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

Ruvuma is the second of the four regions in the Southern Highlands, which includes Iringa, Mbeya and Rukwa, operating as a prime partner for PMTCT under the US Department of Defense. As with Rukwa, the Mbeya Referral Hospital supports Ruvuma for all its advanced care and supervisory needs, working in concert with but not over the regional medical office with the later supporting direct implementation of prevention, care and treatment programs throughout its region. Situations surrounding HIV services in Ruvuma are very similar to Rukwa and development of PMTCT services mirrors that of Rukwa. Both are geographically isolated areas of the Southern Highlands and lacking support for basic, let alone more complex, services. Programs in all three regions (Mbeya, Rukwa and Ruvuma) supported through the US Department of Defense (DoD) are implemented in a coordinated and almost parallel fashion, directly supporting the MOHSW's desire for donor agencies to undertake a more regional focus in developing networks of care.

As with the Rukwa Region, the Ruvuma Region still has only nascent PMTCT services as part of its public care services. In FY 2006, direct Emergency Plan funding to the Ruvuma Regional Medical Office will augmented MOHSW support of PMTCT at the Ruvuma Regional Hospital in Songea and the Tunduru District Hospital. This program is integrated and reflected in the current national program and is not a stand alone, isolated effort.

Funding in FY 2006 will continue to support renovation of the ANC, training, community education/mobilization efforts and commodities procurement for the Regional Hospital. In FY 2006 clinic infrastructure at Tunduru was modified to allow integration of this service into regular antenatal care. Three counselors per site, for a total of six, have been trained in basic PMTCT services following national guidelines. Community education and mobilization under FY 2005 funding will be supported into FY 2007 as part of necessary implementation of this service in the region to encourage uptake. With similar numbers accessing ANC services at the regional hospital and demand for PMTCT as high as in Rukwa, it is estimated that this program will also be able to target 3,000 pregnant women for counseling and testing with approximately 120 to 150 women participating in full PMTCT services from these three sites by September 2007.

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 are provided with infant feeding counseling options and for those choosing to breastfeed, counseled to exclusively breastfeed with early weaning.

Again, as with Rukwa, HIV positive women are evaluated for full ART at the regional hospital with support for these services and strengthening of the referral system as part of treatment activities. 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. Infants will are referred for pediatric follow up care with cotrimoxazole and serologic diagnosis.

Introduction of PMTCT at a time that ART is introduced at the regional hospital is critical in ensuring a continuum of care and a means of identifying potential patients. As part of implementation of the network model, with higher level or better equipped facilities providing technical oversight, the Mbeya Regional Medical Office, Mbeya Referral Hospital and the US Department of Defense supported efforts in care and treatment in the Southern Highlands will continue to provide direct assistance to Ruvuma in the implementation of this and other aspects of prevention, care and treatment as they are introduced and expanded in the region.

Funds in this submission will support national MOHS 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.

The Goal of the national PMTCT programme is to expand PMTCT services in order to reduce the risk of transmission of HIV infection from infected mothers to their babies during pregnancy, child birth and during breastfeeding through integration of PMTCT services in routine reproductive and Child health services in all 21 regions. Since the national PMTCT program inception in 2000, PMTCT services roll-out has accelerated significantly. Currently 544 sites (10%) out of 5,379 in all districts are providing the core elements of PMTCT services including testing and counseling (TC), antiretroviral prophylaxis, and infant feeding counseling integrated in reproductive and child health services. This 10% coverage is low and as a result, by the end of 2005 only 11,435 (9%) of the estimated 122,000 HIV positive pregnant women were receiving Nevirapine prophylaxis. The USG funds several partners who provide PMTCT services in several sites to meet these challenges. In accordance with the current policy of PMTCT regionalization, USG partners are assigned specific regions (rather than choosing individual sites) within which they support the provision of PMTCT services to selected facilities within that region, by working with regional and district government authorities. DoD is the Partner for HIV Care and Treatment activities in Mbeya, Ruvuma, and Rukwa regions and has been asked to be the MTCT partner in these regions based on the PMTCT regionalization efforts. In Ruvuma, DoD supports these regions with a comprehensive program that covers both HIV care and treatment services, VCT services and PMTCT services. At the community level, DoD supports Home Based Care and Orphans and Vulnerable Children services, behavior change and condom promotion.

