Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 553
Country/Region: Nigeria
Year: 2009
Main Partner: To Be Determined
Main Partner Program: NA
Organizational Type: Implementing Agency
Funding Agency: USAID
Total Funding: $0

Funding for Care: Orphans and Vulnerable Children (HKID): $0

The proposed activity will be a new award which will be competitively solicited by USAID/Nigeria, with the

award anticipated during the COP09 program period. It will build upon the successes and lessons learned

from the ENHANSE program activity, which will reach the end of agreement by the end of COP08. With

COP09 funding, the new implementing partner will have a mandate to create integrated safe and supportive

environments for Orphans and Vulnerable Children (OVC) who are affected by HIV/AIDS and TB through

the social sector environment. The activity's major emphasis will be on policy/plans development and

utilization. It will also focus on the use of accurate and strategic information to inform the policy and

planning process and to leverage organized private sector support and resources for national HIV/AIDS

programs as well as improve the political will and commitment of key national and state level leaders.

A major emerging issue in the HIV/AIDS epidemic is the large number of OVC who have lost either one or

both parents as a result of HIV/AIDS or are made vulnerable by the demands imposed by the infection of

one or both parents. The work of the implementing partner on OVC will be to utilize policy development

activities toward the goal of ensuring that there are safe and supportive environments for OVC on a national

level.

The activities for COP 09 will build on earlier accomplishments undertaken by other IPs, namely systems

strengthening for the FMWA-OVC Unit to increase their capacity and the capability of national leadership to

address OVC issues and other programs that have strong focus on the special needs of children.

The use of accurate data to inform program implementation is crucial to program success. The partner will

support the national and state ministries and local government areas to develop OVC policies and

guidelines. The partner will also collaborate with UNICEF and other partners in support of the printing and

dissemination of these policies and guidelines. National civil society organization networks and coalitions,

(e.g., AONN, NEPWHAN, CISHAN, etc), Faith Based Organizations (both Christian and Muslim), and select

Private Sector Organizations will be supported via grants and other funding mechanisms to develop policies

to address the challenges that OVC face within their various organizations and how they can evolve robust

responses that meet national needs. Training will be provided to these and other key stakeholders on

issues related to OVC, stigma, and discrimination. Support will be provided to conduct training on OVC

issues such as stigma, AB, C&OP, child involvement and protection, with technical assistance provided by

other IPs and donors.

To ensure accurate reporting of OVC issues, the partner will support activities such as media tours for

journalists, workshops and roundtables, which will provide a greater understanding of issues affecting OVC

and interventions to address them.

The partner will support the OVC advocacy groups that promote the reduction of stigma and discrimination

while providing psychosocial and group support. The recipient will print and disseminate the newly

developed National OVC Strategy. The activity will also support FMWA supervision of orphanages in

Nigeria.

LINKS TO OTHER ACTIVITIES: This activity is linked to initiatives in child survival, human rights,

elimination of stigma and discrimination, education and income generation. Activities will be linked to those

of other USG IPs providing services in the communities. This activity is also linked to activities of bilateral

and multilateral organizations dealing with issues related to child survival.

KEY LEGISLATIVE ISSUES: The activity will increase legislative engagement in HIV/AIDS and OVC

stigma and discrimination issues. The partner will support the enactment of appropriate legislations that

support national HIV/AIDS programs that will assist in the passing of bills mandating the rights of children,

adoption, and the care of affected children and their families.

EMPHASIS AREAS: This activity's major emphasis is on policy/plans development and utilization and will

focus on the use of accurate and strategic information to inform the policy and planning process. It will also

focus on plan implementation by key national and local stakeholders.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16944

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16944 16944.08 U.S. Agency for The Futures 6392 553.08 USAID Track $500,000

International Group 2.0 ENHANSE

Development International

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $1,956,159

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Due to the strategic shift in the overall PEPFAR programming in FY09 to ensure maintenance of all supported clients receiving

care, OVC, and treatment services as well as the financial integrity of the program, it has become imperative to significantly

reduce HCT activities in order not to create demands that cannot be met through the existing care and treatment services.

