In FY 2007 HHS/CDC will continue close collaboration with the Government of Tanzania, Ministry of Health and Social Welfare (MOHSW), and other key partners to further strengthen technical and program capacity to ensure appropriate Emergency Plan implementation. This will include the establishment and expansion of quality-assured national systems in prevention of mother to child transmission (PMTCT).

In FY 2007, this funding will support the PMTCT in-country program staff to provide technical assistance and support for PMTCT implementing partners. This will ensure that all PMTCT services are in line with the USG technical strategy and national guidelines. PMTCT staff will provide technical assistance for the Ministry of Health and Social Welfare (MOHSW) to finalize and operationalize the recently revised national guidelines, policies and training manuals.

The in-country staff will work with implementing partners to expand PMTCT services to high prevalence regions and districts in order to serve the targeted population. In addition, the HHS/CDC in-country team will work with implementing partners to develop annual work plans, conduct training and ensure the overall program monitoring. Furthermore, the in-country staff will provide technical assistance for the MOHSW to develop national supportive supervision systems. The systems include tools to ensure quality service provision at facility level and they will collaboratively train national and regional supervisors to operationalize supportive supervision activities. In FY07 the in-country team will also support the MOHSW to develop a national five-year PMTCT implementation plan. The team will conduct site visits quarterly to monitor program implementation and progress in line with the cooperative agreement. They will also ensure that all HHS/CDC programs adhere to the national and USG PMTCT strategies and protocols.

The MOHSW, in collaboration with and receiving support from different stakeholders, has increased access to PMTCT services. Expansion of these services has increased from five regions in FY 2004 to 21 regions in FY 2006. Currently over 500 PMTCT service sites are in operation within 21 regions and 84 districts. Thus far, over 200,000 pregnant women have received basic PMTCT services including counseling and testing. Over 6,000 HIV positive pregnant women have received ARV prophylaxis. The USG in-country team, in close collaboration with USG headquarters team, played an instrumental role in supporting the MOHSW to establish national systems that accelerated these services to reach health facility level. These systems include PMTCT monitoring systems.

Despite the overall program success including the availability of PMTCT services at national level, program linkages, provision of comprehensive care services for HIV positive pregnant women, exposed infant follow up, low antiretroviral prophylaxis uptake and partner involvement remains a challenge.

There is a fundamental need for continues technical assistance. The changes are ongoing and will have a significant impact on programs, include shifting from opt-in counseling and testing to opt-out counseling and testing, provision of PMTCT at labor and delivery, and early infant diagnostics. The Tanzania PMTCT thematic group requests on going technical assistance from the PMTCT Technical Working Group (OGAC) in order to identify strategies to mange these challenges and ensure effective implementation of these key policy changes.

Targets

Target Target Value Not Applicable Number of service outlets providing the minimum package of
PMTCT services according to national and international standards Number of pregnant women who received HIV counseling and
testing for PMTCT and received their test results Number of HIV-infected pregnant women who received
antiretroviral prophylaxis for PMTCT in a PMTCT setting Number of health workers trained in the provision of PMTCT
services according to national and international standards

Table 3.3.01:

This activity is linked to activity narratives #9411 and #9460 in AB.

The USG/Tanzania Prevention Working Group has identified its critical technical assistance needs for FY07 funding in AB. These specific requests will assure effective support of the USG Team and identified implementing partners in this section of the COP. This technical assistance is envisioned to provide up to date technical information and programming guidance for effective AB messaging which includes AB for Youth and B Messaging for adult males. The identified technical assistance needs for CDC includes:

Continued technical assistance to assure CDC's effective support and implementation of the NACP TAYOA Helpline activity in this section of the COP. Continued technical assistance from Dr. Joan Kraft will contribute to identifying the most appropriate behavior change interventions for the TAYOA HIV Helpline and its associated community work through youth balozis. .

Table 3.3.02:

In FY07, HHS/CDC will continue to collaborate closely with the Government of Tanzania through the relevant Ministries of Health (MoH) /National AIDS Control Program (NACP), Ministry of Education and Vocational Training (MOEVT) and other key partners to strengthen technical and program capacity for implementing the Emergency Plan. The proposed funding will support the salaries of in-country youth program staff for FY 07 and sites visits to provide direct capacity-building among partners.

