ICAP's main goal is to work in partnership with the government of Nigeria (GON) and local organizations at all levels to support the delivery of high-quality, sustainable, comprehensive HIV/AIDS prevention, care and treatment services using a family centered approach. ICAP works with the USG, other donors and implementing partners, GoN (Federal, State and Local), faith based, non-governmental and community based organizations and other for profit partners across the six states of Akwa-Ibom, Benue, Cross River, Gombe, Kaduna and Kogi targeting a combined population of 22,727,346 using a multi-disciplinary approach to support 30 hospital networks across six states of Nigeria in mostly geographically contiguous locations.

Comprehensive services provided is focused on-site implementation assistance to strengthen systems including HCT to most at risk populations, ART clinics (adult and pediatric) management, support for drugs, equipment and supply chain management, repairs of dilapidated infrastructure, medical records, referral linkages, patient follow-up, integration of prevention into care and treatment (C&Tx), involvement of PLWHA including OVCs, access to laboratory services and ARVs including first/second line regimens for adults and children using national protocols and guidelines. ICAP also strengthens linkages with entry points including: HCT, ANC, pMTCT, child welfare/under-5 clinics, TB clinics, OPDs, inpatient wards, family planning and palliative care services to enhance service uptake and improve quality of services. ICAP will also continue with the implementation of innovative WATCh (Where Are The Children) strategies piloted in COP09 to increase pediatric enrolment and improve child survival. Working closely with national TB/Leprosy Control Program and state/LGA TB control programs, ICAP support sites to provide services to TB/HIV co-infected patients through point of service laboratory support and strengthening of referrals and linkages at the facility/community levels to C&Tx sites. ICAP has also continued to foster, strengthen and expand community linkages, participation and involvement in all the

sites it is presently supporting and is actively putting in place sustainable structures for program continuity at all levels. ICAP supports prevention activities (including condom distribution) at community level through capacity building for CBOs, HCWs and PHEs to ensure that the prevention minimum package is delivered to MARPS and the general population. ICAP will also support states/LGAs by providing the framework to ensure safer and more rational use of ARVs and OI medicines.

In COP10, ICAP will continue to focus on improving access to and quality of care, and program sustainability through the implementation of robust strategies in partnership with all tiers of Government. A major thrust will be through health systems strengthening and human capacity development of policy makers, state officials, providers and community members. ICAP will continue to expand its health systems strengthening plans across these states by continually motivating the states to adapt and establish a chronic care system that will ensure continuity and comprehensive care not only for HIV but to other chronic illnesses as a whole. ICAP will establish QA/QI teams with state/LGA officials who will jointly monitor program progress with state officials and administer the Model of care and Standards of Care assessment tools, including systemic approach to ensure quarterly CD4 monitoring for early enrolment, quality care and identification of treatment failure. ICAP will leverage resources from other health care services and maximize linkages to ensure quality of care to mothers and their children. ICAP will continue to build the capacity of state facility lab personnel with emphasis on quality assurance/management, providing individual on the job trainings to improve service delivery. For sustainability, state quality officers will be trained alongside Regional Lab Advisors to supervise and conduct regular lab audits in preparation for national and international accreditations. Due to the human resource challenge across ICAP supported sites, ICAP will continue to engage the service of post NYSC health providers on a transitional basis and advocate for employment and appropriate remuneration of HCWs to the governments. ICAP will facilitate the institution of innovative procurement and infrastructure repair procedures, gender mainstreaming and public-private partnerships. For sustainability, use of regional stores will be enhanced and capacity of state governments on forecasting, quantification and procurement planning and storage strengthened. LMIS and inventory control systems will be strengthened with emphasis on automation of inventory control and decentralization of logistics systems to lower level facilities. ICAP will also leverage on IPs' resources to maximize treatment costs (SCMS, partnership with Roll Back Malaria etc.) and establish linkages with community pharmacies to expand community based palliative care and referrals.

With the paradigm shift to cost effectiveness, sustainability and local ownership, ICAP M&E will focus on strengthening data quality by implementing a robust standard of care monitoring and contributing to achieving the "three ones" strategy of GoN. Attaining these fundamental goals will involve training, mentoring, joint supportive supervision and logistic support to GoN at all levels

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ACTIVITY UNCHANGED FROM FY2009 ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In COP09, ICAP supported OVC services as follows: appropriately identifying OVC who are not receiving services; providing a holistic family centered approach to care of OVC; providing educational support; services for adolescent OVC (including creating exit strategy at 18 and appropriate prevention message with reproductive health services); providing nutritional assessments and support; providing health care services for HIV infected and affected children; and providing enhanced psychosocial support at both facility and community levels. ICAP further assisted 30 secondary hospitals and 24 CBOs in Kaduna, Benue, Akwa Ibom, Kogi, Gombe and Cross River States to support 6559 HIV-infected and affected children (OVC) to access health care, and other related services at the hospitals, their referral networks, including building community coalitions to boost services in surrounding communities.

