This activity is specifically linked with activity #8682, #8691, #7754, and #7810 in AB, and with #7770, #7667 and #8722.

Despite intensive HIV/AIDS prevention campaigns and an extremely high level of HIV/AIDS awareness in Tanzania, youth risk perception remains low and there is only modest evidence of sexual behavior change. Youth between the ages of 10-24 comprise 30% of general population but account for 60% of new infections. Young women are vulnerable to contracting HIV than men in the same age group. The average age of sexual debut has increased to 18 years for women and 19 years for men. However, almost 11% of young women and 8% of young men report having had sex before the age of 15 years. (THIS, 2004). Through a sub-grant from the National AIDS Control Program, the Tanzania Youth Aware Trust Fund (TAYOA) received support from USG/CDC in both FY 2005 and FY 2006 to address HIV/AIDS education through the implementation of an anonymous and toll-free helpline. The helpline has encouraged youth to access HIV/AIDS information using inter-personal communication, empowering them with knowledge on risk behaviors contributing to the spread of HIV/AIDS. Based on an analysis of more than 17,000 frequent asked questions (FAQs) that were captured, 6,400 (38%) questions were related to abstinence and being faithful. From FAQs, audio-visual information kits were produced and disseminated for sensitization purposes to youth aged 8-14 years attending primary schools, Madrasa (Muslim youth religious classes) and church networks. TAYOA facilitates community-based intervention through youth balozi (ambassadors) to represent concerns on HIV/AIDS at community forums. More than 2,000 youth balozi have been trained to promote abstinence and being faithful messages in five-day seminars that use a using Life Planning Skills manual developed by the Program for Appropriate Technology in Health (PATH). After training, youth balozi conduct AB outreach activities using drama, theatre, debate and sport. In FY 2006, these activities reached 543,170 youth in Dar es Salaam, Coast Region and Zanzibar. Through entertainment-education activities, TAYOA has established 40 helpline clubs and partnered with the HIV/AIDS Faith based Initiatives (HAFI) to perform 25 recreational and educational activities. Examples of activities include composing songs on AB messages that promote delaying sex, partner reduction and fidelity and denounce cross-generational and transactional sex and incest. In collaboration with the National Muslim Council of Tanzania (BAKWATA), TAYOA has also produced Muslim religious songs or "kaswida." The songs have been disseminated in Dar es Salaam (100 copies), Coast region (68 copies) and Zanzibar's primary schools and madras (100 copies). With FY 2007 funding, TAYOA will conduct refresher courses with 2,000 youth balozis and train an additional 3,470 youth balozi as peer educators or helpline club members. The training will emphasize skill building in AB and adopt evidenced prevention strategies that help individuals personalize their risk behaviors using principles of modeling and reinforcement of AB messages at the community level. Additionally, 200 traditional dance troupes, community opinion leaders, imams and priests will be oriented to the Emergency Plan's guidance on how to produce ABC educational messages that endorse positive social and community norms. TAYOA plans to conduct joint AB activities with the Ministry of Education and Culture and the Ministry of Information, Department of Culture. Together these partners will organize 10 AB drama debates and 15 inter-school essay compositions for the promotion of AB. The best essays will be then be used as the basis of BCC materials in a variety of formats such as testimonies, feature articles for low literacy audiences, booklets and illustrative pictures tailored for different age groups. TAYOA will link up with the HIV/AIDS Business Coalition in Tanzania (ABCT) to work with groups that will publicize the best essays in local newspapers. The award ceremony events organized between ABCT and TAYOA will be an entry point for promoting parent-child communication initiatives in addressing AB issues from family level. TAYOA plans to conduct AB activities with 22 higher learning Institutions in Dar es Salaam and Zanzibar. The rationale guiding this activity is that: (1) higher learning institutions students have strong leadership networks that can be used in AB activities and are willing to work with TAYOA; (2) social norms among students promote sexual networks and words such as "msomeshaji-seducer" are commonly used in the student communities; and (3) TAYOA has experience working with and engaging students from higher learning institutions. The aim is to promote positive behavior changes that address fidelity in marriage, reduction of sexual partners among sexually-active youth in Dar es Salaam and Zanzibar at higher learning institutions. This activity will also address common

misperceptions about gender roles and address HIV stigma among student populations. The target is to reach over 5,000 university students, 300 lecturers and over 74,000 youths in neighboring communities through youth forums, workshops and recreational activities. In FY 2007, TAYOA will launch its AB program intervention in higher learning institutions during the annual national youth week celebrations, where higher learning student organization leaders will be involved in the planning process. TAYOA will utilize the existing institution's structures, resources and leadership to advocate for strong be faithful messages that will include gender and male involvement as stipulated in the 5 year HIV/AIDS government strategies. While in Morogoro, TAYOA will also collaborate with the district HIV/AIDS Faith-Based Initiatives (HAFI) structures under Balm in Gilead, support Peace Corps in and out of school programs, and support Youth Net's ABY interventions to facilitate synergy between complimentary USG and government of Tanzania support on ABY activities. TAYOA will hire three additional staff, a technical advisor, and a field supervisor to coordinate, implement and monitor the proposed activities on AB programming. Monitoring and evaluation will be conducted throughout and indicators on the performance of the program will include the number of youths attending VCT services in the 3 regions, number of youths reporting to have learned a positive lesson from the media strategies on ABY, number of outreach activities in schools, and number of trained youths and peer educators on ABY. For sustainability purposes, TAYOA plans to link up and synchronize their activities with the Council Multisectoral AIDS Committees (CMACs) planning cycle in the areas of capacity building, using ABY guidelines that have been standardized and a life planning skills education approach in school youth programs.

This activity is specifically linked with #8687, #9390, #8691, #7754, #7774, #7810, #9060, #9063, #9061, #7727, and #7852 in AB.