An emphasis will be placed on building the capacity of organizations to develop appropriate IEC/BCC materials for ABY. To this end, staff will collaborate with key AB partners including the NACP/TAYOA Helpline program and the Balm in Gilead through the Tanzania HIV/AIDS Faith Initiative. Staff expertise with behavior change and behavioral theory will enhance the effectiveness of HIV/AIDS programs that promote abstinence messages for in and out of school youth.

The in-country staff will also work with MOEVT to review life planning skills guidelines and manuals with the aim of incorporating appropriate AB messages and explore strategies for scaling up other youth approaches in HIV/AIDS education and youth programs. Youth program staff will provide guidance on ways in which the life planning skills guidelines can be used to reinforce and simultaneously address AB prevention while linking with other HIV/AIDS prevention strategies.

Finally, the in-country staff will visit a variety of youth program sites managed by Government, NGO and FBO partners. More time will be spent mentoring the NACP IEC/BCC team on how to develop quality BCC materials tailored to different target groups. A particular focus will be on youth HIV/AIDS BCC educational materials and quality assurance. Emphasis also will be placed on assisting the key implementers to adopt the MARCH (Modeling and Reinforcement to Combat HIV) strategy. At the end of the site visits, the staff will provide feedback to partners and discuss the recommendations set forward.

Table 3.3.02:

This activity relates to HMLB AABB 8223, CDCBase 7837/9473 CT 7776, 7781, PMI, 8233, 7712; SI 7773, 7761;Track 1 ART CU7697/7698, EGPAF7705/7706, HARVARD7719/7722, AIDS Relief7692/7694, DoD7747 HLAB APHL7676 HHS/CDC provides technical assistance and support to MOHSW National Blood Transfusion Service (NBTS) and the Zanzibar Blood Transfusion Service (ZBTS) in implementing activities funded through a central mechanism ( track 1 ) to MOHSW/NBTS and Association of American Blood Banks Consulting services. This technical assistance involves TDY visits from the project officer in Atlanta as well as in country site visits to zonal centres and regional centres operated by the Tanzania Red Cross Society and Millitary hospitals operated by the Tanzania Peoples Defense Force.

Due to the expansion and development of the National Blood Transfusion services the scope for in country technical assistance has greatly widened. HHS/ CDC will recruit a blood safety program officer to coordinate and provide technical assistance to MOHSW/NBTS and the Association of American Blood Banks Consultants.

The program officer will provide technical assistance for the introduction and maintenance of a monitoring and evaluation (M&E) system. An effective M&E system will include the updating, printing and dissemination of M&E tools for blood transfusion services; developing monitoring tools for blood donor clubs; conducting field supervisory visits and biannual progress reviews to develop a detailed implementation plan for FY 07. External Quality Assurance will be put in place to ensure M&E is done by an external agent to complement the internal quality assurance.

The Blood Program officer will also coordinate activities in collaboration with the President Malaria Initiative for prevention of Malaria through provision of Insecticide Treated bed Nets (ITN) to voluntary non-remunerated repeating blood donors and with the Prevention Program for prevention of HIV/AIDS spread through abstinence and be faithful, injection safety and post exposure care using national guidelines.

Due to changes in the contract and conditions on-site, the contracting officer approved several modifications for the National Blood Zonal Transfusion Centers (NBZTC) at the Mtwara and Tabora locations. These changes were not anticipated during COP planning process. Funding for the NBZTC activities were planned for in Fiscal Year 2007 within the MOHSW cooperative agreements. CDC does not have additional funds to address the modification requirements. Both sites are expected to be complete by the end of March and hand-over of the buildings are expected during the month of April. The buildings can not be handed over with out payment for the modifications. MOHSW agreed that the funds should be transferred back to CDC to address short fall in funds.

This activity is linked to narrative #9459 and #8728 in Other Prevention.

The USG/Tanzania Prevention Working Group has identified its critical technical assistance needs for FY07 funding in OP. These specific requests will assure effective support of the USG Team and identified implementing partners in this section of the COP. This technical assistance is envisioned to provide up to date technical information and programming guidance for effective messaging to high risk groups which includes IDU, CSW and other MARP populations. The identified technical assistance needs for CDC includes:

Technical assistance from Dr. Richard Needle is requested to participate and assist in the design process for the TBD MARPS activity with IDUs and CSWs. It is anticipated that this visit will take place in coordination with the USAID technical assistance request for the Other Prevention portfolio review.