In COP10, OVC services will be provided for 7,215 new children and adolescents and 74 caregivers. These OVC will include HIV positive and HIV-negative children of PLWHA or HIV affected orphans. ICAP will also continue to support 24 CBOs/FBOs/NGOs to provide community OVC services in the same states

ICAP family-focused approach is applied not only at the facility level but also at the community and home levels through care services. Community based programming leads to identification of OVC through awareness campaigns, support groups, and community-based HCT. OVC are also identified through provider initiated counseling and testing of children accessing care in health facilities following national norms regarding counseling and consent of minors. Once OVC have been identified, ICAP's OVC program focuses on providing an appropriate balance of services in the facility, community and home settings.

ICAP OVC programming has several key elements: appropriately identifying OVC who are not receiving services; providing a holistic family centered approach to care of OVC and adolescents; providing educational support; nutritional assessments and intervention; providing health care services for HIV infected and affected children; providing psychosocial support at both facility and community levels and activating linkages to economic strengthening activities.

In COP10, ICAP will continue to implement strategies to increase enrolments of OVC and uptake of services. Some of these include: chart reviews of adult PLWHA on treatment to identify children not enrolled and reached with services; weekly reporting systems for OVC tracked and enrolled into care and

treatment, provision of basic care kits (BCK) targeted at OVC and their care givers. ICAP will continue to provide nutritional support to OVC and work with the GON in partnership with MARKETS - a USG IP to leverage resources for providing therapeutic and supplementary foods respectively for OVC diagnosed with malnutrition. Through leveraging resources in COP09 with MARKETS; nutritional support was provided to OVC and caregivers with Richfil - a locally processed family cereal, in Cross River State. MARKETS also conducted a TOT and have sponsored two CBOs in Cross River State to train up to 300 OVC Caregivers on IGAs. In COP10, ICAP will continue to leverage on this collaboration to support OVC and their caregivers on nutrition and economic strengthening. ICAP will also explore linkages to other community-based food and microfinance programs through supported CBOs to promote sustainability and household food security. Economic strengthening opportunities for female OVC caregivers will be prioritized. ICAP will continue to facilitate the establishment of community driven "food bank" initiatives in comprehensive facilities to provide nutritional support to OVC. Food Banks will be supported to build capacities in food drives and stock management; reporting mechanism for OVC beneficiaries of the food banks, will also be strengthened the. Partnerships will be explored to help expand and sustain these innovative food banks to continue to serve OVC and their adult family members. The possibility of linking severely malnourished children to time-limited feeding programs will be explored where availability of and proximity to such programs allow. ICAP will continue to identify and leverage state and local government support mechanisms to further ensure the sustainability and ownership of these initiatives.

Health care services for OVC will continue to emphasize high quality of service delivery, reaching all tracked OVC with clinical services including de-worming with anti-helminthics, malnutrition screening and intervention, ongoing monitoring of growth and development. OVC services will be extended and integrated into identified adolescent clinics to be supported by ICAP. Other areas of emphases will be linkage to immunization, malaria treatment, screening and referrals for TB when indicated, cotrimoxazole prophylaxis (CPT) following national guidelines, diagnosis and management of common and life threatening childhood illnesses As a way of ensuring preventive care at the home level, basic care kits comprising of LLITNs, soap for effective hygiene, water guard and water cans procured from SFH (another USG supported IP) will be distributed to all clients. ICAP will also continue to work through local partners to provide educational support (e.g., school levies, uniforms, school bags and writing materials) to most in-need children following selection criteria locally adapted by the OVC CCC (OVC Community Care Coalition), with guidance from the national OVC Vulnerability Index. Through ICAP support, some of these CBO partners will also continue to provide peer education programming at primary and secondary schools and through targeted outreach activities to reach in- and out- of school adolescents.

ICAP enables the implementation of advocacy and social mobilization, psychosocial support, home based care (HBC), and educational support for OVC and their households through its support and capacity building of local NGOs, CBOs and FBOs, The psychosocial support provided to OVC and their

care givers, is multifaceted and comprehensive; it includes counseling on stigma and discrimination, disclosure, grief, and recreational activities. OVC services are also integrated into community HBC programs. Networking with community organizations and other implementing partners enables leveraging of resources and enhances service delivery and sustainability.