ARV Services in Ruvuma

This activity also relates to activities in PMTCT, (7797), CT (8658), treatment (7747) , and SI 8683.

Ruvuma is the third of the four regions in the Southern Highlands, which includes Iringa, Mbeya and Ruvuma, to be included as a prime partner for treatment under the US Department of Defense. The Mbeya Referral Hospital supports Ruvuma for all its advanced care and supervisory needs, working in concert with but not over the regional medical office with the later supporting direct implementation of prevention, care and treatment programs through out its region.

Situations surrounding care and treatment in Ruvuma are very similar to Rukwa and development of treatment capabilities will mirror plans for Rukwa. Both are geographically isolated areas of the Southern Highlands and lacking support for basic services. FY 2006 Emergency Plan funding, which is just arriving in country, will support the development of additional infrastructure and capacity through clinic and lab renovations and the training of additional staff.

Funding in FY07 to the Ruvuma RMO will support expansion of treatment services at the regional hospital plus extension of support to a second site, Tunduru District Hospital. Current expansion plans will include 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 FY07 funding to the Ruvuma RMO will provide consumables for monitoring and medications for OI prophylaxis and treatment (exclusive of ARVs to be purchased and supplied by MOH and USAID) at both facilities. Laboratory services will continue to receive technical support from the Mbeya Referral Hospital with required equipment for the Tunduru Hospital procured either by the MOH or CDC. With similar capacities being developed in Ruvuma as in Rukwa, it is anticipated that these two hospitals will support a combined 2, 420 on treatment and another 2,600 with care by September 2008.

As in Rukwa, the Mbeya Referral Hospital will assist the Ruvuma RMO in developing a treatment supervisory team to support CTC in the region as they come on line. FY 2007 being requested in this submission in support of these teams will include costs for transport, lodging and meals incurred during supervisory visits. A referral mechanism between VCT and PMTCT services in the region being introduced in FY05 is being strengthened to ensure linkage of services at centers providing counseling and testing at TB clinics, lower-level health facilities and PMTCT interventions at antenatal clinics to the CTC. FY07 submissions under CT will look to strengthen the integration of provider-initiated counseling and testing in these two facilities' outpatient clinics and in patient wards in support of treatment efforts. And lastly, the electronic medical record system being piloted at the Mbeya Referral Hospital (funding under the DoD submission in SI) will be introduced at each of these sites to aid in patient management, reporting to the MOH and tracking patients as they are referred back to smaller facilities to receive their primary care. All of these efforts combined, strengthen the overall program in the region with a focus on developing sustainable systems.

Strategic planning meetings with the Director General of the Mbeya Referral Hospital and the Regional Medical Officers of Rukwa, Ruvuma and Mbeya continue the development of similar program plans to be implemented in the Southern Highlands in support of HIV prevention and care. As in Rukwa, the Ruvuma Regional Medical Office has expressed a desire to develop the capacity of communities to take part and support care and treatment as it is introduced into the region. Local NGOs, FBOs, have been providing training in provision of palliative care and ART adherence counseling to assist in patient follow-up. In FY 2007, the Ruvuma RMO will train and additional 40 HBC providers/dispensary personnel with the ART module developed by the Mbeya Regional Medical Office and a large NGO in the Mbeya Municipality. The Ruvuma RMO continues to work with the Regional Hospital and Tunduru District Hospital in strengthening referrals of hospital patients to these dispensaries and organizations for support and follow up. Key organizations providing this service will be mentored by linking them with a counselor or nurse working in the CTC. Funding will support the training of providers/dispensary personnel, commodities for patient follow up, and continued supportive supervision by the

hospitals and Regional Medical Office.