The Elizabeth Glaser Paediatric AIDS Foundation (EGPAF) will support the Regional TB and Leprosy Coordinator in Tabora region to initiate and coordinate TB/HIV activities in each district hospital and health centre that has both a TB clinic and a CTC. As part of their comprehensive care and treatment program EGPAF will expand services that will increase case finding of TB-positive adults, infants and children in care and treatment clinics and will establish a system that targets to screnning 2040 HIV patients for TB. This will involve institute a "TB screening checklist" as part of routine clinical assessment at each visit; training of providers in co-management of TB and HIV and on effective TB screening (symptom checklist and diagnostic algorithm) and supportive supervision at sites. EGPAF will collaborate with partner supporting TB Clinics by training TB clinic staff (clinical officer in charge, DOTs nurse and lab staff) in Diagnostic counselling and testing so that they can ensure that all TB clients are actively provided diagnostic counseling and testing, either directly in the TB clinic or as part of an active referral system within the facility. Within district and district designated hospitals EGPAF will assist in building linkages between the TB and HIV clinics through a Multi Disciplinary Team approach. Management and contact persons in the CTC and the TB clinic will be supported to plan for implementing an integrated program. To reach lower level centers as part of a district network approach they will increase the referral of TB/HIV positive adult and pediatric clients to care and treatment services and TB service outlets. This will involve linking clients from lower level Health Centers to the appropriate CTC service outlet and tracking through a two way referral system. EGPAF will implement practical measures to prevent TB transmission in health care settings - focusing on minor repairs, innovative work schedules, improved ventilation and protective gear. Finally, EGPAF will conduct community sensitization on TB/HIV interaction, diagnosis and treatment of the two conditions; Providing reagents and supplies for TB and HIV diagnosis; Providing mentorship by staff from Kibong'oto National TB hospital on TB/HIV management.

Project HEART of EGPAF was initiated in February 2004. As of 30th June 2006 it had enrolled 4633 patients on ART including 676 children. By September 2008, EGPAF will have enrolled over 22,000 adults on ART and over 4000 children. Proposed FY07 activities include the following: a) Expansion to New Sites EGPAF will maintain its support to the already existing 28 hospitals in the three regions. In addition, EGPAF will add two remaining hospitals in Kilimanjaro, one in Arusha, expand to five hospitals in the newly acquired Shinyanga region, and roll out ART in 20 health centers in the four regions, to make a total of 56 facilities by the end of the project year. b) Increased CT Building on past successes at Mawenzi and Kitete hospitals, EGPAF will actively promote and support provider-initiated counseling and testing (PICT) at all patient contact points in outpatient and inpatient departments. The project will orient all facility staff in this approach, support training of more counselors and support provision of HIV test kits. In order to mitigate the shortage of health workers, the project will support the use of lay counselors. c) Follow-Up of HIV tested patients At the ART sites, the site coordinator will continue to conduct daily checks on registers at the RCH clinic, outpatient clinic, in-patient wards and the TB clinic to keep track of patients referred to the CTC. Registers of all tested clients at the non-ART sites will be established and information on their treatment and/or referral regularly checked by an identified person. d) To increase identification, diagnosis and enrollment of children, especially those under two years. EGPAF will increase the enrollment of children especially younger ones by promoting and supporting routine CT of children and their mothers at all contact points in the health facilities including immunization clinics. HIV exposed and infected children will be initiated on CTX prophylaxis as appropriate. Symptomatic children will be staged and treated according to national guidelines The Child-Centered Family Care Center [CCFCC] at KCMC will also contribute to the increase in the number of children, especially in the Kilimanjaro region. The CCFCC will contribute by linking PMTCT to Care and Treatment (C&T); by participating in the National Plan to pilot infant HIV testing by DBS-PCR; by conducting outreach training to health care workers to provide a continuum of care to children and families in their communities; by tracking of patients using registration logs from different sites; by communicating with partners in rural areas to maintain home-based care visits when necessary; and by sponsoring the training of two Tanzanian residents in pediatrics with a focus on HIV/AIDS. EGPAF will continue to collect pediatric data disaggregated by age group to increase focus on identification of HIV infected and exposed children under two years of age. e) Quality of Clinical Care EGPAF shall increase the quality of care offered at all sites through training and mentorship; development and use of SOPs and job aids; program linkages and supportive supervision. In collaboration with NACP and other USG partners, the project will support basic and refresher trainings focusing on adult and pediatric HIV care. Clinical mentors will be assigned to at least 20 sites, health workers will be supported technically through a "warm line". A QI checklist based on the National SOPs for ART will be used by the sites at least quarterly for self-assessment and by EGPAF project officers in supportive supervision.