ICAP will also continue to build capacities of these local community and faith based organizations such as Fantsuam Foundation, Tulsi Chanrai Foundation (TCF), GAWON Foundation, Catholic Archdiocese of Ogoja (CACA), Grassroots HIV/AIDS Counselors, ARFH, other CBOs and PLWHA groups to provide family-focused OVC services. These NGOs/CBOs/FBOs provide home based primary care, psychosocial support, nutritional support and links for OVC to health facilities for basic health care needs by providing transport and other support. Training and supportive supervision of health care cadres and CBOs/FBOs members, will be a vital element in ICAP's COP10 strategies. Health care workers in all 30 hospitals will continue to be trained on OVC to enable them to identify HIV-infected and non infected children, to link them into Care and treatment as appropriate. Social workers/ nurses focal persons for OVC will continue to be identified in all comprehensive sites. Onsite clinical mentoring will enhance quality of OVC care and management skills for program sustainability. OVC flow chart, posters, and detailed SOPs will be provided to the sites to support quality improvement and facilitate the delivery of optimal Care and support services for services.

In COP10, ICAP will provide training for additional 194 care providers including, counselors, and community/HBC providers using GON National guidelines, OVC National Plan of Action and SOPs. In addition ICAP and local partners will set up a monitoring system using the nationally approved tools that allows the monitoring of services provided directly by ICAP and/or by referral from ICAP to other organizations.

CONTRIBUTIONS TO OVERALL PROGRAM AREA: ICAP, in partnership with other organizations, will provide training and scale up of OVC services that will enhance the delivery of quality services to 7, 125 OVC and their caregivers enrolled in core programs such as health, educational support, psychosocial support, and food and nutrition. All these activities will improve the lives of OVC reached in line with the national plan of action on OVC and the National Strategic Framework, and will contribute to meeting PEPFAR goals.

LINKS TO OTHER ACTIVITIES: This activity relates to activities in ART (XXXX), Lab (XXXX), Palliative Care (XXXX), TB/HIV (XXXX), AB (XXXX), and SI (5541.09). HIV-exposed and infected children will be placed on prophylactic cotrimoxazole (CTX) following National guidelines. Household members of OVC will be referred for HCT

(5550.09) and children of women enrolled in PMTCT (XXXX) will be offered HCT as well as referred for OVC services. Policy makers and key decision makers in the health and education sectors will be reached by advocacy efforts.

POPULATIONS BEING TARGETED: This activity targets infants, young children, in- and out of school adolescents and other at-risk children in HIV infected and affected families. It also targets the households, including caregivers of OVC. The entry point for OVC in the general population will be ICAP supported sites and partner organizations. Health and allied care providers in clinical and community settings will be trained to provide services to OVC. Community and facility based volunteers, traditional birth attendants and support group programs, will be used to increase access to care and support especially to the underserved.

EMPHASIS AREAS ICAP's area of emphasis will be Community-based services for HIV-infected/affected children (0-17 years), Direct and Supplemental Services, Wraparounds (food, nutrition, IGA, water, and education) and Commodities (water guard, bed nets, etc.). Efforts will continue on improving and sustaining networks, linkages and referral systems as well as capacity development and food/nutrition support. In addition, ICAP will advocate equal access to education and improved legal and social services such as the protection of inheritance rights for women and children, especially for female children, and increased gender equity in HIV/AIDS programming. ICAP will advocate for increased access to income and productive resources for HIV infected and affected women and care givers. This activity will foster necessary policy changes and ensure a favorable environment for OVC programming. In COP10, ICAP support will continue to enhance equity and gender approaches that lessen vulnerability of female OVC by increasing their access to education, care and other support services. Increasing involvement of men in caring for OVC will also be emphasized.

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ACTIVITY UNCHANGED FROM FY2009 ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: In COP09, ICAP has expanded support to a total of 30 health facility networks in the six high-prevalence states of Gombe, Akwa Ibom, Cross river, Kaduna, Benue and Kogi. By the end of COP09, ART will have been provided to a cumulative of 3200 children (including 536 new).

During COP 10 ICAP will strategically focus on reaching HIV positive children needing care and treatment (C&Tx) through various innovative approaches which include: support of pediatric HIV diagnosis; enhanced pediatric case finding and referral to care and treatment; ensuring comprehensive C&Tx services, including ART, for HIV-exposed infants (HEI) and HIV-infected infants and children; and providing enhanced psychosocial support at both facility and community levels. Following National Palliative Care Guidance and USG PC policy, ICAP-supported sites will provide a basic package of care services, including basic care kits, prevention with positives counseling for parents, clinical care (nursing care, growth monitoring, under 5 immunization services, neuro-developmental screening and monitoring; pain management, OI and STI treatment and prophylaxis, nutritional assessment and support, lab- baseline hematology, chemistry and CD4 percentage and follow up, OI and STI diagnosis- psychosocial support, provision of Cotrimoxazole, home based care, and active linkages between hospitals, health centers, and communities.

