Excellence Community Education Welfare Scheme (ECEWS) came on board the PEPFAR grant as an implementing partner with Center for Disease Control and Prevention (CDC), Atlanta with grant number-1 U2G PS000636-01 in 2007. The primary focus of the award was the expansion of sexual prevention services comprising of Abstinence & Be Faithful (AB) and Condom & Other Prevention program (C&OP) to underserved communities in Abia, Akwa Ibom and Cross River States. ECEWS scaled up with the award of Grant Number PS001413 in 2009 to carry out intervention in Abstinence and Be Faithful (AB), Condom & Other Prevention program (C&OP), HIV Counselling and Testing (HTC), TB/HIV Integration, Basic Care and Support (BC&S), Pediatric Care and Support (PC&S), Orphans and Vulnerable Children (OVC) and Strategic Information (SI) program areas.
ECEWS enjoyed robust working relationship with state partners in the life of the project cycle; with active state involvement in site assessment, selection, planning, implementation and monitoring of the MACC-4 project. ECEWS collaborated extensively with other implementing partners and GoN agencies, and community gate keepers in the field, leveraging on their core competences to ensure that beneficiaries of the project were linked to services in domains not covered under the grant and hence our several success stories. In 2011, following a CDC directives, ECEWS transitioned some sites to CIHP (BC&S -24 sites, OVC – 10 sites, and HTC-14 sites). In line with the USG rationalization plan, ECEWS transited the remainder of her sites in Abia, Akwa Ibom and Cross River States (57) to FHI 360 in 2013; relocating to Enugu state where the project eventually closed out. The report details the progress towards the achievement of the MACC-4 targets, the project’s accomplishments, partnerships, and success stories, lessons learned on the project, and the project’s phase-out process.
The goal of ECEWS MACC4 project was to achieve primary prevention of HIV infection through mobile and facility based HIV counseling and testing, age appropriate community target Peer Education with ABC messaging and Care and Support to People Living with HIV/AIDS, Orphans and Vulnerable children and Public health Systems strengthening.
The following objectives were outlined in the grant’s work plan:
- To ensure in Akwa Ibom and Cross River and Abia States that at least 15,000 persons and 767 TB suspects in high risk communities undergo HIV counseling and testing and receive results via 22 facility based sites (including 6 TB DOTs sites) and 3 mobile sites in the first year and at least 200,000 persons in five years.
- To ensure that all identified HIV positive clients are referred for TB testing and treatment, Basic Care & Support in ECEWS supported sites, and treatment in other partner supported sites.
- To provide Basic Care and Support including palliative and Home based care to 3000 persons living with HIV/AIDS and by extension at least 9000 persons effected by AIDS through 25 facility based sites and 10 community sites in the first year and at least 20,000 PLWHA in five years.
- To provide basic care and support including food and nutrition, health and educational assistance as comprehensive primary care to 2500 orphans and vulnerable children including HIV positive children and children of persons living with HIV/AIDS regardless of status in the first year through 10 community sites in Akwa Ibom and Cross River State and at least 40,000 OVC in five years.
- To take Abstinence, be faithful and condoms and other prevention messaging to 2273 high risk persons including 1000 in-school youths and adolescents reached with Abstinence only messaging via community target awareness activities and peer led education in 10 school based sites and 10 FBOs/CBOs in the first year and at least 60,000 individuals in five years.
- To take Condoms and Other Prevention messages including STI management/treatment with balanced ABC model messages via community led awareness campaigns and peer education plus model to 7576 individuals including 1000 Commercial Sex Workers in 10 community target sites developed under COP 07 and 15 community target sites developed under COP 08 and 8 developed in the proposed MACC-4 projects in the first year and at least 140,000 in five years.
- To build the capacity of 29 Health Workers and hold refresher training for previously trained 29 health workers including Nurses, Counselors and other non-laboratories in 22 secondary and primary health facility sites in Akwa Ibom and Cross River State including 6 TB DOTS centres on HIV counseling and testing services using FMOH training guidelines in the proposed MACC-4 project in the first year and at least 240 in five years.
- To build the capacity of 8 Health Workers from 6 TB DOTs centres on the provision of treatment for TB to HIV infected individuals in the first year and at least 40 health workers in five years.
- To build the capacity of 24 extension workers including 14 Health Workers and PLWHAs to provide palliative and home based care to PLWHA clients using national guidelines in the first year.
- To build the capacity of 40 care givers selected from 10 community sites in caring for OVC in the first year and at least 200 care givers in five years.
- To build the capacity of 20 health care providers, counselors, teachers and peer educators to conduct effective prevention interventions inclusive of AB messaging. In the first year and over 200 in five years.
- To build the capacity of 50 Health/Peer Educators including 20 Commercial Sex Workers using the Peer Education plus model to conduct prevention interventions on condoms and other prevention including STI management in the first year and at least 300 in five years.
- To build the capacity of 80 individuals from 69 community target sites including 10 volunteers from 5 partner CBOs/FBOs in strategic information activities in the first year and at least 200 individuals in the life of the project.
