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ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In COP10, GHAIN will continue supporting activities to prevent mother-to-child HIV transmission (PMTCT) in the existing 168 GHAIN supported sites. Through these sites, an approximately 120,000 pregnant women will be tested, counseled and informed of their HIV status as possible. GHAIN staff will continue to train and mentor the facility staff to enable them deliver PMTCT services according to the national guideline, to reduce the risk of mother-to-child-transmission. In addition, GHAIN will continue intensive PMTCT mobilization and awareness in all 16 LGAs of Taraba state aimed at not only saturating the state with PMTCT services, but also to create demand and increase the access to early infant diagnosis (EID) services utilizing the recently commissioned EID laboratory at Jalingo Federal Medical Center. Through these strategies, facilities will be supported to reach approximately 4,000 HIV-positive pregnant women in the COP year.

To increase access and uptake of PMTCT services, GHAIN will continue to support integration of PMTCT services into maternal and child health services commencing at antenatal care (ANC) at the primary health care (PHC) level which serves as an entry point to HIV/AIDS prevention, care and support services for mothers, their infants, family members and the community, This is in line with the minimum package stipulated by the GON and the USG strategy to provide PMTCT service coverage at the LGA

level; initially in states with high prevalence and in facilities with a high volume of ANC clients.

To address gender issues and generate greater male involvement in PMTCT services, couple counseling will continue to be included in the PMTCT/RH/MIP integrated trainings. This will lead to improved service uptake, and adherence to interventions. The continuation of this new strategy will further address the challenges of partner disclosure and the negative consequences (domestic violence, divorce and abandonment) that have occasionally been noted in discordant couples or when women take unilateral decisions to enroll for HIV services.

Using a family centered approach, PMTCT service providers will promote partner testing as well as testing for any other children in the family. In addition, families with HIV positive children will be encouraged to enroll all them into ART, if eligible or the facility-based care and support programs. GHAIN will also continue to support various strategic initiatives such as provider-initiated testing and counseling in ANC and labor/delivery wards and community outreach activities to cluster ANC and delivery facilities so as to increase the number of pregnant women who know their HIV status and thus triggering enrollment for PMTCT services. GHAIN will continue promoting and educating women on infant feeding options (exclusive breast-feeding for six months or breast milk substitute if affordable, feasible, acceptable, safe and sustainable - AFASS) and addressing misconceptions, stigma and retrogressive social norms that impede uptake of PMTCT services in different parts of the country. Comprehensive services will be encouraged through integration with MCH services which includes counseling and linkages to services such as family planning, infant feeding and immunisation in line with the national IMNCH strategic plan.

To ensure effective coverage at the LGA level, the experience and lessons learnt from piloting the HAST (HIV/AIDS, Sexually transmitted infections/reproductive health and TB) model of providing integrated services at the LGA level in various states will be utilized. Community volunteers identified by CBOs and NGOs will be trained using a specially modified national PMTCT incorporating RH modules to render minimum PMTCT services (linkages and referrals, awareness and demand creation for PMTCT) appropriate to their level of care. Referral from the PHC level to secondary facility will be done when the need arises for higher quality care and treatment.

During the year, GHAIN will give more focus to enhancing service quality and strengthening measures for sustainability using performance indicators of the PMTCT service cascade. The skills of health care providers in the supported facilities will be strengthened through additional training and mentoring to cover all modules in the national PMTCT training curriculum and through the integration of RH and malaria services using other funding sources. Family planning services integrated with HIV services will be offered in a number of select facilities to address and strengthen the second prong of core PMTCT

which aims at preventing unwanted pregnancies amongst women/couples that are HIV infected and in a bid to reduce the number of children exposed to the virus. MIP services will be strengthened through mentoring of trained staff and advocacy to facilitate access to preventive therapy and insecticide treated nets. Additional emphasis will be put on strengthening the link of ANC - Maternity - Under-5 services in order to improve a continuum of prevention, treatment, care and support for mothers and children. Linkages to the national Integrated Maternal Newborn and Child Health (IMNCH) will be strengthened and collaborations with other partners working in this area established.

GHAIN will continue to ensure that supported sites provide quality PMTCT service in line with national and international standards and evidence-based best practices. Project activities will be tailored towards improving quality and build in sustainable take over capacity by ensuring that health care workers have up to date PMTCT knowledge and skills; enforcing adherence to SOPs; ensuring that all point of service have the necessary tools, materials and logistics; ensuring that CT with 'opt out' option is offered to all women presenting in ANC, in labor & delivery wards, and post-natal in the family planning units; while encouraging male involvement; instituting effective intra and inter-facility referral mechanisms; and ensuring that antiretroviral (ARV) drugs are offered to HIV + pregnant women. PMTCT prophylaxis will be provided,(zidovudine starting at 28 weeks, zidovudine and lamivudine if starting at 34 weeks until delivery and single dose nevirapine at the onset of labour), or ARV treatment (CD4 count less than 350) according to the national guidelines for their own health. Post-partum interventions for exposed infants including single dose nevirapine within 72 hours of birth and zidovudine syrup for 6 weeks)., CTX prophylaxis is commenced from six weeks after birth, until their status is determined, utilizing the national guideline as basis for treatment decisions.