ICAP family-focused model of care is an optimal platform for pediatric case-finding and referrals. ICAP uses adult care and treatment venues as additional entry points for pediatric services, utilizing a genealogy form that ensures that HIV-positive adults are asked about the HIV status of their children at each visit. In COP 10, targeted testing will be done using skilled CBOs to ensure that children of adult in care and treatment are tested and linked to care.

In COP10 ICAP support for pediatric diagnosis will continue to include: enhancing linkages between PMTCT programs and those supporting OVC and ART services; supporting EID via dried blood spot (DBS) testing; initiating and expanding routine opt-out pediatric testing at inpatient and outpatient wards (including OPDs, casualty wards, well baby immunization clinics, child welfare venues, and adolescent/youth-friendly clinics) following national norms regarding counseling and consent of minors; and providing training, supplies, and laboratory support for HIV testing. DBS is collected from ICAP supported Nationally approved EID sites; ICAP will continue to partner with Clinton Foundation to ensure regular supply of DBS materials to all sites and shipment of samples /collection of results to and from National PCR labs.

In COP09, several challenges were identified as limiting pediatric uptake of care and treatment services. These include: poor linkage between PMTCT and services for HEI; poor uptake of PICT for children of HIV infected adults in ICAP-supported C&Tx programs, OVC programs and within points of medical services for children especially sick children; also there was a lack of segregation of pediatric care data into exposed and infected status which is responsible for lack of determination of proportion of HIV infected children receiving HAART among others. A "WATCh"("Where are the Children") task force was initiated to put in place mechanisms that will identify innovative strategies to reach the children within the shortest timeframe and bring them into much needed C&Tx. The overall aim of the WATCh strategies is to develop systems to improve identification; enrollment and retention into care of HEI and infected children into care and treatment, including treatment with HAART. These interventions will be further expanded upon in COP10 and include: strengthening linkages between antenatal care, maternity and Exposed Infants, ollow up clinics, strengthening the tracking and follow up of HEI, strengthening universal "low hanging" PICT for children of HIV infected adults in C&Tx, OVC , and hospitalized children. This will involve having a minimum of 2 point of service testing for children in all comprehensive sites (in the Pediatric wards and immunization clinics). ICAP will continue to ensure monthly reporting of PICT performed on children of HIV infected adults in care and health services care points (reporting by categories and use of # of admissions would also help evaluate coverage). ICAP will further ensure that strategic approaches including chart reviews and monthly M&E reporting are used to determine program- level performance monitoring of HAART initiation among eligible HIV-infected children on a monthly basis. Also regular chart reviews will be conducted on records of HEIs and HIV-infected children to ensure that all DBS positive Infants are linked to treatment appropriately. ICAP will also ensure that Pediatric clients (both HIV exposed and infected) have priority for defaulter tracking. To further ensure that the children of adult in care and treatment are tested and the positive linked to care and treatment, ICAP will use skilled CBOs for targeted testing and to provide escort services of HIV positive children to comprehensive sites.

Enrolment into care and treatment In COP10, 3,060 HIV-infected infants and children will be enrolled in care, and carefully staged, both at baseline and at subsequent follow up visits. Following clinical and immunologic staging, those not yet eligible for ART will receive clinical services including ongoing monitoring, charting and plotting of growth and development, screening and prophylaxis (IPT) for TB when indicated, cotrimoxazole prophylaxis (CPT) following national guidelines, and diagnosis and management of opportunistic infections as needed. Ready-to-Use-Therapeutic Feeding" (RUTF) using criteria agreed upon by the USG in-country and GON team will be provided at facility and community level via referrals where possible. Parents/caregivers of HIV-infected children (regardless of children' HIV status) will receive a standardized "preventive care package" including basic care kits, ITN water guard, water vessel, ORS, soap and

gloves. Infants and children who are eligible for ART will receive appropriate first and/or second-line therapy accompanied by careful monitoring for toxicity and efficacy and by intensive adherence support. To improve retention in care for children ICAP will continue to advocate for communal support of transport reimbursement/food items for indigent children as well as link caregivers to IGA (income generating activities) in all the comprehensive sites