Therefore the HCT program area strategy in COP09 will focus on providing HCT services to those most in need of HIV care and

treatment and linking those identified to the appropriate care and support services. The areas of strategic focus in COP09 are: to

concentrate HCT activities in medical settings and promote Provider Initiated Testing and Counseling (PITC); increase

collaboration with the basic care and treatment programs as a means of promoting home-based counseling and testing for family

members and contacts of index cases; expansion of couples counseling services, and the direction mobile outreach services to

Most at Risk Populations (MARPs), especially brothel and non-brothel based commercial sex workers, prison inmates and

patients in alcohol or drug rehabilitation centers; to standardize quality of HCT services across the board; increase HCT services

for infants and children; and to strengthen referral networks and program linkages. In addition there is also a strategic focus on

resource leveraging from other bilateral and multilateral donors and building the capacity of the GON HCT team to ensure

program sustainability.

In COP08 the number of PEPFAR-funded HCT implementing partners (IPs) increased from 12 to 24 .These partners will be

providing HCT services in 699 sites across the 36 states of the country and the Federal Capital Territory. In COP09, the target for

individuals that will be counseled, tested and receive their result is 149,080. This represents an 82% decrease from the COP08

HCT target of 808,918. Overall counseling and testing targets for COP09 including HCT in PMTCT and TB settings is 647,256.

This is a 47% reduction in the HCT target from the COP08 targets of 1,216,568 as a result of the overall strategic shift in PEPFAR

program funding.

It is estimated that 1.5 million, or about 1% of the total population, currently know their HIV status as a result of limited access to

HCT services. HCT services are supported mainly by PEPFAR as well as support from other bilateral and multilateral donors

including the Global Fund, the World Bank and the Millennium Development Goal. About 65% of people are currently accessing

services in health care facilities while 35% access services in stand alone HCT sites and mobile community outreaches.

In COP09, 80% of the HCT target for the PEPFAR program will be reached through health facility HCT and about 20% will be

reached through stand alone and community mobile outreach that will be targeted to MARPs. Fund leveraging by USG partners

for HCT from other donors, including test kit leveraging from the GON, will enable partners to provide HIV counseling and testing

that is strategically targeted at the general population, through mobile HCT and community outreach. This will enable individuals

know their HIV status, and use counseling and testing as a means of HIV prevention.

Partners provide HCT services using a strategic mix of models and approaches. These include integrated facility based HCT,

traditional stand-alone HCT, mobile community outreach HCT, and home-based HCT. This mix of service models are employed to

reach varied target populations which includes MARPs, couples, pediatrics, family members and contacts of PLWHA, in and out-

of-school youth, and the general population. In COP09, partners will be laying emphasis on HCT in medical settings, and utilizing

the PITC approach to ensure that hospital in- and outpatients are routinely offered HIV counseling and testing in an "opt-out"

strategy. Those identified as positives will also be linked into care and treatment. Posttest counseling for all clients includes

appropriate HIV prevention messaging, including Prevention with Positives (PwP) activities. Provision of multiple points of HCT

services within health facilities by partners further ensures increased access. Many IPs currently provide TB and STI screening for

all HCT clients and make referrals for diagnosis and treatment as appropriate. To strengthen and standardize this activity and

ensure its consistent use in COP09, all HCT partners will be required to provide TB and STI screening using a standardized WHO

recommended questionnaire and link patients to TB and/or STI services as appropriate.

The IPs are incorporating family centered approaches into HCT services in order to provide counseling and testing to partners,

children and other family members of Basic Care and Support index cases. In COP09, all HCT IPs with Basic Care and Treatment

programs are required to establish collaboration with this program and incorporate HCT services into home-based care services.

This will enable the provision of HCT services to family members and contacts of home-based care index cases. This family

centered approach will not only increase HCT access but will also bring about reduction in stigma and discrimination at the family

level as well as help in dealing with issues regarding disclosure, abandonment and other negative outcomes a family member

may face as a result of his or her status. The Nigeria HCT TWG plans to partner with the OGAC HCT TWG to strengthen this

activity by providing a training of trainers (TOT) on home-based HCT. This will bring about standardization of home-based HCT

across USG IPs and further ensure that services provided are consistent with international standards.

