,500
units of blood will be sent to NBTS for screening.
APIN+ will identify appropriate staff for training by SBFA who, in turn, will utilize standardized training
modules that are approved by NBTS and appropriate to the various levels of trainees. APIN+ will refer a
total of 35 doctors, nurses, and lab workers at supported sites to SBFA for training related to blood safety.
In order to avoid double counting, these 35 targets are counted under the SBFA blood safety narrative.
APIN+ will in turn coordinate step down training of 350 staff from its supported sites in counseling, universal
precautions, good laboratory practices, and lab safety as related to blood transfusion practices. A focal
person within APIN+ will be identified for blood safety. QA/QC activities will include site M&E and personnel
trainings on proficiency in HIV testing, universal precautions, and good laboratory practices. All sites will be
provided with copies of the National Blood Policy, operational guidelines for blood transfusion, SOPs and
job aids to support blood safety activities.
This activity will promote the principles of Universal Safety Precautions, such as the reduction of
unnecessary transfusions, exposure to blood, accidental injury/contamination as well as the essential
consumables and services that protect health care workers from contracting infections, especially HIV.
These universal precaution materials will include personal protective equipment such as hand gloves,
laboratory coats, masks, and other essential consumables for each site. Additionally, each site will make
provisions for the referral of staff for access to post exposure prophylaxis (PEP) when needed. PEP will be
provided through ART drugs activities. Proper waste management will be encouraged at each site through
the use of biohazard bags, suitable sharps containers, and the use of incinerators.
CONTRIBUTION TO OVERALL PROGRAM AREA:
This activity will provide support for seven service outlets at tertiary health care facilities. Individuals will be
trained in counseling and testing and blood bank safety protocols and linkages will be created with the
National Blood Transfusion System. The emphasis on infrastructure building within this program is
consistent with the PEPFAR five-year goal of providing technical assistance for the development of site
specific blood safety policies, protocols and guidelines. Furthermore, it is consistent with the goal of
ensuring a safe, effective and nationally coordinated blood program that provides blood free of the four
LINKS TO OTHER ACTIVITIES:
This activity relates to activities in counseling and testing (5424.08). All blood donors will be screened with
donor questionnaires and provided with full HCT. The universal precaution processes put in place at the
blood bank screening centers will also enhance blood bank workers knowledge on best practices for high
quality HIV testing and the proper procedures for handling of blood specimens throughout the blood banking
protocol. These activities are also linked to our injection safety activities (6818.08) and laboratory
infrastructure (6716.08) through the promotion of universal safety precautions, good laboratory practices,
Activity Narrative: and proper waste management for biohazardous materials.
POPULATIONS BEING TARGETED:
This activity targets adults and particularly, blood donors, aged 18 and above. Additionally, it targets public
health care workers and laboratory workers for training in HIV testing techniques and proper universal
precautions in the handling of blood specimens.
This activity emphasizes upgrading the infrastructure of participating hospitals and their laboratories and
blood banks through training and minor renovation to effectively link up with the NBTS and contribute to the
nationally coordinated blood banking system. In order to develop human capacity, there will also be
emphasis on in-service training of laboratory workers and public health personnel in the implementation of
recruitment of VNRD and safe blood activities. This will also be achieved through quality assurance and
supportive supervision of trained staff. Strategic information will be emphasized in the collection of data
surrounding transfusions done at the site level. Lastly, this program will develop the capacity of local
organizations (blood banks in hospitals) to participate in national blood safety activities. It is expected to
promote awareness about safe blood practices in the communities and indirectly increase the number of
volunteers available for blood donations.
By the end of COP07, APIN+ will be conducting injection safety activities along with other PEPFAR
programs at 16 sites. In COP08, this will increase substantially to 28 sites in nine states (Benue, Borno,
Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). This activity provides the initiation of intensive training
program in injection safety practices for health care workers at 28 of the high volume APIN+ comprehensive
sites, including 11 tertiary and 17 secondary health care facilities. As HIV/AIDS care and treatment
programs are scaled up under the PEPFAR goals, it is critical that the capacity of partners be built to
provide such care in a medically safe environment. This includes education on appropriate practices to
diminish the risks of medical transmission. In HIV endemic settings, health care facilities need to discuss
and adopt policies that address the risks of HIV medical transmission and methods that can be used to
mitigate these risks. In this vein, at all APIN+/PEPFAR sites, a minimum package of safe injection activities
is provided, which includes needle disposal containers, vacutainers and basic educational materials for
staff. APIN+ also provides ongoing training efforts in universal precautions that have been a part of the
continuing education of health care workers. Through this ongoing training in universal precautions, staff
are encouraged to use personal protective equipment such as hand gloves, laboratory coats, vacutainers,
masks, and other essential consumables in order to protect themselves and other patients from exposure to
blood and other bodily fluids.
In COP08, a focus of the trainings provided will be scale up to facility saturation: reaching workers from
every section of the hospital facility. In order to build the human resource capacity of each site for these
activities, at least one workshop on injection safety procedures will be conducted and a total of 450 people
will be trained. APIN+ will collaborate with JSI/MMIS in the development of the training plan and delivery of
the training. For COP08, APIN+ will target healthcare workers (HCWs) at sites who were not provided with
training during COP07 and HCWs at expansion sites. To encourage sustainability of infection prevention
and control, including injection safety, at each site, a standard curriculum developed by JSI/MMIS and
approved by the GON will be utilized. Following the training, step down trainings will be conducted for other
health workers at these sites. Workers attending the workshop will include physicians, nurses, laboratory
workers, community health workers involved in Home Based Care (HBC), laundry workers and
administrative personnel. Site based waste managers and handlers will also be provided with training on
safe waste management techniques. At this workshop, we will review the protocol for safe needle handling,
and disposal. At the training workshop, we will review the policy for provision of Post Exposure Prophylaxis
(PEP) for personnel at APIN+ supported sites as a component of the injection safety policy. PEP will be
provided to employees through the ART drugs and services activities. The funding for this activity will also
support the procurement of color coded bin liners for segregation of infectious wastes and autoclave
containers at 28 APIN+/PEPFAR sites that were not provided with these in COP07. The procurement of this
equipment will be shipped and managed through the APIN+ central warehouse in Lagos. As a part of the
LGA coverage plan for Plateau State, secondary and tertiary health care facilities will be targeted for
training efforts. Trained personnel at these sites will then engage in step down trainings to build capacity in
this area for associated primary health care centers.
The funding will also support the distribution of educational brochure materials and posters on injections
safety for relevant locations at all 28 sites. APIN+ will collaborate with MMIS in the production and
distribution of these educational brochures. Sites will be provided job aids and IEC materials to encourage
behavior change and sustainability. Training activities for each of the 28 sites will be accompanied by the
sharing of safe injection standard operating procedures at each site. Supportive supervision will be
provided to all the sites with technical support from MMIS. In this manner, APIN will build networks among
sites to allow the continued roll out of training, services and best practices in a sustainable manner.
This activity will contribute to the reduction of medical transmission of HIV and other blood-borne diseases
by following universal precaution measures, as well as proper waste management. It will likely improve the
quality of health care and reduce stigma and barriers to comprehensive medical care for PLWHAs by
addressing concerns of health workers and other hospital staff. As the overall program continues to scale-
up, there will be an increase in the number of patients at each of the sites with various needs other than
ART and the need to have well-trained staff in injection safety will be a necessity. The adoption of practices
and policies to address the risks of HIV medical transmission will be important for the overall practice of a
high quality comprehensive HIV/AIDS care and treatment program and prevention of new infections.
This activity also relates to activities in Laboratory Infrastructure (6716.08), Palliative Care (5369.08),
TB/HIV (3222.08), ART Services (6715.08) and OVC (5415.08). Health care workers involved in these
programs will benefit from the training program in injection safety and the adoption of a safe needle, needle
stick policy and PEP protocol, all which will improve the safety for workers involved in these other
POPULATIONS BEING TARGETED:
All levels of health care providers that handle needles and/or blood from patients will be involved in the
training efforts. In addition, heads of service and administrators need to be aware of the policies put in place
to limit medical transmission of HIV. Furthermore, these activities will indirectly target the general
population, who will be provided with safer injection practices, which are designed to prevent transmission
Through these activities, an emphasis is placed on training of staff and capacity development of APIN
+/PEPFAR supported sites. This program will provide the basis for a workplace program through
professional medical associations that will ensure that the care and treatment of HIV/AIDS infected patients
and specimens are handled safely, with minimal risk to our healthcare providers.
Stigma and discrimination also occur in healthcare settings, and this has been reported in Nigeria. As
HIV/AIDS treatment and care programs have been initiated, the training of all levels of healthcare providers
in universal precautions and the risks of medical transmission have helped reduce the stigma and
discrimination that can occur in these settings due to fear of occupational hazard.
In COP07, Harvard/APIN+ supported 17 hospital networks in providing HIV/AIDS care and treatment via a
multidisciplinary, family-focused approach at the hospital and community level. In COP08, APIN+
programming will expand prevention efforts to 28 comprehensive APIN+ sites in 9 states (Benue, Borno,
Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe); these hospital networks and their associated satellite
sites and communities will serve as the platform for APIN+ prevention activities in the coming year.
