ATTACHMENT J.7 - COP 17 Guidance to ART Clinical Implementing Partners.docx

COP 17 Guidance to ART Clinical Implementing Partners

PEPFAR Mozambique

August 14, 2017 Version 1.0

Table of Contents Contents

Introduction

Purpose of This Technical Guidance The technical guidance provided here is to serve as a blueprint to guide PEPFAR’s clinical implementing partners in the development of their COP2017/FY2018 work plans. As per the purpose of cooperative agreements, PEPFAR technical staff will continue to provide guidance and technical support to further define specific program areas and activities, and to ensure implementation is responsive to additional needs and opportunities as they arise. By providing a single reference point documenting the spectrum of expectations and needs across all technical areas at the onset of the planning process PEPFAR seeks to accomplish the following objectives:

· Increase partners’ effectiveness in developing plans aligned to the COP17

· Provide a cross-cutting view of all technical areas to increase planning collaboration and thus more integrated program development and execution

· Ensure work plans are as aligned and thorough as possible with the currently identified needs

PEPFAR 2017 Country Operation Plan In COP17, the PEPFAR team and implementing partners are being asked to increasingly demonstrate strategic use of data to develop and implement plans that target the geographies and populations with the most need, to rapidly progress towards epidemic control. Partner performance and partner management are areas of high-priority for the Office of Global AIDS Commission (OGAC) and PEPFAR-Mozambique, as we jointly seek to ensure PEPFAR dollars are spent in the most cost-efficient and effective way possible to improve health outcomes.

The Ministry of Health (MOH), US government, Global Fund (GF), and other multi-lateral organizations have jointly committed to the achievement of UNAIDS 90-90-90 goals in Mozambique. As such, activities and targets in COP17 have been developed with the goal of having 90% of all PLHIV in Mozambique knowing their status, 81% of all PLHIV on treatment, and 73% of all PLHIV virally suppressed by 2020. National policies to be implemented in FY2017 to support these goals include continued implementation of Test & Start (T&S) with nationwide implementation during calendar year 2018, expansion of routine VL in conjunction with T&S, expansion of alternative service delivery models such as 3-month drug distribution, and adoption of confirmatory testing.

Aggressive Progress Needed in FY2018 In order to support rapid progress towards these goals during COP17 implementation, aggressive targets were developed that include achieving the following by the end of FY2018:

· 6,055,576 - Persons HIV tested

· 437,632 - Persons newly identified with HIV (positive tests)

· 375,202 - PLHIV newly initiated on ART

· 1,262,208 - PLHIV currently on ART

· 95,865 - CLHIV on ART

· 376,771 - Voluntary medical male circumcisions

The goal of having over 1.2 million patients on ART by the end of FY2018 is achievable and vital towards reaching epidemic control by 2020. Reaching this goal require strategic high-yield investments from all stakeholders, ensuring improvements across the cascade from HIV testing to retention on treatment.

COP17/FY18 Guidance Highlights:

· Activities will continue to follow the geographic prioritization and differentiated support models approved in COP15 to maximize investments and assure continued progress toward epidemic control;

· Scale-up districts have been changed only minimally to reflect disease burden and unmet need using the most up-to-date epidemic information available;

· Guidance on types of support for IPs to provide at provincial, district, and facility-levels have been included;

· Emphasis will continue to be placed on directing resources towards finding, linking, and retaining HIV positive persons on treatment;

· Enhanced support for implementing service delivery model changes and quality improvement activities needed to improve availability and quality of ART services;

· Partners will need to further improve support for routine HIV viral load (VL) implementation, with a focus on management of results to ensure VL suppression, to improve quality of life and reduce transmission;

· More specific guidance on Health Systems Strengthening (HSS) activities will be provided to further harmonize HSS approaches across implementing partners;

· Specific guidance on the approach to evaluations has been added;

· In addition to current quarterly data reviews and monthly meetings, routine engagement at the Provincial level should occur to improve the involvement and coordination of DPS staff working in the field.

We look forward to working in partnership with you in achieving these goals and working towards achieving UNAIDS goal of 90-90-90 by 2020.

1. IP-Support Packages at the Provincial, District, and Facility level

1.1 Provincial, District, and Facility-level Staff Support

In order to ensure that provincial and district level health offices receive adequate support to achieve ambitious targets across technical areas, all partners should ensure that high-quality, highly-trained staff are hired and available in a way that supports local capacity building and goals. All partners should submit a matrix of their support model as part of their COP17 work plan, along with an explanation as to the rationale for the staffing approach. A standard/recommended support approach is shown below.

In addition, specific focus should be placed on the type of staff needed to ensure high-quality services at high patient volume health facilities.