Decentralization of pediatric care and treatment services In COP10 ICAP will continue to build capacities of pilot comprehensive PHCs to link to referring hospitals to support HIV/AIDS programs and provide onsite ART refills and follow up for stable patients, at the PHC level. Experienced nurses and community health officers identified in high volume pilot PHCs will be further trained to deliver quality focused pediatric C&Tx services including conduct nutritional assessments and monitor growth and development, provide drug refills based on a symptom checklists, provide CTX and micronutrients, psycho-social and disclosure support, and referral to the comprehensive treatment sites as needed. ICAP will work with local State primary health care agencies to develop/adapt job aids and SOPs for providing HIV care and treatment at the PHC. Pediatric ART services in COP 10 will include having a minimum package of care for infected children at all ICAP sites. This minimum package of care for infected children will include: follow up schedule, WHO staging, growth and development monitoring, TB screening at every visit, CD4 baseline and repeat every 3 months, DBS testing, CTX prophylaxis, immunization, Multivitamins, anti-helminthics, antibiotics (Ampiclox, Co- trimoxazole, and erythromycin), ITN and antimalarials for treatment, basic care kits, baseline investigations and nutritional assessment, food supplement, infant feeding counseling and confirmatory HIV test at 18 months. This minimum package of care for HIV infected children in the PMTCT-only sites is in line with the decentralization of pediatric ART services to smaller sites (PMTCT only) and will bring ARV treatment, care and support services closer to families and communities. This will require building the capacity of the health care workers at the primary and secondary sites to scale up pediatric ART services at these sites. In the PMTCT only sites where there is no CD4 machine, ICAP will continue to support CD4 sample logging using the same channel of sample logging with the PMTCT, TB and Adult ART services.

Human Capacity Development Training and supportive supervision of health care cadres will be a vital element in ICAP's COP10 program. Clinicians at all 30 hospitals will be assisted to identify HIV-infected children, to enroll them in C&Tx, to perform appropriate clinical and laboratory staging of these children, and to provide comprehensive care and support, including the prompt initiation of ART for eligible children. ICAP will also train PHCs staff to encourage task shifting in the care of HIV positive children. ICAP will conduct pediatric ART trainings, ongoing CME and QA activities for 232 clinicians and allied health care providers (including 100 for ART and 132 for Palliative care) who will support pediatric C&Tx. ICAP trainings will

reinforce the need for opt-out testing for pediatric inpatients, pediatric TB patients, adolescent patients and children suffering from malnutrition and common illnesses which are also warning signs of HIV infection. Trainings will also focus on second line and regimen changes for children who are already on ARVs. Additional training and support will enhance the specialized counseling, patient education, and linkages required in early infant diagnosis programs. Adherence trainings and support services will be provided at each site. This will facilitate adherence assessment and support including group counseling, disclosure counseling, patient/family/caregivers education, appointment diary system, referral linkages, patient follow-up, provision of support tools (dosage guides, reminders etc.), linkages to community- based adherence support and retention in care programs.

Clinical Systems Mentoring and Quality of Care Onsite clinical mentoring will enhance quality of care and build site-level clinical and management skills for program sustainability. ART reference tools will include pocket guides, dosing cards, posters, and detailed SOPs. ICAP will support quality improvement/quality assurance mechanisms to facilitate the delivery of optimal C&Tx services. ICAP will also facilitate and actively support onsite standardized HMIS using GON forms and provide onsite assistance with data management and M&E to guide quality improvement measures.

Harmonization of Activities In COP10, ICAP will continue to work closely with other PEPFAR IPs and GON to ensure compliance with National policies, curricula and guidelines, and continue to participate in the USG Clinical Working Group to address emerging treatment-related topics and further promote harmonization with other IPs and the GON.

Community Linkages In COP10 ICAP will continue to work closely with its 24 NGO/CBO/FBO partners to promote community involvement, provide HIV prevention activities and linkages to wraparound activities, and facilitate adherence among HIV positive community members. ICAP will continue to strengthen/establish children support groups as part of the psychosocial support.

ICAP will also continue to provide nutritional support through partner CBOs to all 3,790 (?) HIV + children on ART. Support will include provision of RUTF as needed and other nutritional support. ICAP will also expand its successful Peer Health Educator program, enhancing targeted family counseling and testing, defaulter tracking, and inter/intra-facility linkages. ICAP will continue to ensure that HEI and HIV-infected infants and children are linked into OVC services. Prevention for positives messaging will include a balanced ABC approach messaging for adolescents infected with HIV. All HIV positive infected children/adolescents will be linked to home based care and support, community and social services for

referrals for food and education assistance, economic empowerment, and other wraparound services.

