This activity links to the AIHA Preceptorship activity (#7679) under ARV Services and the National AIDS Control Programme activitiy for coordination (#8692).

Through an agreement with the Tanzanian government, the Evangelical Lutheran Church in Tanzania (ELCT) operates 20 hospitals and 160 primary healthcare institutions, accounting for about 15 percent of the healthcare services in Tanzania. The Pare Diocese of the ELCT provides healthcare services to over 200,000 people at the Gonja Hospital and the 10 dispensaries affiliated with it.

Palliative care is a necessary element of the complex assistance provided to persons living with HIV/AIDS (PLWHA); however, palliative healthcare services, both hospital and home-based, and skilled providers are very scarce. The Twinning Center proposes a partnership between the ELCT, the Southeastern Iowa Synod of the Evangelical Lutheran Church in America (SIELCA), Iowa Health—Des Moines, and Iowa Sister States (ISS) to increase the number of healthcare and non-healthcare personnel able to provide quality palliative care services through training and capacity-building. This partnership would work with the Pare Diocese to achieve the palliative care goals set forth in the Tanzanian Health Sector Strategic Plan for HIV/AIDS (2004-2006).

The SIELCA synod consists of 150 congregations and is in relationship with various social service agencies and educational institutions. The ELCT and the SIELCA have had a companion relationship for 18 years, during which time they have worked together to address issues related to agriculture, education, and water development systems. In the last three years, 20 physicians and nurses from SIELCA have visited the Pare District. Iowa Health—Des Moines is a healthcare system of three hospitals in central Iowa. ISS is a 501(c)3 entity which contracts with all its sister state partners. The four organizations would be partnered to develop and implement a palliative care training program for 200 healthcare and non-healthcare providers that would reach over 2,000 PLWHA in the first partnership year and provide mentoring for healthcare providers, family members, and church volunteers in Pare. The Twinning Center will work with the National AIDS Control Program, as well as with the Palliative Care Association of Tanzania, in updating the national curriculum for home-based care training to include the principles of palliative care for people living with HIV/AIDS; pain evaluation and pain control management according to the World Health Organization (WHO) protocols (March, 2004); principals of HIV symptom management according the WHO protocols (March, 2004); use of complementary and alternative medicine; palliative care support to adults and children; emotional and spiritual aspects of care; and the organization of care including collaboration with NGOs and community and faith-based organizations. Mentoring through partnership exchanges with both ELCT and with local health authorities, such as the District Health Management Teams and District-level Community-based Coordinators will increase the understanding of the model and provide the opportunity for ongoing quality assurance monitoring and sustainability. This effort will be coordinated with the activities of the ELCT Health Department.

This activity relates to other twinning programs to support Palliative Care (#8715), Treatment (#7679), Laboratory Infrastructure (#7676), and Other Policy and Systems Strengthening (#7678). As an OVC partner, this activity will link with the PACT coordinating implementing partner group network for OVC (#7783) and the FHI OVC data management system (#7715).

AIHA is a twinning partnership between the Institute of Social Welfare of Tanzania (ISW) and the Jane Addams School of Social Work, University of Illinois (JASW), with an overall goal to strengthen the ISW pre- and in-service training curriculum to better equip social workers to respond to the needs of OVC.

There is an acute need for trained manpower at the local level to address the needs of OVC, with social workers represented in only about 1/3 of the 132 districts. In addition, many of the existing social workers have no training in the needs of vulnerable children.

This partnership will address both the short-term and long-term needs of OVC. To address immediate needs, the partnership will: 1) develop a short refresher course for current practitioners who have not received continuing education and may not have ever received training on the needs of OVC; and 2) develop a short-term training certification program (possibly in coordination with the Community Development Institute in Arusha, Tanzania) to train para-professionals who can provide direct services to children and families at the local village level. The training for para-professionals will involve the immediate identification and training of lay persons to serve as "social referents" to provide a more immediate response in USG geographic priority areas for most vulnerable children. The social referent training will be a standardized certificate program guided by the Department of Social Welfare, with advisory consultations with the Tanzanian Association of Social Workers.

