This activity links to activities HLAB MOHSW 7758, CDCBase 7834, CLSI 7696, APHL7682, AIHA7676, ASCP 7681, AMREF 7672, RPSO 7792, BMC 7685, ZACP 8224, DoD 7746; Track 1 ART CU7697/7698, EGPAF 7705/7706, HARVARD7719/7722, AIDSRelief 7692/7694, DoD7747, Blood Safety; CT NACP 7776, TB/HIV 7781, PMI, SCMS 8233, FHI 7712; SI NACP 7773, MOHSW 7761.

In Tanzania, significant groundwork has been made in laying the foundation for a stronger national laboratory infrastructure capacity building for HIV/AIDS program. In 2004, with USG support, National Institute for Medical Research (NIMR) Collaborated with MOHSW in its effort to adopt the Laboratory Quality Systems principles published by the International Organization for Standardization (ISO) and Clinical and Laboratory Standards Institute (CLSI)] as a framework for Tanzania. MOHSW designated NIMR as the organization that would serve to implement and execute quality assurance activities for all HIV related testing and technology assessment and transfer on its behalf.

In FY 2005, with USG support NIMR assisted in the planning for the renovation of the National Laboratory Quality Assurance and Training Centre (NLQA&TC) at NIMR headquarter at Ocean Road to be completed by December 2007. The Centre will provide capacity in assessing and improving the quality of testing nationally and serve as a training institute. In the interim, NIMR renovated the lab at the African Medical and Research foundation (AMREF) and provided equipment as a temporary measure to house the national EQA program. To operationalize the program with FY 2006 funding NIMR hired one laboratory manager and one senior laboratory technologist who are working at the AMREF laboratory to implement the national EQA program and form the nucleus of the NQA&TC staff.

In FY 2007 NIMR will conduct quality assessment of HIV/AIDS testing at district, regional and zonal laboratories, develop training materials in collaboration with CLSI, ASCP and APHL. NIMR will participate in the Training of Trainers in HIV related testing and will work with these partners in developing, distance based learning programs, provide technical assistance for proficiency testing and other quality assurance activities including development of standard operating procedures (SOPs) for HIV Enzyme Immuno Assay (ELISA), HIV rapid testing, CD4 counting, automated hematology and chemistry quality assurance.

In FY 2007, NIMR, in collaboration with MOHSW and partners, will work to develop Quality Control and Proficiency testing panels for HIV rapid Testing, HIV ELISA, Chemistry, Hematology and CD4 count and will continue to provide technical assistance for the finalization of NQA&TC and equipping it to function as a reference public health laboratory for HIV/AIDS and related testing and as a training and national External Quality Assessment (EQA) and resource center. The goal of the national external quality assessment scheme (NEQAS) is to provide HIV EQA materials to four zonal labs and Zanzibar, regional and district laboratories, and all HIV testing sites; support enrollment of zonal and regional laboratories in International EQA schemes as per the National EQA framework.

In FY 2007, NIMR will continue to assist MOHSW implement national quality assurance program and carry out monitoring and evaluation of the implementation process in order to identify gaps and recommend corrective actions.

In FY 2007, NIMR will provide technical support to the infant diagnosis strategies adopted by MOHSW and participate in activities related to Incidence Surveillance. The National AIDS Control Program (NACP) of the Ministry of Health of Tanzania in collaboration with National Institute of Medical Research, CDC GAP Tanzania and CDC GAP Atlanta will use the BED-CEIA to monitor HIV-1 incidence in pregnant women attending ANC by district, age-group, and urban/rural residence using retrospective ANC surveillance specimens. The BED capture enzyme immunoassay (BED-CEIA) is a laboratory method that measures the increasing proportion of HIV-1 IgG to total IgG after seroconversion to estimate HIV-1 incidence in a population. These data will be used to identify epidemic patterns for new HIV infection in the general population. In addition, HIV incidence estimates from the BED-CEIA will be compared to HIV incidence estimates modeled from EPP and Spectrum software (UNAIDS) to evaluate plausibility of HIV incidence from the BED-CEIA. The BED-CEIA can be used to estimate and monitor trends in HIV-1 incidence in

cross-sectional sero-surveys, including sentinel surveillance surveys among antenatal clinic (ANC) attendees or other populations, and population-based surveys, such as the Tanzania HIV Indicator Survey (THIS). NIMR will assist MOHSW and CDC GAP Tanzania assess laboratory capacity in preparation for these activities. NIMR will assist in the training of laboratory technicians from the central laboratory and surveillance staff at NACP on the technology to implement and analyze data from the BED-CEIA using generic training material created by CDC GAP Atlanta. The training will be conducted at the African Medical Research Foundation (AMREF) laboratory in Dar es Salaam for 6 laboratory technicians and three staff from the Epidemiology Unit at the NACP, with the assistance from CDC GAP Tanzania. CDC Atlanta will provide two laboratory trainers and one epidemiologist trainer. Following the training, the NACP team will implement the BED-CEIA on retrospective ANC surveillance specimens from 24 sites in 10 regions in 2004, 2005, and 2006 rounds. The estimated number of HIV positive specimens to be tested is 4,000 from ANC surveillance in the three rounds.

Maintenance of Wide Area Network at Regional and National Level for Strategic Information

This activity relates to 7760, 7776, 7771, 8692, and 8221.

