This activity also relates to activities in CT (# 7711, 7835, 7776, 8661, 8663, 8672, & 9085); TB/HIV (7781 & 7791); and ARV services (7757, 7771, 7683 & 8839).

The burden of HIV/AIDS in the Lake Zone, the catchment area for Bugando Medical Centre (BMC), is quite high in comparison to national statistics. HIV prevalence among antenatal clinic attendees it is 12%, while the national HIV prevalence rate is 7%. The Lake Zone accounts for over the third of the total population in Tanzania with a population of 13,000,000. It is estimated that 900,000 Lake Zone residents are HIV infected. Higher prevalence in the Lake Zone is attributed to the shared borders with Uganda, Burundi, and Democratic Republic of Congo (DRC) - all of which are high burden countries. Substantial cross border movement occurs in this area of the country and there is a massive influx of refugees from Burundi and the DRC.

BMC is a zonal referral and university teaching hospital with a bed capacity of 850. The mandate of BMC is to provide training, technical support, supportive supervision, mentorship, and outreach to the six regions of the Lake Zone (Mwanza, Shinyanga, Tabora, Kigoma, Kagera and Mara). Through its existing cooperative agreement with USG/CDC, BMC will continue to rapidly enhance the continuum of HIV/AIDS prevention, care, treatment and support in the Lake Zone.

During FY 2006, BMC adopted the provider initiated model of counseling and testing resulting in 70% of medical ward patients and 90% of tuberculosis patients accepting HIV testing services. BMC implemented provider-initiated testing and counseling (PITC) as a new model to speed up referral to and consequent enrollment in HIV prevention services such as prevention of mother to child transmission, prevention with HIV positives, and care and treatment services.

In FY 2007, BMC intends to work closely with NACP and IntraHealth International to further roll out PICT in 8 primary health facilities in the Lake Zone. BMC will complement these facility-based PITC services by conducting regular community counseling and testing outreach services. This balanced approach will ensure that more people are offered opportunities to test, in line with the HIV serostatus approach to HIV prevention. This strategy also will help with the referral of PLWHA to care and treatment services when they are not severely immunosuppressed and hence more likely to experience improved treatment outcomes.

BMC shall also strengthen existing facility-based VCT services. The increased demand for counseling and testing calls for training and recruiting more counselors. As a result, BMC plans to train 120 health workers and 30 PLWHAs as counselors in the Lake Zone. BMC will also recruit 2 staff counselors. Trainings will involve health care workers from reproductive and child health services (RCH), specialized clinics (e.g., diabetes, sickle cell anemia), inpatient departments (IPD), outpatient departments (OPD) and STI clinics. Training on rapid HIV testing for counselors will be done in collaboration with AMREF using the regional facilitators trained under MOH/NACP and USG/CDC guidelines for non-laboratory staff.

BMC will utilize existing tools for HIV prevention and counseling to be used at HIV/AIDS clinics and post test clubs in the community. To help PLWHA adopt and maintain low risk, a behavior change communication (BCC) strategy will be used by counselors. To assist with this endeavor, counselors will be trained on BCC and other prevention with positives strategies in clinical settings at the national level.

In FY 2007 BMC expects to offer HIV counseling and testing to 20,000 individuals attending the OPD, IPD, and STI and TB clinics. Also more clients will receive CT services in the 8 primary health facilities in the area.

A team of supervisors from BMC in collaboration with the R/DHMT will conduct regular supportive supervision visits to the facilities providing services. BMC will use existing M&E tools for CT developed by NACP to collect the CT data, and BMC will report as required to the regional and national levels.

Enhancing of Contiuum of HIV/AIDS Care and Treatment in the Lake Zone

The Lake Zone is comprised of six regions, Mwanza, Shinyanga, Tabora, Kagera, Kigoma, and Mara. It is one of four zones in the country.

The Lake Zone is a very high HIV-burden area in Tanzania. It has an aggregate population of 13 million, which is about a third of the country's population. It borders Uganda and Kenya, both countries with a high HIV burden. It has refugees from Burundi, Rwanda and Congo. The first AIDS case was reported in Kagera region in 1983. HIV prevalence in the Lake Zone ranges from 5% to 19.4%. Extrapolating from national figures, the estimated number of PLHA in the Lake Zone is over 700,000, and of these, 100,000 require antiretroviral treatment. The grim HIV statistics in the Lake Zone justify the need for intensive scale-up of HIV/AIDS prevention, care and treatment through the network model.