- To strengthen systems and give technical assistance in monitoring and evaluation and data collation in 69 local organizations in the first year and at least 200 local organizations in five years.
The MACC4 Project targeted the following groups:
- Youth, women, children and adult in key populations
- Commercial sex workers
- People living with HIV (PLHIV)
- General Population
- TB patients
- STI patients
- Children orphaned and/or vulnerable to HIV
- Incarcerated populations
- Military populations
- Police populations
- In-school and out-of-school youths
- Health Care workers
|Number of individuals who received HIV Testing and Counselling (HTC) services and received their test results.||126,053||142,690||113|
|Number of eligible adult and children provided with a minimum of one care service including persons affected by HIV/AIDS (PABAs) provided with palliative care.||6,100||4,481||73|
|Number of HIV-positive patients who were screened for TB in HIV care or treatment setting.||–||1,411|
|Number of OVC provided with primary direct support in psychosocial, health, education and nutrition services.||3,050||3,211||81|
|NO of HIV +ve clients who were started on TB Treatment||150||121||105|
|Number of HIV exposed and infected Children provided with paediatric care and support services including Laboratory monitoring.||280||336||120|
|Number of target population reached with individual/or small group level HIV prevention intervention that are primarily focused on abstinence and/or being faithful and based on evidence and/or meet the minimum standards required.||16,158||21,254||132|
|Number of key populations reached with individual and/or small group level HIV preventive interventions that are based on evidence and/or meet the minimum standards required.||48,000||58,289||121|
HTC services targeted MARPs, Children, couples and the general population through mobile/community outreaches to under-served and Most at Risk communities in Akwa Ibom, Cross River and Abia States as such increasing access to life saving ART services via early diagnosis and prompt linkage to prevention, care and treatment. ECEWS provided 142,690 individuals (couples, children, MARPs and general population) with HTC services. Services were provided at facility based sites (88,761 individuals) and mobile HTC unit (53,929 individuals). A total of 11,387 individuals (4486 males and 6901 females) tested positive to HIV representing 8.0% positivity rate. HTC services were provided by 120 trained counselors/testers using the nationally approved serial testing algorithm (DETERMINE, UNIGOLD and STAT-PAK RTKs), protocols and SOPs to individuals at General Out-patient Departments (GOPD), antenatal clinics, STI clinics, in-patient wards, TB clinics and laboratories. Counseling and testing rooms in facilities were maintained to ensure confidentiality and comfort of clients with proper disposal of waste following waste segregation SOPs at different points of service. Our strategies were as follows:
- Provider Initiated Testing and Counselling (PITC) was rapidly scaled up to promote the test to treat strategy of USG. A total of 88,761 individuals (35,504 males and 53,257 females) were reached with HTC services through PITC including children, couples and pregnant women with 6,832 (2,632 males and 4,200 females) individuals testing positive to HIV across the facility based sites. Positivity rates from supported health facilities ranged from 21.5% in Cottage Hospital Ibeno, 15.3% in PHC Esit Eket, 14.3% in Uwem Specialist Hospital to 0.7% in cottage hospital Abayi.
- Pediatric Testing
Pediatric testing was carried out both within supported health facilities (GOPD, Child welfare clinics and children wards) and via mobile/community outreaches especially door to door testing with the consent of their parents/guardian. ECEWS worked with the target states’ Ministries of Education, the Parents Teachers Association, the school Principals/Headmistresses and the school Nurses to provide HTC services to students in schools following consent by their parents/guardian. A total of 6,832 pediatric client (2,983 male, 3,849 female) were tested for HIV with a total of 234 positive clients (116 male, 118 female).
iii. Couple HIV Counselling and Testing
As part of effort at preventing new HIV infection and risk reduction among couples, the MACC4 project trained 22 Health Care Workers (HCWs) on couple HIV counseling and testing according to national guidelines. The ECEWS mobile HTC teams used the door-to-door strategy to provide same day HTC services to couples in their respective homes and communities. The door-to-door strategy ensured that couples receive education about HIV, free HIV test, pre-test and post-test counseling in the comfort of their homes thus reducing stigma and discrimination, and promoting mutual status disclosure. Couples visiting antenatal clinic together were also provided with couple counseling and testing services. Identified HIV discordant heterosexual couples were linked to HIV prevention intervention including vaccine for the HIV positive partner. A total of 423 couples were reached with HTC services.
MACC4 HTC mobile outreaches targeted MARPs and populations in hard to reach settings – commercial sex workers and their clients, police formations, long distance drivers, pregnant women and couples – communities with emphasis on high HIV prevalent communities. In the life of the project, a total of 53,929 individuals (21,571 male, 32,358 female) representing 38% of HTC reach were provided with HTC services with 4,555 individuals testing positive to HIV. All positives clients were linked to care and treatment in comprehensive sites supported by treatment partners.
- Referral and Linkages
Referrals were carried out primarily for care and treatment, TB diagnosis and syndromic management of STI and PMTCT using a 2-way referral form to comprehensive sites supported by CIHP, FHI 360 and HYGIEA kindly provide the data. Referral completion rates stood at 85% for facility based sites and 69% for mobile outreaches. Escort services and SMS follow-up were employed as strategies to enhance referral completion.