In FY 2005, the National Institute for Medical Research (NIMR) conducted a needs assessment for establishing a Wide Area Network (WAN) to connect itself, the Ministry of Health and Social Welfare and the National AIDS Control Program (NACP) to regional and referral hospitals. The assessment looked at the capacity of the hospitals to use computers, the Internet and email as part of an overall management of HIV/AIDS interventions. In FY 2006, the WAN was installed centrally at the Ministry of Health and Social Welfare (MOHSW), including NACP and the NIMR. It connected the central level to seven regions, mainly the large regional and referral hospitals in Iringa, Mwanza, Mbeya, Dodoma, Arusha, Lindi, and Mtwara. The assessment revealed that there was a need for additional computers and a need for training on how to use computers. Staff at the central and the regional levels where the WAN now exist were trained on basic computer use, Internet and email use, and the applications to assist in data collection and reporting.

Now that the WAN implementation is complete, the focus in FY 2007 will be on the use of the technology to support the decentralized approach for HIV/AIDS interventions, an approach supported by the MOHSW. Decentralization of data management and data use means that data entry will occur as close to the points of service as possible, allowing for data analysis, use, and feedback at the implementation level. In addition, possible errors will be identified earlier. Decentralization of data management will also allow staff at the national level to perform their roles of program monitoring more efficiently and allow for sub-national level staff to perform routine data quality audits and program monitoring more efficiently through remote data access, reducing the need for and number of costly site visits. Having the WAN system in place with data transmission services readily available will facilitate timely flow of data from the regional level to the national level. Data and reporting requirements will be received in minutes by email, instead of days or weeks by more traditional means of transporting data - courier, mail, or site visits to collect data.

Although there are no plans for further expansion in infrastructure development beyond the seven regions, the plans in FY 2007 will be to maintain and strengthen the existing network capability, including hardware monitoring, software updates, monitoring system security requirements and technical support for continued use of email and Internet access. These funds will provide for the hiring of two Network Managers to perform these responsibilities and to build the capacity for system support in Tanzania. These staff will be stationed regionally, dividing their work among the seven regions for continued support of the WAN. They will conduct quarterly supportive supervisory visits to the seven regions to ensure systems are operating and address any issues. They will be centrally supported by an existing Network Manager, who will be the contact person for all issues related to connectivity. The regionally-located Network Managers will actively monitor the internet and email connections to ensure the system is operational for transfer of data at the regional and national levels, and conduct trainings on email and internet use at the sub-national levels to ensure proper use of the technologies for timely data transfer.

This activity relates to OPSS activities #7729 and 8981.

The National Institute for Medical Research (NIMR) has played a critical role in supporting the Ministry of Health and Social Welfare (MOHSW) to address the human resource crisis through operational research related to Human Resources for Health (HRH). These studies include a collaboration with the Capacity Project on HRH productivity and workload, and a national retention study that will be conducted with FY 2006 funds. The body of evidence created from developing these studies will form the basis for interventions that the MOHSW will carry out in support of the Emergency Hiring Plan for Care and Treatment Centres (CTCs) and the health sector as a whole. NIMR has also supported the MOHSW through development of a national quarterly HRH newsletter which was recently inaugurated at the Tanzania Annual Joint Health Sector Review. This newsletter facilitates communication and advocacy for HRH-related issues across the public and private sectors.

In order to carry forward the above work at the local level, in FY 2007 NIMR will work with Capacity Project and the MOHSW to implement the productivity and retention interventions at CTCs. The interventions designed will be applicable locally and cost-effective, with potential for national adaptation. The expected outcome of these interventions is higher HRH productivity, more evenly distributed workload, and lower attrition rates, so that more patients will be served annually. Since NIMR is itself a decentralized institution, its satellite branches will be instrumental in monitoring the progress of the interventions. NIMR will also provide a sub-award to the Christian Michelson Institute of Norway to conduct a national workforce performance study that will complement the productivity and workload study findings.

In addition, NIMR will collaborate with I-TECH to develop the capacity of the zonal training centres to design and conduct studies and implement interventions related to HRH. Although the local and district governments are responsible for planning for HRH, these authorities are typically weak in designing effective HRH studies that will inform planning and decision making. With NIMR support, zonal training centres will train district and local government teams to build this critical capacity, thus encouraging local ownership for local problems - and local solutions. Toward that end, NIMR will also support districts in identification of HRH-strengthening activities for integration into their comprehensive health plans and budgets for the Medium Term Expenditure Framework (MTEF). Too often, important projects are not included in the MTEF budget, which precludes an ability to proceed.

NIMR will also continue to support the MOHSW in the quarterly development and publication of the national HRH newsletter. NIMR will also work with the districts to create local newsletters to recognize high-performing health care workers and disseminate up-to-date health information.

In FY 2007, NIMR will also support three Tanzanians to participate in the Kenya-based Field Epidemiology and Laboratory Training Programme (FELTP), a competency-based training programme in applied epidemiology and public health laboratory management. FELTP in Kenya is a collaboration between Kenya Ministry of Health, universities, and CDC-Kenya. With FY 2007 funds, one Tanzanian laboratorian and 2 epidemiologists will be sponsored to build capacity and provide epidemiological and laboratory services at national, regional, or district level. During their 20-month field placement, the three candidates will strengthen the national capacity to respond to public health emergencies, specifically the Emergency Plan. The candidates will learn practical field epidemiology and public health laboratory practice, including quality assurance which will be applied to PEPFAR Tanzania's goals and objectives working with the Ministry of Health and Social Welfare on the implementation and analysis of a national ART monitoring system with the National AIDS Control Program. The laboratorian will also work closely with the MOHSW on the implementation of quality assurance programs for national and reference laboratories.

Deliverables for this activity include: four quarterly HRH newsletters; productivity intervention plan and stakeholder dissemination meeting; eight zonal, regional, and/or district level workshop reports on HRH study design; reports on HRH strengthening activities planned for incorporation into the MTEF in four district health plans; and

quarterly and annual reports from FELTP fellows.