The second two objectives of the partnership, that address the long-term needs of OVC, are to: 1) strengthen the training and mentoring of social work students to respond to the needs of OVC through improving the curriculum and student field work experiences; and 2) to expose ISW's faculty to different models and delivery of community social work training. During FY06, the JASW faculty initiated an assessment of the pre-service curriculum and will identify and recommend new components to be added or revised.

With FY07 funds, the partnership will train a total of 200 para-professionals, and conduct continuing education programs for 50 social workers. In addition to training, activities will include curriculum development, recruitment of lay persons, development of training procedures, and identification of pilot region(s) to implement the social referent (SR) project. The SR recruitment/public relations workgroup (formed in 2006) will work with local community and faith-based organizations and churches to announce the project and recruit lay persons. The advisory committee and pre-service curriculum workgroup will outline competencies for pre-service training and identify appropriate curricula for adaptation. Trainer faculty will be identified to conduct a pre-service curriculum TOT; and additional revisions to the curriculum, if needed, will be made based on the TOT results/findings. In addition, in FY07, the partners will begin their work on continuing education to assess the content needed for refresher course(s) and a continuing education strategy will be developed.

Preceptors Initiative

The American International Health Alliance (AIHA) ARV Services activity described here is one component of a comprehensive set of services further described in the OPSS, Palliative Care, OVC and Laboratory program areas.

The Preceptor Initiative is a component of the Twinning Center's Voluntary Healthcare Corps (VHC). The VHC recruits individuals with expertise in healthcare and HIV/AIDS for mid- and long-term assignments in the twinning partnerships and other projects supported by the President's Emergency Plan. Volunteers provide clinical, educational, and capacity-building services through assignments that are long enough to meet measurable program goals and allow for adequate transfer of knowledge and experience.

The overall goal of the Preceptor Initiative in Tanzania is to increase the capacity of antiretroviral treatment (ART) clinics to expand their care and treatment services through the fielding of trained and qualified professionals. The objectives of the preceptor initiative are1) to identify preceptor placement sites with specific and measurable objectives, 2) to identify qualified and experienced professional preceptors and 3) to orient, field and monitor the preceptors as they provide on-site technical support to ART clinics.

In FY 2006, AIHA established an in-country office that will be responsible for visiting sites prior to volunteer placement, identifying housing, and providing the volunteer with travel support, a living allowance, and medical evacuation insurance. AIHA fielded two nurse managers to conduct site assessments at the regional and district level hospitals and health centers in Singida and Shinyanga to better understand the structure of existing services, introduce the Preceptor initiative to in-country staff and identify specific needs for preceptor assignments. The nurse managers met with regional and district level staff at 10 ARV clinic sites. The medical teams and regional officials were extremely receptive of the preceptor initiative and acknowledged a critical need for on-site technical assistance in both clinical and non-clinical areas related to ART. During the assessments and discussions with the in-country staff, several common need areas were identified. These include training and on-site mentoring in HIV education, clinical ARV treatment, universal precautions, program monitoring and evaluation, and information technology. As stated, assessments were performed in Singida and Shinyanga, and volunteer preceptors will initially be placed at ART clinics there. These regions were chosen in FY06 because under regionalization, no USG ART partner was initially assigned to those regions. Now, in FY07, Family Health International and Elizabeth Glaser Foundation will assume responsibility for the scale-up of services in Singida and Shinyanga respectively. The activities of the preceptorship program will lay a strong foundation and has helped identify areas that need strengthening.

Although the ART clinics in the two regions have been provided basic training, supplies and equipment to expand care and treatment services by the Ministry of Health, they require additional site level support to expand and improve the provision of quality care to increasing numbers of patients on ART. From the areas of identified need, specific scopes of work are being developed outlining clear objectives for each assignment, the required qualifications of the candidates and the expected outcomes of the assignment.

As the scopes of work are developed, qualified and trained candidates will be identified through the VHC recruitment networks and professional associations. A clinical and non-clinical preceptor will be placed at each site to allow coordination of efforts and provide a broader level of support to the clinics. The preceptors will provide on-site guidance for ARV clinic staff through supportive supervision, mentoring, and identification of specific technical assistance needs.