HBC: EGPAF will continue to support the position of "community liaison person" at each site. The community liaison person will maintain contact information for point persons of each CBO and hold regular meetings with these persons to enhance referral mechanisms. TB/HIV: EGPAF will advocate that PLWHAs be screened for TB before initiation of ART, and those on ART be continuously screened for TB. EGPAF will support monthly meetings between CTC and TB clinic staff for coordination of the joint activities. The site coordinator and TB clinic in-charge will reconcile registers weekly. The Regional TB and Leprosy Coordinator will be supported to coordinate TB/HIV activities in each district hospital. PMTCT+ : EGPAF will expand PMTCT and ART services in concert by expanding and improving testing services; by assuring the follow up of mothers and HIV exposed children; by training health workers on identifying the exposed child, on the care of the exposed child and on presumptive diagnosis of infection in symptomatic young infants for early referral. Prevention with positives: The project will sponsor discussions among PLHAs on best approaches to increase testing of spouses and appropriate prevention for discordant couples and shall promote partnership between sites and organizations in the region that directly support primary prevention and behavior change activities. Risk reduction counseling will be included in all counseling sessions with PLHAs.

It has been agreed through meetings held between EGPAF and the RHMTs and DHMTs in the 3 regions that all health institutions with HIV testing capability can start providing a minimum package of care for PLHA. This will consist of CT (VCT and PICT), PMTCT, care and follow up of exposed children, HIV testing for all TB patients, staging of HIV disease, CTX prophylaxis, and treatment of opportunistic infections. EGPAF will support training of health workers at dispensary and health centre level on basic HIV/AIDS care including clinical examination and staging to facilitate early recognition and referral of patients that need ART; training on OI preventive therapy and follow-up for side effects and compliance with treatment. EGPAF will specifically support MOH Quality Assurance structures in lab and the reprinting and dissemination of the SOPs, supportive supervision by QA teams, and re-training as necessary. f) Strengthening M&E EGPAF will recruit regionally-based M&E officers who will train and supervise data entry clerks, paid for by EGPAF, on data recording, data entry and reporting. These clerks and site coordinators will collate, verify and report data and be trained on the paper-based and electronic systems and data management. Site coordinators will be responsible for reporting of overall facility-level data. Each site will be provided with computers with software for data entry, therefore establishing a computerized data management system. Project-recruited regional technical officers will provide supportive supervision in data collection, utilization and monthly and quarterly reporting to MOHSW and USG, and JSI staff will conduct semi-annual monitoring visits. g) Sustainability EGPAF will continue to use hospital staff, developing their capacity. EGPAF will continue to provide hospitals with direct sub-grants to strengthen their planning and budgeting capacity for long term sustainability. They will continue to hold semi-annual meetings with RHMTs and DHMTs. Regional teams will in turn hold quarterly meetings to coordinate HIV/AIDS activities in their individual regions. The RHMTs and DHMTs will be responsible for selecting the primary level facilities for ART expansion. EGPAF will support ART training of members of RHMTs and DHMTs to aid in facilitative supervision. With plus-up funds, EGPAF will be able to provide significant technical assistance for scale-up of treatment, and improve the quality of services provided. They will work in 4 districts, and in 5 of the regions 7 hospitals. In addition, EGPAF proposes to improve the identification and follow up of HIV exposed and infected children using routine immunization visits in two health facilities. The overall goal is to improve integration of C&T for HIV exposed and infected children into existing EPI (expanded program of immunization) and PMTCT services.