CONTRIBUTIONS TO OVERALL PROGRAM AREA: One of the pioneers of family-focused multidisciplinary HIV/AIDS treatment in resource-limited settings, ICAP will be providing in COP010, ART services to 589 HIV infected children, contributing to the GON/PEPFAR targets for Nigeria. ICAP will build the skills of at least 232 care providers thus contributing to national sustainability plans.

LINKS TO OTHER ACTIVITIES: This activity relates to HBHC (XXX), OVC (XXX), HCT (XXX), PMTCT (XXX), HVOP (XXX), TB/HIV (XXX), AB (XXX), and SI (XXX). As expansion of ART services is prioritized to rural areas, ICAP will strengthen referral channels and network mechanisms. Children on ART will be linked to home based care and community and social services. TB/HIV linkages will be strengthened where ART and TB DOTS sites are co-located, and co-location of new ARV sites will be actively promoted in TB DOTS stand-alone sites. All HIV infected children will be screened for TB using the National algorithm while all children infected with TB will be offered HIV testing. Children will be also linked to other child survival programs. ICAP will also provide onsite assistance with data management and M&E to guide quality improvement.

TARGET POPULATIONS: HIV positive children, will be provided access to pediatric ART services. Health care providers in secondary and primary health facilities will be trained to deliver quality ART services.

EMPHASIS AREAS: Emphasis areas are quality assurance/improvement and supportive supervision. ICAP personnel including national and international experts will provide skill and competency-based trainings, CME, and ongoing clinical mentoring to enable onsite staff to provide quality ARV services to children infected with HIV. Emphasis areas also include training, human resources issues, referral networks, infrastructure support, linkages to other sectors and initiatives. Services will also focus on addressing the needs of women, infants and children to reduce gender inequalities and increase access to ART services among these vulnerable groups. ARV services will facilitate linkages into community and support groups for nutritional support and other wrap around services. ICAP will strengthen the integration of HIV Pediatric packages into existing MCH and child survival services. This will be achieved through: decentralization of care of HEIs and integration of HEIs clinics into existing MCH services in PHCs.

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ACTIVITY UNCHANGED FROM FY2009 ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: In COP10, ICAP will continue to work in the six states of Kaduna, Cross River, Benue, Kogi, Akwa Ibom and Gombe.

A total of 107 existing Government of Nigeria (GoN) mission and private health facilities will continue to receive support to provide PMTCT services and community outreach activities through 30 hospital networks and 77 PHCs.

ICAP will train health care workers (HCWs), support infrastructure, purchase equipment and supplies, monitor, evaluate and provide supportive supervision to the sites. Efforts will be made to facilitate the public health approach in taking PMTCT services to PHCs and community levels as essential steps towards universal access and the shared goal of eliminating peri natal transmission.. In COP10, ICAP will work to increase uptake of PMTCT services, including routine antenatal care and facility-based deliveries. ICAP will support PMTCT activities through: HCT for all pregnant women (ANC, labour and postpartum period); ARV interventions dispensed in ANC and maternity for HIV+ women; integrated group counseling into other health services attended by pregnant women and women of childbearing age; provision of services for well/or sick children (Immunization clinic), linkages to family planning and sexually transmitted infections (STIs) clinics; and promote integration of HAART in MCH and at PHCs using trained locum/mobile doctors, to provide 'one shop' services; and reduce delays in initiating HAART at comprehensive sites. Pregnant women, especially HIV-positive mothers, will be supported to deliver in health facilities through the provision of the national safe motherhood program delivery kits ("mama kits"). Mothers-2-Mothers (M2M) support groups will be established and/or strengthened at comprehensive and high volume PHC sites to increase facility-based delivery and reduce the number of women lost to follow up. ICAP will support and train mentor mothers who will spearhead these M2M support groups at PMTCT sites. Mentor mothers will conduct peer counseling to newly diagnosed HIV+ pregnant women, adherence counseling to women on ARV prophylaxis or HAART, provide information on minimum package of care for exposed infants and support defaulter tracking for positive mother-baby pairs. The use of ART for PMTCT will follow the National PMTCT guidelines. ICAP will provide support for psychosocial and adherence issues and for mothers infant feeding choices through appropriate infant feeding counseling. HAART eligible women will be enrolled at the nearest comprehensive site by referral and linkages. Health facilities will be supported to provide basic laboratory services and, if not available on site, will be linked to a laboratory network model in which CD4 testing can be performed by logging samples through specimen transport systems supported with motorbikes. ICAP will provide support for CD4 capability to high volume PHCs . ICAP will expand the use of hand held haemoglobinometers to all the PHCs to monitor women who are on AZT. Exposed infants will be actively linked to pediatric care and treatment through under-5 cards issued in labor and delivery. Women who test negative will receive prevention counseling and appropriate support to remain so.