- Quality Improvement
ECEWS trained Health care workers (22) on Logistics Management of HIV/AIDS Commodities and participated in the rollout plans for LMIS Unification pilot. This accounted for the timely and correct reporting of CRRIRF-RTKs to the central Medical Stores, and minimized incidence of stock outs across supported sites. On-site supervision, program monitoring visits and mentoring/training were unique avenues for building the capacity of counsellor/ testers for qualitative service delivery. Furthermore, use of controls (Dried Tube Specimens), use of client exit survey/counselors’ reflection forms and proper documentation were maximized as standards for service. Client exit survey/counselors reflection forms revealed that 93% of the counselor/testers considered they had good counseling skills, while 86% of the clients considered the counseling session good. Laboratory consumables, monitoring and evaluation tools, HIV Rapid Test Kits (RTKs), condoms and Information Education and Communication (IEC) materials were distributed to the various HTC sites appropriately based on a pulling system using the site level inventory control system linked to the ECEWS warehouse Logistics Management Information System (LMIS).
Abstinence and or Be Faithful (AB) HIV prevention program primarily focused on meeting the prevention needs of vulnerable population made up of young people especially girls (in-school youths, adolescents, orphans and vulnerable children), women with special needs (widows, separated, divorced and single mothers) and general population. Utilizing, the right mix of Combination Prevention for individual and community-level intervention, the project ensured that persons were reached with a suite of behavioral, biomedical and structural interventions. These included community awareness campaigns, peer education models, peer education plus activities, a school-based approach; promotion and provision of HIV counselling and testing. Interpersonal communication and peer education were implored at individual level interventions, community awareness and dialogue were deployed at community level interventions, while ensuring the establishment/strengthening of Abstinence Clubs, FBO health/ HIV committees and promotion of youth friendly services at site of program implementation.
We recorded increased program ownership among the participating FBO population (Anglican Diocese of Umuahia, Mount Zion Light House Full Gospel – Calabar, Anglican Diocese of Uyo, St. John RCM Parish -Abak) as HIV prevention messages were mainstreamed into their various groups’ activities. The group went further to setup HIV coordinating committees and were continuously requesting for HIV counselling and testing services. In the life of the project, 21,657 persons (9,609 males and 12,048 females) were reached with the Combination Prevention Intervention that reinforces behavioral, biomedical and structural approach leading to adoption of positive behavior. Among the in-school youth, 5,610 persons (2,100 Male, 3,510 female) were counselled, tested and received their results, with 43 persons (25 Male, 18 female) coming down positive as against 11,605 persons (4,665 Male, 6,940 female) across targeted FBOs who were counselled, tested and received their results with 90 persons (56 Male, 34 female) tested HIV positive. All positives (81 males, 52 females) were referred for Care and treatment.
Abstinence clubs were setup and functional across the 10 schools on the project, to reinforce messaging to in-school youth. The abstinence clubs carried out outreaches, held discussions, maintained information boards, HIV campaigns, awareness creation activities and sexual abstinence advocacies. Majority of students reached pledged to abstain from premarital sex having signed up to the abstinence till marriage (ATM) code. The project also supported targeted schools with the setup of youth friendly centers and also equipped them with essential literature, IEC, games, and related educational materials, so that young people have access to sexual and reproductive health information and service in confidential and friendly atmosphere.
To ensure quality assurance and improvement, on-site review meetings and mentoring were conducted with peer educators and stakeholders in FBOs that engendered greater community involvement and participation. These meetings ensure that peer educators use the best mix of intervention activities that are directed at strengthening and refocusing existing efforts to allow for positive behavioral change that will significantly reduce the number of new HIV infections. Additionally, salient resources FLHE manuals were incorporated into the in-school training curriculum in line with national guideline. Strategic monitoring visits were carried out across the 20 AB sites for supportive supervision and mentoring that will ensure adherence to standard of operation.
The MACC4 Project targeted high risk populations in focus states of Akwa Ibom (10.9% HIV prevalence), Cross River (7.1% HIV prevalence) and Abia (7.2% HIV prevalence) states with sexual transmission prevention services according to the combination prevention intervention.
A total of 58,289 MARPs and Other Vulnerable populations (7,886 FSWs, 1,813 USM, 1,330 Transport workers/LDD and 47,260 STI suspect/clients and clients of sex workers were reached under the Condom and other prevention intervention. A total of 164 peer health educators were trained across 20 program sites to provide appropriate mix of behavioral, biomedical and structural interventions in line with the national prevention plan’s minimum prevention package initiative (MPPI). Evidence based strategies like community awareness campaigns, Peer Education models, small group discussions, were tailored towards increasing demand for HIV prevention , care and treatment services including condoms, HTC, STI Management, PEP, PMTCT and ART as prevention.
