President’s Emergency Plan for AIDS Relief (PEPFAR) Lisa J. Nelson, MD MPH MSc UEM/UCSD MEPI External Advisory Board Meeting Maputo March 14, 2011

Outline President’s Emergency Plan for HIV/AIDS (PEPFAR) Overview and Coordination Mozambique USG-GRM Partnership Framework Goals PEPFAR Support to Health System Strengthening Synergies between PEPFAR and MEPI Initiative

PEPFAR: the US Response to the Global AIDS Crisis 2003: PEPFAR was launched 2008: PEPFAR reauthorized through 2013 Committed $32 billion through FY2010 Interagency coordination model 2003: U.S. President's Emergency Plan for AIDS Relief launched 2008: Lantos-Hyde Act reauthorized PEPFAR for five additional years (2009-2013) Through 2010, US is committing approximately $32 billion to bilateral HIV/AIDS programs, as well as contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria Interagency coordination model: multiple agencies implement PEPFAR programs, under guidance and oversight of Global AIDS Coordinator at State Department

PEPFAR Mozambique Organization and Coordination Interagency initiative lead by U.S. Ambassador HHS (CDC, HRSA, NIH) Department of Defense Peace Corps Department of State USAID Interagency management structures Coordination Office Senior Leadership Technical Working Groups Important to note that NIH is new sister agency to the USG/PEPFAR family in Mozambique

USG-Government of Mozambique HIV/AIDS Partnership Framework Goals 2009-2014 Reduce new HIV infections in Mozambique Strengthen the multi-sectoral HIV response in Mozambique Strengthen the Mozambican health system, including human resources for health and social welfare in key areas to support HIV prevention, care, and treatment goals Improve access to quality HIV treatment services for adults and children Ensure care and support for pregnant women, adults and children infected or affected by HIV in communities and health and social welfare systems Partnership Frameworks: 5-year strategic agreements with partner nations to ensure the partner government leads the national response, with specific commitments on: Service delivery Policy reform, including addressing key structural drivers of epidemic Financing Under leadership of CNCS, was developed with stakeholders. Signed in August 2010. O Quadro de Parceria é um plano estratégico quinquenal entre os governos do Moçambique e dos Estados Unidos Foi alinhado e está baseado nos planos nacionais como o PEN III, e outros como o Plano Nacional de Saúde e de Desenvolvimento dos Recursos Humanos Additional funding was made available as a part of the Partnership Framework. It is important to note that any and all funds are part of a unified PEPFAR program and that the Partnership Framework is not additional or separate.

Sustainability and Country Led Response Governments and Civil Society empowered to lead, prioritize, implement, and be accountable for a country’s response to HIV/AIDS Align with GRM priorities Increase joint planning Build capacity of national/ provincial systems Provision of technical assistance, organizational capacity building Use of government systems Direct funding to regional governments and local partners Support quality, sustainable services Discuss MEPI as an example of moving toward more a more sustainable response and a country led response to the needs of Mozambique

Developing Efficiencies in Programs Expanding use of costing studies and modeling Coordinating our response with the Global Fund and other donors Identifying, quantifying and disseminating potential structural and program efficiencies Briefly mention Mozambique’s leadership in costing

Key Partners in Mozambique Clinical Partners in 11 provinces Columbia University/ICAP Family Health International (FHI)/Abt Associates Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) Vanderbilt University/Friends in Global Health CARE Funding directly to Mozambican institutions MISAU (2), INS + CMAM UEM (MPH) Provincial Health Directorates (2) M-OASIS Ministry of Women and Social Action (MMAS)

Key Partners in Mozambique American International Health Alliance (UCLA, ANEMO) American Society for Microbiology Universidade Federal do Rio De Janeiro Food and Nutrition Technical Assistance (FANTA) Health Systems 20/20 IntraHealth International ITECH JHPIEGO New York AIDS Institute (HIVQUAL) Pathfinder Partners for Appropriate Technologies SCMS Strengthening Pharmaceutical Systems (SPS) Association of Public Health Laboratories (APHL) American Society for Clinical Pathology Clinical Laboratory Standards Training Institute

PEPFAR Support 2010 Annual Progress Report Supported HIV prevention, care and treatment services in all 11 provinces in Mozambique Provided direct support to >138,000 persons on ART (70% of national total on ART) Counseled and tested >600,000 persons for HIV in facility-based and community counseling settings Support prevention of mother-to-child transmission (PMTCT) services at 338 clinical sites (>30% of all PMTCT sites nationally) Provided HIV counseling, testing and results to >500,000 pregnant women