ICAP will emphasize group counseling and opt-out testing with same day results at ANC, labor and postpartum service delivery points. Partners, households and children will be linked into HCT. ICAP will actively promote community-based PMTCT services through CBOs, to provide "doorstep" counseling

services to pregnant women, their partners and other household members. Clients will be counseled on the beneficial effect of couple/partner HCT/disclosure on adherence to infant feeding choice. Eligible HIV- infected women will be assessed and linked into care and treatment services including ART and cotrimoxazole prophylaxis (CTX). Other activities are enhanced pediatric care including CTX from 6 weeks of age and promotion of best practices for infant feeding, nutritional support and linkages to family planning services. In addition to receiving PMTCT services, each woman will be referred to OVC services upon HIV diagnosis to facilitate care to all of her affected children. ICAP will actively encourage male circumcision as a preventive measure especially in Kaduna and Gombe states.

Identification and follow-up of HIV-infected and exposed children living within the community will be a priority with CBOs/FBOs assisting with adherence issues and defaulter tracking. ICAP will continue to implement a basic minimum package of care services to exposed infants at PMTCT/HCT-only sites. This would ensure that exposed infants are linked into care and prevent loss to follow up. Minimum package include: simplified Exposed Infant registers for data capturing, prophylactic ARV syrups (NVP and AZT) within exposed infant/immunization clinic, growth monitoring, nutritional assessment/infant feeding counseling, child survival strategies counseling DBS at 6wks, HIV C&T services at immunization clinics and for women with unknown HIV status. To implement these services at the PHC level, ICAP will develop minimum training package adapted from the National pediatrics and PMTCT training manuals to train PHC staff. ICAP will advocate to the National Primary Health Care Agency on the inclusion of HIV/AIDS information on road to health charts to help identify HEIs.

ICAP and its sub-partners will train 715 HCWs, using GON curricula, to provide an enhanced package of quality MCH services to HIV+ women. The training will focus on prevention messaging (including balanced ABC messaging),on STI screening/treatment, cervical cancer screening, safer sex, malaria prophylaxis, minimum package of care for exposed infants including child survival strategies, use of ITNs and safe water. It is estimated that about 15% of babies born to HIV-positive women will become HIV infected through breastfeeding. To reduce this risk, ICAP will empower providers to give unbiased infant feeding counseling to mothers based on WHO/GoN recommendations (exclusive breastfeeding, use of BMS based on AFASS criteria). ICAP will support govt efforts through zonal training of trainers on HIV and infant feeding, infant feeding meetings and reprinting of finalized Infant National guidelines. Additional health care providers will be trained to educate and assist mothers make appropriate infant feeding options and discourage "mixed feeding" practices..

Home deliveries remain a very strong preference among many communities in Nigeria as 2/3rds of pregnant women either deliver with birth attendants or in their homes (DHS: 2005, Piper CJ; 1997). In order to reduce the number of HIV positive mothers and their exposed infants lost after home deliveries, ICAP will support GoN to develop a National TBA curriculum to enhance their quality of service at the

grass root level. ICAP will also support community sensitization, organization and capacity building of xxx TBAs across communities surrounding PMTCT sites in the six ICAP- supported states. TBAs will be trained on basic HIV prevention and infection control, safe motherhood, HIV counseling and testing information especially to pregnant women and their partners; and for referral support of newly delivered mothers and their babies for follow up care. Retired midwives and health care providers will be identified to monitor effective identification and referrals of pregnant women, newly delivered mothers and their exposed infants to nearby PMTCT sites for enrolment into care. TBAs will be involved in "Men Taking Action" activities to enhance community support.

ICAP will address the critical challenge of limited/lack of male partner involvement in PMTCT services and will strengthen male involvement through gender transformative activities. Through 'Men taking Action' MTA , ICAP will work with CBOs to increase service uptake, promote positive male norms and behaviors, especially as it relates to discordant couples, and help reduce stigma and discrimination through community based activities. These activities include community education and behavioral change communication (EBCC),"Mobile'' outreach VCT at male-friendly HIV/AIDS events, use of trained community leaders/gate keepers to conduct EBCC and deliver accurate messages related to PMTCT and VCT to male partners of pregnant women attending ANC and to men in the general community. At the end of the sessions, men will be encouraged to undergo rapid HIV testing with HIV+ male partners' appropriate referrals for TB and CD4 screening to nearby health facilities, and linkage into care. ICAP will also encourage facility managers to make their MCH men friendly for HCT and utilizing mainly male counselors where feasible.