In FY09 partners will continue to pay strong attention to couples counseling and testing and address the needs of discordant

couples. To further strengthen this activity, the HCT TWG will be assessing the outcomes and lessons learned in CHCT

implementation by USG IPs after one year of service roll out in the country. The outcome of this assessment will be used to adapt

the CHCT training curriculum in collaboration with the GON. It is anticipated that the adapted training curriculum will be used to

expand CHCT training and services to HCT sites that are not directly supported by PEPFAR. The HCT TWG will be providing the

needed technical support to the GON for this activity.

In COP08, the country fully transitioned into the use of a non-cold chain dependent serial HIV testing algorithm, based on the

recommendations of a PEPFAR-funded National Rapid Test Kit (RTK) Validation exercise. The use of this algorithm continues to

make the testing process simpler, especially for the lay counselors and testers, who as a result of progress being made in the

area of task shifting are involved in the provision of HCT services. It makes same hour counseling and testing a norm and further

increases access to HCT services. The current use of finger-prick samples and non-cold chain RTK have also facilitated HIV

testing during mobile and outreach campaigns.

To ensure increased access to HCT services in the rural areas, the GON developed an HCT protocol for use in primary health

care (PHC) outlets and has been supportive of task shifting efforts, including the training of non-laboratory personnel to conduct

opt-out HCT in primary health care centers. In COP07 and 08, USG HCT IPs supported expansion of HCT services to the rural

areas by activating counseling and testing sites in PHCs. In COP09 however, this expansion to rural sites will be limited to new

partners as a result of funding constraints. To strengthen linkages, partners have established referral networks between these

PHC and secondary and/or tertiary facilities where HIV treatment and care programs exist. Partners are also supporting TB and

STI treatment programs at the PHC levels to further enhance access to these services by those identified through HCT.

In addition to HCT in medical facilities, partners also provide HCT in communities using mobile outreach. In COP09, partners plan

to continue this on a more limited and focused level due to funding constraints. The USG team in Nigeria is collaborating closely

with the GON to leverage HIV rapid test kits for use in the program. Test kits leveraged from this arrangement will support mobile

HCT services for community outreach as a means of providing services and increasing access to the rural communities. Mobile

and outreach HCT will continue to target high risk groups such as commercial sex workers and their clients, and also rural

populations without easy access to HCT services. One IP will specifically be working with Most at Risk Men/Men who have Sex

with Men (MARM/MSM). HCT services targeted at the incarcerated population, including prison inmates and individuals in

alcohol/drug rehabilitation centers will also be supported in COP09. A challenge in providing mobile services is ensuring referral

linkages to care, treatment, and support for those testing positive. The use of standard referral tools by all USG partners will be

pursued in COP09 to help address this. Currently IPs provide clients with referral cards, which they collect from HIV care and

treatment clinics to help with tracking. Some IPs have already developed, and are using, referral directories and the USG is

collaborating with the GON to develop a national Referral Directory. Referral systems for care and treatment are working

reasonably well and IPs are beginning to address the trend of referring clients to their own sites rather than to services provided

by other IPs. The focus now has shifted towards ensuring that clients are referred based on their needs, regardless of which IP is

providing the service. This strategy will be sustained in FY09.

PEPFAR is currently working with the GON to harmonize the various M&E tools used by different sites and IPs and to establish

one national approach to data collection at HCT sites, including a national HCT register. In COP09, all HCT IPs are required to

use standardized GON M&E and data collection tools in order to ensure that appropriate program data are collected and fed into

the national data system for the overall national M&E process.

The GON has adopted "Heart to Heart" as a national branding logo for HCT. In COP08, more service outlets adopted the use of

this logo in order to be identified as centers where high quality HCT services can be accessed. The use of the logo will be

strengthened in COP09. USG IPs also promote HCT services through a combination of print materials, posters, radio, and

community outreach. The radio and community outreach promotion strategies are ideal for reaching the illiterate and the rural

populations, respectively.