In FY 2007, the USG will continue to collaborate closely with the Government of Tanzania, Ministry of Health (MOHSW), and other key partners to further strengthen technical and program capacity for implementing the Presidents Emergency Plan for AIDS Relief (PEPFAR). This will include the establishment and expansion of quality-assured national systems in the areas of surveillance, prevention of mother-to-child transmission (PMTCT), laboratory services, blood safety and blood transfusion, antiretroviral treatment, care, and TB/HIV programs.

USG agencies provide direct technical support for all of its HIV/AIDS programs through US and Tanzania based organizations, which manage and implement in-country activities. These activities are funded through cooperative agreements and contracts that are performed at the field level in direct partnership and collaboration with Tanzanian governmental and non-governmental organizations. The non-governmental implementing partners have considerable experience in the field of HIV/AIDS and have established offices in Tanzania to carry out these activities. The technical assistance (TA) and support provided by USG agencies through our cooperative agreements and contracts will ensure a long-term sustainable system for providing HIV/AIDS services to Tanzanians.

In FY 2007, this funding will support the in-country Palliative Care: Basic Health Care/Support program staff. The staff will: 1) support the National AIDS Control Programme (NACP) - Home-based Care (HBC) Unit co-ordination role; 2) assist with the provision of integrated, high quality care and support for people living with HIV/AIDS; 3) provide guidance for the strengthening of referrals between community and facility based care; 4) assist in the preparation for implementation of the preventive care package; 5) provide guidance on improving the information system; 6) conduct field visits and supportive supervision to USG sites that are implementing HBC; 7) review and compile quarterly and annual reports and oversee the HBC program mid-term review.

In FY 2007, USG will continue to collaborate closely with the Government of Tanzania, Ministry of Health and Social Welfare (MOHSW), and other key partners to further strengthen technical and program capacity for implementing the President's Emergency Plan for AIDS Relief (PEPFAR). This will include the establishment and expansion of quality-assured national systems in the areas of surveillance, prevention of mother to child transmission (PMTCT), laboratory services, blood safety and blood transfusion, antiretroviral treatment, care and TB/HIV programs.

USG agencies provide direct technical support for all of their HIV/AIDS programs through US and Tanzania based organizations, which manage and implement in-country activities. These activities are funded through cooperative agreements and contracts and are performed at the field level in direct partnership and collaboration with Tanzanian governmental and non-governmental organizations. The non-governmental implementing partners have considerable experience in the field of HIV/AIDS and have established offices in Tanzania to carry out these activities. The technical assistance (TA) and support provided by USG agencies through our cooperative agreements and contracts will ensure a long-term sustainable system for providing HIV/AIDS services to Tanzanians.

The FY 2007 funding will support the in-country Palliative Care Basic Health Care (HBC) program with technical assistance (TA) from USG agencies Headquarters. The TA will work closely with the Ministry of Health and Social Welfare National AIDS Control Program HBC Program and its national technical committee that involve partners implementing home based care and facility based care in Tanzania. The TA will support development of monitoring for preventive care package and give technical advice on how to measure the impact of the activities.

Table 3.3.06:

In FY 2007, USG will continue to collaborate closely with the Government of Tanzania, Ministry of Health (MOH), and other key partners to further strengthen technical and program capacity for implementing the Emergency Plan. This will include the establishment and expansion of quality-assured national systems in the areas of surveillance, prevention of mother to child transmission (PMTCT), laboratory services, blood safety and blood transfusion, antiretroviral treatment, care and TB/HIV programs.

USG agencies provides direct technical support for all of its HIV/AIDS programs through US and Tanzania based organizations, which manage and implement in-country activities. These activities are funded through cooperative agreements and contracts and are performed at the field level in direct partnership and collaboration with Tanzanian governmental and non-governmental organizations. The non-governmental implementing partners have considerable experience in the field of HIV/AIDS and have established offices in Tanzania to carry out these activities. The technical assistance (TA) and support provided by USG agencies through our cooperative agreements and contracts will ensure a long-term sustainable system for providing HIV/AIDS services to Tanzanians.

In FY 2006, this funding will support the in-country TB/HIV program staff . The staff will: assist with the development of policy, training guidelines, curriculum and manuals for TB/HIV programs implemented by the USG partners; support the development and use of a national TB/HIV register; conduct field visits and provide supportive supervision to the districts that are implementing TB/HIV programs; and support the NTLP and NACP in preparing scale-up and expansion plans of TB/HIV services on the mainland and Zanzibar.

