AMREF's PMTCT activities run under and are linked to the ANGAZA voluntary counseling and testing (VCT) program. In 2005, AMREF integrated PMTCT services in six of the facilities belonging to Faith-Based Organizations (FBOs). The program worked through a combination of strategies: introducing PMTCT services in sites that already had ANGAZA Counseling and Testing services; Providing an "integrated" PMTCT program in antenatal clinics (ANCs) with VCT services; offering an opt-out counseling and testing (C&T) approach in ANCs; providing C&T in labor wards; and enhancing PMTCT outreach activities by engaging lower-level service facilities (Health Centers and Dispensary).

By June 2006, we had counseled, tested, and delivered results to 12,196 women. Out of 976 pregnant women who tested positive for HIV, 778 (79.7%) received a complete course of antiretroviral (ARV) prophylaxis. AMREF trained over 180 PMTCT counselors.

Despite the above successes, AMREF encountered several barriers that affected PMTCT service utilization and Nevirapine prophylaxis (NVP) uptake. Currently, only about 10% of the nation is covered for PMTCT services. Most of the lower-level facilities do not have the capacity to provide those services. In addition, a certain proportion of mothers may still be missed and fail to access PMTCT services. Male involvement in PMTCT is still a challenge. Many women are missed because fewer providers in a facility are trained in PMTCT services, on average two or three, if these trained providers are on holiday, morning shift, other rotations or is transferred then clients do not access PMTCT service. This necessitate for more providers with in a facility to be trained in PMTCT services.

Funding for FY 2006 activities are only now being expended and since AMREF's cooperative agreement comes to an end in December 2006, this entry is a "zero fund." In FY 2007 AMREF will deploy site-specific strategies to address these drawbacks, including: (1) expanding provider-initiated ‘opt-out' C&T in ANCs and carry-out counseling and testing in labor wards and during the postpartum period (within 72 hours of delivery); (2) ensuring that all providers in ANCs and labor wards are trained in PMTCT ‘whole site training;' (3) improving the environment and quality of antenatal clinics and labor and delivery rooms by carrying out minor renovations (so that more clients access the delivery services and get opportunities to be tested), (4) continuing to create demand for PMTCT services linking to the broader ANGAZA promotion, social marketing, and community mobilization activities. Our demand-creation efforts will target male partners and address issues of stigma and discrimination. The program will use the Community Owned Resource Persons (CORPs) for community mobilization, encouraging male involvement and stigma reduction. We will also hold male discussion platforms at the community level to raise a sense of self-belonging to PMTCT interventions.

AMREF will support follow up for mother-child pairs and supply prophylactic cotrimoxazole syrup for newborns. Other follow-up measures will include integrating PMTCT in under-five, outreach, and family planning clinics; home-based care; and VCT in care and treatment clinics. AMREF will also target counseling and testing to breastfeeding mothers and for mothers delivering at home. AMREF will adopt HIV-testing procedures that have been nationally approved for children less than 18 months of age. AMREF will encourage active follow-up and linkages to outreach and home-based programs in order to support infant feeding choices and to establish infant testing outcomes. AMREF will also link with other programs such as Malaria Control (insecticide-treated nets and Intermittent Presumptive Therapy) to complement HIV interventions.

While the current regimen is still in use, AMREF will continue to access Nevirapine tablets and syrups and determine through the AXIOS PMTCT Donations Program and purchase Capillus through our procurement procedures by applying the Supply Chain Management System (SCMS) used by USG-Tanzania. To support sustainability, AMREF will work with the Ministry of Health and Social Welfare (MOHSW) to ensure eventual availability of test kits and drugs through government channels. AMREF will continue to offer technical support for sites conducting PMTCT services, including provision of PMTCT, job aids for counseling about infant feeding options, and supplies such as cabinets for safer storage of documents and drugs. AMREF will strengthen private-public partnerships by empowering its sub-grantees in their local governments; by supporting the facility technical teams in cascading services to lower facilities; and by supporting community mobilization activities by the CORPs. AMREF will work with its sub-grantees (FBOs) and the respective districts to ensure inclusion of PMTCT in council comprehensive health plans, aiming at ensuring

ownership and long-term sustainability. Under the National AIDS Control Program, pregnant women and their spouses who attend AMREF-supported facilities will have access to quality PMTCT services and referrals to existing care and treatment, sexually transmitted infections and tuberculosis clinics. AMREF will advocate for provision of short-course ARV prophylaxis, and where eligible, for antiretroviral therapy. To increase PMTCT access, AMREF will continue supporting the six primaries PMTCT sites. By the end of FY 2007, a total of 6 facilities will be providing PMTCT services and will have trained and re-trained 150 providers. A projected total of 9,755 pregnant women will be counseled, tested, and receive results—either during their visits to ANCs, during labor, or postnatal. Based on the national prevalence of 8.7%, the program will plan to provide prophylactic ARVs to 755 pregnant women. AMREF will deploy participatory quality assurance (QA) and supportive supervision to ensure sub-grantees take part in revisiting local capacity for performing internal QA for rapid tests and counseling supervision. Testing QA will link up with national plans to strengthen regional and district laboratories. Working with MOHSW, AMREF will introduce clinical audit processes for PMTCT services; we will use facility-based standard operating procedures for PMTCT, which were developed in collaboration with MOHSW.

