MDH has built on its experience with antenatal clinics (ANCs) and PMTCT in Dar Es Salaam (DSM) which has been developed and strengthened over the past 13 years. Harvard is presently providing PMTCT services in six large ANCs in all three districts of DSM since 2006 using PEPFAR funds. The prevalence of HIV among pregnant women at these clinics varies between 8-10%.

To ensure efficient and effective PMTCT service provision at these model sites, site readiness assessment visits were conducted, management and planning meetings were held with stake holders all aspects of PMTCT at the site and district levels were discussed and site specific work-plans were developed; service providers were trained in accordance with national training manuals and PMTCT services were established. In addition, to ensure comprehensive care provision for HIV positive pregnant mothers and to ensure exposed infant follow up, Harvard is currently in the process of strengthening existing referral systems.

Since the national coverage of PMTCT services is about 10%, Harvard School of Public Health intends to expand PMTCT services in Dar Es Salaam and work with the MOHSW to exand PMTCT services and operationalize PMTCT regionalization in Dar region. HSPH is working closely with Muhimbili University College of Health Sciences (MUCHS), Dar es Salaam City Council. With FY 07 funding HSPH worked in 8 health care facilities to provide PMTCT services. The plus up funds will be used to continue supporting the high quality PMTCT services in existing 8 Reproductive and Child Health (RCH) sites and extending support to 6 additional health facilities in the Dar es Salaam (DSM) region and provide PMTCT services to an additional 25,500 pregnant women. The 6 additional health facilities in DSM, are Magomeni and Mburahati Dispensaries (Kinondoni District), Vingunguti and Tabata dispensaries (Illala District) and Kigamboni Health Center and Tambukareli Dispensary (Temeke District). Assessments at these 6 new facilities will be carried out to determine the level of support needed. HSPH plans to ensure that the PMTCT program is well integrated into HIV care for infants and Pediatric AIDS. Activities that will be carried out include intensive training, both didactic and clinic-based for the different cadres of health care personnel working with pregnant women and children and in accordance with national guidelines/training manuals. HSPH will also ensure enhanced supportive supervision to all the sites it supports through two PMTCT coordinators at each RCH facility (labor ward and antenatal clinic). HSPH will ensure the following service are provided: opt out counseling and testing of HIV to all pregnant women, offering a combination of single dose NVP and more efficacious regimen based on facility capacity, post natal follow-up, nutritional counseling and support to infants and lactating mothers. Since the uptake of NVP is related to facility based delivery, selected facilities will receive additional support to improve obstetric, labor and postnatal wards infrastructure, equipment, commodities and services to encourage more women to deliver at these facilities and for those HIV positive, to access NVP. At each of the sites there will be a comprehensive ‘system strengthening approach' through involvement of all stakeholders. Sensitization and orientation, participatory assessments to determine needs, followed by capacity building, supportive supervision, and renovations where required with service delivery enhancement will all be part of the implementation process. HSPH will strengthen Initiatives for the mother, partner and the child to increase access to comprehensive HIV care and treatment for pregnant women and children in DSM employing a nurse counselor to work at each of the existing 8 facilities and the additional 6 health facilities to enroll HIV positive women and their infants in MDH. HIV positive pregnant mothers will be enrolled at the antenatal clinic and receive comprehensive care and treatment through the postpartum period. Enrollment of the infant, infant diagnosis, and follow-up care and treatment for the mother and infant will be strengthened and referral mechanisms will be supported. HSPH Home Based Care system which covers the three municipalities in DSM will be used to help increase patient adherence and minimize loss to follow up of patients and it will be used to facilitate infant diagnosis and the initiation on infants on ARVs. This will ensure that all HIV positive individuals identified through PMTCT receive good quality continuum of care. Renovations, if appropriate, will be done to ensure efficient utilization of physical resources.

This activity narrative links to activity no. 7722 and 7719 ART services. From the start of the program in November 2004 to July 2005, Harvard (MDH) enrolled 16,102 patients in care and treatment, initiated antiretroviral treatment (ART) for 8,500 patients, and provided tuberculosis (TB)-related treatment and care for 4,500 patients. The program has expanded from four to 23 sites, including the three main district hospitals, health centers, and semiprivate and private facilities in Dar-es-Salaam thereby rapidly increasing the number of patients in care and treatment.

At Care and Treatment Centers (CTCs): At our present site, provider-initiated counseling and testing, pediatric care and treatment, and treatment of opportunistic infections, screening HIV-positive patients for TB, if possible referred to TB clinics and MDH receives TB patients from TB clinics for ART. MDH provides laboratory services for better TB detection; strengthens home-based care (HBC) to enable HBC providers to pick up TB cases; trains physicians to diagnose and treat TB in HIV patients and trains lab personnel on TB diagnostics; develops quality assurance processes by using already developed Care and Treatment Standard Operating Procedures (SOP) for treatment of co-infected patients; and provides monitoring and evaluation (M&E) which includes a database with built-in quality checks and surprise Quality Improvement (QI) visits which are conduced biweekly by site managers trained in QI.