1.2 Health Facility Package of Services

As in previous years it is expected that resources and staff time will be allocated so that the areas with the highest burden of disease (scale-up districts and high-volume facilities) receive the most intensive support. Appendix A lists the expected number of visits and types of activities expected to be support based on site categorization. Partners should reference this guidance when budgeting for direct service delivery and supportive supervision, as well as, determining which services should receive PEPFAR-support in scale-up, sustained, and central-support facilities.

2. Care & Treatment

The goal of the adult care and treatment (C&T) portfolio is to implement evidence-based interventions to increase early initiation of ART, provide high quality services, improve adherence and retention, and achieve epidemic control. Supporting further scale-up of T&S during FY18 is one of the key interventions required to reach these targets. Each partner should be engaged in the process of T&S implementation in provinces where they are working, while supporting efforts to improve achievement across the clinical cascade. Specifically partners should work with PEPFAR-Mozambique to clearly identify and document investments needed to improve service delivery and ensure systems are adequate to support T&S implementation. These investments should be included in COP17 work plans

Specific areas of focus in COP17 are listed below and include Linkage to C&T, Early Initiation of ART/Implementation of T&S, Standard ART Support Package, Retention in Care, VL Suppression, TB/HIV, Nutrition, and Quality Improvement (QI). Data collection and close monitoring of these areas will continue to be a core function of partners allowing for continuous assessment of strengths and challenges with implementation. QI and SIMS data should be used to continually improve service provision at the facility-level. In addition, where novel interventions are being investigated, close collaboration with the MOH, rapid turn- around of data analysis, and information sharing across partners, will be key to ensure that successful interventions are scaled-up rapidly.

2.1 Linkage to Care & Treatment

Patient attrition after a HIV diagnosis is a significant challenge resulting in delayed ART initiation and suboptimal treatment outcomes. SIMS data indicates linkage rates into HIV care in Mozambique after diagnosis is poor. Strategies to ensure newly diagnosed PLHIV are enrolled into care must be identified, implemented, and monitored closely. Implementing partners should support provision of a package of services for all patients diagnosed with HIV that includes ensuring linkage to care for patients tested at community- and facility-level.

Some of the interventions that should be implemented by partners include:

A. Reinforcement of post-test counseling.

B. Increased support to ensuring sites have adequate number of all applicable MOH/DPS approved health literacy and demand creation tools and their effective placement and use is monitored to ensure they are being fully utilized at each relevant point of the care cascade from physicians to health educators.

C. Intensified support for facility-based staff to act as case managers and patient navigators (peer educators, counselors, mentor mothers, etc.).

D. Active referral of patients into care services, whereby, the counselor escorts newly diagnosed patients to care service sites.

E. Routine data collection and analysis of performance of linkage to care to determine successful interventions.

2.2 Early Initiation of ART/Implementation of Test & Start

Early initiation of ART is a key strategy towards achieving epidemic control. As part of the roll-out of T&S the MOH has promoted initiation of ART within 15 days of diagnosis, with same-day initiation allowable if patients are deemed ready to start on the day of diagnosis. Clinical partners should aid provinces, districts, and facilities in developing tools to assess patient readiness, ensure adequate counseling is provided, and determine the impact of early ART initiation on both retention on ART and overall retention in care.

Activities to support this goal may include:

A. Provide technical assistance (TA) to ensure implementation of MOH guidelines and policies including T&S, 3-month drug distribution, and 6-month clinic visits for stable patients;

B. Actively support identification and tracking of pre-ART patients now eligible for treatment under updated guidelines, to ensure they return to clinic and are initiated on treatment;

C. Support same-day initiation of ART for adults when possible (facilitated by peer navigators) or provide intensive support to ensure those not initiated the same-day receive adequate counseling and follow- up to begin ART within 15 days as per MOH guidelines;

D. Ensure utilization of demand creation and health literacy tools to increase awareness of updated treatment guidelines and increase understanding of, and benefit in, the importance of early treatment and adherence;

E. Develop systems to closely monitor ART initiation and retention among patients with higher CD4 (350- 500 and >500), and rapidly develop facility-specific quality improvement plans for remediation in sites with decreasing retention;

F. Support evaluation of T&S in order to identify challenges and barriers to implementation.

2.3 Standard ART Support Package

PEPFAR implementing partners will be expected to provide a standard package of services based on the type of site and district. Three service delivery packages are required for service delivery implementation and include (See Appendix A for further details):

A. Central-support sites: These sites are being defined as sites with <500 ART patients, <55 HIV positive pregnant women, and <55 newly identified HIV-positive patients in sustained districts. The service delivery package at these sites will include two or more visits per year (justification required if more than four visits per year needed); support for key logistic elements such as supply chain and specimen delivery; mentoring/supervision predominantly through district or provincial support, and; implementation of streamlined quality improvement process. Data from these sites will be reported to OGAC during COP17.

B. Sustained sites: These sites are being defined as those with >500 ART patients, >55 HIV positive pregnant women, or >55 newly identified HIV positive patients in sustained districts. Support at these sites should include four or more visits per year (justification required if substantially more than four visits are needed), clinical mentorship for key areas such as ART provision, opportunistic infection (OI) management, pediatrics, and TB/HIV.

