The HIV infection affects nutrition through increases in energy and nutrients requirements. The effect of HIV on nutrition begins early in the disease. Asymptomatic HIV-positive individuals require 10% more energy, and symptomatic HIV-positive individuals require 20 - 30% more energy than HIV-negative individuals. Consequently, with additional insults such as infection and cancers, weight loss and wasting are common in AIDS patients. In addition, micronutrient deficiencies may contribute to the disease progression. In the case of pregnant women, the risk of anemia is particularly high, also contributing to adverse birth outcomes. Daily micronutrient supplementation improves body weight and body cell mass, improves CD4 cell counts, reduces HIV RNA levels, and reduces the incidence of opportunistic infections. At the same time, anti-retroviral therapy improves nutritional status, but also may have side effects and metabolic complications.

PEPFAR-funded implementing partners are stepping up their efforts to integrate PMTCT services with Care and Treatment programs. Based on nutritional assessments, pregnant women requiring nutritional support will be identified.

The requested Plus Up funding will be used for a procurement of micronutrient supplementation or nutritional support that will assist with the therapeutic feeding for moderately and severely malnourished HIV-positive pregnant women. This nutritional support will be distributed through the PEPFAR-funded implementing partners.

Table 3.3.01:

Comprehensive palliative care is essential to the health and well being of PLWAs. Volunteers are organized in Tanzania to provide home-based palliative care to people who are infected with HIV/AIDS or other critical chronic diseases. The home-based care kit provided to these volunteers is a backpack outfitted with medication for basic pain and symptom management; bandages and other wound dressing; gloves; condoms; and materials for integrated counseling and testing (where appropriate), hygiene, malaria prevention, promotion of good nutritional practices, integrated prevention messaging, family planning, and other child survival interventions. The supplies not only facilitate care but also endow the volunteer with credibility and a sense that they can provide concrete support as well as psycho-social assistance. Plus Up funding in the amount of $400,000 is requested for the purchase of these kits. The proposed funding would support the purchase of approximately 2,600 kits. Restocking would be provided through local GoT facilities as part of the overall service. In addition, an additional $250,000 is requested for the purchase of nutritional support for people living with HIV/AIDS (PLWHA) who are receiving palliative care services through Home-based Care. HIV/AIDS and malnutrition are both highly prevalent in Tanzania, and their effects are integrated and exacerbated by one another. The current WHO recommendations for the nutrient requirements for PLWHA call for increases for energy over the intake levels recommended for healthy non-HIV infected individuals. The proposed intervention will support those who are HIV-infected with confirmed severe malnutrition. It is estimated that 15 - 20% of the adult population on ART will have severe malnutrition. The requested funding will allow the piloting of the intervention. This pilot will be linked to the funding requested for nutritional support for orphans and vulnerable children. Broader implemention of the nutritional support for severely malnourished HIV-positive individuals will be planned with FY2008 funding.

Table 3.3.06:

Food and nutrition through therapeutic and supplementary feeding are important support for malnourished orphans and vulnerable children (OVC) to ensure their development and wellbeing. In the Tanzania under-nutrition survey (TFNC/UNICEF 2000) a distinctive pattern with respect to age, sex, socioeconomic status and geographical location was noted. Children under-five years of age, adolescent girls and pregnant and lactating women are not only the most nutritionally vulnerable, and their consequences in terms of survival, development and reproduction are most serious.

Parental education, particularly of the mother, on the nutritional status of the children showed that they positively affect nutritional status. In both the 1978 and 1988 censuses, infant and child mortality rates were lower in households with women possessing post-primary education than those with primary or no formal education. Other studies in Tanzania have demonstrated the relationship between income classes and nutritional status of households. Those with no parent or who are vulnerable because of the chronic illness of a parent are particularly at risk or malnutrition. Most have no reliable breadwinners, and suffer from inadequate food intake. The situation is worsened if the child is HIV positive, as food is required for therapeutic purposes to improve health status and chances of survival. It is estimated that about 10% of OVC have severe malnutrition.