At MDH's pilot TB/HIV integration clinic: To maximize entry points for HIV diagnosis and treatment and screening for TB in Dar-es-Salaam, at this site, MDH provides CT, diagnoses HIV, determines eligibility criteria and, if indicated, provides ART at the TB clinic, in collaboration with the National Tuberculosis and Leprosy Program (NTLP) and the National AIDS Control Program (NACP).

Proposed activities: At the CTCs: To further decrease the burden of TB among people living with HIV/AIDS (PLWHA) and increase the HIV care available for TB patients, activities will be expanded from one site to a total of 10 MDH CTCs. Activities will include: screening all PLWHA for TB; referring PLWHA to TB clinics where they will receive TB care and management; and receiving TB patients from TB clinics for ART. It is anticipated that all patients attending MDH supported CTC's will be screened for TB and those diagnosed to have TB disease will be referred to TB clinics for TB treatment. An estimate of 5400 HIV infected clients will be attending care/treatment services and at the same time receiving treatment for TB disease. At the TB Clinics: Results of the pilot will be evaluated and the possibility of expanding complete integration of these activities will be decided after discussions with the NTLP and NACP.

Generally, in addressing TB/HIV care and treatment, MDH in close collaboration with the NTLP and the NACP will focus on the following:

Strengthening communication and referral systems: Key stakeholders have already taken part in sensitization meetings; they include the TB and leprosy coordinators and the HIV/AIDS control program coordinators at all three districts where MDH has proposed activities. they have assessed the communication and referral systems between the CTCs and TB staff at the proposed sites. To improve communication between TB and CTC units, MDH will conduct monthly meetings to build up team spirit, have a holistic approach to patient management, identify challenges, and plan for common solutions. They will work with the NTLP on a standardized TB screening tool and the Ministry of Health (MOH) to harmonize existing referral forms for all TB/ HIV partners. Onsite personnel will be identified in both these units to coordinate referrals and document them in referral logs and national registers. Staff at the CTCs and TB clinics will be able to compare daily logs and generate lists of missed referrals, which they can send to HBC for further follow-up. This will significantly improve: the provision of HIV counseling and testing to all TB patients; screening all HIV-infected patients for TB; linkage of all HIV-infected TB patients to HIV care and treatment; and linkage of all HIV-infected TB suspects to TB diagnosis and therapy.

Data management for effective M&E: MDH will monitor staff skills and consolidate current recording and reporting systems to improve program management and address difficulties of TB diagnoses in HIV patients. Using a strong M&E system at these sites, all

facility-based strategic information systems will be well-integrated to improve quality of care. Staff will be able to use the resulting data collection and the management and reporting system to make information-based decisions to support patients and meet reporting requirements. Furthermore, a combination of supportive supervision, technical assistance, preceptorship, systems strengthening, and logistics improvement will be used to monitor, evaluate, and increase the quality of services.

Capacity building, training and sustainability: This is the core of the program as is seen by the local capacity they have and continue to build. Locally feasible, sustainable SOPs will be developed in collaboration with healthcare providers (HCP). MDH will conduct regional and inter-country workshops where participants can share experiences and lessons learnt in care and treatment of TB/ HIV. Support for personnel to attend workshops with the NTLP, MOH, and other partners on various aspects including the national M&E system will be provided. Minor renovations of the physical structures of the CTCs will be made for optimal utilization of space and improving patient flow.

MDH will use national guidelines and curricula to train HCPs on TB screening, diagnosis, and management of TB/HIV co-infection. In collaboration with the NTLP and NACP, training workshops on TB/HIV indicators, strategic information systems, data documentation and analysis and reporting to personnel will be offered. MDH will train TB clinic staff, strengthen lab diagnostics related to TB, and ensure that regular QI of lab activities at the sites will be done by our central lab.

IEC: In addition to the counseling and information provided by MDH health care professionals, they will offer informational material developed for TB/HIV by the MOH.

This activity relates to activities in TB/HIV (7721) and PMTCT (7720).

Between the start of the program in November 2004 and July 2005, 16,102 patients have been enrolled in care and treatment, including 1684 children, 373 pregnant women and 384 TB patients currently on ARV's. Of these, 8500 were initiated on ART. The Harvard (MDH) program has expanded from 4 sites to 23 sites.

In FY2006, specific achievements have included the implementation of double shifts, strategic site renovations for optimal space utilization, time block patient appointment systems to streamline patient flow in clinics, successfully piloting initiation of treatment at the health center level, piloting integration of TB/HIV activities at district hospitals, piloting new referral systems, piloting new pharmacy software for the NACP, integrating a locally managed quality Improvement (QI) and M&E system, and incorporating a locally assembled and operated human resources and payroll system.

During the proposed funding period MDH will expand care and treatment services in their assigned larger Dar es Salaam (DSM) region under regionalization. MDH will scale up to one tertiary care hospital (Muhimbili National Hospital) and 14 health facilities in addition their current 7 sites (3 District hospitals (DH) Infectious Disease Clinic and 3 Health Centers (HC). In concert with regionalization, different levels of involvement will occur at each of the proposed sites to maximally stretch available resources.