In FY 2007, additional preceptor placement sites will be identified (in coordination with the NACP, USG partners in the region and regional and local officials); additional needs assessments of placement sites will be conducted to determine new preceptor assignments; and additional preceptor scopes of work developed with individualized and measurable objectives for each assignment. 30 qualified and experienced preceptors will be recruited, fielded and supported to provide technical assistance to the identified placement sites. The VHC will monitor the preceptors and institution placements and

preceptor evaluations of their experience will be utilized to improve the program support and appropriateness of placements and defined scopes of work.

This activity links to activities HLAB MOHSW 7758, 7779 NIMR, CDCBase 7834, CLSI 7696, APHL7682, ASCP 7681, AMREF 7672, RPSO 7792, BMC 7685, ZACP 8224, DoD 7746; Track 1 ART CU7697/7698, EGPAF 7705/7706, HARVARD7719/7722, AIDSRelief 7692/7694, DoD7747, Blood Safety; CT NACP 7776, TB/HIV 7781, PMI, SCMS 8233, FHI 7712; SI NACP 7773, MOHSW 7761.

The Twinning Center conducted an open solicitation for a US or non-US based institution(s) to increase Tanzania's human and institutional capacity in the management, coordination, and technical expertise in laboratory services for the diagnosis and management of HIV. Boulder Community Hospital, Boulder, Colorado has been recommended as the US-based partner to CDC. The hospital is part of a larger network—Frontline Laboratories, anchored by the Mayo Clinic and will draw upon its linkages with the Beacon HIV/AIDS Clinic (Boulder). The hospital is fully accredited by the College of American Pathologists as well as the Joint Commission on Accreditation of Healthcare Organizations and is a member of the American Society of Clinical Pathologists (ASCP); the College of American College of Pathologists (CAP); and the Clinical Laboratory Standards Institute. The overall goal of the proposed twinning partnership between Boulder Community Hospital and the five zonal laboratories of Tanzania is to strengthen the pre-service training through a mentorship program. There are five zonal laboratories in Tanzania, each associated with a laboratory sciences training institution - Muhimbili Hospital in Dar es Salaam; Bugando Hospital in Mwanza; Kilimanjaro Christian Medical Center in Moshi; Ikonda Mission Hospital in Iringa; and Mnazi Mmoja Hospital in Zanzibar. These institutions suffer from a lack of trained faculty, few incentives available to retain faculty, and low numbers of graduates; currently, as few as two laboratory technicians serve as part-time faculty. With the introduction of automated laboratory equipment and rapid testing for the diagnosis and management of people living with HIV/AIDS, the laboratory must be strengthened to focus on the use of these diagnostics and implementation of quality laboratory systems. Although specific partnership objectives will not be finalized until completion of a familiarisation visit ( proposed for October 2006) and workplan, proposed objectives include offering exposure and mentorship to the zonal institutes of laboratory services faculty to include the implementation of the laboratory quality systems approach, to provide continuing education for laboratory technicians serving as faculty, provision of professional development opportunities through national, regional, and international training; and to assist the Ministry of Health in implementing sound laboratory policies, guidelines, and standard operating procedures at the zonal level. The partnership is expected to collaborate with all relevant US government-funded health sector programs, particularly the American Society of Clinical Pathologists (ASCP), the Clinical and Laboratory Standards Institute (CLSI), and the Association of Public Health Laboratories (APHL).

AIHA through Boulder Community Hospital is working to strengthen the pre-service training which will result in a sustainable source of laboratorians with knowledge and skills to support the HIV/AIDS care and treatment programs. Currently AIHA offers exposure and mentorship to the school teaching staff on laboratory quality systems, continuing education for laboratory technologist from the zonal laboratories serving as faculty, professional development opportunities through training and mentorship, implementing sound laboratory policies, guidelines and standard operating procedures. It is anticipated that each of the five laboratory training institutions will require at least 5 mentors for each subject area of Chemistry, Haematology, Microbiology, Molecular Biology and Immunology related to HIV/ AIDS diagnosis inclusive of opportunistic infection identification and monitoring of care and treatment. The mentors will be expected to stay in country for variable periods of time from two to four weeks to be effective.

