This activity also relates to activities in treatment (Rukwa).

Rukwa is one of four regions in the Southern Highlands which also includes Iringa, Mbeya and Ruvuma and is served by the Mbeya Referral Hospital for all its advanced care and supervisory needs. This referral hospital works in concert with but not over the regional medical offices. The Rukwa Regional Medical Office (Rukwa RMO) supports the implementation of prevention, care and treatment programs throughout its region, providing funding and supervision to the regional hospital and district level facilities. This includes supporting direct care services, providing quality counseling and testing (C&T) and PMTCT services, and strengthening referrals between facilities and services. As part of the network of care in the Southern Highlands, activities in this submission will build upon a comprehensive program throughout Mbeya, Ruvuma and Rukwa under the supervision and support of the Mbeya Referral Hospital and the US Department of Defense (DoD).

Over the past year, the MOHSW began expansion of PMTCT programs into the Rukwa Region. This region, in part due to its geographic isolation in the far southwest of the country, still has nascent PMTCT services as part of its public care provision. A national rate of 8.6% will be used in determining approximate number of HIV+ women who will qualify and be served with full PMTCT services.

In support of PMCTC expansion, FY 2007 funding will continue to be provided to the Rukwa RMO for modifications to ANC infrastructure at the Nkasi District Hospital. This will include the support for the training of six counselors at the ANC at each facility and integration of PMTCT services as part of regular antenatal care. Continued funding in FY 2007 EP directly to the Rukwa Regional Medical Office supporting point of service provision will complement both MOHSW and USG efforts at the national level.

Community education and mobilization initiated in FY 2005 and FY 2006 will continue to be undertaken in FY2007 as part of provision of this service in the region. Uptake targets include 3,000 pregnant women for counseling and testing with approximately 150 women participating in full PMTCT services from these three sites in a twelve month period by September 2007. Assessment for further expansion of this service in Rukwa will be conducted as part of comprehensive HIV clinical services roll out and in support of national PMTCT expansion plans.

Services include opt-out counseling, those testing negative are given education on protective measures and practices for avoiding infection. Mothers found to be HIV positive are provided with post-test counseling, provided "prevention for positives" information and education on the benefits of NVP prophylaxis. These women are encouraged to bring in family members for counseling and testing at either the ANC or the hospital's VCT center. HIV positive mothers will also be provided with infant feeding counseling options and for those choosing to breastfeed, counseled to exclusively breastfeed with early weaning.

As part of the continuum of care, HIV positive women identified at these centers are referred for evaluation for full ART at the respective HIV Care and Treatment Centre (CTC) at the facility, with support for these services and strengthening of the referral system as part of the activities undertaken under treatment activities. Their infants are followed for the first 18 months for monitoring, cotrimoxazole treatment and serologic diagnosis. Those not qualifying for ART receive NVP prophylaxis upon onset of labor and their infants PEP within 48 hours of delivery from the PMTCT centers. Direct technical assistance and oversight is provided by the Mbeya Regional Medical Office and Mbeya Referral Hospital and through collaboration with the DoD. Both of these Mbeya facilities are very experienced and successful in implementing nationally sanctioned PMTCT programs. This program will be integrated into the national effort over the course of FY 2007.

Funds in this submission will support national MOHSW contributions to expanding PMTCT in this region for commodity procurement for services including reagents for confirmatory diagnostics and safety kits for delivery, technical assistance, referral mechanisms, community mobilization efforts, and contribute to national M&E. NVP will be provided through the MOHSW and Boehringer donation. With plus up funding, DOD will expand PMTCT services in Rukwa region by scaling up PMTCT services to lower level facilities. In all facilities opt-out counseling and testing will be promoted and scaled up in both ANC setting, labor ward and delivery. ARV regimens

based on the new revised guidelines will be promoted. A particular area of focus will be in considering HIV positive women in third trimester of pregnancy on lifetime triple antiretroviral therapy for HIV (if they fulfill the national criteria and are properly selected for adherence). Since the use of more efficacious PMTCT regimen gives the best prevention of ante-natal transmission of HIV, and provides the best protection during limited time of exclusive breast feeding, it will be strongly promoted. The more efficacious regimens (triple therapy) is also known to be more cost effective in averting HIV infection. All effort will be made to ensure the infant and the entire family unit is provided with a comprehensive set of HIV services. In all health facilities efforts will be made to link PMTCT services/sites with CTCs to support the delivery of comprehensive HIV services that are linked across a continuum of care. DoD will develop linkages through direct service support and referrals to larger HIV treatment facility. Providers from smaller facilities such as health centers, dispensaries or remote District hospitals will receive training on the new PMTCT guidelines including the use of more efficacious regimens. Depending on capacity, the use of more efficacious regimen will be promoted and scaled up. Infant diagnosis and follow-up services to the child, and her parents will be supported. Infant feeding and nutritional interventions during lactation period will be promoted.