With central funds, MDH will maintain 8,000 patients on ARV's, an additional 2,000 with FY2006 level funds, and with the increase in funds in FY2007, MDH will enroll and maintain an additional 7,000 patients, to bring a total ever enrolled to 17,000 patients by March 2008, and over 20,000 by September 2008. Children will account for 15% of the total.

In FY2007, activities will focus on certain key areas to support the continuum of care. Preventive package: This will continue to include cotrimoxazole prophylaxis, effective TB interventions including screening for TB at Care & Treatment Centers (CTCs) and follow up of TB patients; and education about safe drinking water and proper hygiene. Linkages will be made between the malaria program and CTCs by having monthly meetings at sites where overlapping activities can be better coordinated. Nutritional counseling and support services will be provided at all sites.

Leveraging local stakeholders' capacity: MDH will strengthen the links between home-based care (HBC) at 23 CTCs and the community by integrating their services with other stakeholders in DSM. A stakeholder analysis will guide the mobilization of appropriate resources and help implement pragmatic collaborative mechanisms. All stakeholders will be instrumental in formulation of a common work plan. The mapping of resources and organizations involved in HBC will be a major contribution both for the program in DSM region and nationally.

Strengthening referral systems: MDH has an efficient referral system based on the modified network model, which will extend to the new 15 facilities. The system will include 2-way referral forms, referral coordinators on-site, cross checking lists of referred patients between facilities on a daily basis, referral documentation and integration of patients accessing different components of care into one central database. Complicated cases will be referred to a tertiary care site. Regular meetings between referral coordinators will be held. The referral system will encompass facility based care and HBC providers in DSM with monthly stakeholder meetings to help identify challenges and plan for common solutions. The 2-way referral systems that will be established between CTC, HBC providers and community based volunteers will ensure proper feedback. Patient lists at the referring and referee sites will be compared at monthly intervals to help track lost patients.

Family testing: HCP will continue to be trained to encourage patients to bring other members of their family and community for VCT. Prevention of positives will be done among all those diagnosed to be HIV positive with emphasis on discordant couples.

Counseling and Testing: The MDH program will use a multi-pronged strategy. MDH will sensitize HCW to ensure that PIT and VCT referrals occur especially for patients with high risk behavior/symptoms of HIV attending other hospital services. VCT providers will be

recruited and based in in-patient wards. Counselors and HBC providers have been trained to bring in other family members especially husbands and children to facilitate VCT, enabling disclosure and making services family-friendly. This will also provide psychosocial support, reduce stigma and reduce domestic violence. Links between existing stand alone VCTs and CTCs will be strengthened and referral systems developed for better patient access to treatment. Mothers visiting immunization clinics will be given VCT and the children tested. Documentation of all patients who are counseled, tested and those receiving their lab results will be done, these records cross verified at biweekly intervals and entered into the central database.

Pediatric Care: To ensure that HIV exposed infants receive optimal care, information from the mothers ANC card will be transferred to the baby's card at delivery to ensure continuity of documentation. Cotrimoxazole prophylaxis will be provided to all exposed children at the sites. HCW will be specifically trained to insist that mothers bring their ANC card to the pediatric immunization clinic. MDH will organize trainings for HCW working in immunization clinics to ensure that information on the infants' exposure status will be transferred to the baby card at these clinics. They will advocate for integration of this with the immunization scheme of the government so that all exposed children presenting at 6 weeks or more will be tested using DBS DNA PCR. Supervisory visit teams with a pediatrician to ensure that quality of care for children. Functional referral systems between the ANC, labor wards, immunization clinic and the CTC will be developed and implemented using specially designed 2-way referral forms and training of HCP from these areas. Additionally all children in in-patient wards and those presenting with a downward trend in their growth chart will be tested. Discussions with the Social Welfare Department and orphanages in DSM to develop mechanisms to increase preferential access to HIV/AIDS care for orphans at their sites. Sensitization meetings for caretakers of OVCs on pediatric HIV testing and CTX prophylaxis will be held quarterly.

TB/HIV: MDH activities in this area are described in the TB/HIV program area.

Quality of Care: Regular QA and QI visits using MDH DSM tools, specific QI lists combined with supportive supervision, technical assistance, preceptorship, system strengthening and logistical improvement will make quality services more accessible. A QI tool with DSM specific indicators of care and treatment developed for the program by JSI Inc, continues to be used for surprise visits to ensure that quality is maintained.

Sustainability: Recruitment of all staff will be through the government system thereby strengthening existing health systems and ensuring continuity of these positions in the long run. Several MDH-trained site managers have been promoted as district hospital directors and district medical officers. Locally feasible, sustainable SOPs will be developed in collaboration with HCW to enable them conduct these services effectively. MDH will conduct regional and inter-country workshops where experiences and lessons learnt will be shared. As access to funds is an important part of sustainability, they will continue helping collaborators apply for funding from funding agencies.