The Ministry of Health and Social Welfare/National AIDS Control Program (MOHSW/NACP) has responsibility for coordinating the mainland Tanzania health sector response to HIV/AIDS. One component of the national response is to encourage healthy behaviors that prevent HIV infection through the promotion of abstinence and faithfulness. NACP, through its IEC/BCC unit, aims to increase communication capacity of health care service providers through behavior change communication and social mobilization trainings with a focus on promoting abstinence among young people and encouraging faithfulness and stable sexual relationships among adults. NACP's IEC/BCC unit maintains and supplies a range of innovative materials such as booklets, leaflets and other audiovisual materials for low-literacy and rural populations and the general public.

In FY 07, NACP plans to further promote the use of IEC/BCC materials and build the capacity skills of staff to address AB HIV prevention effectively. This will be achieved by conducting an inventory of existing information resources, identifying information gaps and thereafter developing appropriate IEC/BCC materials. NACP will also train health care providers and media personnel on the appropriate use of IEC/BCC.

An inventory will provide information on the availability of IEC/BCC materials from various sources, including formal and informal sectors. The materials' content, focus, and relevance for various target populations will be evaluated. Indirectly, the inventory also may provide an indication of the level of understanding on issues related to abstinence, delayed sexual debut among young people and faithfulness in sexual relationships. This project will utilize existing knowledge on major obstacles to an effective HIV/AIDS response, such as issues on stigma and discrimination against people living with HIV/AIDS, and gender inequalities, particularly in the area of information access and utilization.

The AB IEC/BCC inventory will be supplemented by a rapid assessment to explore barriers and facilitators to abstinence and faithfulness and influencing factors. Furthermore, possible barriers and best practices in the community that may affect the delivery of IEC/BCC strategies will be identified and examined. Knowledge of these barriers and best practices will contribute to the success of NACP activities. It is anticipated that the rapid assessment will be undertaken in selected regions by a team of local consultants with expertise in this field. All information from the rapid assessment will be shared with USG partners including STRADCOM to assist with the development of radio programming.

The assessment findings will be used to identify behavioral themes and topics for NACP IEC/BCC materials. The NACP IEC/BCC unit will develop and disseminate reference materials for the Regional and District AIDS Control Coordinators (RACCs and DACCs) and other partners to assist them in their IEC/BCC intervention activities. The unit also will develop and print various IEC materials on AB for the general public. Beyond material development, the assessment findings will be used to conduct seminars with partners and media personnel for the promotion of partner reduction and abstinence campaigns. The NACP IEC/BCC unit will also conduct sensitization meetings with faith-based organizations and other public and private stakeholders implementing abstinence and faithfulness interventions in the project area.

Another area of focus in FY 07 will be developing training materials for service providers, conducting training of trainers (TOT) in communication strategies for behavior change, and involving RACCs and DACCs in IEC/BCC activities in the project area. NACP expects to reach 121 DACCs and 21 RACCs in the country by the end of 2008.

NACP will also use USG/CDC technical assistance to develop and train partners on a BCC strategy to link with the planned STRADCOM radio program. NACP will use Modeling and Reinforcement to Combat HIV/AIDS (MARCH), a BCC strategy that integrates modeling through radio dramas and various reinforcement activities such as small group discussions to target change at the interpersonal and community levels. Technical assistance will be sought for developing a toolkit of appropriate reinforcement activities that build upon and strengthen lessons communicated through the radio program, while extending behavior change to the broader community.

The NACP IEC/BCC unit will conduct routine process monitoring during the funding period. Indicators will focus on trainings delivered, intervention quantities related to proposed activities, and IEC/BCC materials and programs produced through various channels as a result of these efforts.

This activity specifically links with activity #7667, #7695, #9457 and #8722 in OP, and #7774 and #7810 in AB.

Through a sub-grant from the National AIDS Control Program, the Tanzania Youth Aware Trust Fund (TAYOA) received support from USG/T in both FY 2005 and FY 2006 to address HIV/AIDS education through the implementation of an anonymous and toll-free helpline. The TAYOA Helpline provides confidential and anonymous services offering HIV/AIDS information on prevention, pre-counseling, risk assessment and referral linkages to youth aged 10-24 years. With 10 toll-free telephone lines operating 10 hours every day, the Helpline staff communicates with more than 15,000 callers monthly and over 180,000 callers annually in Dar es Salaam, Coast region and Zanzibar. The Helpline is staffed by medical students trained in confidentiality, interpersonal communication skills and counseling techniques.

Additionally, TAYOA provides education to the public through youth elect leaders known as "youth balozis", in order to promote behavior change within the broader context of youth reproductive health services complimenting the government's comprehensive HIV/AIDS plans. Using frequently asked questions from the Helpline, audio visual information kits have been developed and are used by the youth balozis. TAYOA conducted a skills building workshop for 70 community youth balozis on correct and consistent use of condoms to address vulnerable youth on sexual reproductive health and prevention of HIV. Monthly participatory meetings are conducted to discuss reports and provide plans for future activities in the respective wards/streets. Through this approach TAYOA trained 354 youth balozis from each street in Dar es Salaam, 174 in Coast region and 128 in Zanzibar.

TAYOA has also used entertainment and education strategies to increase accessibility to the Helpline phone numbers, as well as promoted a community-based drama series to increase behavioral communications skills, using popular role models and characters that portray culturally accepted messages. Advertising using TV, radio, billboards, street banners and clothing have also been strategies used by TAYOA to increase coverage of Helpline services in communities. TAYOA leveraged resources from the AIDS Business coalition of Tanzania (ABCT) to produce and distribute T-shirts, car stickers, and cartoon-posters on stigma reduction and anti-gender violence discrimination. These messages were produced and disseminated during the annual International Trade Fair (Saba Saba), National Farmer's Day (Nane Nane), World AIDS Day and the Day of the African Child (DAC). These national events are appropriate entry points to reach large numbers of people with prevention messages on condom use, reduction in the number of sexual partners, and youth services.

In FY 2007, TAYOA will continue to build the capacity of youth balozis by conducting knowledge, attitude and skill-based training at national and district levels. These youth balozis will, in turn, orient and train 350 more balozi on HIV/AIDS education and interventions. TAYOA intends to target approximately 10,000 youth balozis by FY 2008.