ECEWS condoms and other prevention activities targeted MARPs and other high risk populations (commercial sex worker and their clients, transport workers (Long distance drivers, commercial drivers, conductors, truck and wheel barrow pushers, loaders and cyclist, uniformed service personnel( Police, Soldiers and Prison officers), women with special needs(Separated ,divorced and Widows), STI patients/suspects and men and women within the age of 20 – 39) with the combination prevention interventions with the aim of reducing new infections in Akwa Ibom and Cross River states. Major drivers of the epidemic among these populations include transactional/inter – generational sex, multiple concurrent sexual partnerships, low risk perception for HIV, sexually transmitted infections, stigma and access to healthcare.
The Basic Care and Support Program aimed at contributing towards achieving PEPFAR’s global drive of improving the quality of care and support services being provided to PLHIVs and PABAs. The program’s goal was to ensure optimal health, promote survival and improve the quality of life of adults/adolescents living with HIV/AIDS and Persons affected by HIV/AIDS (PABAs) across targeted communities.
A total of 4,481 clients (1,960 male, 2521 female) received clinical assessment and staging including TB screening using the WHO symptom checklist, as well as symptom relief, psychological and spiritual support. In addition, 2055 clients in care were provided with OI prophylaxis in form of CPT and referrals were made for the treatment of sexually transmitted infections (STIs) and inter-current diseases such as TB. ECEWS actively advocated for involvement and participation of the different stakeholders at the State and Local government levels on HIV/AIDS programming activities. Key achievements of the program included:
- Strengthened the Provision of BC&S Services in Targeted Communities and Sites
A total of 4,481 newly diagnosed HIV infected clients(1960 male, 2521 female) were recruited via HTC services at ECEWS supported facilities and referral from mobile outreach sites. Recruitment of already existing HIV infected clients (old PLWHAs) was carried out through already existing support groups (23). Clinical services provided to the clients include basic nursing care, OI prophylaxis & management, pain management, nutritional assessment & support, STI screening, PWP, access to TB diagnostics, access to laboratory services (including CD4 count, chemistry and hematology) and referral for DOTs, PMTCT and ART. New clients were also provided basic care kits – a typical basic care kit contained water guards, water vessels, ITNs, IEC materials, soaps and condoms – with a monthly replenishment of water guard and soap for all clients in care. Other complementary services provided were home based care services and psychosocial support through participation in PLHIV support groups. A total of 4,481 clients who were in care and had received at least one clinical service, basic care kit and at least 2 complementary services. 60% of clients in care benefitted from the minimum package of prevention with positives services. 3844 eligible clients were provided with cotrimoxazole prophylaxis according to the current national guidelines within the reporting period. 730 clients were visited at home and benefitted from HBC services.
Access to CD4 test was provided for all clients in care via sample logging mechanism. 4185 clients in care were routinely screened for TB using the symptom checklist and suspects were referred for sputum microscopy. 164 PLHIVs in care were found to be co-infected and were accordingly referred for DOTs and linked for ART. Prevention with positive messaging services was provided to 2190 clients in care. PwP services provided included risk assessment, risk reduction counseling, and provision of condoms to PLHIV, assessment of partner status, and support for partner disclosure, HTC for family members, syndromic management of STIs, adherence assessment/support, assessment of pregnancy intentions & referral family planning. All HIV positive pregnant women in care were referred for PMTCT.
- Ongoing Partnership to Enhance Access to ART and PMTCT Services
Through ECEWS existing partnership with ICAP Columbia University program all newly identified clients were provided access to CD4 and other clinical investigations. ECEWS supported CD4 sample estimation via transport of samples to ICAP supported sites in Akwa Ibom State while HIV infected clients in Cross River State are referred to IDH for CD4 assay. CD4 sample collection from clients in care for logging to ICAP & HYGEIA supported sites were done 3 monthly for pre-ART clients and repeat CD4 done 6 monthly for ART clients.. The project logged a total of 893 samples for CD4 and furnished clients/sites with results. Appropriate linkages and referrals for HTC, DOTs, PMTCT and ART referrals were made to HYGEIA, ICAP and GHAIN sites. All HIV positive pregnant women in care were referred for PMTCT to ICAP or GHAIN sites for continuation of care.
iii. Ongoing Capacity Building Initiative to Improve Program Implementation
On-site mentoring and supervisory visits provided were frequently made to the 72 trained care providers across all ECEWS supported sites. Coordination meetings with support group leaders enhanced quality and consistency of information shared with PLHIVs. 30 Referral Coordinators from 6 Comprehensive ART sites and ECEWS supported care and support sites held a meeting to review progress and challenges with referral completion. Training could not however be implemented due to funding cut.
- Meaningful Involvement and Empowerment of PLHIVs in Focus States
ECEWS supported 22 PLHIV support groups across 13 LGAs in Akwa- Ibom and Cross River States. Support Group meetings held monthly across 22 sites providing a channel to afford HIV clients the opportunity to understand the disease better, share experiences and help each other to overcome stigma, discrimination and also promote drug adherence by acting as treatment buddies for one another. Support groups recorded increase in membership. Average monthly attendance across supported groups stood at 582. Regular home visits to members were carried out monthly by each support group; this has enabled members to be consistent in attendance at meeting and has thus increased membership strength of support groups. Membership and attendance at Support Groups meetings however began to dwindle in the 3rd and 4th quarter of COP 11. This was due to funding cuts resulting in the inability of ECEWS to sustain essential support to the groups. However, Support Group Coordinators and ECEWS care and support team met from time to time to review progress, shared best practices and proffered solution to challenges. All the support groups have been linked to AKNET, the State PLHIV coordinating body and NEPWHAN for registration.
