The Walter Reed Program Nigeria (WRP-N) is a partnership between the United States (US) Department of Defense (DoD) and the Nigerian Ministry of Defence (NMOD) that works through the Emergency Plan Implementation Committee (EPIC) to strengthen HIV research, prevention, care and treatment in military facilities. The program currently spans 20 health sites across 16 states in Nigeria.The WRP-N mission is closely aligned with Nigerias Partnership Framework (PF) and the Global Health Initiative (GHI) as it takes a systemic approach to the reduction in the incidence of communicable diseases, including HIV, tuberculosis, and malaria. Key program elements include: improvement of human resources for health through training, peer support, and supervision; capacity building extending beyond clinical to encompass leadership, management, governance, and accountability; establishment of disease monitoring, logistics and laboratory systems; upgrade of infrastructure; and promotion of research. WRP-N is a unique US Government agency in Nigeria, having already achieved approximately 20% country ownership through funding provided by NMOD, as well as a commitment to scale up funding on an annual basis.WRP-N will continue to pursue increased Government of Nigeria political will and resources, decentralization of services, engagement at the state and local levels, and improved NMOD coordination and program management. Additionally, it will synergize with other donors to ensure cost efficiency, innovation and sustainable development. Monitoring and evaluation of all activities is considered inherent to effective decision making, successful program transition, quality data, and research. The WRP-N will promote the use of electronic information systems and quality data collection tools.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) Adult Care and Support program provides facility-based services with referrals for community/home-based care for HIV-infected military personnel and civilians in 20 military hospitals, spanning 16 states. The program aims to reach out to 40,748 and 56,232 adults in FY12 and FY13 respectively. Additionally, WRP-N plans to improve access to care and support services, with the addition of 3 sites in Lagos, Benue and Niger states. In addition DOD WRP-N will work with a partner to provide care and support services to most at risk populations (MARPs) including MSM groups in Kaduna.

In accordance with the National Palliative Care Guidelines, the minimum care package includes provision of clinical care, a basic care kit, and two supportive services. Clinical care includes cotrimoxazole prophylaxis, nutritional assessment, nursing care, management of opportunistic infections, and STIs tuberculosis, cervical cancer screening, and malaria prevention. The basic care kit includes a long lasting insecticide treated net, a water guard and vessel, soap, hand gloves and/or condoms, and IEC materials on water sanitation and hygiene. Supportive services incorporate psychological, spiritual, social, and preventative approaches. HIV prevention services include the provision of positive health dignity and prevention services, HIV counseling and testing services for family members and sex partners, prevention messages focused on disclosure, partner testing, correct and consistent condom use, mutual fidelity, counseling on high risk sexual behaviors, and integration of reproductive health services.

Strategies to achieve targets include the decentralization of services using the Hub and Spoke model; improvement in the quality of services through the use of continuous quality improvement (CQI) models; enhanced networking and referral mechanisms; task shifting; further strengthening of linkages between adult and pediatric care and treatment, PMTCT, OVC programs, nutritional services, PLHIV support groups, income generating activities, RH/family planning (FP), and other support services; increased retention of pre-antiretroviral (ART) clients through 3-monthly clinical review and follow up of missed appointments; and overall health systems strengthening.

Monitoring and evaluation will be achieved through regular site visits, data quality assurance (DQA) reviews, mentoring, and supportive supervision. The WRP-N will also carry out an evaluation of the impact of malaria on HIV infection amongst program patients and apply the results to improving the management of malaria and HIV co-infection.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) currently supports TB/HIV program integration in 20 military hospitals, across 16 states, serving military personnel, their families, and surrounding communities. In collaboration with the National and State TB Control Programs, the WRP-N will continue to strengthen Directly Observed Treatment Short-course (DOTS) services across all sites. To capitalize on the existing PEPFAR-local government area (LGA) coverage strategy, collaborative activities will be expanded over the next 2 years with the addition of 4 new sites in Benue and the Federal Capital Territory (FCT).

As part of the WRP-Ns health system strengthening strategies, support will be provided for basic renovations, procurement of equipment, and supply of consumables (eg, sputum containers, waste bins, standing fans, and face masks) in order to support TB infection control. Peer health educators (PHE) will be trained and re-trained on the delivery of positive prevention messages, including cough etiquette. In conjunction with the prevention unit, barracks health committees, and faith based leaders, a sensitization program will be rolled out in an effort to encourage communities to refer suspect TB/HIV cases to health facilities. Diagnostic services will be strengthened across all sites, with the provision of fluorescent microscopes. Four Gene Xpert machines will also be procured to improve the early detection of multi-drug resistant (MDR) TB. All detected cases will be referred to the nearest reference laboratory for confirmation.

