The intervention was implemented through religious leaders in 21 states spread across the Southeast, Southwest, Northeast and Northcentral zones.

These clergymen were trained on pastoral and scientific considerations in HIV pathology and subsequently delivered audience-appropriate HIV/AIDS prevention and stigma reduction messaging to their congregations.

In addition, these “activated” clergy served as a bridge between identified health centres and their congregations by leading a team of Church Health Advisors (ideally serving or retired health workers and volunteers) who will target high-risk mother and child pairs by tracking: (1) immunization status; (2) recurrence of symptoms of communicable diseases like fevers, diarrheal disease, respiratory tract infection and skin infections assisted by a screening tool like the Bandason Checklist; and (3) provide or refer for HIV testing and counselling and ART initiation where indicated

GRAIL Project was a nationwide strategy driven by Caritas Nigeria to contribute to addressing the large gap in Nigeria where only 21% of HIV positive children are on life-preserving ART; and more importantly create a community-driven approach to increase HIV diagnosis among these children (focus on ages 0 to 5 years). The findings of the baseline mapping and prioritization of States that were targeted for the GRAIL project are represented in the table below:

• Concerns that Pediatric ART Champions did not receive any post-training hands-on coaching and reassurance which would progressively improve their ability to deliver high impact congregation-based health programs. Telephone follow-up of Champions was not sufficient and actual side-by-side implementation greatly increase to outputs and confidence of the religious leaders.
• Pediatric ART Champions seemed to be reluctant to conduct catalytic activities that go beyond delivering HIV messaging which could result in increased referrals and testing for HIV in Children. Lesson learnt was that it was a huge assumption that the training was enough to produce a community mobilizer and tester of HIV for people, not just children.  Working with the Champions boosted their confidence and showed them a template that could be implemented in the future by their own teams. One of the reasons proffered during the Project Review Meeting was that some religious houses are being labelled “HIV churches” because of the increased frequency of HIV messaging with an attendant fall in congregants and collection.
• Wrong assumption that catalytic activities are to be at no cost or low cost and non-consideration for costed activities hindered the delivery of some activities.
• Concerns that Pediatric ART Champions did not have capacity to organize and deploy the volunteer Church Health Teams in their congregations. Funding to support volunteer teams’ transport and communication is a critical success factor for project.
• Concerns about Pediatric ART Champions referring recurrently ill children to HIV testing facilities which are far from the congregation. Medical outreaches in the church/mosque premises are a veritable way to bringing the services from the clinics to the community using trained medical personnel. This strategy can also address issues of test kit unavailability in referral hospitals
• Concerns about ability of Pediatric ART Champions to easily document their achievements regarding catalytic activities and referral of children for HIV testing. Digital recorded achievements (google forms, MS Excel templates) were reported to be cumbersome and difficult to complete. Paper templates were introduced and those are all some champions in a poor network locations are  able to send to  coordinator/secretary for transcription to a database for reporting.
• Low numbers of referrals and HIV testing of symptomatic children were being reported by some Pediatric ART Champions despite trainings done. High level advocacy to generate stronger buy-in by key stakeholders especially the Champions was intensified, but time was a constraint. This is one lesson and strategy the project will enjoy in its phase iii. Medical fair successfully conducted which can identify children with preventable and or treatable illnesses; including HIV and Tuberculosis.
• Inadequate prioritization of targeted age group in HIV testing of GRAIL beneficiaries. Lesson learnt was that strong emphasis must be placed on prioritizing children in congregational testing activities like the medical outreaches.
• Insufficient time allocated to supporting catalytic activities by Caritas Nigeria program staff due to unavailable dedicated GRAIL staff and competing demands on those officially assigned to supporting the Champions. Without dedicated staff, the GRAIL project activities would only be conducted when other project work permits time and travel and the lesson here is the need to support specific staff for who will work with Champions, support them to meet timelines and deliver quality outputs.

Negative:

• Push-back from some communities due to fears of being labelled (either the priest himself or their place of worship) as HIV- associated with possibilities of transferred stigma or reduced attendance or support.
• Champions who were active on social media did not necessarily use the social media reach and influence to direct

Positive:

• Very good linkage rates (100% of children referred for HTS started ART) for the 2 dioceses which submitted reports. Subject to verification when other dioceses submit their quantitative achievements.
• HIV messaging which targets children with age-appropriate content was done by some of the Champions with positive feedback and impact (because the children passed messages to their family and peers).