C. Scale-up sites: All ART sites in scale-up districts will receive enhanced support, including additional staff support for counseling, patient navigation, and lost to follow up (LTFU) tracing, in addition to the above. Demand creation for T&S and VL will also be conducted in scale-up districts.

2.4 Retention in Care

Patient retention in ART programs is a major challenge, especially among pediatric and adolescent populations, postpartum women, and men. Mozambique’s 12-month retention rate is unacceptably low at 70% nationally in PEPFAR supported sites (APR16). Urgent strategies are needed to improve retention rates in accordance with the Mozambique MOH guidelines. Monthly monitoring of early retention indicators and development of facility-specific work plans to address deficiencies began in COP16 and will continue in COP17. Partners will be expected to show improvements in these indicators through monthly reports submitted to PEPFAR- Mozambique. In addition, partners will be expected to support all of the key activities related to retention listed below:

A. Support the implementation of a family-and patient-centered approaches to care (e.g., integrated service delivery, one-stop-shops, patient navigation support, providers and patients awareness of HIV patients’ rights, support for grievance redress of HIV patients);

B. Ensure implementation of MOH guidelines on identifying, tracking, and supporting patients at high risk for LTFU;

C. Provide sufficient staff support at facilities and in communities to implement strategies to ensure patients at high-risk for LTFU receive intensified adherence support and to make sure tracked patients are linked back to C&T;

D. For stable patients, support the process of offering six-month appointments and three-month drug pick-ups;

E. Assess patient waiting times and process flows to address bottlenecks and for more efficient delivery of care;

F. Support provision of ART service delivery at alternative delivery points, beyond current ART facilities, to decrease the burden of long-distance and frequent travel by patients (MOH has approved using non- ART facilities for ART distribution and is working on details of the approach, sites should be identified and ART distribution plans implemented by all partners once fully approved);

G. Support GAAC expansion through demand creation and develop innovative approaches to expand enrollment including support for implementation of HIV support groups at health facilities;

H. Develop and implement strategies to improve provider-patient interactions and strengthen quality of care provided;

I. Ensure utilization of patient literacy materials on retention in all health facilities;

J. Assess and address discrimination and stigma issues – with a focus on ensuring that healthcare providers respect patient rights, and that patients know their legal rights and do they have a re-dress mechanism when their rights are violated (see also Stigma and Discrimination Section);

K. Develop and evaluate additional community-supported activities (e.g., working with traditional healers, community leaders, community support groups) to determine their effectiveness towards improved retention and further expand knowledge of successful approaches;

L. Support routine LTFU analyses to further determine causes of poor retention;

M. Support expansion of health information systems to better monitor, track. and support interventions for addressing retention (e.g. EPTS, electronic pharmacy patient management system)

2.5 Viral Load Suppression

Achieving the Third 90 of the cascade requires not only maintaining patients on treatment but also ensuring that they are adherent and that their VL is suppressed. Uptake of VL monitoring among eligible patients in Mozambique is increasing dramatically, and logistical challenges are expected to occur until the implementation matures.

Expansion of available VL services, supporting rapid turn-around of tests results, and ensuring providers know how to act on test results are all necessary to support the transition to routine VL monitoring. Partners should also monitor appropriate VL test uptake, data quality, VL turn-around-time, and VL suppression rates by age and gender to ensure programmatic improvement.

For COP17/FY18, IPs will be expected to:

A. Train laboratory and clinical staff on VL implementation and use;

B. Ensure utilization of VL demand creation and patient literacy materials;

C. Support laboratory upgrades to accommodate VL, and/or, point of care VL machines in alignment with VL expansion;

D. Improve laboratory supply chain management;

E. Improve overall lab efficiency, support efficient specimen referral systems minimizing lost samples;

F. Develop systems to clearly monitor flow of laboratory samples and result-reporting including turn- around-times (TAT) to ensure any bottlenecks are quickly identified and addressed.

G. Support routine quality assurance of VL results;

H. Support improved data quality by implementing systems to promote complete legible VL requisitions;

I. Ensure patients with elevated VL receive enhanced adherence;

J. Establish monitoring systems to ensure patients with elevated VL are reevaluated for adherence to ART, are adequately followed, and re-tested to ensure VL suppression is achieved or second-line therapy is initiated;

K. Provide TA to provincial therapeutic committees and the decentralization of second-line therapy decision-making.

2.6 TB/HIV

Mozambique is one of the highest burden countries for TB and TB/HIV coinfection globally. In addition MDR- TB rates have increased. Although HIV-testing and ART initiation for co-infected patients are both high in Mozambique, case detection at just 40% is abysmal. Partner support to ensure key activities to improve case detection, such as rapid scale-up of GeneXpert use and implementation of TB contact tracing, is key to further prevent TB/HIV-associated mortality. Improving implementation of TB infection control and IPT initiation will also be key during COP17.