The capacity of health care workers (HCWs) will be strengthened, through formal TB/HIV training that will include x-ray diagnostic skills, good sputum specimen collection, laboratory acid-fast bacillus (AFB) sputum smear diagnosis, and TB management. HCWs will also have the opportunity to expand knowledge, share best practices, and discuss challenges through, attendance at continuing medical education (CME) and technical review meetings.

The WRP-N will support the National TB Control Program in the development of clinical support tools, job aids, information, education, and communication (IEC) materials, national registers, and referral forms in order to ensure standardization of quality care.

A Continuous Quality Improvement (CQI) program will also be instituted at sites. Bi-annual review of findings will ensure that appropriate interventions can be instituted in response to any identified gaps or challenges.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) Pediatric Care and Support program provides services to HIV exposed and HIV positive children and adolescents. It plans to reach 1,862 and 2,234 children and adolescents in FYs 12 and13 respectively with pediatric care and support services at 20 military hospitals, located in 16 states. There are also plans to expand services, with the addition of 3 hospitals in Niger, Benue and Lagos. The scale up of early infant diagnosis (EID) will be in line with the GoNs plans.

As per the National Palliative Care Guidelines, the minimum care package for each HIV infected child includes clinical care, a basic care kit, and two supportive services. Clinical care includes cotrimoxazole prophylaxis, nutritional assessment, ready-to-use therapeutic food, nursing care, management of opportunistic and sexually transmitted infections, tuberculosis screening, and malaria prevention. The basic care kits are provided to all PLHIV and include a long lasting insecticide treated net, a water guard and vessel, soap, hand gloves and/or condoms, and IEC materials on water sanitation and hygiene. Strategies to achieve targets include the decentralization of services; improvement in the quality of services through the use of continuous quality improvement models; enhanced networking and referral mechanisms including patient tracking; task shifting; further strengthening of linkages between MNCH, adult and pediatric care and treatment, PMTCT, OVC programs, nutritional services, youth friendly clubs, income generating activities, RH/family planning, and other support services; integration of HIV/AIDS services into routine and pre-existing health systems; increased retention of pre-antiretroviral (ART) clients through 3-monthly clinical review and follow up of missed appointments; and health system strengthening. Youth friendly and adolescent centers will also be established to support HIV positive adolescents.

Monitoring and evaluation will be achieved through regular site visits, data quality assurance reviews, mentoring and supportive supervision. Operational research and program evaluation will be conducted to improve the quality of pediatric care and support provided.

The DoD WRP-N will continue to work with the Nigerian Ministry of Defence (NMOD), through its Emergency Plan Implementation Committee (EPIC) liaison office, in the development and provision of appropriate laboratory support to ensure reliable, quality, and timely laboratory test results for people infected with HIV. Appropriate infrastructure support will also be provided.

Presidents Emergency Plan for AIDS Relief (PEPFAR) lab activities will be enhanced through training and mentorship. Quality management systems will be embedded into all laboratory processes and procedures. WRP-N will support 10 laboratories for national accreditation over the next 2 years.

Laboratory network linkages and referral systems, using the hub and spoke model, will be adopted. Treatment sites will expand from 20 to 22, as well as the addition of 7 satellite sites. The 68 Nigerian Army Reference Hospital will also be transferred to WRP-N from Harvard.

In collaboration with the National TB and Leprosy Control Program (NTBLCP), tuberculosis case detection will be enhanced. Gene Xpert platform for the molecular diagnosis of tuberculosis will be evaluated and validated in 2 of the sites (45 NAFH, Markurdi and 44 NARH, Kaduna).

The Defence Reference Laboratory will be expanded to include a malaria diagnostic and quality assurance (QA)/quality control (QC) center.

Molecular diagnostics to support prevention of mother-to-child transmission (PMTCT) and treatment scale up will be expanded and automated, with the addition of 2 new sites (44 NARH, Kaduna and 68 NARH, Yaba Lagos). Evaluation and validation of point of care technologies for CD4, blood safety monitoring, and viral load estimation will also be carried out.

