At present, there are 52 existing PMTCT sites in Mara, Mwanza, Manyara, and Tanga regions.

Data from sentinel surveillance sites in Tanzania indicate that the overall HIV prevalence among pregnant women attending antenatal clinics is 8.7%. Without intervention, 25 - 40% of HIV infected pregnant women will transmit the virus to their newborn during pregnancy, delivery or through breast-feeding. The assumption is that 90% of pregnant women attending ANC agree to test for HIV after counseling. With AIDSRelief support, pregnant women attending antenatal care in selected health facilities in the 4 regions will know their HIV status and prevent HIV infection in their newborn infants. PMTCT clients and their infants will also gain access to comprehensive HIV care and treatment services.

Major Activities of PMTCT Program a) Capacity Building: During the supplemental period, AIDSRelief plans to strengthen the capacity of PMTCT partners through three approaches: staff salary support, central trainings, and on-site preceptorship.

In each of the proposed PMTCT centers, AIDSRelief will provide funding for one full-time nurse dedicated to only PMTCT activities. This will allow the partners to either finance an existing position which was previously funded by another USG partner or MoH, or it will enable the partner to hire an additional PMTCT nurse. In addition to the nurse position, funds will support one community worker per site whose efforts will be to strengthen the essential link between communities and the health facility, which must underpin successful PMTCT programs. The community worker will also be essential to tracking pregnant women and HIV exposed infants. The community worker will facilitate referrals to TB and ART programs and ensure that HIV exposed infants receive prophylaxis.

All proposed PMTCT partners will receive centralized training and on-site supportive supervision. AIDSRelief technical teams will work with PMTCT partners to reinforce the application of MoH policies and guidelines in the provision of PMTCT services. In coordination with NACP, AIDSRelief will train 4 health workers per partner in the clinical delivery of PMTCT services and strategic information. Clinical training will focus on provider initiated counseling and testing, referral systems between PMTCT and ART programs, ARV prophylaxis regimens, post-partum follow-up for mothers and HIV-exposed infants, infant diagnosis, safer delivery options, and safer feeding options. The strategic information training will introduce partners to new government PMTCT data collection tools.

During the supplemental funding period, all PMTCT partners will benefit from at least one on-site preceptorship visit. Emphasis will be given to building referral linkages between PMTCT and ART services. Attention will also be given to provider initiated testing programs, ensuring all pregnant women attending ANC receive opt-out testing. In addition, the technical teams will help the PMTCT community workers strengthen the linkages and outreach into the community for improved follow up of PMTCT patients. The proposed program will concentrate on ways to get more women to deliver in health facilities and ensuring that HIV+ mothers and their babies receive the full package of essential PMTCT and ART services with on-going follow-up.

AIDSRelief will promote HAART regimens for those mothers who qualify for tx and dual prophylactic regimens in line with National and international recommendations for those mothers requiring prophylaxis for prevention of maternal to child transmission. Trainings will promote the national guidelines for PMTCT prophylaxis in hopes of reducing risk of nevirapine resistance and in utero transmission of HIV.

b) Procurement of Supplies: While many existing PMTCT programs receive supplies through government distribution mechanisms, quantities are often insufficient to meet the needs. AIDSRelief will supplement these as per the national PMTCT package. All PMTCT partners will receive a minimum package including HIV test kits, and delivery kits for use in the hospital. In order to ensure that HIV positive mothers are assessed, AIDSRelief will also provide advice and funding to ensure that CD4 tests are carried out on all HIV-positive pregnant women at the time they receive their HIV result. Links and necessary supplies for infant diagnosis will be provided for five health facilities near Mwanza in conjunction with the PCR testing at

Bugando Medical Center.

In addition to these supplies, all proposed PMTCT partners will receive training in forecasting of ARVs for prophylaxis for pregnant women and their infants in accordance with the national guidelines. AIDSRelief will pilot a family-centred approach at Makongoro Health Centre in Mwanza where ART will be provided in the ANC. In line with recommended national guidelines, women will receive triple therapy through the CTC. Women who do not have access to triple therapy at 3 sites without ART programs will use prophylaxis of single dose nevirapine followed by a tail of Zidovudine and Lamivudine for 7 days to minimize developing resistance to nevirapine. Infants will receive single-dose nevirapine after birth and AZT twice for 7 days. c) Continuum of care for HIV-exposed infants As part of its family-centered model of care, AIDSRelief emphasizes the provision of HIV services for children. This includes early infant diagnosis and the close follow up of HIV-exposed infants. To ensure HIV-exposed infants are identified and monitored, AIDSRelief will support the following activities.