- Transitioning of Basic Care and Support Program to CIHP
Following directives from CDC for ECEWS to transition her MAC- 4’s Care and support site to CIHP, a joint assessment (ECEWS/CIHP/State Partners) of affected sites was carried out and 22 care and support sites formally handed over to CIHP in 2011. The sites were made up 12 health facilities and 10 community sites.
As TB/HIV co-infection is responsible for substantial part of morbidity among HIV infected people, the objectives of ECEWS TB/HIV program was to ensure adequate and prompt linkage of TB patients and their household contacts to HIV counselling/testing, TB diagnosis, care and treatment services, ensuring that all HIV patients were screened for TB and linking TB/HIV co-infected clients for services at DOTS and ART clinics. Achievements in this thematic area included:
- Establishment of TB Infection Control Committees
As part of the activities to minimize TB and other nosocomial infections in the supported sites, Tuberculosis Infection Control Committees-TBIC (made up of the facility head, head of GOPD, head of laboratory, and other facility staff and the focal persons of different programs (STI, Care/Support and Referral) supported by ECEWS ) were formed across the 4 TB/HIV sites. The TBIC working in collaboration with the Project Implementation Committee (PIC) formed across the sites, held monthly meetings and made recommendations on infection control, patient triage, healthcare waste management and referrals.
- Strengthening the Provision of HCT Services in Supported TB/HIV and DOTS Sites
Across ECEWS supported TB-HIV sites (4), HTC services were provided to ensure that all TB clients and suspects had unhindered access to HIV test and services. The MACC4 project utilized both provider initiated (PITC) and client initiated HIV counselling and testing in providing HIV test to TB suspect/patients. A total of 4,929 (2163 males and 2766 females) newly presenting TB suspects and patients developing symptoms were identified and provided with HIV counselling services. Also, TB symptom checklist was administered to 4745 PLHIVs in care and TB suspects provided with sputum AFB services. 121 co-infected patients were identified and commenced on DOTs. However, transitioning did not allow for monitoring of clients who completed TB treatment.
iii. Strengthening TB/HIV Collaborative Services in Supported Sites
Provider initiated administration of TB symptom checklist to clients that visited the facility was employed at the General Out-patient Department (GOPD) and other units in the facilities and referrals made for diagnosis of identified TB suspects. TB-HIV services were scaled up care and support sites with the mandatory screening of HIV positives in ECEWS care. Over 80% of HIV positive clients in care were provided with TB microscopy services. 121 co-infected clients identified across the supported sites were linked to ECEWS care and support unit, laboratory monitoring and treatment where eligible. Referral linkages were also strengthened with HIV positive and co-infected patients identified using a 2-way referral system. The process was usually validated monthly by ECEWS referral Focal Persons. Referrals were made to Care/Support, DOTS clinic, STI clinic and for PMTCT services.
- Intensified Case Finding in Target Communities through the TBLS
In the MACC4 project, ECEWS prioritized and supported Tuberculosis and Leprosy Control Program Supervisors (TBLS) and Laboratory Focal persons in supported sites (4 Local government areas) to carry out targeted village centred outreaches to high TB prevalence communities for intensified TB case finding. The essence was to identify and provide immediate referral of identified TB suspects for diagnosis and treatment. Co-infected clients who defaulted in their medication were tracked and brought back to care and treatment as part of effort at reducing incidence of multi-drug resistant tuberculosis (MDR-TB).
- Collaboration with State Governments to Enhance TB/HIV Collaborative Activities
As part of ECEWS collaborative activities with the Akwa Ibom State Tuberculosis and Leprosy Control Program (AKSTBLCP), cotrimoxazole, laboratory consumables (microscope slides, sputum cups, cotton wools, hand gloves, methylated spirit, chlorine tablets, biohazard bags, monitoring and evaluation tools and HIV Rapid Test Kits (RTKs) received from the Supply Chain Management System (SCMS) were supplied to her TB-HIV supported sites based on a pulling system using the site level inventory control system linked to the ECEWS warehouse Logistics Management Information System (LMIS). ECEWS supported the AKSTBLCP in freighting of TB drugs and reagents from the regional warehouse to the state warehouse. Other level of support were in the area of information education and communication (IEC) materials, World Tuberculosis Day (WTD) commemoration, active participation in State led joint supervisory visits to TB/HIV facilities and DOTS sites. Joint site assessment visits were conducted to some PHCs in Akwa Ibom State (PHC Ika, PHC Afahaobong and PHC Uyo) for possible Scale up of TB-HIV collaborative activities. All the TB-HIV sites were jointly supervised by the Akwa Ibom State Tuberculosis and Leprosy Control Program (AKSTBLCP) and ECEWS. ECEWS assisted TBL Supervisors in her supported sites in the provision of funds for tracking TB defaulters and co-infected patients and bringing them back to complete TB treatments to reduce incidence of multi-drug resistant tuberculosis.