Some PEPFAR and Global Fund implementing partners have initiated growth monitoring through measurement of Body Mass Index and specific programs' tool. Partners will be be asked to initiate routine assessments of OVC, so that nutritional care and support can be provided for OVC who are diagnosed as severely malnourished based on Body Mass Index and other standardized nutritional indicators. The requested Plus Up funding will be used to make a bulk purchase of supplementary products through the Supply Chain Management Program (SCMS). For those with severe malnutrition, quantities will be purchased for at least a month's supply of high energy, high protein, and micronutrient rich supplements, e.g., B-imune. Other product will also be purchased that is rich in soya, micronutrients, cereals and fats for longer term use with malnourished OVC. The products will be distributed through implementing partners working in more than half of the districts in Tanzania. The nutritional support is expected to reach about 12,000 OVC, but targets are not changed as they are already service recipients.

Target Populations: Orphans and vulnerable children

Table 3.3.08:

This activity links with all service provider partners in counseling and testing on the Tanzania mainland and Zanzibar and will support the goals of testing approximately 675,000 and roll-out a new testing algorithm (currently Capillus as the screening test with Determine in the confirmatory slot).

In FY 2006 JSI/Deliver assisted the Government of Tanzania (GoT) with test kit forecasting and quantification. Based on this analysis the Japanese International Cooperation Agency (JICA) and the GoT crafted procurement agreements in which JICA would procure 50% of the country's test kits for volunatry counseling and testing and the GoT would procure the remainder. Based on lessons-learned, the USG also set aside FY 06 resources for emergency buffer stocking. In the event, all USG resources that had been available were mobilized to end a national stock out.

In FY 2007, USG will continue, through JSI/SCMS, to collaborate with the GoT and JICA regarding forecasting and quantification. However, during this period the role of SCMS will be expanded to include more proactive engagement with GoT to ensure timely procurement. This expanded role will include tracking the utilization of Global Fund for AIDS, TB and Malaria (GFATM) and AXIOS International resources that have already been committeed to test kit procurement, and the establishment of an early warning system that will allow the USG to moblize diplomatic strategies, if necessary, to eliminate what has been a pattern of recurring stock-outs.

In addition, to facilitate a rapid roll-out of a new testing algorithm, the USG has committed to procuring initial supplies of the new test kits as GoT adapts. Unfortunately, monetization of the needs in this area are extremely difficult to predict as the new testing algorithm has note yet been announced. Therefore, funds set aside are notional at this time but based on cost estimates for 6 months of utilization of the current algorithm which is anticipated to be significantly more expensive than the revised one, until the new algorithm is established. USG hopes that this occurs before the end of calender year 2006. Once established, the USG will then assess the sufficiency of its resources and reprogram if necessary. USG funded test kits will be placed with the Medical Stores Department (MSD), a parastatel of the national government, to be accessed by all public and private health facilities.

The roll-out of the new algorithm will also be supported by activities in the USG Laboratory portfolio through testing of trainers of trainers as well as USG governmental and non-governmental partners receiving CT funding.

This activity links to all activities under antiretroviral treatment. Activities in 2005 represented a turning point in the implementation of the Emergency Plan in Tanzania. With the arrival of the first anti-retrovirals (ARVs) purchased with USG funds in September 2005, the Tanzania program turned the corner into full-scale implementation of the ART strategy. Under COP 2007, support for ARV logistics will continue and expand through funding of JSI's Partnership for Supply Chain Management Systems (SCMS), building on the successes of the previous years under JSI/DELIVER. JSI/SCMS will continue to assist the National AIDS Control Program (NACP) with the quantification of all of the National Care and Treatment Plan's ARVs, and will procure those that are designated as the USG's contribution to the pool.

ARV's procured by SCMS will fulfill the USG's commitment, articulated through a formal memorandum of understanding with the Government of Tanzania (GoT), to provide alternate first line, second line, and pediatric drugs for the country. These are: Abacavir, Didanosine, Efavirenz, Lamivudine, Lamivudine combined with Nevirapine, Lopinavir combined with Ritonavir, Nelfinavir, Nevirapine, Ritonavir, Stavudine, Zidovudine, and Saquinavir. The total cost of approximately $14 million represents 60% of overall expenditures on ARVs in Tanzania. The balance, procured by GoT with GFATM funds, is for first line ARVs.