5 health facilities will be linked into laboratory services available at Bugando Medical Center for early infant diagnosis. This will require training in taking the correct infant blood sample as well as establishing linkages for transporting the samples to Bugando and receiving the results. At present, the NACP's Pediatric Working Group, in which AIDSRelief technical staff is actively participating, is finalizing the national guidelines for early infant diagnosis.

All 29 sites will put in place infant follow-up mechanisms to ensure that HIV-exposed and HIV-infected infants receive appropriate services and interventions. Linkages between AIDSRelief's PMTCT and ART programs will ensure that both mother and child are enrolled in care and treatment services. At ANC, AIDSRelief will use registers to track HIV-exposed infants and encourage their mothers to utilize the available services. The identified HIV-exposed infants will be followed up periodically and will be eligible for cotrimoxazole prophylaxis from 6 weeks after birth until proved to be HIV-negative. Those who are HIV-positive will be staged using WHO criteria and managed accordingly. d) Linkages with other services: AIDSRelief's comprehensive care and treatment approach provides an excellent platform to strengthen PMTCT programs. Key to this is linkages within the health facility and links into communities. By integrating PMTCT into antenatal care, AIDSRelief hopes to link with the CTC in order to identify women who will benefit from HAART earlier in the pregnancy and will then return for delivery at a health facility. HIV-positive women from PMTCT will be referred to the CTC using a special form with space for feedback to PMTCT staff. There will also be a register at the CTC noting which programs have referred patients to the CTC. AIDSRelief will also support community mobilization for both increased HIV testing in pregnant women as well as increasing awareness of communities to the benefits of deliveries in health institutions and the appropriate follow-up of their infants. We will use lessons learned from couples testing at Makongoro Health Center to scale-up this activity during COP'08.

Targets

Target Target Value Not Applicable Number of service outlets providing the minimum package of 29  PMTCT services according to national and international standards Number of pregnant women who received HIV counseling and 13,300  testing for PMTCT and received their test results Number of HIV-infected pregnant women who received 3,383  antiretroviral prophylaxis for PMTCT in a PMTCT setting Number of health workers trained in the provision of PMTCT 838  services according to national and international standards Coverage Areas Manyara

Mara

Mwanza

Tanga

Table 3.3.01:

This activity narrative links to activity #. 7692 and 7694 on ART Services.

AIDS Relief has incorporated efforts to maximize the entry points for early HIV diagnosis and treatment and screening for TB and is working to strengthen links between these services through a process of networking, training, and supportive supervision within a network of institutions providing quality HIV care and treatment to underserved populations in Tanzania.

Objective: To strengthen the capacities of Care and Treatment Centers (CTCs) to be able to detect more TB cases among HIV-positive clients, provide referrals to TB units, and deliver appropriate care to TB/HIV co-infected clients.

AIDSRelief will work with health facilities and other partners to: strengthen the capacities of CTCs for early detection of TB cases among HIV-positive patients and facilitate referral to a TB clinic for appropriate treatment; to strengthen capacities of CTCs to receive TB/HIV co-infected clients referred from TB units for appropriate HIV care and treatment, including cotrimoxazole prophylaxis if indicated; to strengthen referral linkages and monitoring between CTCs and TB services in order to capture the maximum number of patients and to identify those who do not complete the referral link; and to collaborate with other stakeholders working on TB/HIV linkages.

Partner sites will be located in the Manyara, Tanga, Mara, and Mwanza regions. Work sites will include the two existing health facilities and 10 new service outlets bringing the total to 12

In FY 2007 proposed Major Activities includes: Facility Needs Assessment and Sensitization of Key Stakeholders:

AIDSRelief appreciates and recognizes complementary efforts of various stakeholders in achieving objectives. AIDSRelief will identify these players throughout the process as part of the needs assessment at each facility. Sensitization workshops will be conducted for key stakeholders (e.g., TB and Leprosy Coordinators, HIV/AIDS Control Coordinators) and health facilities key staff (from CTCs and TB units) to help these professionals better understand the TB/HIV link and its implications. Finally AIDSRelief will design an individual facility-based workplan to address various gaps identified during the needs assessment.

Capacity Building: Sustainability and the building of local capacity will be a priority throughout implementation. Using the Tanzania National Guidelines for TB/HIV Linkage, and trainers from the National AIDS Control Program (NACP) and the National Tuberculosis and Leprosy Program (NTLP), key health facility staff will discuss relationships between TB and HIV, TB screening, diagnosis and management of co-infected patients in many scenarios. The number of staff to be trained will depend on factors such as staff availability and area prevalence rates.