To address these challenges, and move toward the achievement of the 90-90-90 goals, USG and IPs will need to work closely with the MoH and health facilities in an enhanced manner to ensure implementation of key activities. Monthly meetings of TB focal persons from each partner will begin during COP16 and continue into COP17 to assess key indicators related to TB case detection, infection control, and IPT. It is expected that all partners will in addition support the following:

A. Expanding and strengthening TB/HIV collaborative activities to ensure that 100% of TB/HIV co-infected patients receive ART, through expansion of One-Stop Model of Care (OSMC).

B. Enhancement of TB screening, TB diagnosis, treatment of active cases, and provision of IPT to all PLHIV without active disease. This methodology should be expanded to all settings including MCH services and in programs targeting high risk groups including KPs.

C. Provision of on the job training to TB nurses, clinicians and supervisors working in TB and HIV clinics including PMTCT and CCR.

D. Enhancement of contact tracing of household members and social contacts of TB index cases.

E. Establish TB active case finding in conjunction with targeted community activities with traditional healers, activistas, health educators, mothers to mothers and mobile clinic outreach.

F. Strengthen diagnostic capacity through enforcement of the use of GeneXpert as the first diagnostic test to establish a TB diagnosis among PLHIV.

G. Strengthen training of clinicians and laboratory personnel in the use of GeneXpert, with improvements in the sample collection, referral, real-time reporting of the test results, and same day treatment initiation.

H. Support GXAlert connectivity and its use at the district and provincial levels to implement and oversee identification of MDR TB and facilitate index case contact tracing.

I. Support implementation of TB infection control (TB IC) measures (administrative, environmental, personal protection); TB IC risk assessment, plan development and implementation; and, periodic evaluation using routine M&E tools (e.g., TB IC dashboard).

J. Expansion of health care worker (HCW) TB screening, establishment of HCW screening registries and concurrent HIV testing.

K. Support the implementation of TB, HIV, and STI package of services for prisoners.

L. Determine feasibility and pilot with MOH a screening and treatment program for miners with latent TB.

M. Support the implementation of the MOH TB prevalence survey.

N. Support the adaptation and implementation of the new MDR-TB short course treatment regimens.

O. Participate in joint TB/HIV planning, training and supervision with national, provincial and district authorities P. Strengthen linkages and coordination with community organizations to increase case finding through raising awareness of TB disease, association with HIV and availability of treatment free of charge.

Q. Organize and participate in community campaigns including community outreach, media and school- based messaging in order to disseminate messages on TB and HIV at the household and community levels.

R. Support supply chain management to avoid stock-outs of TB lab supplies and medication.

2.7 Prisoners

In addition to the activities above, partners should focus and improve delivery of HIV and TB/HIV preventive and treatment services to incarcerated populations, where current challenges include deficiencies in routine screening, infection control implementation, and coordination to ensure adequate clinical service provision on entry and exit.

To improve services to this highly vulnerable population, implementing partners should support:

A. Systematic HIV/TB/STD screening for all new entrants to prison with monthly monitoring of the number and percent of new entrants diagnosed at the time of incarceration.

B. Establish in collaboration with MOH HIV/TB/STD treatment services in the prison.

C. Assessment of infection control needs, and support for improvements, or provision of IC related equipment and materials to reduce transmission of HIV and TB among incarcerated populations.

D. Define training needs for dedicated health staff or prison peer educators in prisons.

E. Assure HIV, TB, and HIV/TB co-infected prisoners released from incarceration have an appropriate referral and linkage plan and linkage and retention rates are determined and rates are monitored monthly to assure continuity of care and treatment.

2.8 Nutrition

In order to reduce morbidity and mortality of HIV+ patients, partners should support implementation of NACS so that all eligible patients may be assessed, screened, counselled and linked to treatment when needed.

Partners should coordinate with WFP to guarantee (where available) nutritional support and improve logistics. Partners also need to ensure good data quality collection at site.

In particular:

A. Conduct trainings and mentorship session to HCW and CHW on nutritional assessment and provide job aids (PRN 1 and 2).

B. Equip all supported HFS with adequate supplies for nutritional screening (scales, etc.).

C. Coordinate activities with nutrition community partners where available and document referral and counter referrals.

D. Improve data availability guaranteeing availability of registers for PRN 1 and 2 (MCH registers and PRN books), nutrition tables and all needed IEC materials.

2.9 Quality Improvement (QI)

Quality improvement is an essential practice for responding to site- and above site-level variation. It also aims to improve on-going benchmark performance of PEPFAR investments. Challenges to controlling the epidemic requires timely approaches to differentiated care in service delivery, improving site-level management, and use of data at the facility-level for on-going change. QI is even more relevant given the newly released T&S guidance, a high priority for improving linkage and referral for improved retention, and health systems strengthening approaches to achieve VL targets.