With the increasing influx of drugs to support the ART program, comes a concomitant concern over the handling and security of these commodities, from the time they enter the country until the time they are received by the patient. To help safeguard the ARVs, zonal "SWAT" teams were established in 2006 to create a linkage between the 8 Zonal Medical Stores Departments (MSD) and clinics. (This will build upon the successful work carried out under JSI/DELIVER in 2006 by two consultants monitoring ARV logistics and providing supportive supervision to the 19 ART sites in Dar es Salaam.) These SWAT teams, comprised of two people each (an individual with pharmacy expertise and an individual with clinical expertise) will move within the MSD zone to assist facilities in quantifying their drug requirements, provide on-the-job training to improve performance of ARV-related logistics functions, and ensure that MSD is able to fill requests. An additional supervisor, based in Dar es Salaam, will coordinate these teams and serve as the link between the central MSD warehouse and the 8 zonal stores, thus completing the monitoring chain from the drugs' point of entry into the logistics system to their exit at the service delivery point. Whereas the pharmacist staffer of the two person team will support drug management staff in the sites, the clinical staffer of the team will support clinical staff in understanding the prescription and ordering process for the drugs. Thus the two person team will ensure that ARVs are available at the facility and are prescribed properly. These teams will also serve as an opportunity to link into the activities of the Twinning Center (see ART AIHA activity narrative for more information) and treatment. Treatment partners, with a presence in facilities, will guide SCMS SWAT teams to identify technical assistance in drug and logistics that the partners may not be best placed to provide. The Twinning Center will provide preceptors for ART facilities which do not have a direct USG partner. The preceptor may join the team to provide expert input at the facility level and as on-going supervision for sites which may "graduate" from preceptorship.

In FY 2005, JSI/DELIVER piloted an Integrated Logistics System for commodities including PMTCT, ART and home-based care in two of the country's 21 regions. In 2006, the USG funded the expansion of the ILS to two additional regions. Three more regions were trained using funds leveraged from DANIDA. COP 2006 funds will allow two to four more regions to be trained, in step with MSD's expansion of their packing line capacity. COP 2007 funds will be used to continue this process, and to support MSD's computerized database in capturing facility-level data on usage of drugs and related medical supplies. The progressive roll out of the ILS will have profound implications on MSD's data entry requirements, and JSI/SCMS will continue to support MSD through locally-procured IT services and staff, including expanding electronic ordering by ART sites and districts. Data from this database will be invaluable, both to central level decision makers as well as zonal and district managers supported by the SWAT teams who will also monitor the roll out of the ILS. In addition to support in the development, training and implementation of logistics systems for the various commodity groups and programs (ART, PMTCT, STI drugs, HIV test kits, essential drugs, etc.), JSI/SCMS will expand their quantification and ongoing monitoring to include ARVs, HIV test kits, STI drugs, drugs to combat opportunistic infections, reagents, lab supplies and equipment, and will procure many of

these items on behalf of the USG.

SCMS will also continue to provide technical assistance to a wide range of development partners including all PEPFAR partners, Global Fund partners, the Development Partners Group, as well as the various divisions of the MOHSW involved in commodity distribution; NACP, Reproductive Child Health Services, and in particular, the Pharmaceutical Supply Unit, which will be strengthened over time to assume its key role of coordinating all commodity management for the MOHSW.

With plus up funding, 3 of the 5 regions that are still using old systems will be able to rapidly transition to the ILS, thus improving forecasting, timely procurement, and distribution. Experienced zonal training centers will be used for the necessary training along with already developed, tested and used training materials. The additional resources will also support the upgrading of remaining zonal medical stores with the packing lines necessary to implement ILS. Funding for the remaining 2 regions will be included in the '08 COP thus facilitating a completed roll-out by September 2008.

This activity links directly with all care, treatment, TB/HIV, and PMTCT service delivery activities.