ICAP will work in close partnership with GoN on HIV early infant diagnosis (EID), offering HIV infant diagnosis testing in line with the National EID initiative from 6 weeks of age using DBS. HIV positive infants will be enrolled and linked to appropriate care and treatment. ICAP will support GON at training HCWs on EID at PHCs and in the finalization of EID training curriculum. A joint USG/GON/ICAP team will provide ongoing M&E and supportive supervision activities and contribute to the national PMTCT program's M&E efforts. ICAP is also earmarking USD125, 000 for procurement of goods and supplies through the SCMS mechanism

CONTRIBUTIONS TO OVERALL PROGRAM GOAL: ICAP and its sub-partners target states with some of the highest seroprevalence rates in Nigeria. Providing services at the primary and secondary levels assists the GON in achieving its goal of decentralizing PMTCT services beyond the secondary care level. ICAP will significantly contribute to an increase in PMTCT services by supporting 107 existing secondary and primary health care facilities government, mission and private health facilities and also indirectly supporting GON ministries/programs in their rapid scale-up plans for PMTCT.

ICAP will strengthen national and state PMTCT programs by: support of capacity building of master trainers for PMTCT services; production of GON approved infant feeding support tools; support adaptation of IMAI Document for HCWs at the PHCs,printing of national PMTCT registers; support of regular coordination meetings in collaboration with other partners at all government levels. ICAP will also strengthen the programmatic skills of partner CBOs/FBOs in line with GON sustainability plans.

LINKS TO OTHER ACTIVITIES: This activity is related to activities in ARV services, Basic Care and Support, OVC, counseling and testing, SI, Lab, and Sexual Prevention. Provider-initiated opt-out HCT will be offered to all pregnant women at ANC, and to their partners. Women presenting in labor will have rapid HIV tests and receive single dose NVP if positive. Infants born to HIV-infected women will access ART (single dose NVP and ZDV) and CTX prophylaxis. Infant PCR HIV testing via DBS will be conducted with HIV positive infants linked to appropriate OVC care and treatment services. PC linkages will enable HIV+ women and family members access to support groups. Pregnant women will be linked into FP services. Partner counseling/communication will be promoted through sexual prevention activities. M&E activities at PMTCT sites will contribute to the national PMTCT program's M&E efforts using national PMTCT MIS.

POPULATIONS BEING ADDRESSED: Pregnant women, postpartum mothers, their partners and household members including HIV exposed infants and HIV infected children will be targeted and supported so that they have full access to HCT at multiple entry points of care. HIV infected women will be provided with PMTCT/PMTCT plus services, while HIV infected infants and children, and infected partners, will access care and treatment services, including OVC services. Uninfected women will be supported to remain HIV negative. CBOs, FBOs, TBAs, support groups, and men will also be targeted so that they participate fully in community based PMTCT services. Healthcare providers will be trained on providing services while the management skills of GON policy makers and implementers at all levels will be also improved.

EMPHASIS AREAS: Emphasis will be on training, increasing gender equity in HIV/AIDS programs, human capacity development and SI. Equipping women with IGAs, communication skills and legal Aid counseling, will promote gender equity in HIV/AIDS programs and increase access to services by the vulnerable groups of women and children. Emphasis will also be on primary prevention of HIV infection and prevention of unintended pregnancies among women living with HIV. HCT services will be integrated in RH/FP services while all PMTCT clients will be referred to access RH/FP services post-delivery. The health status of HIV+ women will be further enhanced by actively screening them for TB and cervical cancers. Recognizing the impact of male

involvement on a woman's access to PMTCT and VCT services, ICAP will use MTA strategies to enhance partner testing, endorsement of infant feeding choices, and engagement in care. From a public health view, tasks can be shifted from more specialized to less specialized HCWs. At comprehensive/ high volume PMTCT/HCT-only sites, "Mentor Mothers", will be trained to spearhead Mothers to Mothers (M2M) support groups. They will also be trained to participate in peer/adherence counseling, minimum package for HEIs and tracking of defaulting mother-infant pairs, thus further leveraging task-shifting. At the State government level, ToTs will build capacity of State and local government PMTCT Task Force and also provide an opportunity for task shifting and promote sustainability by engaging state personnel in clinical systems mentoring activities at sites.

In COP10, under 'PEPFAR Nigeria's accelerated PMTCT plan', ICAP, 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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