APIN+ will implement its condom and other prevention (COP) programming activities in line with the overall
PEPFAR Nigeria goal of providing a comprehensive package of prevention services to individuals reached
(thereby improving the effectiveness of this messaging) through a balanced portfolio of prevention activities
which will also include abstinence and be faithful activities. In COP08 APIN+ will implement this activity at
both the facility and community levels utilizing a combination of multiple strategies in this implementation,
including community outreach campaigns, peer education models, infection control activities, and STI
management/treatment. The goal of the program is to be focused on the communities targeted and to
saturate those communities with messages conveyed in multiple fora. Utilizing such a methodology, a large
number of people will be reached with messages received via one method or another, but the target group
will be those individuals that will have received condom/other prevention messaging: (1) on a regular basis
and (2) via at least three of the four strategies APIN+ will employ (community outreach campaigns, peer
education models, infection control activities, and STI management/treatment). The target for this intensive
COP activity campaign is 32,633 individuals.
In COP 08, all APIN+ supported treatment sites will integrate prevention counseling and services for people
living with HIV into HIV care and treatment clinics. Specifically, healthcare providers and lay counselors in
care and treatment settings will be trained to deliver prevention messages during routine clinic visits using
tools and job aids. Social peers will be utilized from PLWHA support groups. Prevention messages will
promote correct and consistent condom use and where appropriate will incorporate AB messaging for a
balanced approach. In conjunction with the delivery of prevention information, clients are provided with
syndromic management/treatment for STIs, referrals for preventative care and other wrap-around services
as necessary. High risk HIV negative individuals tested at STD clinics will be provided prevention messages
to reduce their likelihood of acquiring HIV.
Community outreach efforts and PLWHA support groups will be utilized and prevention interventions and
information will be included in their activities. These support groups provide key community linkages for
PMTCT, palliative care and ART services. Support group activities will include the dissemination of
prevention information for HIV-infected individuals (funded under BC&S) as well as community outreach to
high risk populations to encourage HCT and healthy behaviors including recommendations for partner
notification and condom use. For HIV negative individuals, trained counselors will provide education on
HIV/AIDS transmission, risks, and risk reduction strategies including HIV testing.
Several APIN+ sites target Most At Risk Populations (MARPs) including outpatient STI patients, border
traders, military personnel, fashion designers, young male market agents, and motor mechanics. A
prevention program for young male market agents has been established in the Ibadan marketplace and
implemented through the Association for Reproductive Family Health (ARFH) NGO. HaltAIDS, a community
based-NGO in the poor community of Tudun Wada in Jos, has an established community HCT center,
which currently provides prevention messages, condoms and HCT to 150 community members per month.
HCT in Victoria Island PHC clinic serves the Kuramo Village community where most residents are sex
workers and bar workers, resulting in greater than 60% HIV prevalence in this high risk population.
Following the destruction of the Kuramo site in 2006 APIN+ discussions with the Lagos State Government
have resulted in the government's agreement to reestablish the HCT clinic in the vicinity of Kuramo village
to serve the needs of that population. Prevention activities at these clinics will provide educational materials
based on the risks that this population faces and distribute condoms. In addition to comprehensive
counseling on HIV prevention and risk reduction, HIV-infected individuals identified through this activity are
referred for palliative care and evaluation for ART eligibility. An emphasis on high risk men through these
community based efforts will also enhance prevention efforts and facilitate access to their partners. This
funding will support the implementation of behavioral interventions for MARP at stand-alone HCT centers,
the development of educational prevention materials developed by ARFH and HALTAIDS and referral for
STD diagnosis and treatment. Where appropriate, APIN+ will build site capacity for STI syndromic
APIN+ will implement the peer education model at healthcare facilities as well, targeting job peers who are
healthcare workers. Healthcare workers at each site will be trained, especially focusing on infection control
practices in the workplace. Health and allied care providers will be supported to adopt positive attitudes and
behaviors including safe practices to reduce their risks of exposure. Facilities will be assisted to implement
SOPs for post-exposure prophylaxis should exposure occur.
This funding will be also used to support the procurement and distribution of written prevention messages
and condoms. The materials will provide patients and clients with HIV prevention information using the
"ABC" model, including information about healthy behaviors, safer sexual practices, PMTCT, and condom
usage. Prevention messages will also include information about other STIs. Condoms will be offered to all
individuals at all sites and will be provided to APIN+ by the Society for Family Health (SFH).
Additional staffing and training of counselors will also be provided by this funding, including a dedicated
fulltime staff person. This activity will provide support for training of 380 individuals in condom promotion,
STD prevention and risk reduction.
CONTRIBUTION TO OVERALL PROGRAM AREA
These prevention activities are consistent with PEPFAR's 2008 goals for Nigeria, which aim to support a
number of prevention strategies as a comprehensive prevention package. In order to be maximally
effective, the prevention messages developed at different sites will be tightly targeted to various high risk
groups that they serve. Furthermore, these activities are consistent with the PEPFAR 5-year strategy, which
seeks to scale up prevention services, build capacity for long term prevention programs, and encourage
testing and targeted outreach to high-risk populations. The establishment of networks and referral systems
from prevention efforts at the community level to PMTCT and HIV care and treatment will help facilitate the
scale-up of the overall program.
LINKS TO OTHER ACTIVITIES
This activity relates to activities in counseling & testing (5424.08), AB (15652.08), care & support (5369.08),
TB/HIV (3222.08), ARV services (6715.08), and OVC (5415.08). The provision of such services at the
community level will serve as an important platform from which general HIV/AIDS information can be
provided and risk reduction strategies discussed.
Populations Being Targeted
These activities seek to target young people and adults, particularly those from high-risk populations.
Prevention messages will also target HIV infected individuals who are receiving ART and care services.
Targeting these populations is important to encourage safe sexual practices, HCT and other prevention
measures. Health care workers will also be targeted for training on the most effective prevention measures
for various risk groups.
Key Legislative Issues Addressed
These activities address gender equity issues by providing equitable access to prevention services for men
and women. In some cases, our activities seek to target men who may be at high risk for HIV in order to
promote condom use as a means of prevention and access to services for their sexual partners. Male
targeted counseling seeks to address male norms and behaviors in order to encourage safer sexual
practices. Strong prevention programs that accommodate the array of societal and cultural norms can also
help reduce stigma and discrimination. The provision of such services at the community level will serve as
an important platform from which general HIV/AIDS information can be provided and risk reduction
Through these activities, we place major emphasis on community mobilization and participation, as an
element of outreach for prevention efforts. Additionally, we place major emphasis on training and minor
emphasis on infrastructure and human resources in order to build the capacity of counselors and providers
in a full range of prevention strategies. We also place emphasis on information, education and
communication as an essential element of outreach to high-risk populations, and on developing networks
for linking these activities to HCT, PMTCT, and other ART activities to serve as a source of prevention
In COP08 APIN+ will expand its provision of basic care and support services from 24 sites under COP07 to
36 sites in 9 states (Benue, Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). All 36 APIN+
supported sites will identify HIV-infected persons not only through the traditional approach of HCT in the
PMTCT, HCT, TB and ART centers but also through provider initiated HCT and opt out HCT in an open
access approach to ensure that HCT is available to all clients utilizing a facility. These 36 sites include 11
tertiary teaching hospitals, 25 secondary hospitals and 2 primary health care clinics. 28 of these sites
provide comprehensive ART services while 8 additional PMTCT sites also provide ART to infected children
identified through the PMTCT program. All HIV-infected individuals are clinically pre-assessed for eligibility
for ART services. Palliative care services are consistent with the Nigerian Palliative Care Guidelines. Facility
-based palliative care services will be provided to approximately 16,900 ART ineligible PLWHA and 53,600
ART eligible PLWHA for a total of 70,500 PLWHA clients. People Affected By HIV/AIDS (PABAs) will be
reached through the community and home based care (HBC) of the PLWHA clients; therefore, it is expected
that a total of 211,500 people will access services (70,500 PLWHA and 141,000 PABA). A network model of
care will be used for service delivery. APIN+ will provide at least one clinical service (laboratory, OI
prophylaxis & management, HBC) and at least two other services in the psychosocial, spiritual or preventive
domains to all PLWHA served.
Implementation of the PEPFAR-Nigeria LGA coverage strategy in the program areas of PMTCT and
TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in at least one health facility in
every local government area (LGA) of 6 identified states, will also provide direction to the APIN+ care and
support scale-up planning for Plateau state. In connection with APIN's role in the LGA coverage plan for
Plateau state, scale up of palliative care services will occur in 12 LGAs where APIN currently supports sites
and in 5 additional LGAs. This will ensure that adult and pediatric patients identified through associated
PMTCT and TB/HIV activities in these 17 LGAs will be provided with care services at 25 secondary health
facilities with referral networks to 2 primary health facilities.
APIN+ will ensure that 50% of BC&S funding is directed to HBC activities. The program will identify,
collaborate with and strengthen the capacities of support groups, including AIDS Alliance, and CBOs to
deliver palliative care services, including the provision of community and HBC services such as domestic
support, management of minor ailments, pain management, referral services, and counseling services.