A. Provide TA for QI strategy expansion and appropriate implementation.

B. Support DPS in planning and monitoring QI activities and ensuring facility level participation in QI cycles.

C. Support QI implementation at the site level and supported by site-level plans.

D. Establish facility level email groups to provide regular communication with key personnel on QI, MOH guidelines, critical levels of RTK or ARV pending to prevent stock outs.

E. After each visit to a facility, the IP will leave behind a documented QI plan for continuity.

F. Support central level in review of QI documents and tools, coaching provincial teams and monitoring QI activities, and in the analysis of QI data.

G. Share and expand best practices.

H. Implement QI in all VL and EID laboratories.

I. Develop QI plans (documented) with the health facilities to respond to weaknesses identified in SIMS reports.

J. Provide TA for clinical mentoring and analyze mentoring data.

K. Optimize the use of already existing data sources for QI data analysis and develop tools, were appropriate.

L. Develop and implement audiovisual training platform for continuous distance learning.

M. Assure QI quality plans aligns with National Quality Improvement Guidelines.

N. Use of information at the facility level to advance data quality and service quality improvement.

3. Maternal & Child Health

Provision of high quality PMTCT services is essential to the reduction and elimination of vertical transmission of HIV in Mozambique. The most critical challenge for PMTCT in Mozambique is retention of pregnant and lactating women along the entirety of the care cascade. PEPFAR partners are expected to support high performance in all aspects of the PMTCT care cascade with a particular focus on retention and adherence among pregnant and breast feeding women (PBFW) as well as the care cascade for HIV exposed and infected infants.

Partners are encouraged to work closely with the MOH/ DPS/HF to improve the quality of care within the MCH services as one of the steps to improve retention for the mother and baby pairs in care.

3.1 Prenatal & Intrapartum Care Cascade

Support MOH/DPS and facilities in implementation of mentor mother/mother educator strategy by building effective peer mentoring programs for pregnant and breastfeeding women, integrated with systematic approaches for reducing LTFU and intensified support during the first six months of ART, with particular intensity after ART start and following delivery. Collaborate with Mothers2Mothers in program design and implementation, as appropriate. Ensure lay health workers at each facility are dedicated to MCH peer mentoring.

Support the HF to ensure high quality of ANC according to the MOH guidelines and standards of care. Ensure that all PW have access to the wide range of services, including HIV and syphilis test, TB screening, nutrition screening and treatment if needed, ITP malaria, INH prophylaxis, etc.

Prioritize improved PTMCT retention and adherence throughout the care cascade via multiple modalities including improved counseling and psycho-social support capabilities of both health professionals and lay health workers for the implementation of the MOH National Psycho-Social and Positive Prevention Strategy. Build capacity of clinicians to identify women at risk of GBV and to provide high quality support, counseling and referral for victims and survivors of GBV. Train health workers to provide respectful care and effective counseling messages.

Support implementation of VL monitoring during pregnancy and lactation concordant with MOH guidelines.

Lay personnel — as needed, hire, train, mentor and supervise dedicated MCH lay personnel to work closely with MCH nurses to complement their scope of work. Lay health personnel may include facilitators of mothers’ support groups, mentor mothers, health/peer educators, lay counselors and activists. Lay health workers should provide the following services in coordination with healthcare providers:

A. Pre-test, post-test and pre-ART initiation counseling, as well as, treatment literacy education.

B. Adherence and retention counseling tailored to individual patient circumstances.

C. VL counseling.

D. Patient navigation within the health facility.

E. Design and implementation of follow-up plan tailored to each newly diagnosed PBFW including home visits if feasible and consented.

F. Ongoing psycho-social support (individual and group counseling sessions; support groups at facility and community level) from pregnancy throughout the breastfeeding period.

G. Re-enforce the use of m-Health technologies (phone calls, SMS, Commcare, etc) including cellphones and airtime specific for MCH services, algorithms for follow up, tools to ensure that the activities and outcomes are documented.

H. Monitor early (1-6 months) retention and intensify support for women at apparent increased risk for early drop-off or default.

I. Promote hospital delivery and adherence to post-partum visits.

J. During pregnancy, educate women about services for exposed children, need for follow up at CCR and early enrollment in services to ensure EID and other care.

K. Provide ongoing support to the mothers/caregivers until definitive diagnosis of exposed infants and ensure that mother/infant pairs are linked with appropriate services based on HIV status and needs.

Promote an enabling environment to increase male involvement Partner testing – in coordination with the provincial/district/health facility teams, develop and implement innovative strategies to test more partners of PBFW, regardless of their HIV status.

Support the HF to create a system to ensure effective linkages for male testing positive at the ANC to care and treatment or to VMMC services if testing negative. Strategies include but are not limited to:

A. Use of male peer educators to reach male partners accompanying PBFW to health facilities to engage them in PMTCT (counseling for testing, assistance helping navigating the health system if testing HIV+); provide counselling for ongoing follow up during pregnancy & breastfeeding (regardless of HIV status).