- Capacity Building Efforts to Improve TB/HIV Program Implementation in Supported Sites
Members of TB Infection Control Committees (20) from across 4 ECEWS supported sites received training that enhanced their functionality in infection control leading to the development of site specific TB Infection control plan. As a result of the work done by the committees, targeted facilities recorded positive changes in infection control including proper disposal of medical waste, arrangement of work stations in accordance with best practise, participation, administrative support and greater ownership.
vii. TB Program Quality Assurance
Program quality assurance activities carried out include routine review of sputum smear standards, filtration of stains before use, program monitoring visits, blinded re-checking, record checking for completeness, contact tracing, retesting of positive blood samples across the facilities during CD4 analysis, use of DTS (Dried Tube Specimen) as controls, continuous onsite mentoring and use of client exit survey/counsellors reflection forms.
The overall focus of the ECEWS OVC program activities during the period under review, was to sustain ongoing efforts and build a sustainable program that will ensure that the full range of OVC services prescribed by the national guidelines were available to all eligible OVC within their local communities. ECEWS OVC program was domiciled in 10 sites serving 18 local government areas in Akwa-Ibom and Cross River states. OVCs were reached with services ranging from psychosocial support, health care, preventive medical care, legal protection (facilitation of birth registration with the National Population Commission), and the provision of basic educational materials. Details of our implementation effectiveness are follow:
- Strengthening Care and Support Services for OVC
The MACC4 Project has served a total of 3211 OVC with a minimum package of OVC services according to national guidelines and standard of practice. 103 OVC were dropped from the program (due to migration -54, loss to follow up-25, dead-8 and graduated-16). The Orphans Vulnerability Index (OVI) and Child Status Index (CSI) tools were used in identification and selection of the program beneficiaries. Basic Care Kits containing long lasting insecticide treated net, water guard and water vessel were provided to all OVC in care with household-based replenishment of water guard on a monthly basis. All children in care equally benefitted from psychosocial services, nutritional counseling & support, protection services and education. 49% of OVC in care were provided with nutritional support in form of food parcels and food supplements; 96 severely malnourished children including 14 HIV infected OVC identified using the Mid Upper Arm Circumference tapes and BMI were provided with Ready-to-Use-Therapeutic-Food (Plumpy nut) ; 66% with educational services (school uniforms, sandals, exercise books) and 643 children without birth certificates were provided with birth certificates through a collaboration with the National Population Commission. Our success with the National Population Commission was seen a best practice and paved way for other IPs to provide this vital support to OVC at no cost.
- Strengthening Community Structures to Benefit OVC
Community sensitization was carried out to paramount rulers, village heads and other community stakeholders across ECEWS OVC supported communities. This was to create awareness and enlighten them on the OVC program and increase ownership of the program. Across these communities supported the establishment of community development committees. The committees were proactive in the area of child protection, resource linkage, program monitoring and local input. Community volunteers were trained and participated in home visits to provide counseling services, assess the welfare of OVC and replenish commodities based on needs. During these visits attention was paid to the health, nutrition, and living conditions of beneficiaries. 26 PHC received medications and training that enabled them to manage early childhood illness in addition to caregivers who were trained on how to provide first aid for the children. 50 Individuals comprising head teachers, principals and teachers of schools supported with block grants (curriculum based text books) were trained on ensuring educational access for OVC in their various schools with emphasis on proper use of the books, attendance and performance monitoring for OVC. This contributed to improved school attendance rates and performance of OVC attending schools.
iii. Providing Psychosocial Support to OVC
34 OVC Kids’ Club held monthly meetings reaching out to the 3,211 OVC in the project and other children in these communities who attended the club’s sessions. Kids’ club sessions included age appropriate messages on HIV/AIDs transmission, prevention strategies and care for PLHIV at home, bible stories (on obedience, respect, morality and God fearing attitude e.tc), facilitation on hygienic toilet and hand washing practices, environmental sanitation, signs and symptoms of malaria, how to overcome fear and stigma from the community/ society, Others include sessions from SESAME STREET WORKSHOP “Adventures of Kami and Big Bird” and a drama performances depicting various societal ills and good morals. Skill building academic topics like “The Falling Game” (which is to enhance trust and group cohesiveness and to encourage children to take responsibility for one another); Learning how to work together and understand one another’s needs; Facts or Fiction- How Well Do We Know Our Facts about HIV were also treated.
- Resource Leveraging for OVC
ECEWS partnered with SESAME Street Workshop to pilot the use of play-way method, reaching 2,045 children with the “Adventures of Kami and Big Bird”. In collaboration with USAID/MARKET, a Training-of-Trainers workshop was conducted for eight ECEWS OVC Care Providers on Micro Enterprise Fundamentals and Home Stead Farming Fundamentals who in turn conducted site-level step-down training to 1260 caregivers (parents & guardians) of OVC. In furtherance to improving the nutritional status of children enrolled in the program, ECEWS collaborated with the Clinton foundation who provided ready to use therapeutic food (RUTF) – Plumpy nut- to 96 severely malnourished children 14 of which were HIV positive children. 1040 bags of Grand Vita were received from USAID/MARKET and distributed to 833 OVC between the ages of 6 months to 10 years across 5 sites of Onna, Oron, Uyo, Calabar and Abak.