IPs will be providing HCT based training to 1,005 individuals in COP09. These training will be based on identified training needs

and will include training on basic counseling and testing, supervising counselors, couples counseling, PITC, medical waste

management and injection safety. The USG HCT TWG in country will collaborate with the OGAC HCT TWG to provide a Training

of the Trainers (TOT) on home-based counseling and testing for all HCT IPs in order to strengthen home based counseling and

testing for the family members and contacts of PLWHA, and further ensure that services are provided following standard best

practices. Similar training collaboration will be established with the PMTCT and pediatrics treatment program areas to provide

training on pediatrics counseling and testing. It is anticipated that this will increase counseling and testing services for the pediatric

population and also ensure standardization of service quality.

In COP09, all RTKs for HCT IPs will continue to be procured in pooled orders through the SCMS test kits procurement

mechanism based on COP09 targeted forecasting. Partners, however, depend on their respective structures for test kits

distribution, while SCMS provides support to partners on test kits forecasting, needs quantification and logistics management

information system. HIV test kits logistics systems which are supporting HCT programs are specific to each IP and different from

the National logistics system. A persistent challenge is the harmonization of logistics systems not only among PEPFAR IPs but

also with the GON. A priority area in FY08 and FY09 is for harmonization of the Logistics Management Information System

(LMIS).

USG/Nigeria will continue to collaborate with the GON on expansion plans, training, and policy development, and will leverage

funds from donors including the Global Fund and DFID, for the procurement of condoms. These collaborative efforts will be

strengthened in COP09.

To further improve the quality of HCT services and ensure consistent quality improvement across the board, IPs will be provided

an updated guideline on the minimum quality requirement in HCT. In COP09, the implementation of standard quality control and

external quality assessment for HIV rapid testing at all HCT sites, will be done by adopting the "Quality System" approach which

will be a priority. Proficiency testing programs, regular HCT site monitoring, and mentoring of counseling and testing staff will be

emphasized. Re-testing will be continued in facility-based HCT sites and wherever possible. Proper and safe waste handling and

disposal is also part of this system approach.

The GON supports PITC in principle, but a government policy is essential to get the health facility administrators buy-in into the

strategy. There is not yet a policy that provides for routine HIV counseling and testing in certain populations where it is most

needed, such as for prison inmates or other incarcerated populations. The recent IBBSS revealed a very high HIV prevalence rate

among commercial sex workers (25%), and MSM (13.5%), other populations that could benefit from policy development. As

programs and partners re-strategize for more effective targeted HCT for CSW, an enabling policy is necessary to address issues

surrounding rights to health services for these populations. Government policies on task shifting and pediatrics testing are also

key legislative items to the overall program, its reach and its effectiveness.

In summary, the Nigeria PEPFAR program has seen rapid increase in the number of persons accessing HCT services. The focus

now is on building a sustainable strategy and addressing policy and service quality issues as we move into PEPFAR II.

Table 3.3.14:

Funding for Health Systems Strengthening (OHSS): $0

The proposed activity will be a new award which will be competitively solicited by USAID/Nigeria, with the

award anticipated during the COP09 program period. It will build upon the successes and lessons learned

from the other USG policy partners' program activities, which relate to activities cutting across all other

program areas. It is a national, state, and local level integrated project mandated to create an enabling

environment for HIV/AIDS working with public and private sector institutions. Activities will include

developing the capacity of line ministries and the uniformed services, and continuing support for the Global

Fund (GF) Country Coordinating Mechanism (CCM) and the GF grants implementation.

The activity will support preparation and/or review of local and national HIV/AIDS evaluations, strategic

frameworks, and responses, focusing largely on health and education, with some cross-sectoral activities

pertaining to agriculture (nutrition) and the economy (workplace programming, income generation, etc.).