The Lake Zone is the catchment area for Bugando Medical Center (BMC). BMC is a Consultant Zonal Referral University Teaching hospital, a zonal training centre and a zonal reference laboratory for HIV/AIDS/TB. It has a bed capacity of 850. In FY2005, BMC entered into a direct cooperative agreement with HHS/CDC. USG direct support to BMC, despite the presence of other implementing partners in the Lake Zone, is a necessary step in building indigenous capacity and sustainability. In FY2006, BMC main focus was on building the skills and capacity of health care workers for ART delivery. They trained 108 health care workers using the national ART curricula. Through these efforts, and with the direct support of AIDSRelief, an estimated 2,000 PLWHA were enrolled on ART at BMC. Distance to point of service (POS) delivering ART services is a significant deterrent to access HIV/AIDS care for poor PLWHA in the rural lake area. To help address this in FY06, BMC introduced an ART service model to four primary health care centers in the Lake Zone in order to bring the services closer to the community.

Historically, the role of the zonal/referral hospitals has been to oversee health programs in their zones. BMC oversees health programs in the Lake Zone on behalf of the MOH and provides technical support for their implementation. The mandate of BMC has been to support the provision of quality HIV care and treatment to PLHAs by carrying out ART training and supportive supervision to lower level facilities within the Lake Zone.

Under regionalization, where USG ART partners have been assigned specific regions within which to support the scale-up of ARV services, the role of the referral/zonal hospitals is evolving. This is due to the fact that the regionalization strategy has become an opportunity to build the capacity of each Regional Medical Office (RMO) to fulfill the responsibilities of their role, which is to coordinate and oversee all health programs within their region. EGPAF, Columbia and AIDS Relief have been assigned regions within the Lake Zone.

Now, zonal hospital staff will serve as consultants, providing technical assistance (TA) both to the growing Regional Health Management Teams (RHMTs) and to lower level facilities within regions of their zones, but under the coordination of each RMO. They will especially focus on the regions in which they are located.

In the Lake Zone, the USG ART Partners assigned to each region will help build the capacity of the RHMT's to perform supportive supervision as part of the RMO coordination role. They will help organize supportive supervision teams and schedule supervision visits until the RHMT's fully assume that responsibility. With USG funding BMC will help train the RHMTs, serve as a technical arm within these supportive supervision teams and under the direction of the RMO, will train and provide TA to lower level facilities within the zone. In addition, given BMC's long-standing relationships within Mwanza, the region in which they are located, they will strengthen linkages and referrals to their facility from the community as part of a continuum of care.

In support of this approach, and because the lack of highly trained HCW in primary health care facilities is a major obstacle to rolling out ART services, BMC will continue to focus mainly on capacity development. Their activities also help to support decentralization in two ways. First, the provision of training sessions at the zonal level instead of centrally,

and secondly, their provision of TA to primary level facilities supports the decentralization of services from regional and district level facilities.

Specifically, BMC will be funded for training and supportive supervision, the provision of technical assistance to lower level facilities and the enhancement of linkages. 1) In collaboration with the USG ART partner that supports the particular region, BMC will build the capacity of the RHMTs. In FY07, BMC will train over 30 RHMT members from all regions in the Lake Zone on HIV/AIDS clinical management and on the use of the supportive supervision tool, in order to enhance their supportive supervision skills on HIV/AIDS services.

2) Serving as the technical consultants for ART, BMC will carry out supportive supervision and training for HCW at lower level health facilities. In FY07 they will train at least 160 HCW, strengthening existing health teams and building new ones. These trainings will consist of refresher trainings at the district level using the national curriculum and initial trainings at primary health centers using the adapted WHO IMAI curriculum, whose adaptation the USG is supporting in FY07. Supportive supervision to these facilities will be carried out jointly with regional USG partners and RHMTs.