Supported sites will provide a range of facility and HBC services, including prevention for positives
(balanced ABC messaging as appropriate), clinical care, prophylaxis and management of OIs, lab support,
adherence counseling, psychosocial and spiritual support, and active linkages between hospitals, health
centers, and communities. Through counselors and clinicians, APIN+ will provide referrals for TB, family
planning, safe motherhood, wraparound services and child survival programs as appropriate. As medical
needs of patients are identified, they will be provided with clinical care services by clinicians or referred for
specialty care as necessary. HIV-infected individuals will be provided with cotrimoxazole prophylaxis
according to national guidelines. Diagnostics for common OIs may include: Candida albicans, protozoal
infections, and gastrointestinal parasites. CD4 count is performed at least every 6 months for all PLWHAs.
Activities that focus on prevention with positives (PWP) include HCT for family members and sex partners,
counseling for discordant couples, counseling on healthy lifestyles and positive living, prevention messages,
and IEC materials on disclosure. APIN+ will support integration of syndromic management of STIs and risk
reduction interventions into care. All enrolled into care will receive risk assessment and behavioral
counseling to achieve risk reduction. These activities are provided through individual counseling and
outreach by site PLWHA support groups. All PLWHA will be provided with a basic care package including
clean water kits, ITN, and IEC materials on PWP. Pain management assessments will also be conducted by
clinicians and HBC providers and analgesics will be provided. Commodities distributed as a part of the
palliative care services are procured centrally through the APIN+ Abuja program office and central medical
stores in Lagos. Distribution of commodities to individual sites is coordinated through supply chain
mechanisms in place for laboratory test kits and ART drugs. During COP08, APIN+ will collaborate with
SCMS for the procurement and distribution of specified OI drugs.
Facility-based and community-based HBC teams partner to provide a continuum of HBC services
depending on client needs. When ART patients miss scheduled clinic visits, or bed ridden clients are
reported by the community HBC team, the ART site HBC team provides follow-up according to a program
based SOP, utilizing a HBC kit provided to these outreach teams. The team will provide basic medical
assessments of signs and symptoms, basic nursing care, nutritional assessments and psychosocial support
and make appropriate referrals. An HBC kit (consisting of ORS, bleach, cotton wool, gloves, soap, calamine
lotion, vaseline, gentian violet, etc.) will be used by HBC teams and, when needed, visiting teams will
provide refills of cotrimoxazole, paracetamol, additional clean water kits and additional bed nets to patients
and their families.
APIN+ partners with PLWHA support groups and CBOs to mobilize communities provide psychosocial
support to PLWHAs and their families, provide ART adherence counseling, and assist with patient follow-up
and HBC activities. APIN+ will build the capacity of these groups to develop innovative means of interacting
and supporting HIV infected populations and PABAs. Site HBC activities will be supervised by a hospital
A total of 700 health care and non-health care workers will be trained in palliative care, including HBC, using
national training manuals. This will be in line with the National Palliative Care Guidance and the USG
Palliative Care policy. These activities will strengthen the overall health systems and provide an integrated,
comprehensive health care package to patients. During COP08, APIN+ will place special focus on scaling-
up pediatric palliative care services through the initiation of training efforts in this area and the establishment
of linkages for these services related to the identification of HIV-infected babies through PMTCT activities.
In connection with SI activities, APIN+ will utilize data collected in this area for monitoring and evaluation.
APIN+ will also develop and implement QA/QC protocols and develop a quality improvement program which
evaluates health system processes and patient outcomes in order to enhance quality of care.
Harvard will contribute to the COP08 palliative care goal by providing basic palliative care services in 36
health facilities. Palliative care services will be provided to 70,500 PLWHA and 141,000 PABA for a total of
Activity Narrative: 211,500 people served. The program will contribute to strengthening human capacity through training of
health workers, community workers and PLWHAs and their families. These activities are consistent with the
PEPFAR 5-year strategy as they seek to scale up palliative care services and build capacity to provide care
and support for PLWHA.
LINKS TO OTHER ACTIVITIES:
This activity relates to activities in TB/HIV (3222.08), PMTCT (3227.08), ART Services (6715.08), OVC
(5415.08), AB (15652.08) and COP (9216.08). Linkages between sites will be developed for referral
networks and capacity building in this area; improved outreach to the community will allow for different
levels of medical intervention as needed. APIN+ will facilitate linkages with other organizations providing
livelihood development programs for PLWHA and PABAs. Identified OVC-headed households will be linked
to OVC programs. The program will also link to other USG IPs, the private sector and the GON.
POPULATIONS BEING TARGETED:
This activity targets all HIV infected patients who seek treatment and care at the 36 Harvard APIN+ sites
participating in this program. In addition, PABAs are targeted for services. A total of 700 individuals will be
trained in palliative care.
This activity focuses on community mobilization and the development of networks through palliative care
and outreach initiatives. Additionally, this program focuses on logistics, commodity procurement for
treatment and care modalities, training, and information, education and communication. This program
seeks to increase gender sensitivity in programming through counseling and educational messages
targeted at vulnerable women and girls. Furthermore, through gender sensitive programming and improved
quality services the program will contribute to reduction in stigma and discrimination and encourage men to
contribute to care and support in the families.
APIN Plus/Harvard sites will identify HIV infected patients through PMTCT, HCT centers and ART centers
and hospitals. These sites constitute a network of delivery points in nine states (Benue, Borno, Ebonyi,
Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe) and include tertiary teaching hospitals (11) and secondary
hospitals (24), for a total of 36 TB/HIV service delivery sites in COP08. APIN+, with other implementing
partners, will execute the PEPFAR-Nigeria LGA coverage strategy in Plateau and Lagos, ensuring the
provision of TB/HIV services in at least one health facility in every local government area (LGA) of these
states. This is an essential step toward universal access to TB/HIV services, and will focus on developing
programming at the secondary and primary level. All HIV-infected individuals are clinically pre-assessed for
eligibility for ART treatment; it is expected that 33,350 HIV positive clients will be screened for TB in COP08.
TB screening by sputum examination is conducted according to national guidelines. The 48,500
maintenance patients already on ART will also be monitored for TB. All HIV infected women (5,475) from
our 36 PMTCT sites will be assessed for ART eligibility and screened for TB. The TB clinics at 9 of our sites
are National TB centers offering the government DOTS program. At all of our associated DOTS clinics, we
will implement HCT for 10,000 clients presenting to the DOTS center; it is expected that 5,000 of these will
have TB. In all, it is expected that 16,550 TB/HIV HIV/TB co-infected patients will be identified and will
receive treatment for TB and be linked to APIN+ ART clinics for evaluation of eligibility for ART and
provision of treatment and palliative care.
NIMR is the National Tuberculosis Reference Laboratory and will provide an important resource to other
APIN+ sites in strengthening their capacity for TB diagnosis and cross-training of health care workers in
TB/HIV. TB services provided at these clinics will be integrated with ART services and HCT in order to
promote the development of a comprehensive system of care for individuals with HIV/TB co-infection. This
will be part of the 500 health care workers in both HIV and TB clinical and laboratory settings to be trained
in COP08. APIN+ TB/HIV program officers and facility staff will be provided with formal TB/HIV training to
enhance their productivity, including retraining on x-ray diagnostic skills for clinicians and retraining on good
sputum specimen collection and laboratory AFB sputum smear diagnosis for laboratorians. A dedicated TB
program officer provides TB expertise to all APIN+ sites and is responsible for training efforts and reporting
of TB patients to the NTPLCP.
APIN+ will prevent nosocomial transmission of TB to HIV+ patients through such measures and principles
such as basic hygiene, proper sputum disposal, and good cross ventilation at clinics. Facility co-location of
TB/HIV services is preferred to clinic co-location. The national guidelines on TB infection control on co-
located sites will be implemented in all sites. Patient and staff education on infection control measures will
be routinely carried out to ensure program success. APIN+ will upgrade facilities as needed through
infrastructure support such as basic renovations, upgrading equipment and procuring supplies and
consumables (e.g. sputum containers).
To date, more than 30% of APIN+ clinic attendees present with pulmonary tuberculosis. Depending on
clinical status, many patients will be treated for TB prior to receiving ART, following the NTBLCP Guidelines.
Concurrent ART and TB treatment follows the National guidelines of d4T+3TC+EFV (800mg). All co-
infected patients with CD4 values <200 cells/mm will receive cotrimoxazole. INH prophylaxis therapy will
only be provided on a case by case basis following the NTBLCP guidelines. Five hundred HIV+ patients are
estimated to be given IPT. The TB DOTS sites will be supported to provide holistic patient care according to
National and IMAI guidelines.
APIN will also continue to work with GON in providing support for the Federal Public Health Laboratory,
which was developed into a national reference lab in COP07. TB diagnostic capacity will include culture,
PCR, and sequencing for resistance testing. At NIMR, APIN will provide technical assistance in the
implementation of MDR-TB and XDR-TB surveillance activities in Nigeria.
Pursuant to the State LGA coverage plan, APIN+ will work with secondary sites in 17 LGAs of Plateau and
Lagos states. Secondary sites will be linked with two tertiary care sites for specialty care and are fed by
patient referrals from primary health care centers. To ensure continuous availability of drugs and
commodities in supported sites, APIN will partner with the USG PEPFAR team to strengthen logistics
management within the states where it works.