The purpose of this activity is to procure cotrimoxazole in support of the Government of Tanzania's (GoT)'s National Care and Treatment Programme. It will be used in GOT-designated care and treatment centers, as part of our PMTCT+ programs, and by trained health care workers providing palliative care to those with Tb or otherwise benefiting from cotrimoxazole. Cotrimoxazole prophylaxis has a demonstrated beneficial effect in preventing death and illness episodes in adults with both early and advanced HIV disease, as well as with children. Cotrimoxazole remains an important intervention, even with increasing access to ART, as its use can improve survival independent of specific HIV treatment. Current evidence and recommendations suggest it should be used before children require ARVs because it may even postpone the time at which ART needs to be started. According to WHO recommendations, prophylactic dosing with cotrimoxazole for HIV-infected children with any sign or symptoms suggestive of HIV is a key intervention that should be offered as part of a basic package of care to reduce morbidity and mortality.

With funds from COP07, the USG will purchase sufficient quantities to provide an uninterrupted supply of cotrimoxazole for all individuals under care and treatment, HIV-positive individuals in TB settings, pregnant women who are HIV positive, and HIV-exposed children (children born to HIV infected mothers or children identified as HIV-infected with any clinical signs or symptoms suggestive of HIV, regardless of age or CD4 count). Approximately 144,000 persons will be served with the purchase.

While cotrimoxazole is available for use in Tanzania, it is primarily available through the Essential Drug Program (EDP Kit) and through the Sexually Transmitted Infection Program. These sources, plus those purchased through the private sector, are not sufficient to cater for the increased needs posed by care and treatment and PMTCT programs. The USG would use SCMS to procure additional cotrimoxazole to fill in the gap. This purchase would be a first step toward using SCMS for reliable procurement for USG programs, and would help ensure an uninterrupted supply for USG-funded programs. The availability of cotrimoxazole to the USG implementing partners will help ensure its integration into the basic package of services.

All targets are indirect, as they are already counted under care, treatment, or PMTCT+ programs.

With plus up funding, sufficient quantities of Cotrimoxazole will be procured to support of the Government of Tanzania's (GoT)'s National Care and Treatment program. It would provide for an uninterrupted supply of Cotrimoxazole for all HIV exposed children and their HIV positive mothers.

While Cotrimoxazole is available for use in Tanzania, it is primarily available through the Essential Drug Program (EDP Kit) and through the Sexually Transmitted Infection Program. These sources, plus those purchased through the private sector, are not sufficient to cater for the increased needs posed by care and treatment and PMTCT programs. In addition to Cotrimoxazole, additional HIV rapid test kits have to be procured in order to offer HIV testing to mothers with unknown HIV status. The project will be carried out in three regions with initially 2 facilities per region participating (total of 6 facilities). We anticipate that we have to offer testing to 10 mothers in order to identify one positive mother child pair.

In addition, the requested Plus Up funding will be used for a procurement of micronutrient supplementation or nutritional support will assist with the therapeutic feeding for moderately and severely malnourished HIV-positive children, and nutritional support for HIV-exposed infants and young children. For those with severe malnutrition, quantities will be purchased for at least a month's supply of high energy, high protein, and micronutrient rich supplements, e.g., B-imune. Other product will also be purchased that is rich in soya, micronutrients, cereals and fats for longer term use with malnourished HIV-positive children. The products will be distributed through implementing partners working at Care and Treatment Clinics throughout Tanzania, starting with a pilot with two partners. The nutritional support is expected to reach about 2,500 HIV-positive children,

but targets are not changed as they are already service recipients.

This activity links to activities HLAB MOHSW 7758, 7779 NIMR, 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, FHI 7712; SI NACP 7773, MOHSW 7761

With the FY 2007 funding USG/HHS/CDC will place $ 200,000.00 for negotiation of reagent procurement for the National Quality Assurance and Training Center (NQA&TC) currently under renovation and expected to be completed by December 2007. Through this mechanism various laboratory supplies and reagents and kits for HIV rapid testing and ELISA kits, PCR, CD4 count, Chemistry, Hematology Hepatitis, syphilis and Opportunistic infections tests kits will be procured.