The activity will participate in the design of key policies and plans for all HIV/AIDS program areas to ensure

improvement in data use for policy and planning purposes, with a strong focus on the special needs of

children, gender, and trafficking in persons (TIP). The activity will perform the following: continue to support

the National Assembly to enact appropriate legislation that supports national HIV/AIDS programs; promote

policies that minimize use of injectables, appropriate waste management, and limitation of blood transmitted

infections while also fostering the practice of non-remunerated safe blood donations and transfusions; and

collaborate with the GON to evolve strategies for dealing with the HIV/AIDS challenge in incarcerated and

displaced populations. Significant effort will also be placed upon the development, dissemination and

practical application of HIV-related appropriate technical guidelines and policy initiatives throughout the

nation, with a particular emphasis on assuring the adaptation and adoption of such materials at the State

level.

The activity will also provide training and capacity building for the GON, key FBOs, CSOs, and other

partners on technical areas for implementation of HIV/AIDS initiatives. It will also serve as the platform

through which USG implementing partners dialogue for greater harmonization of activities via workshops

and the exchange of information. The selected implementing partner will work with NIBUCAA or similar

institutions in support of the direct establishment of Public-Private and Private-Private Sector partnerships

that support wrap-around programs in HIV/AIDS treatment, care, and support.

CONTRIBUTIONS TO OVERALL PROGRAM AREAS: It is expected that the policy and guidelines

developed and the work of the individuals trained will have a significant impact on PLWHAs. The policies

and guidelines will help facilitate improved delivery of high quality and harmonized clinical and laboratory

services. Issues related to greater ownership and support for PEPFAR in Nigeria will be facilitated via

enhanced opportunities for dialogue and consensus building leading to greater sustainability.

Barriers to effective program implementation that arise from the predominant religious zones will be

minimized by the special focus on FBOs to develop their own HIV/AIDS national and local policies, plans,

and operational guidelines. Barriers that arise from excessive bureaucracy within federal, national, and

local level institutions will be overcome by providing TA to these institutions to improve their capacity to

carry out their core mandates around coordination of national programs.

LINKS TO OTHER ACTIVITIES: The activity is linked to initiatives in other HIV/AIDS program areas that

cover reproductive health and population activities, child survival, and education. In addition, it links to the

integration of HIV/AIDS into family planning and vice versa via new guidelines which will be developed. It is

also linked to initiatives with the uniformed services, national management of TB, as well as programs

addressing OVC. The new award is also intended to support a broader range of Investing in People

initiatives in the health and education sector, and so funding and collaborative opportunities will also be

leveraged from non-PEPFAR USG supports.

The activity is linked via the national multi-sectoral response to HIV/AIDS to activities in most ministries and

parastatals of government, such as in the prisons, the armed forces and police, FBO, youth, and women.

Further activities related to cross-cutting initiatives such as gender, human rights, and the elimination of

stigma and discrimination form major linkages to this activity. It is also linked to the activities of the Global

Fund in Nigeria.

POPULATIONS TARGETED: The activity focuses largely on national, state, and local level public and

private sector institutions, especially those playing a significant role in addressing HIV/AIDS prevention,

treatment, and care. In addition, the activity targets media organizations, as well as the national and state

legislatures. The activity also targets the leadership of faith-based and community-based organizations as

well as national networks of those living with the virus or associated with them.

KEY LEGISLATIVE ISSUES: This activity will increase legislative engagement with HIV/AIDS-related

issues, especially those addressing institutionalization of the current structures leading the national

response. In addition, this activity will be addressing specific legislation related to the workplace and

HIV/AIDS, as well as the larger context of HIV/AIDS stigma and discrimination. This activity will also target

legislative and policy issues at the State and Federal levels.

EMPHASIS AREAS: The activity's major emphasis is on policy/plans development and utilization. The

activity will also focus on the use of accurate and strategic information to inform the policy and planning

process. It would also focus on leveraging organized private sector support and resources for national

HIV/AIDS programs as well as improving the political will and commitment of key national, state, and local

leaders.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13104

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13104 3238.08 U.S. Agency for The Futures 6392 553.08 USAID Track $3,000,000

International Group 2.0 ENHANSE

Development International

6739 3238.07 U.S. Agency for The Futures 4180 553.07 ENHANSE $3,800,000

International Group

Development International

3238 3238.06 U.S. Agency for The Futures 2772 553.06 $2,150,000

International Group

Development International

Table 3.3.18: