This activity is a targeted evaluation linked to Strategic Information, Palliative Care and HIV Treatment activities and is a continuation from an approved FY 2006 entry. According to the 2005 HIV/AIDS Indicator Survey (THIS), 8% of couples tested for HIV were found to be discordant. The THIS states that "the vast majority of these cohabitating couples do not mutually know their HIV status", confirming anecdotal experiences on the ground. The goal of this targeted evaluation is to assist in the development of interventions that will increase the likelihood of self-disclosure of HIV status and reduce the negative impacts, perceived or real, related to disclosure. To meet this goal the evaluation will ask the question "what are the social and personal factors that either promote or hinder an individual's decision to disclose their HIV status to their partner(s)"? The evaluation will employ qualitative methods with clients who have been tested in clinical (i.e. those that are providing CT as part of other services such as ANC and TB) as well as VCT sites. In the VCT setting, clients will be asked, pre-test, if they had considered implications of a positive test result vis-à-vis partner notification and strategies they think they might employ to disclose their status. Interviewees identified through clinical settings will not be interviewed pre-test as they will not have entered the service for the purpose of getting tested for HIV and have, presumably, not considered this issue. Both types of clients will then be followed-up to document actual disclosure decisions and behaviors as well as barriers and facilitators related to disclosure. It is anticipated that barriers might include fear of stigma and discrimination as manifested through property dispossession, familial separation, and social isolation; fear of being blamed for bringing HIV into a relationship and possible violence and retribution; being faced with difficult decisions regarding childbearing; and perceptions that telling a partner that they might be HIV infected could hasten illness or death. All of the barriers to disclosure mentioned above have been documented in other settings but have not been validated in the Tanzanian context. Validation and/or identification of other possible concerns is critical for the development of effective counseling and community support interventions. Understanding factors that facilitate disclosure is also critical for the development of action oriented interventions. Findings will be validated through focus groups and individual interviews with members of PLHA organizations. Outputs of the evaluation, which will be completed within FY 2006, will include documentation of: barriers and facilitators of disclosure for adult men and women; manifestations of stigma and discrimination in the Tanzanian context; societal, communal, and familial contexts that support the seeking of voluntary testing services; and the role that counselors and providers can play in preparing a client to self-disclose. Findings will be disseminated through national stakeholder events as well as during USG program review meetings. The timing for this evaluation is ideal because the Ministry of Health, through intensive support from the USG, will be considering the development and implementation of integrated CT across clinical services. The findings of the study will inform the content of new protocols and guidelines and play a key role in developing effective counselor training materials. The result will be counseling techniques targeted towards Tanzania specific barriers to disclosure and overall improvement of provider-patient communication. Counselors and providers will be more effective in preparing and assisting clients to voluntarily disclosure and will also be able to introduce clients to the concept of shared confidentiality. Evaluation findings will be utilized by all USG partners that are developing mass media, and print materials and by partners that are working within communities to address stigma and discrimination. Community engagement efforts will help identify specific actions that can be undertaken by leaders or key community members to create an environment where people feel free to disclose their status. The findings will also feed into activities that are designed to create dispel myths about C&T and ART.

National Survey Research and Data Dissemination and Use

ORC Macro, which implements the MEASURE Demographic Health Survey project, has a long history in Tanzania. Most recently, Macro has provided technical assistance to the Ministry of Health and the National Bureau of Statistics (NBS) to carry out the Tanzania HIV/AIDS Indicator Survey (THIS), the Tanzania Demographic and Health Survey (TDHS) and now the Tanzania Service Provision Assessment (TSPA) survey. In addition, Macro has collaborated with local organizations to produce several well-received dissemination products and activities, including a curriculum on using the THIS data; print materials; geographic information systems (GIS) training, and mapping of USG HIV-related interventions nationwide. For 2007, Macro is proposing to carry out several dissemination, data utilization, and capacity building activities related to the TSPA and the TDHS surveys as well as beginning a second HIV/AIDS Indicator Survey to provide up-to-date data on the prevalence of HIV and related behavioral patterns in Tanzania.

At present, MEASURE DHS is providing technical assistance to the National Bureau of Statistics (NBS) to implement the Tanzania Service Provision Assessment (TSPA) survey. Fieldwork for the TSPA was completed in mid-August 2006; the results will be available in 2007. The TSPA includes critically important data on the availability and quality of voluntary counseling and testing of HIV, prevention of mother-to-child transmission of HIV, treatment of tuberculosis and other opportunistic infections, and antiretroviral therapy throughout the country. The results of this survey will help USG, Government of Tanzania, and other agencies supporting health care delivery to improve planning, monitoring and evaluation of health services.

To ensure that these important survey findings are used to the fullest extent for activities funded through the President's Emergency Plan in Tanzania and for other government and private activities, ORC Macro is proposing to prepare and print 5,000 copies of a simple, user-friendly Key Findings Report on the HIV findings from the TSPA and the TDHS. This Report is designed to be accessible to non-technical audiences who need to understand the status of HIV-related health care services in Tanzania, including Parliamentarians, community health workers, and community-based NGOs. The HIV Key Findings Report will be written simply with clearly designed graphics so that these important audiences can easily absorb the information. The large print run also ensures that the information will be available nationwide, including to all district health management teams and to community multisectoral AIDS committees. In addition, Macro will prepare 1,000 compact disks with PowerPoint presentations on the TSPA findings for organizations working on HIV-related activities to use with their constituents.

The second proposed dissemination and data utilization activity for TSPA findings is to convene twelve one-day seminars with major stakeholders in Dar es Salaam and in two other regions selected by the USG, to provide an intensive briefing on the HIV results. The TSPA is a new survey and thus will be more difficult for key stakeholders and audiences to understand. The objectives for these proposed one-day seminars are to increase stakeholders' understanding of the TSPA findings on access and quality of services and to increase their ability to apply these findings to program planning, budgeting, and monitoring and evaluation. Participants will break into small groups to review the text and tables of the HIV TSPA report and make sure they can correctly interpret the tables and graphics. Finally, participants will work on a series of exercises which will help them identify priorities for change and consider the most appropriate interventions to address major issues emerging from the TSPA. Audiences most likely to benefit from these seminars are project managers, health care providers, USG cooperating agencies, government agencies like the National AIDS Control Programme, and non-governmental agencies like the Christian Social Services Commission.

The third proposed activity for FY 2007 is to collaborate with the National Bureau of Statistics (NBS) to begin the second Tanzania HIV/AIDS Indicator Survey (THIS). The THIS will collect data from about 12,000 women and men age 15-49, nationwide, on knowledge, attitudes, and practices related to HIV/AIDS, using internationally accepted indicators. In addition, with informed consent from survey respondents, interviewers will take blood samples to test for HIV, allowing for analysis of national HIV prevalence and for assessment of background and behavioral characteristics associated with HIV infection. Unlike the previous THIS, the survey to be conducted in 2007 will facilitate the provision of

counseling as well as results if desired by the respondent. The second THIS will also allow for analysis of changes over the past 4 years in such important indicators as age of sexual debut; condom use outside of marriage, frequency of HIV testing and counseling, and the prevalence of orphaned and fostered children. Data will be collected in both urban and rural areas and will be representative at the national level, regional level and for wealth quintiles. For 2007, Macro is requesting funds to cover a portion of the local costs and technical assistance including: adapting and pretesting the questionnaire; drawing the sample and doing the household listing, and training interviewers, data processors, and laboratory technicians.