This program wills follow-on activities from a previous two-year program that ended in September 2008

implemented by FHI. The GDA with MIDEMA has two goals: (1) the establishment high quality

prevention (PMTCT, Voluntary Counseling and Testing and sexual prevention reaching mostly the CSW)

and an Anti Retro Viral treatment center at the Matadi Clinic; and (2) the development of a global public-

private alliance. By September 2008, the project has successfully trained 12 doctors and 12 nurses in HIV

related prevention care and treatment activities, provided equipment for HIV test and biological

monitoring. In addition, 1,899 people of the 1,949 clients counseled and tested, received their HIV results

(97.4%), 654 clients were treated for STI, (mostly CWS and their clients) and 34 pregnant women

received PMTCT service. As the Midema contribution, the Matadi clinic maternity building was

inaugurated in late October 2009 with new staff hired including a gynecologist, a pediatrician and several

nurses, which provide an opportunity to set a quality HIV program.

This 3-years program will build on the past experience and pursue the same objectives to develop quality

prevention care and treatment program in the Matadi clinic with a focus on PMTCT, HCT, STI treatment

targeting high risk populations (CWS and their clients), management of OIs and CTX prophylaxis, adult

and pediatric care and treatment as well as nutritional support. Labo capacity will be assessed to ensure

that equipment and supplies are adequate and sufficient for the new patients.

MIDEMA will provide a minimum of $1 cash and in-kind cost-share for every USG $1 spent, thus

leveraging private sector resources and maximizing USG investment. USG support will focus on

strengthening technical capacity while the MIDEMA support will continue to ensure the functionality of the

clinic including provision of ARV, STI and OI drugs.

OI prevention and treatment is a significant but often neglected route to improving the quality of life of PLHAs that can be offered more easily than ART. This project will extend training for OI components of care beyond the limits of those facilities that will offer ART. The project will integrate prevention and treatment of common OIs as an important element of HIV/AIDS care and support. Patients with OIs that can be managed at the first line health institutions will be treated there and those who require further investigations will be referred to higher-level health institutions for diagnosis from which they are referred back to their usual source of care for treatment and follow up. The Program will take advantage of existing integrated HIV Program through PATH to refer patients who need nutritional and economical assistance.

Treatment and prophylaxis for these illnesses will follow national guidelines. There will be provision of cotrimoxazole preventive therapy to all patients who need it based on national protocols. In addition, primary care services such as screening and treatment for hypertension, diabetes mellitus, hypercholesterolemia, depression, and chronic alcoholism will also be provided as part of this comprehensive HIV care program.

Management of OI cases will be based on existing lab equipment and reagents available on the site that the previous USG funded program offered to the site. Lab staffs will be trained to using such equipment, including the CD4 counting system (Dynabeads), automated equipment for hematology (Coulter), biochemistry equipment and the ionogram.

Patients meeting the eligibility criteria for starting ART (as described by the national guidelines and/or

internationally recognized guidelines) will be educated on the benefits of ART, management of side effects and the importance of a high level of adherence to the treatment. In addition, these patients will be screened for barriers to ART adherence such as depression, alcohol abuse, malnutrition, non- disclosure, and non-supportive familial environments. Non-ART eligible patients will be screened for eligibility to start cotrimoxazole preventive therapy. Any patients presenting symptoms of HIV-related OIs will be managed appropriately at the site or referred to other sites for complete diagnosis and treatment (e.g. TB clinics for those with symptoms suggestive of TB).

Because of the limited availability of ARV drugs within this program, there will be explicitly defined patient selection criteria to decrease frustration in the PLHA community. ART will be provided first to HIV+ MIDEMA workers and their dependents, then others eligible for ART living in Matadi and the surrounding area. Any other patient who is eligible to receive ART will be referred to other treatment services around Matadi

This program will develop strategy that increases awareness to MIDEMA employees, and to general

population that has access to the MIDEMA CCLD clinic on abstinence and be-faithful. MIDEMA/CCLD

will collaborate closely with local partners such as Population Services International/Association de Santé

Familiale (PSI/ASF) and other PATH partners to coordinate AB-prevention methods. The MIDEMA-CCLD

activists will develop outreach session in the work place (MIDEMA and other companies affiliated to

MIDFEMA) and in the community to promote this strategy.