HIV Prevalence by Province Cabo Delgado 9.4% Niassa 3.7% Percentagem de mulheres e homens de 15-49 anos com infecção por HIV Nampula 4.6% Tete 7.0% Zambézia 12.6% Sofala 15.5% Manica 15.3% Moçambique 11.5% Inhambane 8.6% Gaza 25.1% Maputo Província 19.8% Maputo Cidade 16.8% Source: INSIDA

Health Systems Strengthening Goal: Strengthen the Mozambican health system, including HR for health and social welfare in key areas to support HIV prevention, care and treatment goals Increase # of health care and social workers and improve the capacity and quality of pre-service, in-service training, faculty development and post-graduate training Improve management capacity, motivation and retention of health and social workers Improve supply chain system at all levels Health Information System (HIS) Improve and expand the public health infrastructure

USG Systems Strengthening Support HSS budget in million $ PEPFAR II: focus on HSS Strong HR component: 140.000 HCW target Huge infra-structure investments (training facilities, rural health centers, warehouses, lab, etc) GHI: improve and sustain health outcomes through strengthened HS (beyond HIV) U.S. Fiscal Year PEPFAR Funding (USD) 2006 2.0 2007 2.8 2008 6.8 2009 8.7 2010 41.4 2011 39.4

Existing Conditions

Recent Improvements in Lab Infrastructure

Current HIV-Related Lab Capacity in Mozambique 41 CD4 instruments PIMA point of care CD4 instrument currently in pilot sites in Maputo city (2) Maputo province (2) Sofala (2) and Niassa (2). Plans underway to expand to 9 sites in Gaza 4 labs performing DNA PCR for early infant diagnosis (EID) 1 labs with viral load capacity

Male Circumcision (MC) 3 clinical trials demonstrated >60% effect in preventing HIV transmission Completed surgical capacity assessment in 2008 Pilot project in 6 sites approved by MOH6000 procedures to date Expanding to 24+ sites in 2011 MOH approved demonstration project to assess the feasibility of scaling up MC within minor surgical wards Five sites (4 MOH and 1 military) Services initiated in Hospital Militar de Maputo 100 males circumcised Nov-Dec 2009 Training for staff at two additional sites (Boane and Chokwe) to begin in March

Systems Strengthening – Human Resources Support the MOH Dept of Human Resources’ (DRH) National Strategic Plan for HR development (PDRH 2008-2015) Support to MoH in-service training institutions: faculty development and scholarships Strengthen the Community Health Worker (CHW) program Support MPH degree in epidemiology and lab (FELTP) at UEM Support in-service training activities Strengthen the HR Information System (HRIS) Mechanisms of Support Cooperative Agreement with Implementing partners Direct Technical Assistance (Technical Advisor) to CHW program Cooperative Agreement and Technical Support to UEM (FELTP)

USG Strategic Information - HIS Support the MOH Dept of Health Information’s (DIS) National Strategic Plan for Health Information Systems (HIS) (2010-2014) Securing sufficient qualified human resources for the HIS activities at all levels Improving management of the HIS Securing appropriate infrastructure & information and communication technology at all levels Mechanisms of Support Cooperative Agreement with MOH DIS Direct Technical Assistance (Technical Advisor) to DIS Cooperative Agreement and Technical Support to M-OASIS (Mozambique node of Open Architecture and Standards in Information Systems, based at UEM)

Areas for Potential Coordination/Synergy with MEPI (1) Maputo Central Hospital (MCH) MOH DIS is developing a patient-level medical record system at MCH CDC support for lab information system (NetAquire) at MCH Health training institutions Support faculty development in surgery technicians courses

Areas for Potential Coordination/Synergy with MEPI (2) Strengthening Human Resources in HIS Coordination of HR development with M-OASIS Financing courses for Health Statistics Technicians (Técnicos Médios de Estatística Sanitária) at Maputo’s Institute for Health Sciences (ICS) Responding to for identified HIS needs (e.g. at Provincial level) Enterprise Architecture MOH DIS (with M-OASIS support) is in the early stages of developing an enterprise architecture for HIS in Mozambique Importance of inclusion of various HIS initiatives to ensure overall coordination and ultimately interoperability

Key USG PEPFAR Contacts for MEPI Collaboration Overall Contact: PEPFAR Country Coordinator, April Kelley, kelleyal@state.gov Human Resources Contact: Shirley Eng-Breard, seng-breard@usaid.gov HMIS Contact: Strategic Information Branch Chief, Amy Dubois duboisa@mz.cdc.gov USAID IHO Lead: Polly Dunford, Pdunford@usaid.gov CDC Mozambique Director: Lisa Nelson, nelsonl@mz.cdc.gov

For further information, please visit: Thank You For further information, please visit: www.PEPFAR.gov