TAYOA will continue to expand its national HIV/AIDS Helpline services and incorporate Helpline Service Clubs to reach 55,000 rural, low literacy youth through the dissemination of audio-visual materials. These materials promote the reduction of gender-based violence and coercive sexual activities, mobilize communities to address norms and behaviors on trans-generational and transactional sex, and advocate for correct and consistent use of condoms. All of the materials distributed contain the Helpline telephone number where callers can receive important resources and further information on these topics. Helpline audio materials will be used to support workplace and school-based programs for HIV prevention and life planning skills education. In collaboration with ABCT, the Clubs will also conduct community-based Helpline refresher training for high risk groups such as barber shop owners, bar and hotelier attendants, taxi drivers, female saloon owners, small business traders and bus conductors at Ubungo Bus Terminal.

TAYOA will procure condoms through the T-MARC Project and disseminate them through 210 outlets in the Ubungo Bus terminal Information center, youth meeting areas known as "kijiweni," barber shops, through taxi drivers, and the long distance bus driver's association called TABUA. The goal is to disseminate 10,000 condoms every month in Dar es Salaam, Coast region and Zanzibar.

TAYOA will also scale up activities in four higher learning institutions in Dar es Salaam region, including the University of Dar es Salaam, Muhimbili College of Health Sciences, Open University of Tanzania, and Tumaini University. The target is to reach 9,500 students, 500 lecturers and 75,000 residents of surrounding communities. TAYOA plans to build the capacity of student leaders, establish new Helpline clubs and train youth balozis, opinion and community leaders on strategies to promote and access Helpline services. For sustainability purposes, TAYOA will utilize existing student structures and premises to establish HIV/AIDS information resource centers.

This activity relates to all activities under Palliative Care-Basic Care and Support because of their coordinating role for Palliative Care services. It also relates to activities in ART Services (#7771), VCT (#7776), PMTCT (#7760), TB/HIV (#7772), and SI (#7772 and #7773).

The Tanzanian Health Sector Strategy for HIV/AIDS includes home-based care (HBC) as one of the interventions under HIV/AIDS care, treatment, and support. The term HBC in Tanzania refers to the broad spectrum of palliative care. HBC has been recognized as one of the most effective alternatives to mitigating the physical, mental, emotional, and economic difficulties of PLWHAs and their families. Physical, psychosocial, palliative, and spiritual services are included as part of comprehensive home-based care.

The Ministry of Health and Social Welfare (MOHSW) started implementing HBC in 1996 in 8 districts. Since then, many partners have initiated support for HBC. By September 2006, more than 70 districts were implementing HBC countrywide, 61 of which had some involvement from the MOHSW National AIDS Control Programme (NACP). However, establishment of HBC in Tanzania is still inadequate. There is only partial coverage of regions, with entire districts lacking HBC services, and services are often not comprehensive or linked to Care and Treatment Clinics (CTCs). Though data is inadequate, NACP estimates that 40% of the districts in Tanzania have not established services at all. The MOHSW has developed guidelines and training materials to guide, standardize, and harmonize both HBC training and service delivery, but implementation of the services is still fragmented and uncoordinated.

To address this service and coordination gap, FY07 funding is being requested for NACP to implement several critical components of a national program. One component of this activity is to provide training for HBC providers in districts where services have not already been established. Activities will include training of 20 district trainers, 300 health facility HBC providers, and 600 community-based care providers in 10 districts. The program targets five regions: Tabora, Shinyanga, Rukwa, Ruvuma, and Singida, where HBC services are weak, cut can be linked to ART services in Care and Treatment clinics supported by USG partners, namely Elizabeth Glaser Pediatrics AIDS Foundation, Department of Defense, the American International Health Alliance Twinning Program and AIDSRelief. NACP will coordinate with the USG partners implementing HBC in these regions to harmonies activities in order to ensure maximum district coverage and avoid overlap. Two districts will be covered in each region. With FY07 funding, care will be provided for over 4,000 people living with HIV/AIDS (PLWHAs) in the targeted communities. Specific interventions to be supported include: health education, including community sensitization on HIV prevention, nursing care, management of opportunistic infections (including pain management), basic counseling, adherence support, and referral for further management. In addition, cotrimoxazole prophylaxis will be provided to patients according to the national guidelines for prevention and management of opportunistic infections. The plan also involves the provision of insecticide-treated nets for prevention of malaria to improve the health status of PLWHA and their families.

A second component of the activity is to strengthen the coordination of key HBC players at the national level and enhance supervision by Council Health Management Teams (CHMTs) at the district level. Funding will be used to enhance the capacity of the Counseling and Social Support Unit (CSSU) at NACP to coordinate the national HBC implementation, including the standardization of HBC training, packages of services, and reporting systems. Funding will support quarterly coordination meetings for HBC implementing agencies as a step to improve standardization, coordination, and synergy among these services. These meetings will be conducted at all levels. At the national level, NACP will coordinate with HBC implementing partners and districts. At the district level, CHMTs will coordinate with HBC implementing partners and facilities. Finally, at the community level, the HBC focal point at the health center or dispensary will coordinate the community groups and volunteers involved in HBC. Because the CSSU at NACP is severely understaffed, an additional staff member will be hired using FY07 funds to strengthen the capacity of the unit and assist with the coordination detailed above.

In order to further enhance coordination, the CSSU will adopt the regionalization strategy of partners currently used in care and treatment. The staff person funded in FY07 will help to develop a work plan for HBC activities at the CSSU and ensure its implementation. The

person will also conduct periodic supportive supervision to the HBC sites to ensure the quality and comprehensiveness of activities being implemented.

The final component of this activity is the development and implementation of a national monitoring system for palliative care to enable providers to improve services at all service delivery points. This system will be developed by the CSSU, in collaboration with the Monitoring and Evaluation Unit at NACP. The initial system will be paper-based, but after the system has been successfully deployed, the NACP will ensure that an electronic database for the HBC monitoring system is designed. The rollout of the paper-based system at a national level will occur after a pre-test in three regions where HBC has already been established. The proposed regions for this activity are Coast, Iringa and Dodoma.