B. Dialogue and collaborate with communities and community leaders to identify opportunities for including men in prenatal care and care of HEI. Use opportunities such as feiras de saude C. Scale up successful male involvement strategies via sharing of best practices among clinical partners.

D. Create innovative approaches to accommodate couples and/or male participation.

E. Create linkages with private companies to promote healthy behaviors including HIV counseling & testing.

Support rollout of cohort based PMTCT/MCH registers and train clinicians in longitudinal follow-up of PBFW and mother/infant pairs.

Support immediate transition to provision of HAART for PBFW in facilities where clinicians continue to provide AZT to women opting out of Option B+. Provide TA to support counseling skills improvement for better acceptance of ART.

PMTCT Specific HCT Guidance:

A. Support retesting of HIV negative PBFW in accordance with MOH HTC guidance—all PBFW testing negative need to be re-tested 3 months after the negative test.

B. Support re-testing of HIV positive PBFW according to MOH guidelines.

C. Partner testing – in coordination with the provincial/district/health facility teams, develop and implement innovative strategies to test more partners of PBFW, regardless of their HIV status.

D. Participate in partner testing and notification TA with ITECH as appropriate.

E. Support design, implementation and monitoring of rational patient flow for male partners tested in MCH to ensure linkages with ART services if testing HIV positive and to VMMC services if testing negative.

F. Provide individual counseling to all HIV negative male partners of HIV positive women on the benefits of partner adherence on reduction of transmission risk.

G. Build clinician capacity to test for, diagnose and manage TB/HIV co-infection in pregnant and lactating women.

3.2 HIV & Family Planning Service Integration

IPs are expected to support the goal of sustained, effective use of family planning methods and improved access to and uptake of a high-quality contraceptive method mix among PLHIV, with particular emphasis on women, youth and adolescents. Partners should identify and address barriers that prevent WLHIV from receiving FP services. FP services and safe pregnancy counseling should be integrated and provided as part of the continuum of HIV care and treatment in various settings such as: ART consultation, CCR, SAAJ, community- based outlets, etc. Sites should have trained providers for FP and safe pregnancy counseling as well as adequate space to promote privacy and confidentiality.

A. Train and mentor health personnel in counseling and provision of contraception methods.

B. Ensure provision of contraception methods for HIV positive women in postpartum care as well as CCR. Ensure compliance and informed choice.

C. Ensure that all women attending FP services benefit from HTC and if positive are effectively linked to care.

D. Support the health facility (if applicable) on implementation of CECAP services: provide training and material and ensure coordination between MCH services and C&T for effective linkages.

3.3 Pediatric Case Identification, Care & Treatment

IPs will continue to implement impactful pediatric case finding, care and treatment activities initiated under the ACT program. IPs are expected to continue to seek programmatic innovations to improve pediatric case finding, linkage, adherence and retention.

Care cascade for HIV exposed infants (HEI) A. Facilitate linkage between ANC, L&D and CCR; assist facilities in tracking women after delivery to ensure CCR enrollment of exposed infants.

B. Support timely PCR/DBS or EID POC testing as appropriate, with focus on testing before two months of age.

C. Support improved linkage to care for HIV positive infants and strengthen care cascade for HIV exposed infants.

D. Train staff in the collection and management of blood samples for DNA PCR testing, to reduce the number of rejected samples.

E. Support laboratories in implementation of evidence based standards for inclusion of DBS samples for DNA PCR testing.

F. Establish SOP for timely identification of delayed return of PCR results and follow back to the testing laboratory requesting the results.

G. Revise and strengthen laboratory forecasting and logistic systems including EID early warning systems.

H. Improve logistics of sample referrals and delivery of results inside health facility and to facilities and caregivers while reducing laboratory TATs.

I. Implement EID POC in selected health facilities in coordination with national POC EID strategy.

J. Support CCR clinics in ensuring systematic tracking via collaboration with lay health workers of all HEI, and HIV positive infants to maximize testing and linkage to care. Ensure tracking documented in registers.

K. Build capacity of MCH nurses to provide integrated care for HEI, addressing general growth and development as well as provision of routine HIV testing for all children at risk.

L. Support implementation and ensure use of the new algorithm for enhanced prophylaxis for babies (when the MOH releases it)

Pediatric case finding:

A. Intensify index case, prioritizing sites with high HIV prevalence in ANC.

B. Strengthen implementation of routine opt-out testing (ROOT) in all pediatric wards (including adult wards attending children < 15 yrs), TB and malnutrition clinics.

C. Train clinicians in presumptive pediatric HIV diagnosis to improve consistent implementation of MOH guidelines and assess the use and case finding outcomes from implementation of guidelines at the site level.