All clients who are tested will receive results on the same day as feasible. HIV testing of all partners of pregnant women will be actively encouraged and women/couples counseled and linked to FP services as needed. This will be ensured through linkages with the scaled up GHAIN supported RH-HIV integrated services. Those who test negative to HIV will receive post-test counseling on how to remain negative. Positive and discordant couples will be given prevention for positive package and provided information to address their future fertility desires (family planning services). GHAIN will utilize lessons learnt and best practices from other programs in ensuring that positive mothers delivering outside health facilities have access to single dose nevirapine in labor.

Mothers' support groups will also be used to track and support mother-infant pairs and other family members in the communities and link them to care. In addition, strengthening of SBC activities in the facility and community will be continued as a strategy to improve awareness on the need for mothers to deliver in the facilities and to return for care and support for themselves, their babies and for their family. In addition, the family will be encouraged to enroll all their children into the facility based care and support

program.

GHAIN will continue to train lay counselors to provide counseling services to pregnant mothers, thus, reducing workload and burnout of regular counselors. Other activities will include encouraging male involvement by using trained community gate-keepers to sensitize the community with special focus on men; encouraging men to accompany their wives to the clinics and ensuring that holistic services are offered to HIV+ pregnant women and their families. Positive pregnant women identified at PHC level, will have their CD4 done at the linked secondary facility through sample referral. Identified positive women will subsequently be followed up at an HIV comprehensive care centre to ensure continuity of care. CD4 test will be prioritized for pregnant women to identify and refer those who require ART for their own health. PMTCT services will also be geared towards ensuring that in labor & delivery rooms, safe obstetrical practices and universal precautions are implemented.

Funding will address capacity building of health care workers on counseling (HIV, FP, IFC amongst others), strengthening linkages with EID services and support to families on infant feeding options in accordance with the mother's choice and, the national guideline on infant feeding. GHAIN will train and re-train pharmacists on pharmaceutical care, pharmacy best practices and adherence counseling in PMTCT sites while collaborating with the community pharmacists to expand the reach and quality of services at LGA and community level.

Joint GON/USG/GHAIN supportive supervision will be carried out to all the sites on a quarterly basis, in addition to regular onsite mentoring and support of the sites by FHI/GHAIN technical team. Appropriate tools for program monitoring including National PMTCT registers will be provided to all the sites while monthly DQA will be carried out in collaboration with the relevant state and national bodies. Feedback will be provided to the facilities and stakeholders through the monthly M&E meetings hosted at SACA offices. The quality of services will be assured through facilitative supervision, M&E, QA/QI analysis and QA checks using standardized national tools developed for this purpose. In line with the '3 ones', GHAIN will disseminate information through regular reporting to the GoN via NACA and NASCP.

As part of its strategy to enhance the sustainability of PMTCT programs, in COP 10, GHAIN will rededicate its efforts towards ensuring that technical and institutional capacities of its PMTCT implementing agencies (IAs) are strengthened to effectively plan, implement, monitor, maintain and evaluate PMTCT programs. During the period, GHAIN will transition activities to the respective federal, state, local governments departments responsible for PMTCT, as well as FBOs and NGOs currently supporting PMTCT programs. To actualize this strategy, GHAIN will support the responsible government departments and agencies to prioritize developing and retaining health care workers; strengthening health systems; building their capacities to plan, implement, monitor and evaluate PMTCT activities; and

to have a solid understanding of financing and costing information to inform planning and decision making concerning PMTCT programs.

Additionally, GHAIN will ensure that in addition to technical skills oriented training, HAST LGA based IAs (CSOs) receive training in organizational development with emphasis on such topics as governance, program design, monitoring and evaluation, resource mobilization and financial management. Also, during COP 10, GHAIN will focus on providing TA and oversight leaving IAs to assume more implementation responsibilities. Additionally, GHAIN will ensure proper documentation and dissemination of SOPs, national policies, guidelines and standards to IAs to enable them continue implementing quality and effective PMTCT interventions after GHAIN. GHAIN will support IAs to ensure that by the end of the 3rd quarter, they all have developed clear and measurable transition and sustainability action plans.

Further, to enhance local and national ownership, GHAIN will continue empowering federal, state and LGA governments to plan, monitor and evaluate PMTCT programs in line with the national HIV/AIDS policy and PMTCT guideline. Through training and advocacy, national and local governments will be empowered to assume full responsibility for creating demand for accurate information and services on PMTCT including creating demand for HIV testing and counseling as well as linking PMTCT efforts with prevention and treatment.

In COP10, under 'PEPFAR Nigeria's accelerated PMTCT plan', GHAIN, will strengthen its support to PMTCT service delivery by implementing activities that further improve the coverage and quality of PMTCT services. These activities will be directed towards increasing utilization of PMTCT services at existing service outlets through demand creation in collaboration with community resources and ensuring the upgrade of existing supported PHCs offering stand alone HIV counseling and testing to render at least minimal package of PMTCT services. In order to leverage resources, priority will be given to PHCs located in the selected focal states with presence of other donor agencies and in local government areas already earmarked for HSS support through GFATM. Where new sites are envisioned, those that are used for national ANC sero-sentinel surveys but yet to commence PMTCT services as well as PHCs located in communities with high HIV prevalence rates above the National average will be given priority.

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