This activity relates to activity numbers AMREF follow-on (CT), 7781(TB/HIV), 7771(ARV), 8062(SI) and 8092 (palliative care).

The Ministry of Health and Social Welfare/National AIDS Control Program (MOHSW/NACP) has the responsibility of coordinating the Tanzania mainland health sector response to HIV/AIDS. An important aspect of this response is the mainland client-initiated voluntary counseling and testing (VCT) program, which was initiated in 1988. To date, there are over 975 VCT sites in the mainland, 161 of which operate with direct support from USG. During FY 2005, approximately 427,000 clients were reported by NACP to have attended VCT services in the existing mainland sites. NACP through its Counseling and Social Support Unit (CSSU) coordinates the mainland Counseling and Testing (CT) program through development of policies and guidelines, training protocols and manuals, and standard operating procedures and job aides. CSSU also provides supervision and technical guidance to the implementing partners, strengthens the training of counselors to secure the required quantity and quality of services, and monitors the progress of implementation of CT activities through reports from district councils, NGOs, and other stakeholders.

Currently, NACP is reviewing the counseling and testing guidelines to put greater emphasis on provider initiated testing and counseling (PITC). The development and finalization of the CT policies, technical guidelines, protocol and manuals will enable health care workers, and counselors to enhance their ability to provide quality CT services. These new proposed approaches to CT will provide support to enhance partner/family disclosure of HIV status and promote other prevention interventions. The USG is supporting the MOHSW/NACP process to rapidly roll out CT in public health facilities in Tanzania mainland and introduce PITC in-patient departments (IPD), out-patient departments (OPD), and TB and STI clinics. This will be coupled with the training programs for health care workers and counselors. In an effort to operationalize PITC, 16 health facilities will be selected to assist the NACP to review its structure and functions in order to provide adequate capacity for managing and coordination of CT activities on the mainland.

Plans for FY 2007 include continuing to support the coordination function and expansion plan to increase access to quality CT services in public health facilities. The funds will strengthen the CSSU at NACP to carry out its coordinating role and support the training of 233 health care workers and counselors to ensure a minimum quality standard for the services. The NACP CSSU will also promote the availability of CT services, print and disseminate revised CT guidelines and information, education and communication (IEC) materials on CT services, and monitor and evaluate CT services.

In FY 2007, the CSSU will focus on following areas:

Activity 1. Establish client initiated VCT services and conduct renovations at 25 new sites within 10 regions - Kagera, Kigoma, Mara, Mwanza, Mbeya, Rukwa, Ruvuma, Singida, Shinyanga and Tanga, and maintain the existing activities in 80 client-initiated VCT sites.

Activity 2. Establish PITC services at 16 health facilities within 12 regions - Dar es Salaam, Dodoma, Kagera, Kigoma, Mara, Mwanza, Mbeya, Rukwa, Ruvuma, Singida, Shinyanga and Tanga. The introduction of PITC will respond to the increased need to access the care and treatment program on the mainland. It is envisaged that by increasing the coverage of CT services in clinics providing TB and STI services, people living with HIV/AIDS will be identified and referred to ART services.

Activity 3. Train 25 new counselors and health care workers from 25 new sites, and re-train 60 counselors on PITC, and 25 districts VCT supervisors and 123 health care workers from IPDs, OPDs and STI clinics using CT and PITC guidelines. This activity will also strengthen the District Health Management Teams to manage and supervise the implementation of quality CT services at the council level through monthly/quarterly coordinating meetings. It will also strengthen the referrals and linkages to care, treatment and prevention activities in all sites and the integration of CT services into other services. Currently, the USG is supporting the NACP process in reviewing the national training curriculum in order to harmonize and standardize the CT training.

Activity 4. Work in collaboration with the IEC unit at NACP to design, develop and pretest

IEC messages for the public health facilities. The IEC materials will address uptake of counseling and testing services at selected districts. Production will be provided by the USG/USAID TBD partner in CT.

Activity 5. Monitor the progress of CT activities with technical assistance from the USG. The tasks will include conducting supportive supervision, strengthening monitoring and reporting, and improving the referrals and linkages to care, treatment and prevention.

Activity 6: Roll out the CT paper-based monitoring tool and guidelines to all facilities providing counseling and testing services. This roll out will include training on the tools and the guidelines for national, regional and district staff. With finalized tools in place, oversight will be provided for the development of an accompanying electronic monitoring system to be located at national, regional and district levels, and in facilities with sufficient existing capacity. The system will assist in the flow of data from facility to the national level, and will strengthen the data feedback loop and data quality throughout all levels. CSSU will also provide oversight on the development of the training materials, implementation, and training of the electronic system. This will be added as a component of the current National Training curriculum for CT staff.

Through these efforts, NACP will counsel and test approximately 100,000 individuals at its supported sites by September 2007. An additional 100,000 clients will be reached indirectly through the overall coordination efforts of MOHSW/NACP at all CT sites.

Strengthening HIV Treatment Services: NACP

The National AIDS Control Program (NACP) ARV Services activity described here is one component of a comprehensive set of services further described in the Counseling and Testing, Care and Strategic Information areas.

The Government of Tanzania (GOT) adopted care and treatment for PLWHA as one of its key strategies in the Health Sector Response to HIV/AIDS. The Ministry of Health (MOH) Care and Treatment Plan was approved by the cabinet in October 2003. To implement the plan, the MOH established the Care and Treatment Unit (CTU) within the NACP. The NACP Care and Treatment Unit (CTU) is responsible for coordination, management and implementation of the National HIV/AIDS Care and Treatment Plan. The CTU works with four other units of the NACP and other health and multi-sectoral partner organizations to develop policy and comprehensive care and treatment strategies and ensure their implementation in public, private and community based settings.