D. Build capacity of clinicians to appropriately use sign and symptom based testing (PICT) in all entry points attending children’s including urgent care clinics.

E. Ensure use of the new algorithm on HIV testing for children (when the MOH releases it)

Improve pediatric C&T:

A. Support the implementation of activities to improve pediatric adherence and retention activities such as:

a. Implement flexible consultation schedules for pediatric patients to harmonize with school attendance.

b. Support to the implementation of LPV/r pellets via TOT and HF level training and mentorship sessions for HCW, parents and caregivers.

c. Scale up the implementation of age and gender adequate peer support such as mentor mothers, adolescents living with HIV and other family approach strategies to support adherence and retention.

d. Support the scale up of specific activities to improve pediatric adherence and retention such as multi-month prescription, 3-month consultation scheduling for older and stable children.

e. Promote and conduct in-service training sessions to improve timely pediatric ART initiation and compliance with MOH guidelines on CD4 and VL monitoring.

f. Build clinician capacity to identify orphans and OVC and link them to existent programs at the health facility and community level.

Pediatric TB/HIV:

A. Scale up One Stop Model for TB/HIV in co-infected children.

B. Support implementation of standard practices for presumptive TB diagnosis and follow-up.

C. Ensure all HCW in TB clinic are trained in pediatric HIV and receive ongoing clinical mentoring.

D. Ensure all HIV positive children are screened for TB and either started on treatment or on IPT as appropriate.

E. Provide technical support, on-the-job training and mentorship to HCW on the use of new pediatric TB drugs formulations.

Nutritional support:

A. Support nutritional screening, counselling and support for HIV infected pediatric patients and coordinate nutritional support as appropriate with WFP.

B. Conduct trainings and mentorship session to HCW on nutritional assessment and provide job aids C. Equip all supported HFS with adequate supplies for nutritional screening including registers.

D. Support in both HF and community levels. Use both facility and community HW.

Adolescent support:

Develop and disseminate age appropriate counselling and support materials for adolescents living with HIV including but not limited to topics such as safe relationships, adherence, treatment as prevention, FP, and disclosure. Promote and implement teen clubs for psycho-social support and adherence/retention.

3.4 Integrated Pediatric & PMTCT

Prioritize reducing LTFU via multiple modalities including, but not limited to, weekly identification of defaulters (antenatal, postnatal, HEI, pediatric) followed by immediate tracking at community level in coordination with lay health care workers, development and implementation of tools for tracking outcomes via electronic media and mobile health platforms. Document reintegration in care for returning patients. Develop and implement tracking algorithm for those patients not identified or returned to care after initial efforts at community outreach. Assist healthcare providers and lay personnel in developing visible process for routine review of facility retention and adherence data to promote performance improvement.

Clinician mentoring:

Ensure that HCW (physicians, nurses and allied health professionals) providing HIV care in MCH settings are adequately trained to ensure quality services provision:

A. Support for supervision and in-service education of healthcare providers.

B. Develop clinician capacity to monitor and support adherence and appropriately identify and manage new HIV diagnoses, treatment failure and opportunistic infections.

C. Continue support to provincial level mentorship and training units.

D. Develop and implement strategies for family-oriented HIV care.

E. Support the roll out/ dissemination of National pediatric HIV/PMTCT communication strategy for behavior change, demand creation and health literacy (patient’s rights, ARV drugs, etc.) at the community level.

3.5 Quality Improvement

Support and integrate QI processes at facility, district and provincial level with focus on both pediatric and PMTCT indicators (including early retention and VL); actively support MOH QI strategy focused on PMTCT indicators (including early retention indicators) with regularly scheduled QI meetings at the DPS level and routine facility-level discussion of performance data using existent MOH approved tools and new tools that are being developed by UCSF.

4. Prevention

4.1 HIV Testing & Counseling

The primary objective of the HTS program is to identify and link HIV positive individuals to C&T services. Secondary objectives include increasing identification of men who are HIV positive (as they are currently underrepresented in HIV care), and maintaining test quality.

COP17 strategy focuses on high-volume, high-yield, scalable modalities. In FY16, 64% of all HIV diagnoses made outside of the ANC setting were made through PICT, so optimization of this modality is paramount. Program data collection identified emergency rooms, urgent care, and inpatient settings as high-yield, underutilized PICT settings, which will be remediated in COP17 through efforts such as hiring of additional lay counselors, training of direct service providers, and refinement of symptom-based screening.

Co-located VCT, the highest yield high-volume modality, was expanded to all feasible sites not requiring infrastructure investment in COP16. In COP17, clinical partners should advance implementation of CQI on low-productivity VCT sites (reporting ≤ 32 positives per quarter). Partners should look for ways to more strategically use lay counselors if they are not being productive in VCT.