This activity relates to activities in Lab (#7676), ARV Services (#7679), and OPSS (#8981).

Since 2003 the Muhimbili University College of Health Sciences (MUCHS) School of Nursing worked with the University of Michigan (UM) to expand HIV education for teachers and students in all of Tanzania's 56 pre-service nursing schools, including 23 certificate programs, 22 diploma programs, seven advanced diploma programs, and four degree programs. In FY 2005, the partnership was formalized when Rapid Expansion funds were awarded to the American International Health Alliance Twinning Center to support a twinning partnership between the two universities. Although UM needed to withdraw from the partnership, the Twinning Center has continued to provide project leadership to further define the HIV/AIDS core competencies for nurses in Tanzania and to ensure that the curriculum development activities move forward. In August 2006, the Twinning Center reached an agreement with CDC to continue this important work by partnering MUCHS with the University of California, San Francisco (UCSF) School of Nursing. The first formal visit between the two institutions will be conducted the first week of October, 2006.

The following activities will be completed by the end of FY06: HIV/AIDS modules and supportive materials developed and approved by the MOHSW and stakeholders; Master Teacher Training of Trainers (TOT) conducted, with two teachers trained from each of eight zones; and nursing tutors from each pre-service institution trained to use the new modules and materials. Each of the 56 institutions will also be supported, where possible, to address infrastructural needs such as lap tops, projectors, clinician support tools, and reference materials. Some support may come from Plus Up funds that were awarded to JHPIEGO to support nurse midwifery schools in FY 2006. Twinning volunteers from UCSF will provide technical assistance during each phase of training roll out, from co-facilitation of TOTs to clinical mentoring and short-term gap filling for tutors who are undergoing training. A Life Skills intervention for nursing students will also be piloted and implemented in FY 2006 in conjunction with the zonal TOTs.

In FY 2007, the focus of training will shift from nursing faculty to nursing students so that the ultimate goal of the program - to produce nursing graduates confident in their ability to provide HIV-related services and protect themselves from HIV - can be reached. Mentors from UCSF will be fielded to provide continued support to nursing faculty teaching the new content to students in the nursing institutions. Exchanges with other resources-constrained countries, such as Thailand, may be provided to selected Tanzanian nursing leaders faced with addressing the challenge of empowering nurses to assume more responsibility and accountability as members of a multidisciplinary health care team. Building on the volunteer model, longer-term in-country volunteer opportunities will be explored with organizations such as the UK-based Volunteer Support Organization (VSO). Monitoring and evaluation will comprise a large component of the program in FY 2007, and will focus on assessing pre- and post- training knowledge and ability of tutors to conduct effective subsequent trainings, and other institutional advances. Material support to the nurse training institutions will also be continued in FY 2007 to ensure that all tutors have the appropriate equipment to facilitate teaching of the new content.

By the end of FY 2007, approximately 6,596 nursing students will receive increased HIV/AIDS instruction each year, and 2,091 will graduate annually with a strong foundation in HIV/AIDS prevention, care, and treatment. MUCHS and UCSF will coordinate with the pre-service laboratory partnership and with I-TECH to ensure standard approaches to pre-service training. This and other pre-service programs will help to ensure sustainability of PEPFAR in Tanzania.

Of these funds, $50,000 will support a Twinning partnership with a community-based organization that works with Most At Risk Populations (MARPS), such as Injecting Drug Users (IDUs), to build this capacity in Tanzania. Deliverables for the MARPS partnership include: 1) documented goals, objectives, and activities for the partnership, as well as a work plan; 2) reports on exchanges that occur during the fiscal year; 3) quarterly and annual progress reports.

With the availability of Plus Ups, an additional $100,000 will support the MARPS partnership in its first year. Deliverables for the MARPS partnership include: 1)

documented goals, objectives, and activities for the partnership, as well as a work plan; 2) reports on exchanges that occur during the fiscal year; 3) and quarterly and annual progress reports. Note: changes in targets for training stigma and discrimination reduction are for the MUCHS/UCSF partnership.