Since its establishment in 2003, the unit has successfully coordinated the development of several tools, including the National Guidelines for Clinical Management of HIV/AIDS in Tanzania, the Training Curriculum and Materials on Basic Management of HIV/AIDS, Comprehensive Management of Pediatric HIV/AIDS, Adherence Counseling and Laboratory. Furthermore, the NACP CTU has been able to coordinate the provision and expansion of ART services to 200 sites.

Since October 2004, at the inception of the National Care and Treatment program, to date, the number of patients ever enrolled on ART exceeds 49,000, with children accounting for over 4,500 of patients. The number of health care workers (HCWs) that have been trained on the basic management of HIV/AIDS is almost 1,500 with a percentage that have received focused training on Pediatric HIV/AIDS care.

In FY07, USG funds will support the NACP in the expansion of care and treatment services down to primary health facilities and the maintenance of the existing 200 ART sites. These two components will be supported through the sub-components of coordination, implementation of training, continuing medical education and strengthening of supportive supervision at the regional level.

NACP will spearhead the expansion of ART services to the community level by selecting 500 new ART sites at the level of primary health facilities i.e. health centers and dispensaries. The selection of facilities will be done in collaboration with the Regional and District Health Management teams and the USG ART partners working in these regions. These lower level sites will not immediately provide the full complement of HIV/AIDS care and treatment services but will initially serve as refill locations, treatment outreach centers and/or initiation of ART sites. Expansion of services will require an assessment, development of strengthening plans (including human and physical infrastructure development) and phased implementation of services at these sites. The staff at this level will be trained in the basic clinical management of HIV/AIDS using the adapted WHO Integrated Management of Adult and Adolescent Illnesses (IMAI ) training package. The USG is also funding the WHO country office to adapt this curriculum in FY07. From each primary care health facility, a multidisciplinary clinic "HIV Care and Treatment Team" will be selected for training. Each team will include doctors/clinical officers, nurses, adherence counselors, and pharmacy technicians. The total number of health workers to be trained is expected to be 1,000. Of these, about 500 clinicians and nurses will also be trained on comprehensive pediatric HIV/AIDS care.

Continuing medical education will be given to both the newly trained HCWs and the initial HIV care and treatment teams through a system of practical training that fosters ongoing professional development. This includes frequent refresher trainings, supportive supervision and clinical mentorship/preceptorship. To support this in FY2007, the NACP is planning to develop a clinical mentoring program so as to ensure sustainable quality care is provided by all trainees. As part of a decentralized and thus sustainable system, the Regional Health Management Teams (RHMTs) will be trained to provide supportive supervision activities to sites within their regions.

Beyond training and supportive supervision, the NACP will focus on developing a more reliable monitoring and evaluation system, expanding treatment literacy and updating current protocols and curriculum. USG support for these activities is described in the Strategic Information and OPSS section. In addition, to evaluate the quality and impact of the national program, the USG is funding a targeted evaluation in FY07 within the ARV services section.

Patient monitoring and tracking is still a major challenge for the NACP. The CTU will collaborate with other units within the NACP, the USG and other donor partners to establish a more effective and sustainable patient tracking and monitoring system to enable effective patient and program monitoring and evaluation and linkages to care.

To expand treatment literacy, CTU, in collaboration with IEC unit will continue to develop various IEC materials (brochures, leaflets, posters, wall charts) and conduct TV and radio programs.

Finally, since the management of HIV/AIDS is very dynamic with progressive and frequent changes, with USG support, the CTU plans to finalize, review and update the national clinical guidelines, national training materials and SOPs used at tertiary and secondary levels and the IMAI documents to be used at primary health care levels. Finally, the CTU, in collaboration with the Human Resource Directorate and other departments of MOHSW, training institutions and I-TECH, a new USG partner, will introduce HIV/AIDS prevention, care, treatment into the pre-service curriculum of various training institutions in the country.

Strengthening the National Care & Treatment (ART) Monitoring System

This activity is related to Activity ID # 8062 - Support to National electronic systems; ID # 7814 - WHO support to program monitoring; ID # 7771 - National coordination of care & treatment services; ID # 7761 - Maintenance and use of Regional Wide Area Network (WAN); ID # 8822 - Data warehouse platforms and ID # 8840 - Monitoring the impact of ART in Tanzania

This activity builds on activities started using FY 2005 and FY 2006 funds and continues to strengthen the care and treatment monitoring system.

Using existing funds from USG as well as funds from the Royal Netherland Embassy (RNE) through PharmAccess International (PAI), the NACP has started to review and modify the Care and Treatment Centre (CTC) monitoring system to include a facility-based monitoring & reporting component. This included adapting the World Health Organization (WHO) facility-based chronic HIV/AIDS care registers to the Tanzania situation. The use of these registers will be limited to care and treatment facilities that do not have capacity to use onsite electronic systems to synthesize information collected on the nationally standardized patient encounter forms. These facilities make up 50% of the existing 204 sites located at Zonal, Regional and District hospitals. A further 400 sites located at Health Centers and Dispensaries will become functional in 2007 and will use chronic care registers. The system is being piloted in 6 regions using USG and RNE/PAI funds. The NACP plans to scale up the use of these registers to 100 of the initial 204 and to another 100 of the additional 400 sites.

In FY 2007, The NACP using USG and RNE/PAI funds will coordinate and implement Care & Treatment activities including; a) revision of registers and reporting forms based on lessons learned in the pilot; b) training of trainers; c) training of regional, district and facility staff to use the system; d) printing and dissemination of the tools, and e) development and implementation of supportive supervision protocols.

Coordination of the assessment of the impact of ART in Tanzania: Treatment programs need to develop longitudinal databases to enable them to analyze information on individuals enrolled on ARV therapy in order to monitor quality and impact of ART. This includes getting information on outcomes such as program retention and reasons for loss, mortality, regimen change, adherence to treatment and HIV drug resistance, changes in weight and CD4 counts, and change in health status. The USG has been supporting the development of longitudinal databases (electronic medical records) at USG treatment sites. In FY 2007, USG will support piloting analyses of information in these databases at a sample of these facilities. Laboratory indicators will also be collected at these facilities for a more comprehensive impact analysis. In order to ensure ownership and sustainability, NACP will provide leadership and coordination for this activity.