This program will employ strategy that increases awareness to MIDEMA employees, and underserved people like the CWS and their clients about HIV sexual prevention. MIDEMACCLD has trained activist who have experiences to provide quality BCC information to these underserved people. MIDEMA/CCLD will collaborate closely with local partners such as Population Services International/Association de Santé Familiale (PSI/ASF) and other PATH partners to coordinate prevention methods. CCLD will carry out several coordinated sensitization sessions throughout Matadi. The message on "confidentiality guarantee" should be clearly diffused to encourage participant confidence in the service delivery, which is a main concern in the workplace. In addition, CCLD will make available condoms for these people in needs. The outreach activities will, using these community counselors, promote the benefits of knowing

HIV status for partners and children and encouraging patients to bring them to the clinic with household extension visits as necessary.

STI management is a component of this program. This strategy has been demonstrated as one of the essential components of the HIV prevention and care package. It will be delivered at primary health facilities in the health district. Medical staffs have been trained to identify STIs in every patient presenting genital symptom (such as ulcers or discharge/bubon/abdominal pain), prescribe appropriate drugs according the national algorithm, provide them with education on prevention of future infection, provide and promote condoms, and encourage patients to bring their sexual partners for testing and treatment. Complicated cases will be referred to the general hospital where a more advanced diagnosis can be done using laboratory procedures. The Program will provide needs commodities to ensure effective treatment. HCT will be offered to all patient presented in STI clinics through trained counselors.

To maximize prevention of pediatric infections, this program will universally implement "opt-out" testing at ANC, Labor and Delivery, and Postpartum services where PMTCT services are offered. In addition to offering HIV counseling and testing; syphilis testing and treatment; promotion of male partner testing will be provided; as well as iron and folic acid supplements according to MCH guidelines. Referral and health promotion to encourage regular ANC visits, child growth monitoring and vaccination, and family planning will be enhanced through:

• Actively providing family-based testing of partners and other children, including home-visits as indicated • Integrating HIV counseling and testing within maternity services • Intensifying promotion of early and complete ANC consultations and use of maternity services through social workers, community-based health volunteers, and -organized campaigns. • Promoting treated bed nets and providing presumptive treatment for malaria in cases of fever, and intermittent prophylactic malaria treatment to the end of pregnancy (in accordance with national guidelines and with commodities supplied by the National Malaria Program, Global Fund, and PMI partners).

The program will train MIDEMA CCLD/CMM staff according to the needs of their specific post and function, vis a vis the new PMTCT programs linked with the maternity. The program will use the country newly adopted policy that emphasizes on opt-out counseling and testing for ANC clients, ARV

prophylaxis using an expanded bi-/triple-therapy regimen, safe motherhood, strengthening infant feeding counseling and support and provision or referral for family planning services. Training will also include guidance how to handle and store ARV drugs used in the PMTCT program. Pharmacists will be trained for appropriate storage.

This program is follow-on the previous GDA collaboration that ended in September 2008. The previous

program offered to MIDEMA CCLD lab equipments, including the CD4 counting system (Dynabeads),

automated equipment for hematology (Coulter), biochemistry equipment and the ionogram. Lab

technicians have been trained. This program will build on that investment, will refresh training of lab or

train new technicians, provide reagent and ensure maintenance of these equipments. Additional new

equipments could be acquired on need-basis.

The MIDEMA CCLD clinic ins not a TB diagnosis center but is a TB treatment center even if the Centre

high-qualified clinician that may ensure high quality of TB treatment. This project will advocate to the

MoH to accredit that MIDEMA become as TB diagnosis center. However, the project will promote TB

testing for all CT clients presenting possible TB symptoms, as well as active TB case finding among

PLHA. The program will also promote active HIV testing using PICT approach to all TB patients. The

MIDEMA CCLD staffs have been trained and are equipped to perform a specific TB diagnosis and

DOTS. The Center will be a set all requirements for TB-control and serve a learning center for TB

Infection control in the context of HIV. Referral for appropriate care services of TB-HIV co-infected will me

made to other USG supported program in MATDI (PATH integrated HIV program).