CONTRIBUTION TO OVERALL PROGRAM:
The provision of TB diagnostics and treatment within participating ART facilities is consistent with the
PEPFAR goal of ensuring that all facilities offering ART develop the ability to diagnose TB and provide
nationally accepted DOTS sites within their facility. There will a deliberate attempt to locate HCT in DOTS
centers so as to increase detection of co-infected TB/HIV patients. At these facilities, APIN estimates that it
will provide clinical treatment for TB to 16,550 patients with HIV/TB co-infection either prior to or during their
ART therapy, thus contributing significantly to the 2008 PEPFAR goals. At all APIN+ sites referral to TB
DOTS sites that are either co-located or within short proximity will be provided. The provision of TB
diagnosis and treatment, infrastructure building and health care personnel training under this program will
work towards building and maintaining Nigerian National tuberculosis treatment capacity, which is
consistent with the PEPFAR 5-year strategy.
This activity also relates to activities in HCT (5424.08), Care & Support (5369.08), ART Services (6715.08),
PMTCT (3227.08) and OVC (5415.08). Through this activity linkages between participating treatment sites
and the National Tuberculosis Reference Laboratory will be provided. Additionally, linkages to potential
patient populations through outreach initiatives, HCT activities, and ART services will improve utilization of
care opportunities created through PEPFAR funding. This activity is linked to care and support and ART
services because TB diagnosis and treatment are provided as a part of patient palliative care and support at
sites which also provide ART. A high TB co-infection rate has a major impact on ART management.
This activity targets adults and children with HIV and TB co-infection by providing a mechanism for critically
important TB diagnosis and treatment both prior to the initiation of ART and also during the course of ART
therapy. Newly enrolling ART patients will be prescreened for TB in COP08 and TB that develops in
patients that are currently on ART therapy will be diagnosed and treated. All HIV infected pregnant women
participating in APIN+ PMTCT programs will also be eligible for TB diagnosis and treatment under this
Activity Narrative: program.
Emphasis areas include local organization capacity building, and health-related wrap around activities.
This activity will increase gender equity by focusing on strategies which seek to reach an equitable number
of co-infected men and women. Furthermore, it seeks to provide additional focus on support for pregnant
women who have TB/HIV. Through data collection and patient surveillance from this activity, APIN will be
able to show the breakdown of men and women who are accessing TB diagnostics and treatment services.
Outreach activities and patient counseling also seek to address stigma and discrimination and increase
access to information, education and TB diagnosis and treatment for women and girls with HIV.
In COP07, APIN Plus/Harvard (APIN+) conducted OVC activities in 25 sites in 7 states (Plateau, Oyo,
Borno, Lagos, Kaduna, Benue, and Enugu). In COP08, APIN will work at 36 sites in 9 states (Benue, Borno,
Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). These OVC sites constitute a network of delivery
points including 11 tertiary teaching hospitals, 24 secondary hospitals and 1 primary health care facility.
APIN+ will identify HIV-infected OVC through PMTCT, HCT centers, ART centers, and hospitals through an
opt-out, family centered approach in which all children below 18 years that are identified through an HIV+
adult family member or caregiver (PMTCT client, adult ART client or adult BC&S client) will be offered HCT.
APIN+ also provides these services through one CBO. Expansion to the 36 sites will include the addition of
primary and secondary health facilities in 5 new LGAs in Plateau state. While many of the APIN+ supported
original PMTCT sites are classified as secondary or community-based in nature, the expansion sites in
Plateau state and elsewhere represent a continuation of the overall movement from tertiary to secondary
and primary sites as these new sites are virtually all secondary or community-based. APIN+ will strengthen
the coordination of PMTCT, ART and OVC services for seamless movement of HIV+ children across the
various services. The experience gained from the initial rounds of this activity will assist in more efficient
implementation of OVC activities in the new centers. In addition, active PMTCT programs at 36 sites will
identify HIV-exposed infants who will require PCR diagnosis and clinical assessment to determine ART
OVC who are ART eligible will be provided ART services funded under APIN+ ART activities. APIN+ will
provide care and monitoring through the OVC program to 4,500 HIV positive children who are on ART, 336
HIV infected infants identified through the PMTCT activities, and 100 HIV infected children identified through
the HCT activities. In addition, APIN+ will provide OVC services to 3,864 HIV negative children whose
parents or caregivers had or have HIV/AIDS. These 8,800 OVC will receive multiple services through APIN
All HIV-infected OVC will be provided with cotrimoxazole prophylaxis according to national guidelines.
Preventive care services for all OVC including diagnostic testing for common opportunistic infections (OIs)
will be performed at pre-assessment including testing for malaria. Preventive care kits, including kits
obtained from SFH (a USG supported IP) and provided to APIN+ by the USG will be distributed. Kits include
multivitamins, clean water kits, ORS (preparation and use), and bed nets and will be provided to caregivers
for all infants and children covered under this activity. All OVCs are also provided with nutritional
assessments and support, psychosocial support, birth registration assistance, and referrals for wraparound
services in this area based on identified needs. APIN+ will utilize referral mechanisms for education and
nutrition support where appropriate and will prioritize partnering with these new USG-supported wraparound
services in states where these activities are co-located with APIN+.
Monitoring and evaluation of all aspects of the OVC program will be conducted as a part of the SI activities.
APIN collects electronic data on patient care, which is used for site and program specific evaluation of
services provided in each of the OVC program areas, including evaluation of CD4 counts, loss to follow-up
and viral suppression. This data is used to conduct program evaluation and provide feedback to site
investigators on a quarterly basis. Onsite data managers will conduct monthly evaluations. APIN+ will also
develop and implement an internal QA/QC program in this area to provide feedback to sites on performance
and identify best practices and areas for strengthening and support.
APIN+ will partner with persons living with HIV/AIDS (PLWHA) support groups to provide outreach to OVC
and their families and caregivers through HCT advocacy, ART education and counseling, stigma reduction,
risk reduction and ART adherence. These PLWHA community outreach groups will provide support to ART
patients, their families, and other persons affected by AIDS (PABA) on the many psychosocial issues
involved in HIV infection and ART treatment. These PLWHA groups will also assist with patient follow-up
and home based care. Outreach through the PLWHA support groups will also encourage utilization of HCT
services by other family members. Support will include referrals for wraparound services, including: special
educational services for OVC, food and nutritional support, and income generating activities for caregivers
and older OVCs. APIN+ will work with the USG team to identify ways in which it can utilize leveraged
resources for developing therapeutic nutritional programming such as community therapeutic care
programs. APIN+ will build the capacity of the support groups to develop more innovative means of
interacting and supporting HIV-infected and affected populations. APIN+ will also explore partnerships with
traditional OVC providers in the communities in which it works for potential synergy of activities.
This funding will also support training for 400 healthcare providers and caregivers of HIV-infected OVC.
Healthcare providers to be trained include pediatricians, counselors and nurses in the area of pediatric care
and support services. Training in this area will be coordinated with FMOH and follow National Guidelines on
pediatric care. These activities will strengthen the capacity of sites to provide comprehensive care to OVC.
Training of caregivers will be done through community and home based programs with support groups and
home based care providers.
Outreach activities through PLWHA support groups will seek to provide comprehensive psychosocial
support for OVC and their families. These services are consistent with the National Plan of Action for OVC
in Nigeria and the Standard Operational Guidelines for OVC services. Additionally, APIN+ seeks to
strengthen the capacity of the PLWHA support groups to continue to provide psychosocial support and
outreach to PLWHA and OVC. Capacity development at the community and facility levels and consistency
with national guidelines will ensure sustainability. Through working with pediatric ART and PMTCT sites to
provide pediatric C&S services for HIV-infected OVC, APIN+ will scale-up the ability of participating sites to
provide comprehensive and sustainable services for this OVC population, which is consistent with National
objectives and the PEPFAR 5-year strategy.
This activity also relates to activities in PMTCT (5415.08) through a system of referrals to provide pediatric
care and support services to HIV-infected pregnant women and their infants. Linkages will be made to
BC&S activities for adults (5369.08) and TB/HIV activities (3222.08) in order to ensure a comprehensive
system of care for OVC and their families. The integration of pediatric ART services (6715.08) and care
linked to active PMTCT and adult ART centers will facilitate the development of the overall network of care
for HIV-infected families and communities. Linkages to outreach initiatives and HCT (5424.08) activities
Activity Narrative: seek to improve the utilization of care opportunities created through PEPFAR funding. Additionally, through
SI activities (3226.08) information about efficacy of care, derived from data collected on the patients treated
under this activity, may be used to develop new treatment protocols to increase the quality of pediatric OVC
These activities seek to target OVC who have been exposed to HIV through pregnancy and breastfeeding
from an HIV-infected mother through the identification of exposed infants from PMTCT programs. We will
also identify OVC from other areas as targets for supportive pediatric care and family outreach. Outreach
initiatives also seek to target mothers and family members of HIV-infected OVC, including PLWHA, to
ensure comprehensive family psychosocial support. Caregivers of OVC are also targeted to encourage
HCT for potentially exposed children. APIN also targets caregivers by providing them with preventive care
packages to be utilized for the benefit of the OVC. APIN will target street youth and out-of-school youth
through community outreach initiatives based in HCT clinics. With the 36 PMTCT sites proposed, which
includes support for existing sites and expansion, the target of 8,800 will be reached without difficulty.
Emphasis is placed on training through activities focused on training healthcare providers and caregivers in
the care of HIV-infected and affected OVC. These activities will also place an emphasis on the development
of networks and referral systems in order to support the development of a comprehensive system of care
through links to community PLWHA support groups and PMTCT, HCT and ART sites.