- Scaling up the Nutritional status of OVC
The project provided nutritional support to 1248 children with emphasis on malnourished OVC and HIV positive children. 917 OVC in 563 households received food parcel while another 714 OVC in 331 household were provided with supplemental food including ready for use therapeutic food (RUTF): which were provided to 96 severely malnourished children (14 HIV positive children inclusive). 69 Care providers were trained on management of severe acute malnutrition including dosing chart for Plumpy nuts and growth monitoring using the WHO weight-for-age growth chart for ages 0-5 years and standard deviation score card for those above 5 years. In addition to the provision of therapeutic and supplemental food to OVC, nutritional counseling services were provided to caregivers during home visits and they were taught on the use of locally available food sources for the improvement of their children’s nutritional status.
- Facilitated Access to Medical Care Services for OVC through an Innovative Vouchering Model System
As part of the continued effort by ECEWS to improve the health of OVC and their caregivers, basic care kits were distributed to all newly enrolled children. Water guard replenishment continued in all household within the reporting period, household whose LLITN and water vessels were damaged were replaced. ECEWS advocated and supported free treatment of common childhood illnesses for OVC as well as growth monitoring for all OVC in enrolled Care and this improved access to medical services for OVC in Akwa Ibom and Cross River states. To further improve access to medical services, an innovative treatment vouchering model was used to provide drugs for OVC in care at 20 ECEWS supported Primary Health Centers in Akwa Ibom and Cross River states – drugs available for OVC at these PHCs include: antidiarrheal, antimalaria, antihelminthics, haematinic and antibiotics.
As a result of sustained health education for OVC caregivers and provision of antiseptic soaps for 1088 under five OVC in the program, the project recorded improved hygiene and hand washing practices at home with fewer children in the program falling ill. All the beneficiaries on the project benefited from routine de-worming, access to HCT and appropriate childhood immunization. The 341 HIV positive OVC were linked to care and treatment and supported to access these services.
vii. Educational and Child Protection Linkages
1679 OVC on the project received direct educational support under the project. ECEWS community volunteers and care providers monitored school attendance, performance and progress of OVC in school, providing prompt follow up where necessary. This strategy helped to improve OVC performance and attendance in school. Using the CSI tool, a total of 357 children were provided with school uniforms, sandals and writing materials. 30 Secondary schools and 20 primary schools attended by OVC on the project received block granting of text books for their libraries. ECEWS advocated for and secured waivers on user fees for the OVC in these schools.
In appreciation of the efforts of the ECEWS OVC program in facilitating linkages to educational services the Cross River State Government through the commissioner for Women Affairs donated Ninety (90) school bags to ECEWS supported OVC in the state.
ECEWS implemented the MACC4 Pediatric Care and Support services in 14 facility based sites in Akwa Ibom and Cross River States targeting HIV positive children. ECEWS employed several innovative strategies to increase uptake of pediatric care and support services. Pediatric clients were recruited into the program via provision of HCT services at supported PHCs at OPD, emergency units & wards, routine screening of children at immunization centers, HTC screening of children from households of adult PLHIVs and targeted Community mobilization outreaches for HTC. Accordingly, HIV Testing and Counseling services was provided to 6,832 children (2,983 males and 3,849 females) with a total of 234 reactive (116 males and 118 females). Growth monitoring, nutritional assessment and support was carried out at a regular interval to assess growth and development, nutritional supplement/support/counseling was provided for 163 pediatric clients via OVC nutritional support. Access to Early Infant Diagnosis (EID) was provided via collection of DBS samples from HIV exposed babies for testing.
All clients were linked to the OVC programme and received essential social services including psycho-social support via KIDS club activities, medical care via free treatment vouchering system, educational support and social protection through issuance of birth certificates by National Population Commission. Access to CD4 estimation was provided for all clients in care via sample logging and referrals. All eligible clients were served with cotrimoxazole prophylaxis according to national guidelines, and provided basic care kits (ITN, water purifier, water vessels, water guard, IEC materials and soap). CPT was provided for HIV exposed infants, symptomatic HIV infected children, and TB-HIV co-infected children and children over 5 years with CD4 ≤ 350 µl according to the current national guidelines. IEC materials and other HIV awareness campaign methods were used to educate care givers on the need to know their HIV status, facts on TB, hand washing benefits and universal precaution.
- Strengthening DBS for EID to Improve Diagnosis
ECEWS worked with the Ministry of Health (Akwa Ibom and Cross River States) on supply of EID reagents to her supported sites and also supported the sites to log DBS samples to CHAI supported PCR lab in University of Uyo Teaching Hospital in Akwa Ibom State and GHAIN supported PCR labs in University of Calabar Teaching Hospital in Cross River State. Dry blood test (DBS) samples were collected from HIV exposed infants at 6 weeks and repeated 6 weeks after cessation of breastfeeding.