Surveillance: ANC, Drug Resistance, HIV Case Definition, Data Analysis

This activity is related to activity ID number 8060 - strengthening Strategic Information (SI) capacity at Epidemiology and Monitoring & Evaluation (M&E) Unit of the National AIDS Control Programme (NACP) and activity ID 9593- procurement supplies for surveillance activities at NACP

This activity narrative has four components; a) Antenatal Clinic (ANC) surveillance, b) HIV drug resistance threshold survey, c) sensitivity of HIV case definition, and d) analysis of data for planning and advocacy.

ANC Sentinel Surveillance In the four years of collaboration between the NACP and the USG, there has been substantial progress in the implementation of HIV & STI surveillance activities at ANCs. Coverage has grown from 24 sites in six regions (2001/2002) to 128 sites in all 21 regions (2006/2007) of mainland Tanzania. The methodology of ANC surveillance has also substantially improved. For instance, the use of Dried Blood Spots (DBS), which are easily transportable, has enabled coverage to remote sites with no lab capacity. Training site and lab staff as well as supportive supervision visits to sites have improved the quality of data in these surveys. Lastly, the decentralization of testing to zonal laboratories will go a long way to build capacity as well as improve the timeliness of the surveys.

For the 2007-2008 round of ANC surveillance, we will maintain full coverage of all 21 regions in Mainland Tanzania, with at least six sites per region. A total of 126 ANCs will collect data for a period of three consecutive months according to the standard protocol. ANC surveillance activities will include maintenance of the surveillance workgroup; training of ANC and lab staff; procurement and distribution of supplies; data collection; supportive supervisory visits; HIV testing of collected DBS samples; data management, analyses, report preparation and dissemination.

The surveillance workgroup will be expanded to include more members in accordance with the increasing number of participating regions. The main function of the workgroup is to ensure standards in data collection techniques as stipulated in the surveillance protocol. During this fiscal year, the workgroup will be expanded to cater for coverage of 21 regions. Salaries for work group members and other project collaborators will not be paid from project funds.

Before the three-month data collection period begins, the NACP will purchase and distribute supplies and print and distribute data collection forms.

Staff from all participating ANC sites, together with the laboratory technologists and Regional AIDS Control Coordinators (RACCs), will be trained on the surveillance protocol. This will ensure adherence to the survey protocols and assure quality of data.

During the three months of specimen and data collection activities, members of surveillance working group will carry out supportive supervision at least once every month to all participating ANCs to ensure that surveillance activities are carried out according to the protocol.

During supervisory visits, ANC sites will be provided with funds for regular shipping of DBS and data forms to the testing laboratory. Surveillance staff will be given a token during the three months of data and specimen collection.

HIV testing of the collected ANC samples will be decentralized to four referral hospital labs, Muhimbili University College of Health Sciences-HIV Reference laboratory, Bugando Referral Hospital, Mbeya Referral Hospital and Kilimanjaro Christian Medical Center (KCMC).

As a quality assurance mechanism, 10% of all specimens will be retested at the AMREF laboratory in Dar es Salaam. The surveillance advisory group will analyze data, and prepare and disseminate reports.

HIV drug resistance (HIVDR) surveillance

The HIVDR surveillance intends to examine whether standard first-line antiretroviral drugs regimens will continue to be effective in settings where they are widely available. Because of the high mutation rate of HIV-1 and the necessity for lifelong treatment, it is expected that HIVDR will emerge in treated populations where antiretroviral treatment (ART) is being rapidly scaled up.

USG Tanzania supported HIVDR threshold surveys in Dar es Salaam region alongside the 2005/06 and 2006/07 rounds of ANC surveillance. In FY 2007, the survey will be in six urban sites; two sites each in Mwanza, Kilimanjaro and Mbeya regions where the zonal laboratories are located. Samples will be leftover blood obtained through the ANC survey using unlinked anonymous strategy. For each site, 60-70 consecutive HIV positive blood specimens from persons meeting eligibility criteria will be identified to ensure that amplification and genotyping are successful in 47 specimens (the survey sample size). The number of specimens with mutation consistent with HIVDR will be used to determine the prevalence of transmitted HIVDR for each drug and drug category in the standard initial ART regimen(s). Using the binomial sequential sampling and classification plan, HIVDR prevalence will be categorized as: low prevalence (<5%), moderate prevalence (5-15%), or high prevalence (>15%). The first component of this strategy is to obtain baseline estimate of the prevalence of HIVDR, followed by repeat surveys to assess the frequency of transmission of HIV drug resistant strains within a geographic area.

HIV Case Definition In order to facilitate the scale-up of access to ART, and keeping with a public health approach, WHO has introduced revised case definitions for surveillance of HIV and the clinical and immunological classification of HIV related disease. HIV case definitions are defined and harmonized with the clinical staging and immunological classifications to facilitate improved HIV related surveillance, better tracking of incidence, prevalence and treatment burden of HIV infection, and plan appropriate public health responses. In light of these revisions, a sensitivity analysis to compare the current case definition to the revised definition will be conducted to ascertain the effect of the revisions on number of cases and potential impact on persons eligible for ART. This analysis will be conducted with the technical assistance of the CDC to build capacity. Results will be used for program planning and advocacy.

Analysis for advocacy HIV/AIDS related data are not always analyzed systematically to improve program planning or translated into evidence-based policies. The NACP with CDC Tanzania and headquarters will use a synthesized approach to analyze and model data from ANC surveillance, surveys (e.g., Tanzania HIV Indicator Survey, Service Availability Mapping, and other surveys), and data from other sources, such as from reproductive health services and tuberculosis. The results from these analyses will be used for advocacy and evidence-based decision making within the specific program areas, such as prevention, and to strengthen commitment and potential resource allocation.