Monitoring and Evaluation: AIDSRelief will train CTC staff on the use of TB/HIV indicators tools, data collection, analysis, and reporting. This will help hospital staff to become more comfortable with various data-reporting tools in use at their facilities and to meet the criteria of the National Care and Treatment Plan and supporting partners. Well-integrated and efficient facility-based strategic information systems will assist CTC teams to analyze collected data and use it for planning and decision making.

Development and Dissemination of Screening Tools: In collaboration with various stakeholders, AR will develop a harmonized, comprehensive TB screening tool and disseminate it for use in voluntary counseling and treatment centers.

Establishment and Strengthening of Efficient Referral Mechanisms AIDSRelief will establish and strengthen efficient referral mechanisms for clients diagnosed with TB at the CTCs, ensuring that they are referred to TB units for appropriate treatment. Also those referred from TB units and co-infected with HIV will be received and managed at CTCs accordingly. AIDSRelief intends to strengthen this bidirectional traffic by

conducting regular meetings between the TB units and CTC staff teams. These meetings will help staff to build team spirit around patient management, identify challenges, and plan for common solutions.

Supportive Supervision: AIDSRelief will provide regular onsite supportive supervision in both clinical and technical mentorship and monitoring. This will involve onsite training via AIDSRelief's multidisciplinary team. Ongoing opportunities for skills improvement to hospital staff, especially to those dealing with data management will be provided. AIDSRelief will provide technical assistance to local partner treatment facilities and maximize opportunities provided through collaboration with the Ministry of Health and Social Welfare (MOHSW) with the goal of establishing an efficient and accurate medical records system for TB/HIV services that is based on quality data and consistent with the national referral system.

Information, Education, and Communication Materials: IEC materials developed for TB/HIV from the MOHSW will be made available to clients. This will be supplementary to the health information provided at the clinic

Working with Other Partners: AIDSRelief will use approved national guidelines to train our staff and use facilitators from NTLP and NACP whenever possible. Also, AIDSRelief will collaborate with other key partners (e.g., NTLP in Tanga, and PATH in Mwanza) who are working on TB/HIV linkages; so that efforts and activities will be complementary including managing HIV among those referred from the TB unit and referring HIV-positives with TB to them.

Targets: AIDSRelief's goal is to screen 100% of all HIV clients enrolled for care and treatment at each service facility for TB. It is predicted that approximately 30% of these targeted clients will be co-infected with TB. At least 90% of TB patients will be screened for HIV; 50% of them will be expected to to be HIV-positive.

AIDSRelief ART services (Tz funds)

The AIDSRelief Consortium (AR) FY07 activities will build upon the accelerated scaling up of activities under the regionalization plans funded through FY06 plus-up funds. AR will provide direct support to both GOT and FBO ffacilities in Mwanza, Mara, Manyara and Tanga to reach a target of 20,897 patients on ART by September 2008 in 32 Local Partner Treatment Facilities (LPTFs) and 3 satellite clinics. The pediatric ART target is 2717, 13% of the overall ART patient target, and AR anticipates accelerated pediatric enrollment as the program continues to grow.

The AR FY07 strategy will support the integration of HIV/AIDS care and treatment into existing health facilities with an emphasis on quality assurance/quality improvement (QA/QI). Key components will include 1) sustainability and training 2) a family-centered model of care 3) community linkages and 4) monitoring and evaluation.

Sustainability and Training: A central element of the program remains sustainability. This will be achieved by: incorporating Regional Health Management Teams (RHMTs) in activities and increasing their supportive supervisory skills; providing ongoing clinical trainings to support the GOT in offering sustainable, equitable, quality HIV care and treatment; engaging communities by educating them about their own health and promoting their key role in sustaining the program; involving PLWHA at the community and national levels with policy advocacy; working with the GOT to establish a QA/QI program. Pharmacy, basic strategic information and financial compliance training will be also provided to all sites. FY07 trainings will focus on new sites and biannual CME sessions will be instituted. AR will ensure that companies providing lab equipment provide on-site training during installation.