- Improving Access to Services in Hard to Reach Communities through Home Based Care
Provision of home based care services to children in care with priority visits conducted to the homes of defaulting care givers, children with advanced HIV disease and care givers without support groups. 88% of the clients in care were visited at home and benefitted from HBC services.
iii. TBA engagement to Improve Pediatric Case Finding
ECEWS collaborated with Clinton Health Access Initiative (CHAI) to increase access to pediatric HIV care and treatment. As part of this initiative over 200 Traditional Birth Attendants from Akwa Ibom and Cross River States were engaged for referral of their clients (pregnant women and their children) for HIV counseling and testing services. This contributed significantly to the identification of 295 HIV exposed infants out of which 27 tested positive and were referred for HAART.
- Transition of Program to CIHP
The ECEWS Pediatric Care and Support Program was one of the thematic areas transitioned to CIHP as part of the CDC Nigeria harmonization plan.
The ECEWS SI Team participated in all programmatic trainings and review meetings where the team provided leadership in program monitoring, indicators definition, data analysis, feedback, and documentation. 24 persons from ECEWS-supported CBOs received training in Monitoring and Evaluation of programs. The SI Unit also facilitated the implementation of intra and inter IP referral co-ordination leading to improvement in completed referrals. Electronic data management platform was deployed to manage and analyze data to inform better decision making. The SI team participated in the development of all Program Areas’ implementation work plans and conducted Routine Data Quality activities to ensure data and report completeness and integrity.
As part of efforts to enhance the capacity of ECEWS to utilize data for decision making, an electronic data management tool was developed and deployed for use at the central level to collate and analyze data for better program monitoring across all technical program areas. Technical assistance was provided to program leads in the development of their implementation work plans to meet set goals and objectives.
Review of national M&E tools and development of new ones to meet the requirements of the NGI was carried out; quantification of all essential tools was done to ensure that adequate number of tools were procured to meet program needs and ensure proper and qualitative documentation of services.
The M&E team participated in all programmatic trainings carried out by other program areas with particular reference to their data capturing tools and referral co-ordination/activities. Monitoring & Evaluation Training has been conducted for 12 persons drawn from ECEWS-supported CBOs aimed at building their capacities to manage site information and reporting same to the various LACA M&E focal persons, ECEWS and other relevant stakeholders. Referral training and referral review meeting was conducted for the 32 ECEWS referral focal persons and partners from treatment facilities, including representatives of SACA & States Ministries of Health.
Routine monthly programmatic M&E visits are carried out to sites for data validation and collection. Joint on-site mentoring visits are being conducted for site M&E focal persons on programmatic Monitoring & Evaluation with particular emphasis on their data capturing tools across all ECEWS sites. ECEWS Strategic Information program ensured quality assurance through:
- Reporting following the national strategic reporting framework
- Use of nationally approved M&E tools and registers
- Consistent monthly M&E visits to sites
- Indicators in the data collecting tools are well defined
- Data quality check is conducted and validated before reporting
- Site staff are regularly put through the indicators definition
- Validation of data source(s) and longitudinal registers before reporting
ECEWS in line with the principle of strengthening the national M&E system under the principles of the “three ones”, has actively participated in the formation of state M&E TWG in Akwa Ibom State, and is fully active in strategic information activities in Cross River and Abia states. As an outcome of its commitment, ECEWS currently chairs the Monitoring & Evaluation Technical Working Group in Akwa Ibom state, and was instrumental to the development of Akwa Ibom State Strategic Plan (AKSSP) for 2010 to 2015. ECEWS has contributed significantly to the national level data validation exercise conducted by NACA and NASCP and has consistently submitted quarterly reports to NACA and NASCP systems.
- Key Achievements
- A total of 84 persons have been trained so far on Strategic Information in from ECEWS-supported CBOs.
- Effective collaboration with SACA Akwa Ibom, Abia and Cross River States
- On-site mentoring/twining to ensure data completeness and validity across all sites before collection and collation
- Qualitative and complete data collected, disaggregated and reported from sites.
- Proper documentation of reports and data through use of proper/national DCTs and employment of longitudinal registers in the field.
- System strengthening on reporting and documentation of activities and data for technical program officers across all program areas.
- Established referral collaboration relationship with 6 Comprehensive Treatment Hospitals across Akwa Ibom and Cross River states for effective referral of PL-HIV clients for ART services.
- 32 referral focal persons from ECEWS-supported sites and Comprehensive Treatment Hospitals trained on referral activities and reporting.
- Procurement of adequate national data collecting tools for all technical program areas to ensure complete and proper documentation.
- Distribution of M&E tools to all sites through a proper supply chain system to ensure tool availability at all times for proper documentation of services.
- Implementation ECEWS Strategic Information (SI) activities under the “One M&E Framework” by supporting standardized HIV indicator reporting systems at program sites and registering sites in the national M&E system.
- Collaboration with the Akwa Ibom SACA on the development of the State Strategic Plan for (2010 – 2015) period.
- Collaboration with SACA, IPs and other stakeholders in the coordination of strategic information activities in the state.