Strengthening SI Capacity at NACP

This narrative relates to SI activities ID numbers 7772, 7773, 7761, 8062 and National Counseling and Testing - # 7776, ART Services - # 7771 and Home Based Care (HBC) - # 8692

This activity has 3 components: a) human and infrastructural capacity strengthening at the NACP Epidemiology, M&E Unit, b) revision of the Health Sector M&E framework and coordination of reporting to TACAIDS and c) use of Personal Digital Assistants (PDAs) for supportive supervision

The Epidemiology and M&E Unit has primary responsibility of all strategic information activities of NACP. Among the unit's responsibilities are: 1) Surveillance and surveys including Ante-Natal Clinic (ANC) based sentinel surveillance for HIV and other STIs, HIV drug resistance threshold surveys, behavioral surveillance surveys (BSS) among Most At Risk Populations (MARPS), and AIDS case surveillance. The unit also participates in national population-based surveys such as the Tanzania HIV Indicator Survey (THIS) and plays a major role in national HIV/AIDS data analyses, report preparation and dissemination. 2) Monitoring HIV/AIDS interventions, such as counseling and testing, care and treatment, home-based care, prevention of mother-to-child transmission, TB/HIV, blood transfusion and laboratory services. Activities include the development/adaptation of data collection tools and electronic systems; training on paper-based tools and synthesis to move from data collection to reports. Other activities include: supportive supervision to ensure data quality and timeliness of reports, data & report flow, maintenance of the tools (review/evaluation to modify as necessary), maintenance of electronic systems, and integration of all HIV/AIDS monitoring systems. 3) Compiling health sector response data for HIV/AIDS and reporting these to the Tanzania Commission for AIDS (TACAIDS). These activities, which fall under M&E, include: a) development of an M&E framework to plan the health sector response, as well as to track the progress against set targets to the HIV/AIDS epidemic; b) capacity building and technical assistance to NACP and national project officers in the planning, monitoring, and reporting of activities within the various HIV/AIDS interventions; c) capacity building for data use for program improvement at national and sub-national levels. 4) Capacity-building on M&E to other units within NACP. 5) Public health evaluations and program evaluations.

In FY 2007, the USG will provide funding and technical assistance to strengthen the infrastructural and human capacity required to enable the Epidemiology and M&E Unit to meet the above responsibilities. These will include maintaining and/or recruiting new staff, providing funds for logistical support to enable personnel to perform their duties such as training, supportive supervision, and procuring equipment and supplies as required. In rationalizing the human capacity requirements of the unit, six cadres of staff have been identified as follows: 1) an epidemiologist in charge of the unit; 2) an M&E officer to oversee activity planning, monitoring and reporting, as well as capacity building, data use and program evaluation activities; 3) a surveillance officer to coordinate all surveillance activities; 4) three program monitoring officers in charge of all sub-national level program monitoring activities including data quality assurance, training and supportive supervision; 5) two data managers to maintain all central level databases; 6) three data clerks to enter data as required. The Unit currently has staff who are full-time MoHSW employees as well as contract staff supported by donors including the USG. FY 2007 funding will be used to maintain the existing USG-supported personnel, as well as to fill vacant positions (officers in charge of M&E, surveillance, and counseling and testing).

M&E The USG will support NACP in revising the health sector M&E framework to monitor and evaluate the health sector's response to the HIV/AIDS epidemic. This framework should include plans to develop and/or strengthen existing linkages between the different interventions, provide a comprehensive set of national and international indicators to track progress against set targets, create a more standardized way of reporting health information up to TACAIDS, and provide guidelines for developing work-plans, monitoring programs, and reporting all HIV/AIDS intervention activities. The M&E Officer, recruited above, will provide oversight for the development of the M&E framework including

recruitment of a consultant to assist, plan, develop and implement the framework. The two shall coordinate packaging, dissemination and training on the framework.

The M&E officer will also: a) coordinate the health sector information reporting to TACAIDS; b) work with NACP program officers to plan, monitor and report all NACP activities; c) coordinate technical assistance from NACP partners to build National M&E capacity including data synthesis and use for program improvement.

To address data collection and transfer related issues for program monitoring data, the Epidemiology and M&E Unit will hold a focus group with a few selected Regional and District Health Management Teams to gain a better understanding of the challenges in data collection and transmission, including human resources at the sub-national level. Information gained from this exercise will be used to strengthen data transmission and address existing barriers.

Use of PDAs for supportive supervision:

Supervision is one of the keys to the success of a quality program. Supportive supervision at the regional and district levels to health facilities is one of the integral components of program monitoring within NACP. Currently, most regional supervision programs keep paper management records. They report back their findings to the national level. The introduction of new data collection methodologies will assist in ensuring quality data are collected and used in real time. Supervisors will be able to record the standardized information from their visits on PDAs, synchronize these data on their computers, analyze and share the data using a variety of methods, allowing for both feedback and feed-forward. The questionnaires and supervisory checklists would be made using EpiSurveyor (free software) on a computer and transferred to EpiSurveyor on the PDA. The regional officers would download the PDA data to their desktop computers after each supervisory trip and then combine the data on a quarterly basis. They would analyze the downloaded data in a statistical package and transfer the results to the national level via e-mail or other method. The use of PDAs will be piloted in Dar es Salaam where there are computers and capacity to analyze the results. Implementation trainings on using the PDA and the supervisory checklist will be conducted as part of regular meetings held with the region.

Behavioral and Biological Surveillance Surveys Among Most At Risk Populations (MARPs) in Mainland Tanzania

This activity relates to the activity ID number 8061 which strengthens SI capacity for NACP Epidemiology, M&E Unit.