When completed, equipped, and staffed, the laboratory will support MOHSW to introduce, develop and implement HIV/AIDS laboratory quality systems in Tanzania. Also the laboratory would conduct quality assessment of HIV/AIDS testing at Zonal, Regional and district laboratories, develop HIV laboratory training materials, train trainers in HIV/AIDS related testing and testing specific quality assurance, support and conduct HIV surveillance for prevalence, drug resistance threshold and Incidence testing, establish a central area for receiving and delivering distance-based training, and provide technical assistance for external quality assessment (proficiency testing) programs.

The reagents and laboratory supplies purchased will be used for these activities by the National Quality assurance and Training Center.

Procurement of Supplies to Support Surveillance Activities

This activity is linked to activities #7773 and #8060.

The USG has provided support to the National AIDS Control Program (NACP) for HIV surveillance activities, including the provision of funds for the procurement of specimen collection, transport and laboratory testing supplies needed for the surveys. The USG has funded the Antenatal Clinic (ANC) HIV sentinel annual survey and the HIV Drug Resistance (HIVDR) threshold survey. In FY 2005, USG provided support for the national ANC surveillance, which covered 90 sites in 15 of the 21 regions. Additionally, USG provided technical assistance for the pilot HIVDR threshold survey in Dar es Salaam region, with six participating sites. This included guidance on supplies needed for the survey as well as technical assistance with specimen collection and transport for six participating sites and National Health Reference Lab, Muhumbili University College of Health Sciences (MUCHS), where HIV testing was carried out. FY 2006 USG funds were used to support the scale-up of the national ANC surveillance from 15 regions to all 21 regions, with a total 128 participating sites. Funds were also used to conduct another round of the HIVDR survey in Dar es Salaam region.

The FY 2005 and FY 2006 funds were used by NACP for the procurement of supplies such as Enzyme-linked immunoassays (EIA) test kits, filter paper, pipettes, dried blood spot (DBS) cards (for collecting specimens) and gloves. However, as a result of existing procurement procedures, NACP has faced challenges in obtaining the necessary supplies in a timely manner to conduct the surveys. This has led to delays in carrying out required activities.

USG plans to support the NACP in FY 2007 to maintain 128 sites participating in the national ANC surveillance, and to provide funding for NACP to conduct HIVDR threshold surveys in six urban sites in three regions (Mwanza, Kilimanjaro and Mbeya). Based on the previous experience and to ensure continuity of these important activities, USG will provide FY 2007 funding for procurement to the Supply Chain Management System (SCMS). This will ensure specimen collection, transport and testing supplies are received in time and will prevent shortages of supplies which could lead to delays in surveillance activities. ANC surveillance supplies will cost $400,000. This includes EIA test kits, storage bags (for storage and transport of specimens), desiccants, humidity indicator cards, filter paper, pipettes, DBS cards, data collection forms. Since the HIVDR threshold surveys are nested within the ANC surveys, the overall cost for supplies is much less, at approximately $140,000. This includes storage bags, desiccants, humidity indicator cards, filter paper, pipettes, DBS cards. As a part of the validation of the sample results, quality assurance is conducted, specifically re-testing 10% of the all tested samples. Technical assistance will be provided for this activity, which is described in activity #7773 in the SI program area. Additional test kits to conduct quality assurance for collected specimens will be purchased using FY 2007 funds.

Use of Personal Data Assistants (PDAs) will be initiated beginning in FY 2007, as tool for data collection for supportive supervision activities. These are commonly used in many other countries in the region, to reduce data entry errors and time needed for data entry. Data are available in a timely manner for analysis and to be used for decision making at the district levels. In Tanzania, these tools will standardize data collection during supportive supervisory visits as well as to ensure a more timely flow of data from field to NACP headquarters. Moreover, the units are PC-compatible making transfer for data from the data collection tool to database, relatively seamless. As a pilot, 200 PDAs will be purchased at $50 per unit. Regional and district level health personnel participating in the pilot will be identified and trained on using the units in a one-day training, which is part of overall SI capacity building, described in activity #8060. In addition to the PDAs, car chargers will be procured to ensure that the battery is charged at all times. This method of data collection will ease the work load on district health staff and motivate them to use the data for informing their programs. SCMS will procure the PDAs and additional supplies.