3) As an extension of this TA to lower level facilities, BMC also plans to help introduce ART services to an additional 7 primary care health centers, in order to hasten ART scale-up and expand access to HIV/AIDS services. Their physicians will provide on-site mentoring and ensure best practices in these lower level facilities after they are trained.

4) There are few linkages between health institutions that provide ART and communities. To address the continuum of care, existing linkages from BMC to communities, community based organizations, home-based care programs and PLWHA networks will be developed. To ensure this continuum and to maximize adherence to opportunistic infections prophylaxis, antiretroviral and anti tuberculosis treatment support and in collaboration with the Ministry of Health Home Based Care Unit, BMC will support training of facility and community based health care providers. BMC will allocate funds to support community outreach services, hire community outreach public health nurses and support joint BMC and community stakeholders' meetings. BMC has developed a model to ensure tracking of patients to maximize adherence to care and treatment regimens and if scaled up, these models can be a national example for best practices. An example is the inclusion of PLWHA and their families and communities to strengthen adherence. This will also help to overcome denial, stigma and discrimination.

For effective roll out of HIV/AIDS treatment, community acceptance and preparedness is critical, so funds will be used by BMC to support treatment outreach efforts. This will allow PLWHA, community leaders, and health care providers to conduct advocacy, education and stigma reduction meetings in the communities. This will pave the way for increased uptake of HIV/AIDS treatment services.

BMC will continue to operate in a network model, and strengthen collaboration with the Ministry of Health and Social Welfare and NACP, USG partners in the regions, RHMT's and district health management teams, PLWHA support networks and community based organizations. This will ensure complementation of services, maximization efficiency and effectiveness and better utilization of resources.

This activity links to activities HLAB MOHSW 7758, 7779 NIMR, CDCBase 7834, CLSI 7696, APHL7682, AIHA7676, ASCP 7681, AMREF 7672, RPSO 7792, 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 Ministry of health and social welfare (MOHSW) has decentralized HIV/AIDS laboratory infrastructure and capacity building to the zonal referral laboratories to expand HIV/AIDS lab capacity and to embrace the network model for a continuum of HIV/AIDS prevention care and treatment services. BMC is a referral and teaching hospital for the six neighboring regions of the lake zone with a catchment population of approximately 13 million. The lake regions are Mwanza, Kagera, Shinyanga, Kigoma, Mara and Tabora. The Bugando Medical Center (BMC) zonal referral laboratory capacity is currently inadequate and an obstacle in achieving the emergency plans for care and treatment goals of the lake zone.

BMC is being funded for the first time in FY 2007 with special focus to the laboratory services at the center. BMC will apply the quality system approach to build its own capacity as a center of excellence and support a network of regional, district faith based and private laboratories supporting HIV/AIDS prevention, care and treatment in the lake zone. The BMC will train staff at the BMC lab to perform testing for HIV diagnosis, disease staging and treatment monitoring in order to optimize prevention, care and treatment services, train laboratory and non-laboratory staff from other facilities providing similar services and support and help monitor performance through supportive supervision. BMC had started to implement activities to strengthen laboratory capacity in collaboration with various implementing partners including Columbia University , HHS/CDC Tanzania, National Institute for Medical Research (NIMR), African Medical and Research Foundation (AMREF), the Association of Public Health Laboratories (APHL) the Clinical and laboratory standards Institute (CLSI), the American society for clinical pathology (ASCP), GTZ, JICA, AXIOS, Clinton Foundation, Track 1 partners and other ART partners. The high volume chemistry, Hematology and CD4 equipment have been procured by HHS/CDC Tanzania with FY 2005 funding and installed. Training of laboratory technologist on HIV/AIDS standard of care tests, equipment maintenance and preventive maintenance for users, rapid HIV test training to laboratorians and non lab staff from other intervention areas like PMTCT, Counseling and testing (CT), TB/HIV and introduction to Quality system approach in the laboratory services were implemented in FY 2006 With FY 2007 funding BMC laboratory will, in collaboration with partners implement quality system in the BMC laboratory and establish a network from which all laboratories levels will be supported. The Quality system implementation will follow active gap analysis strategy and focus on areas of specimen management, Quality assurance,