The Defence Reference Laboratory will provide and support QA/QC activities across all of the HIV counseling and testing centers. Additionally, a retesting protocol will be developed and implemented for random samples of patients tested prior to the development of the National HIV Testing Algorithm.

Rapid and molecular diagnosis of sexually transmitted infections (STIs) and clinically indicated opportunistic infections (OIs) will be supported in all the sites and through a specimen referral system to the Defence Reference Laboratory. Supply Chain Management System (SCMS) will continue to provide equipment procurement, laboratory consumables, and preventive maintenance services.

To ensure ownership and sustainability, a phased transition plan for laboratory activities to NMOD-EPIC will be jointly developed and implemented. WRP-N will also support the development of a laboratory strategic plan for the NMOD.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) will continue to support strategic information (SI) activities at 25 comprehensive and satellite Nigerian Ministry of Defence (NMOD) sites, and an additional 8 prevention of mother-to-child transmission (PMTCT) sites.

Key focus areas will include: strengthening capacity for program monitoring and evaluation (M&E); use of electronic information systems for patient management and program reporting; and supporting research and surveillance activities.

The NMOD-WRP-N SI team will support the Government of Nigeria (GoN) to roll out newly revised data collection tools to all NMOD sites, as well as facilitate site-based trainings with other WRP-N staff on the use of the tools. Emphasis will be on activities that enhance the quality of data being generated across program areas and sites. Quarterly joint site visits and data quality assessments (DQAs) will be carried out in order to ensure high quality program data, while joint program data reviews will also be carried out with the WRP-N and NMOD staff. The team will also participate in the national M&E technical working group (TWG) meetings.

Trainings focused on program M&E, medical records, data quality, data demand and use, and data analysis will be carried out for 100 site staff. 2 site M&E staff will be supported to participate in the MEASURE Evaluation M&E training at participating universities. Program and data review meetings will be held every quarter with the site M&E teams. Furthermore, program initiatives that are aimed at improving quality of care, patient tracking and retention, patient and data flow within the facility, and review of clinical outcomes will be supported.

In support of the GoNs efforts to utilize the District Health Information System (DHIS) as the national reporting platform, the program will deploy DHIS 2.0 to 20 NMOD sites. SI staff will provide technical assistance to ensure appropriate utilization of the system. Additionally, the Emergency Plan Implementation Committee (EPIC) Electronic Medical Record (EMR) system will be deployed to 6 additional sites. Focus will be on continuous system improvements to strengthen patient management and monitoring (PMM). The program will facilitate the participation of NMOD in the National Health Data Consultative Committee (HDCC).

Technical assistance will be provided for all surveys, surveillance, basic program evaluations (BPEs), and research activities to be carried out by the WRP-N.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) will continue to support HIV care and treatment services in 20 existing and 3 new sites, through its partnership with the Nigerian Ministry of Defence (NMOD) Emergency Plan Implementation Committee (EPIC).

EPIC will be supported to develop a 5-year strategic plan, in line with the National HIV/AIDS Strategic Response Framework and the Partnership Framework Implementation Plan (PFIP). The capacity of EPIC and the NMOD sites to develop, implement and monitor programs will be strengthened, through specific trainings and mentorship schemes.

The Clinical Training Centre at the 44 Nigerian Army Reference Hospital, Kaduna will be completed and enable capacity development for a cadre of military trainers, who will then be able to provide step-down training to the sites. It will also provide pre-service training for 200 health care workers enlisted in the National Youth Service Corps (NYSC) and in-service training to NMOD personnel in various areas of HIV prevention, care, and treatment.

As part of its support for national systems, the NMOD/WRP-N will adopt the District Health Information System (DHIS) 2.0 as the platform for program reporting. The capacity of EPICs monitoring and evaluation (M&E) team will be expanded in system management in order to enhance the availability of data for program planning, management, and decision making.

The WRP-N will continue to support the NMOD-owned, Supply Chain Management System (SCMS)-operated warehouse, which manages distribution of drugs and laboratory supplies to all NMOD points of service.