Index-case testing had a promising beginning in FY16 and will need to be brought to full scale in COP17. Clinical partners should refine their index-case testing strategy to increase volume as well as yield, increasing testing of sexual partners of people diagnosed with HIV through disclosure support and assisted partner notification. In developing these methods, clinical partners should collaborate with ITECH, which has been funded by PEPFAR and endorsed by MOH to provide central support for index-case testing. M&E systems will need to be developed or maintained that allow specific reporting of index case testing, whether conducted in the facility or community, and allow disaggregation of contact type (adult sex partner, child of index case), as well as, identification of tests conducted incidentally on people who are not contacts of index cases.

Linkage to care of HIV positives is a programmatic priority. Clinical partners should also develop or improve methods to increase linkage such as reinforcement of post-test counseling, intensified coverage of peer educators to accompany clients and act as case managers, active referral into care whereby the counselor themselves escort newly diagnosed patients into care services, introduction of real-time defaulter tracing system to find and re-integrate diagnosed PLHIV into care services, expansion of the HTC one-stop model, where the patient file is opened at the point of testing, prioritization of newly diagnosed PLHIV in the (usually long) lines to receive care services and revision of HTC M&E tools to incorporate linkage measurement. Clinical partners should seek innovative ways to improve linkage rates and track linkage to care at the individual level of those who test positive and do or do not initiate ART. Partners should facilitate implementation of new HTC registers when they become available.

SIMS also highlights HIV testing quality as a programmatic weakness. To improve rapid HIV testing COP17 will:

A. Disseminate the national testing quality improvement guidelines in which the HIV rapid testing minimum standards are defined.

B. Provide HCW refresher training and ensure certification to perform HIV testing.

C. Ensure that all facilities that receive the standardized specimen panel respond accordingly in collaboration with the INS, DPS, and implementing partners.

D. Activities to assure quality of testing including use of dried tube specimens for external quality assessment (EQA), logbooks at service delivery sites, and provision of basic resources to maintain high quality testing will continue.

E. Supportive supervision will continue in collaboration with central and provincial health authorities.

Clinical partners should develop and implement innovative strategies to increase HIV testing of men such as ensuring sufficient HIV testing capacity on evenings and weekends in emergency rooms.

Clinical partners should facilitate implementation of re-testing for confirmation of HIV positives as expansion of this practice is directed by MOH.

4.2 Key Population Program Integration

Key Interventions with CSW/MSM within health facility:

· In-service training.

· Integration of KP into EPTS and HTC registers.

· Linkages and monitoring of HIV care and treatment services.

· Implementation of newly approved MOH KP Guidelines including national T&S.

Package of KP Services:

There are twenty-two (22) health facilities designated by MOH as “KP-friendly” and they will receive critical support and staff training in order to effectively serve these populations, through an approved package of services that include:

A. Risk assessment and reduction, behavior change and health education messaging.

B. HIV C&T (including partners and counseling for safe sexual practices).

C. Provision of condoms and lubricants.

D. STI screening, diagnosis and treatment.

E. TB and other OI screening.

F. Screening for cervical and prostate cancer.

G. Provision of SRH counseling, FP, and contraceptive mix to all CSWs.

H. Provision of Post Exposure Prophylaxis (PEP) according to the national algorithm.

I. Provision of GBV package of services.

J. T&S for MSM and CSW.

K. Provision of ART for prisoners and PWID according to the norms for general population.

L. Nutritional support as indicated.

In addition, PEPFAR-Mozambique will support interventions for prisoners. Clinical partners should support these efforts in the following ways:

· Ensure that all HIV positive prison population in setting within the ratio of T&S health facility begin ART once status becomes known.

· Coordinate efforts with Pathfinder, the PEPFAR funded lead partner for HIV prevention in prisons.

4.3 Gender-based Violence (GBV)

In order to address GBV as a risk factor for HIV acquisition, health-seeking behaviors, and adherence to HIV treatment, the PEPFAR Gender-based Violence Initiative (GBVI) that began in 2011 provided our clinical partners with central funds to scale up the provision of post-GBV care services in ART clinical sites. Through the GBVI, we succeeded in expanding post-GBV care services from 42 HFs in 2011 to approximately 395 HFs in COP16. Despite this marked achievement in scaling up the clinical response to GBV in Mozambique, the provision and reporting of post-GBV care services in PEPFAR-supported ART clinical sites is still very low.

As we discussed in multiple partner meetings leading up to the end of central funding for the GBVI 2016, PEPFAR expects an integration of post-GBV care services into the ART clinical platform moving forward. A small proportion of the C&T budget is dedicated to providing the minimum package of post-GBV care services in ART sites. Targets in COP17 have been set for all scale-up sites in an effort to guarantee the minimum package of post-GBV care services is available. Targets were also set by finer age bands, gender, and by type of violence. Partner M&E teams are expected to report this triple-disaggregated data (by age, gender and, type of violence). The new MOH-approved GBV registers are set up to capture the indicators in this way to simplify reporting.