The CDC/HHS in Tanzania has been collaborating with the World Health Organization (WHO) in providing technical assistance to Tanzania Ministry of Health, AIDS Control Program (NACP) to conduct surveillance activities. Tanzania is confronting a generalized HIV epidemic; the prevalence among pregnant women presenting for antenatal care at sentinel surveillance sites is 8.7% (Ministry of Health and Social Welfare, 2005). Recent surveys carried out by the University of Texas Health Sciences Center and the Muhimbili University, College of Health Sciences, University of Dar es Salaam uncovered newly introduced high risk behaviors among sex workers and injection drug users (IDUs), which are overlapping populations. In 2000, HIV prevalence among presumed sex workers in Moshi Town in Northern Tanzania was reported as 26.3% (Kapiga, et al. 2002). In 2005, McCurdy, et al reported that sex workers in Dar es Salaam described a new practice they called "flashblood." This practice involves a heroin injector drawing back blood into the syringe after injecting heroin. The blood is then injected by another user to mitigate the effects of withdrawal. At the time, the practice was only reported by women. More recently, men are reporting it, too. In a recent study more than half (57%) of used syringes collected from a sample of 500 sexually-active IDUs in Dar es Salaam and tested for HIV in residue blood were positive (McCurdy, 2006). Further, the increase in heroin use among sex workers has led to an increased HIV prevalence in this population. As female heroin users' addiction increases, they are more likely to turn to sex work to meet the financial needs of their habit. Anecdotal reports suggest that heroin use has spread throughout Tanzania. This core group of potential HIV transmitters could lead to a wave of new infections in the broader population through non substance using sex partners, clients of sex workers, and regular sex partners (spouses) of these clients. These developments warrant the consideration of increased attention to sentinel surveillance of these most at risk populations (MARPs).

In an effort to provide a cohesive and coordinated approach to behavioral and HIV surveillance among MARPs, the NACP with the assistance of USG and WHO, will convene a consultation meeting of key stakeholders in FY 2007 to map a strategy for increased surveillance of MARPs in mainland Tanzania. The consultation will focus on surveillance designed to inform the rational development of prevention programs for MARPs including substance users, especially heroin users, and transactional sex workers.

Additionally, the NACP will utilize FY 2007 and existing funds from USG to pilot surveillance methods for bar workers as a proxy for sex workers in at least one site (Morogoro) in FY 2007. This will be done with a to-be-determined sub-partner. Activities will include a) training of trainers in behavioral surveillance methods including respondent driven sampling methodology (RDS), b) training field data collectors on the survey methods, c) data collection, d) data management, analyses and report preparation, e) dissemination of study results.

Support to National Monitoring Systems Training and Implementation through the University Computing Centre

This activity relates to 8060, 7814, 7776, 7760, 7756, 7761, 8692, 8690, 8695, 8221.

The Ministry of Health and Social Welfare (MOHSW) has supported a decentralized approach to management of HIV/AIDS intervention programs. For program monitoring, this involves data collection, synthesis and use at the point of service. Decentralization of program data management will result in early identification and correction of errors, as well as synthesis and use of this information to improve service delivery. Furthermore, data quality assurance can be strengthened within the existing structure for supportive supervision. Thus, where capacity exists, clinics, and other points of service (POS), will use the national electronic system to manage and synthesize data, as well as transmit reports to higher levels. On the other hand, POS with no electronic capacity will submit summary reports to the district level where data entry, aggregation and onward reporting will be done. Districts with no capacity to manage data electronically will submit compiled district summaries to the regional level for management, synthesis and onward reporting. Where information synthesis takes place at district or regional levels there will be feedback reports to the facility to ensure data use for program improvement. This approach strengthens the role of districts and regions in promoting the use of data to inform technical and management decisions.

The University Computing Centre Limited (UCC) is a limited company wholly owned by the University of Dar es Salaam, one of the training arms of the MOHSW. UCC has capacity not only for software design, but also for training, roll-out and ongoing support of users. UCC has zonal centres in Arusha, Mbeya, Dodoma and Mwanza as well as two centres in Dar es Salaam. Each of these centres is equipped with training rooms with a computer for each trainee and a projector. Each centre also has full time well-qualified and experienced computer trainers who not only train people in standard packages, but also in UCC-designed software. UCC also has the capability for logistical support for training with administrators who have experience in organizing and administering extensive geographically dispersed training sessions for Government of Tanzania employees. In addition, UCC has experience in ongoing contact with a large user base to resolve problems and incorporate feedback, and the capability to provide help desk services both by phone and through site visits.

Under UCC's Global Fund grant, they are able to fund the software development centrally for the MOHSW/National AIDS Control Program (NACP), regions and districts and POS provided that the software development is directly related to HIV/AIDS information management. However, the additional training roll-out and support to non-Global Fund sites will require additional resources.

In FY 2007, NACP would like to ensure a coordinated approach to national systems development and use. This includes ensuring that national guidelines, paper-based collection tools and the electronic systems for monitoring HIV/AIDS intervention programs are harmonized, properly implemented and used. NACP supports the efforts of UCC to provide the training to national and sub-national staff on the use of these systems and provide oversight and user support to ensure proper use of the systems for all the interventions. This activity funds training of regional, district and facility level data management staff on the UCC-developed software, software that is based on the national standardized data collection tools for three of the HIV intervention areas - Care & Treatment, PMTCT, and Voluntary Counseling and Testing. The activity also funds further software development activities at UCC in each of these areas to ensure that standard reports are available at sites incorporating both the Government of Tanzania (GoT) HIV/AIDS indicators and USG indicators. Technical assistance will be provided by USG Tanzania to NACP and UCC on data quality. For facilities, as well as district and regional offices, efforts will focus on improving data quality with standard quality control processes. Within the UCC software development activity, efforts will focus on building the same quality control processes into the software. The MOHSW will continue decentralization efforts within NACP, with accountability for data quality being enforced at each level where paper and electronic systems exist.

In FY 2007, UCC will coordinate and conduct 10 training sessions on the electronic systems, including training for USG implementing partner staff. The UCC will train regional, district and facility-based staff on these systems. UCC will coordinate the setup of the systems for all users, and ongoing support on the systems, as issues arise. A single source for assistance on use and support of its systems will improve the decentralized approach, which NACP wholly supports, and the quality and use of the data at all levels.