This activity provides comprehensive counseling and testing services (HCT) to at risk individuals, delivered
through 40 service outlets (28 comprehensive APIN+ sites, 8 additional PMTCT sites with ART services for
HIV+ children identified through PMTCT services, and 4 stand alone HCT centers) in 9 states (Benue,
Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). This is an increase from the 20 active sites at
the end of COP07. At these sites 78,500 individuals will receive HIV counseling & testing and receive their
results; targeted populations include Most At Risk Populations (MARPs), clients presenting to the health
care facilities, blood donors, and family members of PLWHA. Provider initiated HIV testing is utilized as an
additional strategy to reach clients at the health care facilities. Seventeen of these additional sites will be in
primary health centers and secondary hospitals some of which will be activated through the implementation
of the PEPFAR-Nigeria LGA coverage strategy in the program areas of PMTCT and TB/HIV, designed to
ensure the provision of PMTCT and TB/HIV services in at least one health facility in every local government
area (LGA) of 6 identified states.
Individuals identified as HIV-infected at stand-alone HCT clinics will be referred for palliative care, PMTCT
and ART services as appropriate. Those identified as positive at APIN+ comprehensive sites will be referred
to PMTCT and ART clinics for treatment and palliative care services. Prevention for HIV positive individual
will be incorporated into HCT activities including promotion of HCT for family members and sex partners,
counseling for discordant couples, counseling on healthy lifestyles and positive living, prevention messages
and IEC materials on disclosure. APIN+ sites use family counseling sessions and "love letter" strategies to
encourage partners of HIV-infected patients to access HCT so that couples receive HIV counseling and
testing together. Counselor training will include couple counseling to strengthen this program. Pediatric
patients that are identified at testing points of service will be enrolled into the APIN+ supported OVC
program and ART as necessary. HCT will also be offered to patients receiving TB services at each of the
APIN+ sites throughout TB/HIV program activities. HCT is offered to blood donors as per Blood Safety
activities. Patients identified as HIV-infected are provided with referrals to ART and palliative care services.
APIN+ will use the National "Heart to Heart" logo at supported HCT sites so as to reflect the integration
within the national program. Through these activities, 4 stand-alone HCT service outlets are also maintained
which provide HIV testing as well as pre- and post-test counseling and condom distribution. At all HCT
outlets, patients are provided with Information, Education & Communication (IEC) materials on HIV
prevention and referrals for ART services and palliative care as appropriate. The materials will address HIV
prevention using the "ABC" model, providing information about healthy behaviors, safer sexual practices,
STI prevention, PMTCT, and condom usage.
HCT services are also provided in community settings in conjunction with projects in Lagos, Plateau and
Oyo states that serve specific MARPs including: outpatient STI patients, bar workers, sex workers, border
traders, military personnel, fashion designers, and motor mechanics. Mobile HCT services will be used to
reach these populations. Activities targeting these populations are linked with APIN+ sites to provide referral
linkages to PMTCT, Palliative HIV/TB and ART services depending on eligibility for ART.
Condoms will be made available at all HCT sites in conjunction with the delivery of AB messages. The
Society for Family Health (SFH) will supply condoms. Training of 420 individuals in counseling and testing
will use the National testing algorithm and will educate trainees on appropriate counseling messages
specific to the different high risk groups with which they work. Refresher training will be provided during the
year, particularly after final revision of the National training curriculum. HIV testing is performed with rapid
test assays and same day results are given. Following HIV diagnosis with the National testing algorithm,
immunoblot confirmation will be provided during assessment for ART. This is done by HIV laboratories at
APIN+ comprehensive ART treatment centers.
The UCH Virology lab will establish and coordinate a regular QA/QC program to insure that HIV serologic
testing at HCT centers meets national and international standards. This lab will also ensure coordination of
HIV testing SOPs and provide regular training for new lab personnel. The USG team will be providing
APIN+ with rapid test kits that will be managed by the pharmacy logistics team in Lagos and stored and
distributed from the APIN+ central warehouse. APIN+ will continue to harmonize the logistics process with
GON LMIS and ICS activities.
APIN+ HCT activities are consistent with the PEPFAR 2008 goals for Nigeria, which aim to increase uptake
of HCT by supporting HCT centers, which are linked to treatment and care services, and to expand their
reach through mobile testing services. By continuing to support and build the capacity of HCT centers and
provide linkages to treatment and care centers, these activities will be able to meet the increasing utilization
of these services, expected to result from HCT outreach initiatives identifying infected individuals. The
network of HCT centers linked to HIV services and care will provide a sustainable network for infected and
affected individuals in APIN+ catchments areas.
This activity also relates to activities in Palliative Care & Support (3222.08), Condoms and Other Prevention
(9216.08), TB/HIV (3222.08), ART Services (6715.08) and OVC (5415.08). Through these activities, APIN+
has incorporated a number of currently funded HCT prevention programs (i.e., Gates Foundation) to provide
access to a broad range of palliative care, support and ART services. This network of community, research-
based and tertiary care institutions should provide sustainable and high quality HIV and related services to
the communities served. Furthermore, both primary and satellite APIN+ sites are linked in order to provide
laboratory and specialty care support, as related to the HCT activities.
These activities target adults for HIV counseling and testing, particularly those from most at risk populations,
as described above. Targeting these populations is important to encourage utilization of HCT services and
provide ART treatment for eligible HIV infected individuals. Counseling provided through these activities
also seeks to target PLWHA who are newly diagnosed by encouraging them to bring their partners and
other family members in for HCT. In addition, target populations include orphans and vulnerable children.
Emphasis is on in-service training contributing to human capacity development, and quality assurance and
Activity Narrative: supportive supervision. These activities will also address gender equity issues by providing equitable
access to HCT services for men and women. In some cases, the activities seek to target men who may be
at high risk for HIV in order to provide a mechanism for HCT as a means of prevention and access to
services for their sexual partners. Male targeted counseling seeks to address male norms and behaviors in
order to encourage safer sexual practices. Counseling also seeks to address sexual norms and issues of
HIV related stigma and discrimination.
Track 1 and 2 funds are combined for this activity.
Through these activities, Harvard/APIN+ will provide ART drugs to 48,500 adult and pediatric patients at 36
APIN+ sites in nine states (Benue, Borno, Ebonyi, Enugu, Kaduna, Lagos, Oyo, Plateau, Yobe). These sites
include 28 comprehensive ART sites serving pregnant women, adults and children, and eight PMTCT sites
that also provide HIV+ children identified through the PMTCT program with ART. At all sites APIN+ will
provide the ART prophylaxis options and triple drug regimens for eligible pregnant women consistent with
the national guidelines. Thus, a total of 36 APIN Plus sites will be providing ART drugs through ART or
In COP08, APIN+ will begin to collaborate with Clinton Foundation for the procurement of second line drugs
for adult patients and all pediatric drugs for pediatric patients. Drugs procured through SCMS will be
shipped to APIN's Central Medical Stores (CMS) in Lagos, from which they will be distributed to sites in
accordance with an internal supply chain management system. We will purchase first-line ART drugs
directly from drug manufacturers and through different ART purchasing agents, including IDA and SCMS,
as applicable, in accordance with USG regulations and NAFDC Registration and following Nigerian National
ARV drug regimens. We have developed SOPs for supply chain management, drug usage, drug regimen
tracking, drug distribution, warehouse storage and individual pharmacy site management. These SOPs are
also used for procurement and distribution of OI drugs and certain lab supplies and test kits.
All drug orders are based on projections of patient numbers as determined by several factors including: rate
of patient enrollment, weight class of patients affecting drug dosage, gender, rates of toxicity, and rates of
failure. Our rates of drug ordering and estimation of buffer stock needs have been informed by our
experience with lengthy and variable order to delivery times, global shortages (e.g. BMS and Merck),
splitting of most orders, delays in NAFDAC registration and lengthy clearance of drugs in country. As a
result, our drug orders had been adjusted to accommodate with an increase in buffer stocks. This year, we
have buffer stocks for approximately 3-5 months for all of the requisite first and second line drugs, most of
which are fixed dose combinations and other FDA-approved generic drugs.
Capacity building and training for our APIN+ CMS at NIMR and individual site pharmacies is ongoing to
support pharmacy management and implementation of the National ART Program. Harvard/APIN+ is
participating in the ART harmonization process with the GON. The goal of these activities is to facilitate the
pharmacies' ability to scale up capacity as patient utilization of ART increases. The CMS is located at NIMR
(Lagos), where the project operates and manages a warehouse that provides storage for drugs once they
enter the country. An electronic bin card system is utilized to track and monitor drug stores and distribution.
A subcontract with Fed-Ex provides monthly distribution to all site pharmacies. Assessments of all facilities
to determine infrastructure needs have been conducted in COP07 and will continue to be conducted in
COP08 for new sites. These site capacity assessments have been the basis for efforts to strengthen the
supply chain management system for new sites. Ongoing assessments ensure sustainability of pharmacies
and supply chain management at the sites. All site pharmacists have participated in regular training
sessions and work with site data managers in providing regular supply chain information electronically to
our central pharmacy. The computerized supply chain information system linked to patient clinical records
also provides reporting data for M&E at each site. Our logistician consultant conducts regular drug inventory
audits to our central warehouse and individual site pharmacies.