AMREF will organize basic training on PMTCT data management for selected groups of participants, including medical records staff. AMREF will use the nationally adopted monitoring tools and support sub-grantees to collect PMTCT data and report in a timely way to the district health authorities and the MOHSW. AMREF will routinely submit quarterly, semiannual, and annual reports to USAID as per the guidance.

The African Medical and Research Foundation (AMREF) Counseling and Testing (CT) program (also called ANGAZA meaning ‘shed light') was founded in 2001 with USAID support. In FY 2006, AMREF employed a combination of strategies to implement the program including the provision of sub-grants to partners who run either stand alone and/or integrated CT services; VCT services to rural and underserved population through mobile clinics; and social marketing campaigns to create demand for services through promoting the ANGAZA brand. Through these strategies, cumulatively, AMREF trained 838 counselors and reached 364,387 people with VCT services in FY 2006.

Despite the above efforts, AMREF encountered several barriers that affected utilization of CT services. C&T coverage is still inadequate and does not reach the entire population. While there are significant numbers of facilities and organizations providing various forms of counseling and testing (approximately 975) this represents only 1/5th of all the health facilities in the country. Other barriers include inadequate number of counselors to provide services; high counselor turn-over in some sites; ‘longer' counseling sessions (protocol dependant); and delays in adopting provider initiated testing and counseling due to lack of a National PITC policy document.

Funding for FY 2006 activities has recently been received and since AMREF's cooperative agreement comes to an end in June 2007, initially, "zero funds" were required to reach the goals proposed in this narrative.

In FY 2007, AMREF will deploy several strategies to address the barriers mentioned above and to improve C&T coverage. It will continue to provide CT services through the existing 65 static and 11 mobile sites. The program will increase accessibility to CT services through additional sub-grants to FBOs, NGOs and Governmental organizations, resulting in a total of 75 sub-grantees being supported by AMREF in FY 2007. As part of its work with sub-grantees in FY 2007, AMREF will prepare them for hand-over to the new TBD partner (activity #8656).

PITC will be expanded in clinics through integration into services such as TB, STI and MCH and inpatient settings, following national guidelines, protocols and training curriculums to be developed by the Ministry of Health and Social Welfare (MOHSW). As a participant in the national CT working group, AMREF will advocate for links with care and treatment, family planning services, and home-based and palliative care. Subsequent to the development of national training curriculums, the program will carry out PITC training for 240 providers, including updates in strategies for testing children, C&T for the disabled, and lay counselors.

Access to C&T will be improved and expanded through an increase in mobile services provided via vans, motorcycles, and bicycles. Through leasing, AMREF will introduce a boat with a mobile VCT clinic on Lake Victoria to access hard to reach fishing communities on the several islands on the lake.

In keeping with the MOHSW guidance, AMREF will support the use of "lay counselors" and work with sub-grantees to implement this new initiative. AMREF will continue to create demand for Counseling and Testing services through innovative social marketing techniques and community mobilization methods. The program will continue to promote and advocate for couples counseling and disclosure, engage churches, mosques and other religious setting, and facilitate premarital counseling and testing. The communication tool to facilitate couple disclosure developed during FY 2006 will be scaled-up to other ANGAZA sites.

AMREF will work with the MOHSW in phasing out the old (Capillus and Determine sequential testing using veneous blood draw) and adopting of the new, to be determined, HIV testing algorithm and will engage/rely on the new SCMS mechanism to procure and distribute buffer stock of test kits and other commodities. Psychosocial support to clients diagnosed as HIV infected will continue to be provided through Post Test Clubs (PTC), ensuring linkages for continuum of care including referral to care and treatment clinics (CTC) for assessment, staging and consideration of antiretroviral therapy as well as the provision of prophylaxis for opportunistic infections.

Monitoring and evaluation (M&E) will be strengthened to ensure quality services and

efficient reporting. AMREF shall collaborate with VCT district supervisors to conduct mystery client and client exit survey in the selected sites. AMREF will liaison with MOHSW/CDC to ensure the quality of HIV testing is maintained according to national standards.

In order to enhance sustainability, the program will (i) ensure sites with VCT activities supported by AMREF are integrated in the district's Comprehensive Council Health Plans (CCHP), so that the financial support to these services is picked up by the local authorities; and (ii) work with districts to decentralize the supervision of these services to the Council Health Management Teams (CHMTs). This will ensure districts take over management oversight of the services.

Through these strategies, AMREF anticipates that a total of 311,278 individuals will access VCT services in FY 2007; however, as these were captured in FY 2006, targets here are zero.

Through the ANGAZA program, AMREF has extensive experience training and implementing a range of interventions including capacity building, social marketing and provision of VCT services. The NACP has recently adopted the Provider Initiated Testing and Counseling approach in an effort to strengthen and broaden opportunities for clients to access HIV services. The MOHSW is now in the process of developng new technical guidelines, protocol and manuals with a view of rolling out the program at a national level. The USG has identified AMREF as one of several partners to assist MOHSW to rapidly pilot the training phase of this approach. Plus up funds will be used under the leadership of MOHSW and in close collaboration with other USG partners to pilot the PITC training materials. AMREF will utilize its two training classrooms at its headquarters, experienced trainers (2 clinical and 4 laboratory technicians) and other resource persons to support the Ministry with the pilot. They will run two classes of 25 participants each for five days and through 4 training sessions and in total will train over 200 participants. In carrying out the pilot training, the AMREF team will keep track of the training process, document issues and questions that arise so that it can provide inputs to the national roll-out.