Support and upgrades of laboratory infrastructure will ensure the generation of reliable, quality, and timely laboratory results across all sites. The capacity of NMODs laboratory personnel will be strengthened in laboratory processes, procedures, and investigative activities, through centralized and onsite training, international exposure, and a mentorship program. Qualified qualitative assurance (QA) monitors will be equipped with appropriate tools and empowered to implement a quality management system in all NMOD sites. The malaria diagnostic and QA/quality control (QC) center will be developed to improve malaria case detection across the program. Finally, teams at two laboratories will be up-skilled to perform PCR assays, as well as support the evaluation and validation of point of care technologies for CD4, tuberculosis, and viral load estimation.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) will continue to support injection safety activities across all military sites and blood safety activities will be carried out at 4 sites. In collaboration with the Nigerian Ministry of Defence (NMOD), WRP-N blood safety activities will continue to strengthen linkages with the National Blood Transfusion Service (NBTS).The program will support the NBTS blood drive activities to increase national blood supplies through recruitment of voluntary, non-remunerated blood donors from the 4 military barracks communities. It will also strive to increase the number of first-time donors and the proportion of military and civilian personnel who are regular donors. These objectives will be facilitated through blood drives within professional and social activities, using the national blood donor screening questionnaires, with the data being remitted to the NBTS.

Additionally, sites will be supported in establishing systematic transportation of blood collections to the nearest NBTS site for processing and screening for the 4 transfusion transmissible infections (TTIs) using ELISA. This will include the provision of hazmat mobile storage containers. Blood that has passed the NBTS screening will be collected and stored at the 4 collaborating centers, minimizing the use of rapid test kits for emergency blood transfusions. The NBTS will provide monthly feedback on TTIs rates found by ELISA screening.

Finally, the program aims to strengthen the capacity of military and civilian personnel in blood safety practices through training that will include collection, storage, and transportation safety practices. Step-down training incorporating donor recruitment and management, testing for TTIs, and waste management will be conducted at each site, reaching X health personnel. Quality assurance (QA)/quality control (QC) will be instituted for all processes, and sites will be provided with copies of the National Blood Policy standard operating procedures and job aids. WRP-N will also encourage close collaboration between the NBTS and NMOD with the aim of establishing a fixed blood collection center at one of the NMOD sites, potentially enhancing collection, safety, and availability of voluntary, non-remunerated blood donations.

Injection safety activities will promote the Universal Safety Precautions, including reductions in unnecessary transfusions, exposure to blood, and accidental injury/contamination, as well as the provision of essential consumables and services that protect health care workers and other exposed individuals (e.g., rape victims) from contracting transmitted infections. Consumables, including personal protective equipment such as hand gloves, laboratory coats, and masks, will be provided to all US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) sites. Additionally, each site will make provisions through their antiretroviral therapy (ART) activities for staff to access post exposure prophylaxis (PEP). Safe waste management practices will be promoted through the use of biohazard bags, sharps containers, and incinerators.

The WRP-N will expand injection safety practices to an additional X sites. Activities will ensure availability of safe injection equipment and provide capacity building in areas such as safe waste management system and injection techniques.

The WRP-N will continue collaborations with AIDS Support and Technical Assistance Resources-One (AIDSTAR1) for training, commodities procurement and review of safety protocols. AIDSTAR1 will train select site personnel on supportive supervision and transfer of technology (TOT), enabling them to provide step down trainings and supervision to their colleagues, using the national curriculum. At least XX military health care personnel and waste handlers will be trained or re-trained. The cadre of trainers will conduct biannual refresher trainings across XX sites.

The WRP-N will also procure, via Supply Chain Management System, commodities required for safe injection/needle handling and disposal. These may include disposable syringes, respiratory masks, surgical gloves, waste/sharps collection units, PEP kits, and reprinted or adapted information, education, and communication (IEC) materials for all sites.

Finally, WRP-N will continue to assess site waste management systems, with renovations of waste-disposal pits and incinerators being conducted as required.

Joint supportive supervision and mentoring visits will be conducted on a monthly basis by WRP-N staff.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) will continue to provide comprehensive AB and C prevention services to 22 military facilities and their surrounding communities. In line with the National Prevention Strategy, WRP-N will support the provision of combination approaches with a minimum of three interventions under COP12, including community engagement, peer education/plus (PEP) and condom services.

WRP-N will support EPIC- AFPAC to assess, revise and disseminate the armed forces HIV/AIDS policy to improve the implementation and provision of quality HIV/AIDS services. The program will continue to enhance its peer education interventions, by supporting the training and re-training of military and civilian peer educators.

IEC materials will be developed and provided as tools to encourage and reinforce AB and C information. The knowledge and life- skills of barracks school youths on AB and C prevention will be improved, using the Family Life Health Education (FLHE) school based curriculum. Additionally, evidenced based discussion manuals and guidelines will be provided for abstinence-only initiatives, parent-child communication and school based clubs activities.