AR will provide on-site supervision and mentoring to all 32 health facilities in tandem with RHMTs, improving quality of care at care and treatment centers (CTCs) while strengthening supervision and clinical capacity of RHMTs. AR will also enlist RHMTs in decision-making related to the distribution of resources. Strengthened RHMTs will contribute both skills and improved information gathering up to the national level. Assessments identified critical human resource needs in many CTCs. AR will support such needs through direct contracts or other mechanisms as necessary for an initial 12 month period to overcome critical needs and help build clinical capacity of existing staff. This is with an understanding that the government includes these additional staff in their budgets after 12 months.

Family-Centered Model of Care: AR promotes a family-centered approach to HIV care and treatment and is committed to building its pediatric patient load to 13% of total patients. The family-centred model will require orientation of all hospital staff in HIV and the basic principles of treatment; review and identification of linkages between the CTC and other potential points of entry to reach men and children especially - i.e. MCH, ANC, general outpatient and inpatient services and encouraging provider-initiated diagnostic testing. In addition, AIDSRelief, through its strong relationships with community outreach, will sensitize communities to the need to bring in infants, children and their spouses for testing. Special attention will be given to mentoring in pediatric care and treatment to strengthen skills of care providers. AIDSRelief will ensure that staff in the LPTFs are trained using the NACP pediatric training modules. In addition, AR is developing a pediatric counselling training model which will be reviewed and possibly adapted for Tanzania. Strategic linkages, already ongoing, with the Clinton Foundation and the African Network for Caring for Children with AIDS (ANECCA), will also enhance pediatric recruitment and capacity building.

Strengthening Linkages with Community Based Programs: AR quality data from other countries indicate the importance of a continuum of care and patient adherence in achieving durable viral suppression to first line regimens. These experiences indicate that a community referral and adherence component that reaches down to the household level is essential. AR interventions will emphasize the cost effective allocation of available resources between treatment facilities and community-based organizations to support patient adherence. These include regular visits of facility staff to community-based organizations providing care and support to PLHAs, emphasizing and promoting Prevention for Positives and healthy living. Faith-based health facilities often have existing networks in

place which AR will use to strengthen these links through lay community health volunteers, training, and supervision. To ensure optimal adherence at government facilities, AR will also link CBOs within government CTC catchment areas to nearby treatment facilities. All facilities, whether faith-based or government, will develop community outreach plans. These links with CBOs also include AR's long standing work with food and OVC programs.

ART quality of care: AR offers a comprehensive portfolio of services that enables safe and successful ART initiation and scale-up ranging from diagnosis of HIV, an emphasis on treatment preparation, clinical mentoring, diagnosis and treatment of OIs, community mobilization and education, patient monitoring, lab training, pharmacy systems and maintenance of medical records. Three multi-disciplined technical teams of clinicians, counselors, nurses, pharmacy, and strategic information experts will provide on-site TA to all sites. In addition to an initial site visit and formalization of care and treatment (C&T) plans at the CTC, TA will include 2 week visits to strengthen HIV C&T and provide on-site staff mentoring. Significant emphasis will be placed on patient adherence preparation, links to community outreach, improving outpatient clinic efficiency, and strengthening continuity of care. During the mentoring process, teams will also address improving the diagnosis of OIs and linkages between TB/STI and PMTCT services. AR will strengthen linkages between VCT and TB centers. All TB patients will be screened for HIV. By strengthening pharmacy forecasting and procurement, AR will ensure sites access cotrimoxazole for prophylaxis and fluconazole for those who require this. In addition, AR will work with the MOH to define a basic care package and pilot such a package (insecticide treated bed nets, cotrimoxazole, clean water, etc.) at one site.

Monitoring and Evaluation: To increase the efficiency and effectiveness of M& E, AR will focus on capacity building, strengthening of SI systems and the promotion of data use, and the integration of AR M&E systems with MOH systems. A total of 32 staff at 16 LPTFs activated in FY07 will be introduced to the national data collection system. AR will provide monthly SI support to all sites to ensure timely compilation of indicators and the integration of tools into clinical practice. The data collection will be facilitated through the introduction of computers into sites and dedication of one staff member to capture the data. To improve the use of data in clinical care, AR will link SI staff and clinicians and use routine quality improvement activities. AR will also conduct a life table analysis to examine factors associated with entry and exit from the program. Such tools will give AR and CTCs the ability to improve patient management, address adherence challenges, and maintain quality of care. AIDSRelief will base two of its SI Associates regionally to assist with data collection and M&E support. One will be based in Arusha in support of partners in Manyara and Tanga and another in Mwanza to support partners in Mwanza and Mara. A senior SI advisor based in Dar es Salaam will coordinate regional efforts, synthesize data and liaise with SI staff at both USG and NACP.