Our long-term goal is to support a sustainable supply chain management system for ART that incorporates
existing and bolstered Nigerian institutional structures and is harmonized with GON activities. Continued
collaboration with SCMS and GON procurement efforts contribute to this goal. Implementation of the
PEPFAR-Nigeria LGA coverage strategy in the program areas of PMTCT and TB/HIV, designed to ensure
the provision of PMTCT and TB/HIV services in at least one health facility in every local government area
(LGA) of 6 identified states, will help to guide the ongoing site expansion for ART and PMTCT. As a part of
that plan, secondary health care facilities covering all 17 LGAs in Plateau state will be targeted for
pharmacy support and drug distribution. As expansion of ARV drug services is prioritized to rural areas,
APIN+ will strengthen existing referral channels and support network coordinating mechanisms. Each new
site will be visited by a team of technical staff from Nigeria and Boston as well as other sub-partners.
Pharmacy and logistics management procedures will be assessed and be part of the site development plan.
Recommendations for drug storage, equipping of pharmacies and minor renovations are considered. All
APIN+ pharmacists have completed the IDA ARV training program. Pharmacists hold meetings on a
quarterly basis and training updates are provided. On a monthly basis, drug updates are provided to all
APIN + investigators by email. Pharmacists and their data entry staff also participate in the electronic data
tracking system; regular training in computer entry and database management are also provided.
This funding will specifically support the procurement of ART drugs, their distribution and storage in a
central pharmacy established at NIMR (Lagos). Funding supports the central pharmacy, security, equipment
and two full time pharmacists. Subcontracts to JSI and Crown agents for supply chain management are also
included. All drug regimens are consistent with the National ART guidelines for adult and pediatric patients.
Funding in this activity provides drugs for 44,000 adult and 4,500 pediatric patients on appropriate ART
Harvard has allocated $3,015,506 of its ARV Drugs budget to SCMS for procurement of commodities. This
amount is captured under the SCMS Drugs activity.
CONTRIBUTION TO OVERALL PROGRAM AREA
Through these activities we will have provided ART drugs to 48,500 patients at 36 ART service outlets. We
have almost doubled the number of ART service provider sites from 17 and increased the number of states
from seven to eight. In addition, we have scaled up our PMTCT activities with 36 points of service providing
access to PMTCT services for 56,250 women. Through these activities, we will continue to strengthen the
structure of our ART drug procurement system, as described above, in accordance with PEPFAR goals in
order to ensure cost effective and accountable mechanisms for drug procurement and distribution.
Furthermore, efforts to build local capacity through infrastructure building and training mechanisms are
consistent with PEPFAR 5-year goals to enhance the capacity of supply chain management systems to
respond to rapid treatment scale-up. Additionally, through procurement via SCMS, we seek to provide
support to efforts to build national capacity related to drug procurement and distribution.
Activity Narrative: LINKS TO OTHER ACTIVITIES
This activity also relates to activities in TB/HIV (3222.08), ART Services (6715.08), and Strategic
Information (3226.08). Through this activity, we will maintain significant linkages with PMTCT (3227.08) and
ART Services through the procurement of ART drugs for individuals served by these programs. Additionally,
we will develop and maintain linkages to TB/HIV activities, with expansion focusing on co-locating ARV sites
with existing DOTS sites. The supply chain management system will serve to provide drugs to ART sites
that are providing TB services in conjunction with ART services. SI activities will provide crucial information
for M&E as well as efficacy of the drug regimens, which may impact drug procurement decision-making.
POPULATIONS BEING TARGETED
The primary target of these activities are health care workers, including program managers doctors, nurses,
and pharmacists who are involved in the drug procurement and distribution process. Furthermore, by
building mechanisms for drug procurement, these activities seek to target PLWHA, both adults and children,
who are in need of or already receiving ART care.
Emphasis areas include strategic information and local organization capacity building.
Training initiatives have also been incorporated into these activities in order to build the local human
resource capacity to manage a sustainable drug procurement and distribution system.
Track 1 and 2 are combined for this activity.
In COP07 Harvard/APIN+ provided comprehensive ART services in 17 sites In COP08 will provide high
quality ART services to eligible patients at a total of 36 sites; 28 comprehensive ART sites (11 tertiary and
17 secondary facilities) and eight PMTCT sites that also provide ART for HIV+ children identified through
PMTCT services. The 28 sites are located in the nine states of Benue, Borno, Ebonyi, Enugu, Kaduna,
Lagos, Oyo, Plateau, and Yobe. This will provide ART services to a total of 48,500 individuals, including
44,000 adults (14,000 new) and 4,500 children (1,500 new) at the end of the reporting period. At the
additional eight PMTCT sites there will also be ART services provided for eligible pregnant women and
eligible infected infants. Implementation of the PEPFAR-Nigeria LGA coverage strategy in the program
areas of PMTCT and TB/HIV, designed to ensure the provision of PMTCT and TB/HIV services in at least
one health facility in every local government area (LGA) of 6 identified states, will increase the reach of
adult and pediatric ART services as well.
For patients at the Federal ART sites, the program anticipates GON provision of first line ARV drugs and
PEPFAR support for ART care and services. As patients require alternative or second line drugs, they will
receive PEPFAR provided drugs. GON provision of first line drugs, when actualized, will allow for additional
adult and pediatric targets. APIN+ estimates that 2,500 additional adults will be placed on therapy through
the leveraging of GON drugs. APIN+ will also partner with Clinton Foundation and Global Fund (GF) as
appropriate to leverage resources for providing antiretroviral drugs to patients. The site investigators and
project managers will actively participate in the GON National ART program. Harmonization of data
collection for M&E will be coordinated with USG and GON efforts. APIN+ has provided technical assistance
and training expertise to the National ART program's training program for adults and pediatric patients,
which will continue in 2008. APIN will continue to participate in the USG coordinated Clinical Working Group
to address emerging topics in ARV service provision and to ensure harmonization with other IPs and the
ART provision and monitoring follows the 2005 revised National ART guidelines for adult and pediatric care.
All sites focus on the integration of ART services for all patients regardless of the source of funding for
different components of treatment (e.g. external funding sources for services or lab commodities). A
standardized protocol for adult and pediatric ART services is followed at all APIN PEPFAR sites. At each
site support is provided for the management of electronic data and patient medical records for use in the
provision of clinical care. Continued support to ART sites in the area of pediatrics, including the training of
pediatric clinicians, will build capacity at sites to provide pediatric ART. TB diagnosis and treatment is
provided to all patients via facility co-location of DOTS centers and/or referral of patients into ART from
DOTS sites. ART eligible patients identified through HCT conducted at a DOTS site will be provided with
ART. By the end of COP07 all APIN+ ART sites will be co-located with DOT centers to facilitate TB/HIV
service linkages. All HIV infected clients will be symptomatically screened and confirmed with laboratory
and radiological diagnostics as indicated while all TB patients will be offered HIV testing.
Patients are identified through HCT services including facility based, mobile, and family centered strategies.
Those initiating ART are provided ART EAC prior to and during ART provision. ART EAC will follow the
National Curriculum for Adherence Counseling and includes partner notification, drug adherence strategies
and other prevention measures. Care services including prevention for positives will be provided for all ART
patients as outlined in the BC&S narrative.
Non-ART eligible individual that are enrolled in care will have periodic follow-up to identify changes in
eligibility status. Patients are also encouraged to refer family members for HCT. ART EAC is reinforced with
PLWHA support groups at each site, which serve both PEPFAR and Federal ART patients. PLWHA on
treatment are encouraged to have a treatment support partner to whom he/she had disclosed status to
improve adherence and to optimize care.
Scheduled physician visits are at three, six, and 12 months and every six months thereafter; patients pick
up ART drugs monthly. At each visit, clinical exams, hematology, chemistry, and CD4 enumeration are
performed. All tertiary site labs perform the necessary lab assays. Secondary and primary sites with limited
lab capability send samples to an affiliated tertiary site lab for analysis. Electronic clinic and lab records
provide data for high quality patient care and centrally coordinated program monitoring.
Clinical staff meets monthly for updates and training. Each site has a clinic coordinator and a central
committee determines and approves drug regimen switching. As clinical training needs are identified for
new sites or new staff at existing sites, APIN+ provides training on regimen switching and other relevant
topics. APIN+ will continue to implement internal and external QA/QC programs through SI activities and will
allow sites to further monitor the level of patient care. In COP07, APIN+ developed standardized indicators
and piloted QA assessments at ART sites; results were utilized to strengthen services at sites. In COP08,
APIN+ will continue to implement these assessments at additional sites. At each site, indicators specific to
site needs and activities will be developed.
In addition to providing training to improve care at supported sites, APIN+ will also fully support the training
of 100 lab scientists working at GON and GF supported sites. APIN+ will utilize its training lab to train them
in ARV lab monitoring including good laboratory practices, HIV rapid testing, automated CD4, hemogram
and chemistries. This will serve to increase the quality and sustainability of ARV services outside of
This funding will support the personnel, clinic and lab services for training of 800 people, monitoring of
44,000 adults and 4,500 pediatric patients at the end of COP08, which includes 14,000 new adult and 1,500
new pediatric patients. Funding is also used to support renovations of physical infrastructure at expansion
sites to build physical capacity for the provision of ART services. A total of 48,500 patients will be provided
with ART services. Treatment is provided as a part of the National ART Program in 11 tertiary care teaching
hospitals and federal medical centers, located in Plateau, Lagos, Oyo, Borno, Kaduna, Enugu and Benue
states. Services will also be provided in 17 secondary level hospitals/clinics in Oyo, Yobe, Borno and
Plateau States. Mobile services are also provided to patients served by a CBO in Ebonyi State.