The out-of-school youths will be reached via religious and recreational centers, and mammy markets using trained peer educators who will create out of school clubs that will provide peer education and income-generating activities (IGAs)..

In partnership with the Armed Forces Programme on AIDS Control, male and female condom distribution will be strengthened and information, training and skills will be provided on appropriate condom use.

The capacity of barrack groups (religious, community and institutional) will be developed to incorporate and implement AB and C, leadership, and gender activities into their yearly work plans and outreaches. These activities will extend to military and civilian personnel.

Sexually transmitted infection (STI) management will be strengthened by offering high quality STI services to military personnel, dependents and civilians. AB and C prevention messaging and condom provision will also be integrated into other HIV/AIDS services.

Capacity building for PLWHA support groups will include community level Positive Health Dignity and Prevention (PHDP) services and IGAs.

The National Prevention Intervention Tracking Tool (PITT) will be used to track and report on the implementation of activities.

US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) will continue to extend free access to HIV testing and counseling (HTC) services across 34 military sites. In an effort to improve identification and treatment of HIV positive patients, provider-initiated testing and counseling services will also be available at every site and include patients diagnosed with sexually transmitted infections (STIs), as well as patients from outpatient clinics, inpatient wards, and tuberculosis (TB) clinics.

Linkages will be fostered between health facilities and communities, and/or barrack health community trained volunteers who can escort patients to the HTC center for access and uptake of services. The WRP-N will integrate HTC services into STI, family planning, antenatal, and blood donation services. Additionally, all individuals who test HIV positive will be screened for TB.

Sites will provide high quality, cost-effective HTC using the national algorithm and same day results.

There will be a focus on couple testing and counseling. Partner referrals for HTC, as well as referrals for positive, health, dignity, and prevention (PHDP) and other related services, will be facilitated by PLHIV lay-peer counselors across sites. The integration of HTC, treatment, and prevention programs will take a family-centered, community perspective, including the introduction of a decentralized model in partnership with the Government of Nigeria.

Mobile HTC will encourage the uptake of services by most-at-risk populations (MARPs). HTC will also be integrated into community activities, such as health bazaars, military day celebrations, and social activities.

The WRP-N will support the Armed Forces Program for AIDS Control (AFPAC) to provide quality HTC services and prevention activities to new military recruits and peacekeepers during service medical assessments. This will be achieved through training and re-training of XX facility staff, volunteers, PLWHAs, and implementing partners, using the national curriculum. The WRP-N will also continue to include the training of non-laboratory staff to assist with task shifting. Oversight and supervision of non-laboratory counselor-testers will be provided by facility laboratory personnel.

Clinic renovations, privacy screens, and other relevant equipment will be provided.

Sites will be provided with national guidelines and SOPs, receive quarterly supportive supervision/mentoring visits, and participate in registers and studies.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) will continue to provide comprehensive AB and C prevention services to 22 military facilities and their surrounding communities. In line with the National Prevention Strategy, WRP-N will support the provision of combination approaches with a minimum of three interventions under COP12, including community engagement, peer education/plus (PEP) and condom services.

WRP-N will support EPIC- AFPAC to assess, revise and disseminate the armed forces HIV/AIDS policy to improve the implementation and provision of quality HIV/AIDS services. The program will continue to enhance its peer education interventions, by supporting the training and re-training of military and civilian peer educators.

IEC materials will be developed and provided as tools to encourage and reinforce AB and C information. The knowledge and life- skills of barracks school youths on AB and C prevention will be improved, using the Family Life Health Education (FLHE) school based curriculum. Additionally, evidenced based discussion manuals and guidelines will be provided for abstinence-only initiatives, parent-child communication and school based clubs activities.

The out-of-school youths will be reached via religious and recreational centers, and mammy markets using trained peer educators who will create out of school clubs that will provide peer education and income-generating activities (IGAs)..

In partnership with the Armed Forces Programme on AIDS Control, male and female condom distribution will be strengthened and information, training and skills will be provided on appropriate condom use.

The capacity of barrack groups (religious, community and institutional) will be developed to incorporate and implement AB and C, leadership, and gender activities into their yearly work plans and outreaches. These activities will extend to military and civilian personnel.

Sexually transmitted infection (STI) management will be strengthened by offering high quality STI services to military personnel, dependents and civilians. AB and C prevention messaging and condom provision will also be integrated into other HIV/AIDS services.