ARV Services in Rukwa Region

This activity also relates to activities in PMTCT (7796), CT (7794), and palliative care (7723), treatment (7747), and SI (8683)

Rukwa is one of four regions in the Southern Highlands which includes Iringa, Mbeya and Ruvuma and is served by the Mbeya Referral Hospital for all its advanced care and supervisory needs. This referral hospital works in concert with but not over the regional medical offices. As with the Mbeya Regional Medical Office (MRMO), the Rukwa Regional Medical Office (Rukwa RMO) supports the implementation of prevention, care and treatment programs through out its region, providing funding and supervision to the regional hospital and district level facilities. This includes supporting direct care services, providing quality counseling and testing (CT) and PMTCT services, strengthening of referrals between facilities and services, conducting training in palliative care to HBC providers, and supporting community education on health service initiatives.

Identified as one of the MOH sites for initiation of ART in FY04, the Rukwa Regional Hospital in Sumbawanga is poorly equipped, its infrastructure inadequate, it has few trained staff, and critical commodities are limited to support such efforts. Laboratory equipment to support CD4 monitoring and safety labs purchased by the MOH recently arrived to meet one of their most critical needs. FY 2006 Emergency Plan funding, which is just about to arrive in country, will continue to support the development of additional infrastructure and capacity through clinic and lab renovations and the training of additional staff.

Funding in FY07 to the Rukwa RMO will continue to support expansion of treatment services at the regional hospital plus extension of support to a second site, Nkasi District Hospital. This includes increasing the number of individuals trained through NACP efforts in the region to an additional 12 personnel (at least six individuals per facility) under the Mbeya Referral Hospital submission in this section. Direct FY 2007 funding to the Rukwa RMO will provide for consumables for monitoring and medications for OI prophylaxis and treatment (exclusive of ARVs to be purchased and supplied by MOH and USAID) for both hospitals. Laboratory services will continue to receive technical support from the Mbeya Referral Hospital. It is anticipated FY07 funding will support a combined 1,200 patients on treatment and another 1,600 patients with care by September 2008.

In support of the expansion of treatment to other facilities in the region, the Mbeya Referral Hospital will continue to augment the Rukwa RMO in developing a treatment supervisory team to support Nkasi and other CTCs in the region as they come on line. Experienced clinicians will be places with this team for two to three weeks, in the early stages to maximize effective monitoring.

A referral mechanism between newly established VCT and PMTCT services in the region has been established. Building upon existing structures, this referral system aims to link services at centers providing counseling and testing at TB clinics, lower level health facilities and PMTCT interventions at antenatal clinics to the CTC. Provider initiated counseling and testing will be strengthened in these two facilities' out patient clinics and in patient wards to identify the maximum number of treatment ready patients.

In 2007, PMTCT services will be integrated within ANC and CTC. Pregnant women in their third trimester will be identified and evaluated for triple ARV if their CD4 is less than 350/microliter. Currently 9 % of the ART and care population is between the ages of zero to 14 years. Pediatric uptake will be increased by increasing the enrollment of children especially younger ones by promoting and supporting routine counseling and testing of children and their mothers at all contact points in the health facilities, including immunization clinics, outpatient clinics, and in-patient wards and through PMTCT programs. Through these sites, the pediatric ward at the referral hospital, and linkages with over ten NGOs and FBOs providing support to OVCs in the Municipality, pediatric cases will be identified and evaluated for treatment.

Rukwa RMO will promote couple counseling and testing for all clients that receiving counseling, care and treatment. This strategy will become the backbone for the hospital's efforts to promote prevention for positive and will also assist in boosting the number of

males on treatment. As part of ensuring the continuum of care, the Rukwa RMO works in close concert with several NGOs and FBOs in the Municipality. These organizations not only assist in patient identification and referral to the HIV Care and Treatment Center (CTC) at the hospital but provide at home follow up of patients under treatment. In order to link services, training will emphasize that care for People Living with HIV/AIDS should be provided in a continuum with links from care & treatment to other programs within the health facilities and extend from the health facilities into the community.

In FY 2007, an electronic medical record system being piloted at the Mbeya Referral Hospital will be introduced at each of these sites. In FY05, use of the paper versions of the patient report forms for this database was introduced at the regional hospital to familiarize medical staff with the use and benefit of the system. The Mbeya Referral Hospital maintains the electronic medical record system and provides the hospital with weekly patient reports. By extending this capacity directly to the region in FY07, physicians and hospital administrators can make better real time decisions that will improve services at their facilities.

Lastly, based on the model of the continuum of care developed by the regional medical offices in the Southern Highlands, the Rukwa RMO will continue to develop the capacity of local organizations and dispensaries in extending support for HIV care and treatment into the community. Training of these providers in basic palliative services will include the addition of ARV education and counseling in treatment adherence as part of service delivery. Using the module on ART support in HBC developed by the Mbeya Regional Medical Office and a large NGO in the Mbeya Municipality, FY 2007 funds will continue to support the Rukwa RMO in training 40 HBC providers/dispensary personnel. Linkage of hospital patients to these dispensaries and organizations for support and follow up will be undertaken and evaluation and monitoring of HBC programs in the region conducted ensuring quality care.