CONTRIBUTION TO PROGRAM:
ART activities are consistent with the PEPFAR goal of scaling up capacity to provide ARV drugs, services
Activity Narrative: and lab support to serve more HIV+ people. The 28 comprehensive ART sites represent a significant
increase in the number of ART sites. Additionally, APIN+ will expand to two new states, with the majority of
new expansion sites being secondary level sites. APIN+ will seek to support the expansion of ARV services
into more local areas by developing a network of secondary or primary health care clinics providing ART
services that are linked to tertiary health care facilities. Plateau State will be targeted for additional
expansion through PMTCT services as a component of the PEPFAR Nigeria LGA coverage plan. As
expansion of ARV drug services is prioritized to rural areas, existing referral channels and support network
coordinating mechanisms will be strengthened. These networks will ensure that facilities are able to develop
linkages, which permit patient referral and the provision of specialty care support. A tiered structure for ARV
provision and monitoring established in COP07 provides a model for additional expansion efforts in COP08
in order to meet PEPFAR treatment goals.
LINKS TO OTHER ACTIVITIES:
This activity is linked to ART drugs (9888.08), OVC (5415.08) for pediatric palliative care, adult BC&S
(5369.08), PMTCT (3227.08) as the program will support 36 PMTCT sites, TB/HIV (3222.08) to provide
ART to patients with TB, Lab (6716.08) to provide ART diagnostics, HCT (5424.08) as an entry point to
ART, and SI (3226.08) will provide the GON with crucial information for use in the evaluation of the National
ARV program and recommended drug regimens. This program is linked to PMTCT services to optimize the
PMTCT by providing ART to eligible pregnant women.
POPULATIONS BEING TARGETED:
The care and treatment components of these activities target HIV-infected adults and children for clinical
monitoring and ART treatment. The operational elements of these activities (M&E, health personnel training,
infrastructural supports, technical assistance and quality assurance) target public and private program
managers, doctors, nurses, pharmacists and lab workers at PEPFAR sites. The expansion of ART services
to secondary health facilities will increase access to necessary services in poor communities.
Emphasis areas include in-service training. This increases gender equity by providing equitable access to
ART services for both sexes. Counseling services will seek to identify and provide appropriate referrals for
women who are or are at risk of becoming victims of violence. ART EAC will seek to provide referrals to
wraparound services, such as food & nutrition programs and educational services. ART EAC will also seek
to address stigma and discrimination.
Track 1 and Track 2 funding will be combined for this activity.
This activity provides maintenance of activities at the National Central Public Health Reference Lab
(NCPHRL) and HIV labs at tertiary (11) and secondary (22) health facilities in Plateau, Oyo, Borno, Yobe,
Lagos, Enugu, Kaduna, and Benue States. These 34 labs represent an overachievement of our COP07
target (30 labs in the same 8 states). In COP08, APIN+ proposes adding additional expansion sites by
building the infrastructure and capacities of 3 labs in secondary health facilities in Plateau state to for a total
of 37 labs. In addition, we will expand the capacity of labs at primary health facilities throughout Plateau and
Oyo states (HIV testing). By the end of COP07, our 11 major tertiary level labs and the NCPHRL will have
capabilities for hematology, automated chemistry analyzers, and laser-based lymphocyte subset
enumeration. Ten of these facilities will also have PCR technology.
APIN will work with GON in developing the NCPHRL into a national reference lab, a project identified by the
MOH as a priority. This lab will serve national HIV QC/QA needs and with 2-3 additional APIN+ supported
labs, will serve as a national laboratory training center. This lab's capacity will include standard HIV assays,
clinical chemistries, hematology, and TB culture. In addition, we will continue to strengthen existing labs by
providing backup equipments to major tertiary sites in geographically isolated areas to avoid interruption in
service. Equipment maintenance is coordinated through assistance from a consultant trained in the
maintenance of freezers and through the manufacturers for other items.
All 37 labs will provide HIV diagnosis through rapid test technologies. All 36 ART sites will have western blot
capacity to confirm HIV status prior to initiation of ART. HIV serology, hematology, chemistries, and CD4
enumeration will be supported at all secondary hospitals with referral to the tertiary labs for PCR diagnostics
and viral loads. Primary health care facilities are closely partnered with secondary and tertiary care facilities,
allowing for baseline and periodic evaluation with full lab monitoring. The primary facilities provide limited
lab monitoring with basic clinical, hematologic and CD4 assays. We are currently screening for TB by
sputum and/or pulmonary X-ray at all ART sites. We will be evaluating the use of PCR diagnosis of TB at
selected tertiary sites in COP07; this will help to guide programmatic decisions regarding its use in COP08.
Our labs with infant PCR diagnostic capabilities will continue to assist other PEPFAR IPs, using dried blood
spots (DBS) to transport specimens from distant satellite sites. APIN+ will support the PEPFAR-Nigeria LGA
coverage strategy (PMTCT and TB/HIV). Secondary sites will have lab capacity for HIV serology,
hematology, chemistries, and CD4 enumeration. Primary feeder sites will be limited to HIV serology with
referral to the secondary sites for additional lab monitoring.
Standardized lab protocols have been developed to accompany the PEPFAR clinical protocol and
computerized lab results link with patient records. These protocols include provisions for the disposal of
biomedical waste in accordance with good laboratory practices. Quality control / quality assurance (QA/QC)
policies have been developed and detailed annual assessments of all lab activities are conducted. Quarterly
QA/QC lab site visits are conducted by the HSPH project management team and will use a standardized
assessment tool developed in Nigeria by the Lab Technical Working Group (LTWG). Results from the
proficiency testing and site visits will be sent into a centralized system within Nigeria, developed and
supported by the PEPFAR LTWG. EQA for lab tests was established in COP07 and is operational for CD4,
HIV, HCV and HBV serology, chemistries, VL and HIV PCR diagnostics; through individual lab registration
with UK-NEQAS and CAP. All PCR labs will participate in the CDC's DBS DNA PCR proficiency program
(EID QA). We provide support for 264 lab staff persons (based at sites), responsible for implementation of
lab protocols, data entry and performance of lab tests. In addition, we provide support for 7 APIN+ staff who
provide technical assistance to sites. Regular lab training allows the development of high quality lab
standards in our PEPFAR labs and this has been networked to our secondary and primary labs with specific
tailoring to the needs and skills at each level. Biannual trainings are provided on specific techniques/topics
integrating QA/QC, good lab practices and biosafety. Competency monitoring/evaluations and refresher
trainings will be provided within individual labs. PEP protocols have been implemented at each of our labs,
supported under our ART drugs activities. APIN has supported international laboratory accreditation for
NIMR and in COP08 will seek international accreditation for 2 additional labs and local accreditation for 10
A laboratory information system (LIS) will be implemented at sites, with appropriate capabilities, to
streamline the capture of lab data, minimize transcription errors and facilitate data entry and results output.
We will continue to participate in LTWG monthly meetings to ensure harmonization with other IPs and the
GON, including the development of a common lab equipment platform (appropriate for each lab level).
Procurement of lab reagents is structured in two ways. Reagents available in Nigeria are procured directly
by the sites from specific distributors. Labs are advised to maintain a 3 month reagent buffer. Most reagents
needing importation are ordered at HSPH and shipped to our central warehouse in Lagos. PEPFAR funding
supports procurement of lab equipment, generators and water purifiers necessary for lab work. Equipment
costs for tertiary labs can be high in the first year, but represents significant infrastructure development.
Secondary and primary labs, including VCT facilities, have lower start up costs. Maintenance costs include
minimal renovation costs for some labs, replacement of small lab equipment and training costs for additional
personnel. As further regional networks are developed around these centers of excellence, training, lab and
clinical support will be provided to secondary and primary points of service.
CONTRIBUTION TO OVERALL PROGRAM AREA:
These activities contribute to the goal of maintaining high quality services as the PEPFAR program
expands. APIN will perform 1,137,248 tests in COP08, including HIV diagnosis and tests for disease
monitoring including CD4 enumeration, PCR diagnosis of infants and VL. In addition, we seek to train 720
lab staff members in FY08. APIN will provide training at their supported training facilities to a large number
of non-APIN and non-PEPFAR supported laboratorians. Training lab staff will assist in building the human
resource capacity of our sites to provide sustainable lab support to sites providing high quality HCT and
ART treatment. Nine labs at tertiary care hospitals will have the capacity to perform early infant diagnosis
(EID) by HIV DNA PCR. These labs are also linked to PMTCT sites, to provide a mechanism for EID as a
part of the PEPFAR supported national scale-up plan (consistent with 2008 PEPFAR objectives for Nigeria).