Capacity building for PLWHA support groups will include community level Positive Health Dignity and Prevention (PHDP) services and IGAs.

The National Prevention Intervention Tracking Tool (PITT) will be used to track and report on the implementation of activities.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) provides prevention of mother-to-child transmission (PMTCT) services in 25 military facilities nationwide. About 80% of the clients receiving PMTCT services are civilians from surrounding communities.

As at July 2011, 8636 women had received counseling, testing and results. 484 HIV positives received antiretrovirals (ARV) for PMTCT. In FYs 12 & 13, 15224 and 21384 pregnant women respectively will receive counseling and testing for PMTCT, generating 500 and 700 respectively receiving ARVs for PMTCT. The program will continue to use highly active antiretroviral therapy (HAART) in the ART sites and Zidovudine (AZT) from 14 weeks in the satellite sites. Clients will receive relevant baseline and follow up laboratory investigations through point of care tests, sample batching and transfer. There will be an emphasis on capacity building and collaboration with the Nigerian Ministry of Defense (NMOD) for the management of PMTCT services in order to ensure sustainability and ownership.

WRP-N will expand across high HIV burden states, with the addition of 8 satellite sites. To achieve cost efficiency, WRP-N will leverage equipment supplies, mentorship, and supportive supervision from the existing military health insurance program and the Emergency Plan Implementation Committee (EPIC) partnership. Emphasis will be placed on increasing male involvement through strengthening of partner testing, capacity building for couple counseling services and linkages for gender based violence screening.

In line with the Global Health Initiative (GHI), WRP-N will integrate PMTCT services into reproductive health services. It will also continue to strengthen the linkage of post partum PMTCT clients and their families for care and treatment. Integration efforts will be achieved through collaboration and leveraging, and referral linkages. In addition, all sites will provide positive health, dignity and prevention (PDHP) services. Quality will be assured through trainings, mentoring, supportive supervision, and continuous quality improvement (CQI) activities. WRP-N will monitor monthly target achievements and activities. Over the next two years, 120 providers will be trained on PMTCT and integration activities. The laboratory program area will provide quality assurance (QA) and oversight in HIV testing and counseling (HTC), and laboratory related activities for PMTCT. Health care providers will continue to be up-skilled in the provision of infant feeding counseling and support to both mothers and their babies.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) will procure anti-retroviral (ARV) drugs to treat 26,533 patients, comprised of 24,939 adults and 1,594 children, in FY12 at 21 military treatment facilities, spanning 16 states (Lagos, Oyo, Edo, Benue, Anambra, Imo, Enugu, FCT, Kaduna, Kano, Plateau, Borno, Delta, Rivers, Cross River and Sokoto). In FY13 these numbers will rise to 24,185 patients, comprised of 22,272 adults and 1,913 children. In setting COP12 & 13 targets, consideration was given to consolidating WRP-Ns COP11 accomplishments, with a focus on continuous quality improvement

WRP-N will continue to provide all sites with the necessary system and infrastructure upgrades, commodity security, and capacity building for efficient forecasting, procurement, storage, and distribution of ARVs. Technical support for drug management will also continue. Pharmacists and other health workers (eg, pharmacy technicians and assistants) will be trained and re-trained in general drug management, adverse drug reaction (ADR) reporting, and the use of standard operating procedures (SOPs). Mentoring will also be provided. Logistics management procedures will be assessed as part of site development planning.

WRP-Ns annual forecasting exercise will be done in conjunction with the United States Government (USG) Logistics Technical Working Group and Supply Chain Management System (SCMS). An estimated 60% of people living with HIV/AIDS (PLWHA) and already enrolled in care will qualify for and receive antiretroviral treatment (ART) during FY12, while 4% of the patients are expected to be on second line ARV regimens. In line with the national guidelines to simplify therapy for children, the use of pediatric fixed dose combinations (FDC) will be stepped up over the next 2 years.

CONTRIBUTION TO OVERALL PROGRAM AREA:

The ART drug activity will ensure that quality ARVs are supplied to all patients in a timely manner, as well as contribute to the Presidents Emergency Plan For AIDS Relief (PEPFAR) target of providing ARV drugs to an increased number of PLWHAs in Nigeria and the Government of Nigerias (GONs) plan for universal access.

FOCUS AREAS:

Focus areas will include local organization capacity building, logistics, training (including in-service supportive supervision), renovations of pharmacy/stock rooms, quality assurance/quality improvement, and linkages with other sectors and initiatives. WRP-N will also work with relevant stakeholders in FY12 to implement the GOCO warehouse plan.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) Adult Care and Treatment program currently provides HIV care and treatment to over 12,000 PLHIV, including military personnel and civilians, in 20 military hospitals, spanning 16 states. The program will expand with the addition of 3 sites in FY12 and FY13, in Lagos, Benue and Niger where there is high unmet need. The program plans to reach 18,560 and 22,272 adults receiving antiretroviral therapy (ART) during FY12 and FY13 respectively, and 6,379 adults newly enrolled on ART by the end of FY12.

Strategies to achieve targets include the expansion of ART services to high burden areas, decentralization of services, and improvement in the quality of services through the use of continuous quality improvement (CQI) models, including the evaluation of clinical outcomes. In accordance with the Global Health Initiative (GHI), HIV/AIDS services will be further integrated with malaria, tuberculosis and other services, resulting in a spill over benefit to non-HIV hospital patients. Adherence support for PLHIV receiving ART, follow up of missed appointments and contact tracking will continue to be strengthened.

A Clinical Training and Research center (CTRC) has been established at 44 Nigerian Army Reference Hospital, Kaduna to conduct pre-service and in-service training including basic ART training for doctors, nurses and pharmacists; antiretroviral (ARV) refill for nurses; and advanced ART training for doctors. The CTRC facilities will be used by the military, Federal Ministry of Health and other implementing partners (IPs). WRP-N has developed a mentorship program to enhance the knowledge and skills of service providers. A regular supportive supervisory schedule will ensure quality service provision, adherence to standards, on-the job training, and provision of job aids.

Performance is tracked on a monthly basis against targets and the CQI program will identify gaps, allowing for the development of improvement plans. The procurement of 3 viral load monitoring machines will also improve service quality. Patient outcomes will be reviewed annually.

In collaboration with the NAFDAC, WRP-N will continue to monitor ARV pharmacovigilance (PV) at all sites. Other activities will include training and re-training of care providersand improved reporting of adverse drug events.

In collaboration with the Nigerian Ministry of Defense (NMOD), WRP-N will review the NMOD Strategic Framework developed in 2007 to ensure it is aligned with the National Strategic Framework II and the Partnership Framework.

The US Department of Defense Walter Reed Program Nigeria (DoD WRP-N) Pediatric Care and Treatment program will contribute to the national pediatric scale up of antiretroviral therapy (ART) services by expanding HIV treatment into 3 new hospitals in Benue, Lagos, and Niger. The WRP-N plans to reach 1,594 HIV positive children with ART in FY12 and 1,913 in FY13.

Strategies to achieve targets include the expansion of ART services to high burden areas and improvement in the quality of care and treatment. Services, which will take a family-centered approach, will be integrated into existing maternal, neonatal and child health (MNCH) services. Linkages with other relevant services will also be strengthened. This approach aims to reduce stigma, promote adherence, and provide quality family HIV/AIDS care and treatment. To address retention in care, the WRP-N will continue to strengthen adherence support to people living with HIV (PLHIV) receiving ART, through follow up of missed appointments and contact tracking. Pediatric corners will be established, ensuring that sites are children friendly.

A pediatric mentorship program will be developed to support on-site Pediatric HIV Care and Treatment. Through this program, experienced pediatric ART physicians will be engaged periodically to provide hands on supervision; observation and random case file review, to identify site-specific challenges, strengths, weaknesses and opportunities for quality improvement. They will establish site-specific plans to accomplish improved pediatric ART uptake and retention in care, conduct on-site training and continuous medical education (CME) among health providers and practical demonstration and tutoring on issues and tools to update knowledge and skills of care providers. Intra- and inter-facility referrals (as well as to community) for HIV services will be strengthened through a strong follow up program for HIV exposed infants and HIV infected children.

Performance is tracked on a monthly basis and the Continuous Quality Improvement (CQI) program will identify gaps, allowing for the development of improvement plans. The procurement of 3 viral load monitoring machines will improve patient monitoring and help detect treatment failure early. Patient outcomes will be reviewed annually. In collaboration with the National Agency for Food and Drug Administration and Control (NAFDAC), the WRP-N will continue to monitor ARV pharmacovigilance (PV) at all sites.