APIN will partner with the GON and Clinton Foundation for procurement of EID test kits and specimen
collection supplies. The NIMR PCR lab will provide QA support for the EID program in the Southern half of
Activity Narrative: Nigeria (through retesting). Through a tiered system of labs at tertiary, secondary and primary sites we are
able to ensure that patients at community based primary facilities are provided with a full complement of lab
monitoring as a part of ART treatment and care. Our training activities include management and
competency training, which seeks to build sustainability. We have provided training to lab workers through
the MOH ART training program at the NIMR. Lab workers from all 36 states and the FCT are invited to
participate on a biannual basis at the NIMR and JUTH sites. Three of our sub-partner sites are actively
involved in lab training for the MOH training program resulting in 14,000 indirect targets without budget
These activities relate to activities in PMTCT (3227.08), Counseling & Testing (5424.08), Palliative Care
TB/HIV (3222.08), ART Services (6715.08) and OVC (5415.08). Our labs are crucial in providing adequate
HIV diagnostics in PMTCT, C&T, OVC, Palliative care and ART services. Furthermore the lab provides
other diagnostics such as OIs. As a part of this activity, we seek to build linkages between labs and our
patient care sites in order to ensure that lab information is fed back into patient records for use in clinical
care. Our SI (3226.08) activities provide support in M&E, including data management of testing results.
This program targets public and private health care workers with training to maintain high quality lab
This activity focuses on infrastructure building, creating a network of quality labs supported by strong tertiary
labs, as well as commodity procurement and logistics. This activity also focuses on QA, training and the
development of networks / linkages. QA and training are reinforced by the collaborative nature of the tiered
network of labs. This program seeks to address gender equity by building the capacity of labs at affiliated
sites to conduct testing related to PMTCT. Increased lab capacity will permit the sites to provide equitable
treatment for both women and men.
In COP07 APIN+ provided support for SI activities at 38 sites. In COP08, APIN+ will provide support to 40
sites (36 ARV and PMTCT sites, four stand alone HCT sites). These activities include Monitoring and
Evaluation (M&E), Health Management Information Systems (HMIS), operational research studies,
improved data management and maintenance of data quality in all APIN+ sites and the central public health
laboratory. Funds will also be utilized to build the capacity of site staff and Harvard School of Public Health
(HSPH) personnel in the above areas and promote efficient use of data to improve services and influence
policy. In collaboration with the HSPH team, a data manager and an M&E Officer assist the sites with on-
site clinical, pharmacy and project reporting data collection. APIN+ will collaborate with the GON at both the
federal and state levels. In line with the PEPFAR-Nigeria LGA coverage strategy, APIN+ will engage in
scale-up for the capture of data from primary and secondary health facilities in each of the 17 LGAs of
Plateau state. Data capture from these facilities will be coordinated through data entry and management
teams at secondary and tertiary health care facilities in Plateau state.
A relational database system interlinked by ID number has been developed and contains different data
required in the course of care and treatment, ART drug pharmacy logs, toxicity records, discontinuation
forms, PMTCT and pediatrics. All paper files are stored in locked file cabinets as hospital patient records.
Data are electronically entered at sites by trained data entry clerks. The data are then uploaded to a
password protected web server, accessible to authorized personnel and data managers in Nigeria and
Boston. Electronic data is used to prepare timely reports for GON and USG. Data managers conduct M&E
of the data collection and reporting process and provide feedback to each site. The APIN+ electronic record
system is functional and responsive to the GON Patient Management Monitoring (PMM) forms and provides
access to pharmacy pickup data, lab results and other clinical patient information. This data is used for site
and program-specific evaluation of services provided in each program area, including evaluations of CD4
counts, loss to follow-up and viral suppression. SOPs govern data entry, security, management and report
generation related to the ART treatment and care protocol. Paper based National registers are also in use
at APIN+ supported sites. Where the electronic register is available, data is entered from paper documents
to the electronic format. Refinement of instruments and databases is ongoing to accommodate program
reporting requirements from HQ, central, and the GON. In addition, facility based data reporting will be
harmonized with the new National Public Health data system.
APIN+ will provide computer hardware and software support to sites as services expand. Site evaluation
teams will implement an annual M&E plan for APIN+ globally and for each site, with M&E results fed back to
the sites to promote systems improvement. HSPH will continue to participate in the National M&E technical
workgroup (TWG) and the SI team will continue to be active participants on the USG-Nigeria SI TWG.
In 2006 and 2007, JSI conducted Quality Improvement (QI) visits to APIN+ supported ART sites, focusing
on ART services. Through HIVQUAL, additional QI indicators will be added in a coordinated fashion with
USG-Nigeria and the GON. These QI efforts are linked with similar long term efforts in other Harvard
PEPFAR countries (Tanzania, Botswana). In COP07, APIN+ initiated and piloted an internal QI initiative,
designed at collecting qualitative and quantitative data regarding quality indicators on the provision of adult
ART services at each site. In COP08 APIN+ anticipates scaling up these activities to conduct QI
assessments at additional sites that have not been previously evaluated and to expand to other program
areas including PMTCT and pediatric treatment. In COP08, APIN+ will adopt most of the QI activities to this
cross-site model with significant input from Boston, the Nigerian program offices and colleagues in
Botswana and Tanzania. Each site will be visited regularly by APIN+ M&E staff throughout the activity
period; on-site TA and supportive supervision will be provided. Each site will also be assessed internally
once it has had patients enrolled for at least one year. Regular inter-site interactions will be encouraged,
facilitated by HSPH personnel in Nigeria and from the US. All related activities will be carried out in all
supported sites to develop management experience for sustainability. APIN+ will facilitate good working
relationships with state level M&E staff and will regularly communicate on monitoring activities, thereby
encouraging their active involvement. This involvement will build the capacity of the state level staff and
In COP08, 800 individuals will be trained in monitoring and evaluation (M&E), surveillance, and HMIS.
APIN+ M&E and data staff conduct 3-4 training sessions centrally per year. In addition, they conduct
regional data management training for personnel working with medical records and patient data on a regular
basis. For other disciplines such as clinicians, nurses, pharmacists and laboratorians, data collection and
M&E modules are incorporated into their respective technical training sessions.
Public Health Evaluations (PHEs) assess the efficacy of ART at all sites to provide feedback on program
implementation, PMTCT activities and related ART interventions (funded under their respective program
areas). During COP08, APIN+ will conduct a PHE to evaluate the rate and predictors of mother to infant
transmission across five different antiretroviral therapy prophylaxis regimens, dependent on time of entry
and mother's health status, in accordance with the Nigerian National PMTCT guidelines. APIN+ will also
investigate the rate of breast milk transmission in infants found to be HIV negative at six weeks and followed
until 18 months of age. Additionally, APIN+ will conduct a PHE to investigate drug resistance relative to viral
subtype. These subtype drug resistance PHE has been supported by National Institute of Allergic and
Infectious Diseases (NIAID)/National Institute of Health (NIH) funding in the past. Results of these PHEs will
provide information to the Nigerian National ART (NNART) committee about co-infections and the levels of
drug resistant virus for use in the evaluation of national drug regimens.
SI activities supported by APIN+ are consistent with the 2008 PEPFAR goals to strengthen site capacity in
the areas of data management and analysis. APIN+ will also provide SI support to its local administrative
office, central pharmacy and warehouse. Training provided by APIN+ is consistent with 2008 PEPFAR
goals to conduct human capacity assessments and training to build SI human resource capacity at sites
providing ART. In 2008, PEPFAR plans to strengthen surveillance efforts and PMM systems in Nigeria.
APIN+ SI activities are consistent with these goals in that funding will be used to refine and implement a
global M&E plan for all supported sites and for each site individually. Furthermore, APIN+ will continue to
collect data on the efficacy and utilization of ART at current sites and build data management capacity at
new sites. The data collection activities will facilitate the ability of PEPFAR to report on Emergency Plan
indicators, which may be used for programmatic decision-making.
Activity Narrative: LINKS TO OTHER ACTIVITIES:
These activities are linked to PMTCT (3227.08), OVC (5415.08), TB/HIV (3222.08), HCT (5424.08) and
ART Services (6715.08), where SI is used for QA/QC and M&E. In M&E activities, APIN+ will link to the
National M&E TWG and Nigeria MEMS. Additionally, through the provision of information technology (IT)
support and data management personnel, APIN+ will provide linkages between all supported sites as
related to data sharing and HIV surveillance in PEPFAR program areas. Through operational research
studies, APIN+ will collaborate with the FMOH, GON, NNART committee and the NIAID/NIH.
POPULATIONS BEING TARGETED:
The SI M&E activities target program managers and evaluation officers, site coordinators and principal
investigators to provide them with a mechanism for programmatic evaluation. The data collection and
management components of these activities target medical record clerks, data managers, and other health
care workers who are involved in the implementation of these processes. Lastly, the M&E and capacity
building efforts target implementing organizations, including community based and faith based organizations
involved in the provision of ART, HCT, BC&S, TB/HIV and PMTCT services.
These activities emphasize monitoring, evaluation, and reporting through data collection and
implementation of M&E plans. Emphasis is placed strategic information, PHE, human capacity development
and local organization capacity building.
This activity will address gender equity issues through the collection of data on the breakdown of sex
accessing ART care. Through this data collection, we will be able to contribute to national surveillance on
the impact of HIV on both sexes. This data will be essential to the development of outreach, treatment
programs and education to reach an equitable number of men and women.