In FY 2007, USG will continue to collaborate closely with the Government of Tanzania, Ministry of Health and Social Welfare (MOHSW), and other key partners to further strengthen technical and program capacity for implementing the President's Emergency Plan for AIDS Relief (PEPFAR). This will include the establishment and expansion of quality-assured national systems in the areas of surveillance, prevention of mother to child transmission (PMTCT), laboratory services, blood safety and blood transfusion, antiretroviral treatment, care and TB/HIV programs.

USG agencies provide direct technical support for all of its HIV/AIDS programs through US and Tanzania based organizations, which manage and implement in-country activities. These activities are funded through cooperative agreements and contracts and are performed at the field level in direct partnership and collaboration with Tanzanian governmental and non-governmental organizations. The non-governmental implementing partners have considerable experience in the field of HIV/AIDS and have established offices in Tanzania to carry out these activities. The technical assistance (TA) and support provided by USG agencies through our cooperative agreements and contracts will ensure a long-term sustainable system for providing HIV/AIDS services to Tanzanians.

In FY 2007, this funding will support the in-country TB/HIV program with technical assistance from USG agencies Headquarters. The TA will meet with the Ministry of Health and Social Welfare specifically National Tuberculosis and Leprosy and National AIDS Control Program and its National TB/HIV Technical Committee. The TA will focus on HIV laboratories and assess Quality Assurance (QA) of HIV testing in TB clinics. The technical assistance will be in TB laboratory strengthening, including TB lab smear microscopy networks as well as strengthening the national reference laboratory for QA of smear microscopy, culture, and drug susceptibility. Also there will be TA on Mid term target evaluation of TB/HIV activities and progress.

Targets

Target Target Value Not Applicable Number of TB service outlets providing counseling and testing.
Number of TB postive individuals who received counseling and
testing for HIV, and received their results, at TB service outlets. Number of service outlets providing treatment for tuberculosis (TB)
to HIV-infected individuals (diagnosed or presumed) in a palliative care setting Number of HIV-infected clients given TB preventive therapy
Number of HIV-infected clients attending HIV care/treatment
services that are receiving treatment for TB disease Number of individuals trained to provide treatment for TB to
HIV-infected individuals (diagnosed or presumed)

Table 3.3.07:

During the next fiscal year, HHS/CDC will continue to collaborate closely with the Government of Tanzania, Ministry of Health (MOH)/National AIDS Control Program (NACP), and other key partners to further strengthen technical and program capacity for implementing the Emergency Plan. HHS/CDC provides direct technical support for all of its HIV/AIDS CT programs, which are implemented in collaboration with Tanzanian governmental and non-governmental organizations. The non-governmental implementing partners have established offices in Tanzania to carry out CT activities.

In FY 2007, this funding will support in-country CT program staff. In-country program staff will work with the MOH/NACP to develop national CT policies, guidelines, protocols, and curriculums. Guidance will also be provided for establishing and expanding CT services, strengthening supervision systems, and conducting routine monitoring and evaluation. In partnership with the Zanzibar AIDS Control Program (ZACP), in-country staff will also support CT efforts by helping ZACP develop an annual work plan. In-country staff will assist other non-governmental partners by ensuring compliance with national policies and guidelines, harmonizing CT training efforts, and facilitating the exchange of lessons learned among partners. Finally, staff will conduct site visits throughout mainland Tanzania and in Zanzibar to observe service provision, monitor cooperative agreements, and ensure appropriate program implementation.

This activity relates to technical assistance provided by DOD and USAID. FY 2007 funds will support counseling and testing (CT) technical assistance (TA) visits by USG headquarters staff including Centers for Disease Control and Prevention (CDC), Department of Defense (DOD), and United States Agency for International Development (USAID). This activity supports the travel, per diem and miscellaneous costs of CDC participation. The TA builds upon a March 2006 interagency technical assistance visit made by the CT technical working group (TWG). This TA team made a number of recommendations to strengthen national CT services including: increased CT promotion, introduction of an updated HIV test kit algorithm, use of lay counselors in CT settings, development of a provider-initiated counseling and testing (PICT) training curriculum, and stronger prevention counseling including increased condom education and distribution. In the coming year, USG staff will provide technical assistance in order to improve upon these issues, as well as to address the complexities of HIV counseling and testing for couples and children.

In FY 2006, USG/Tanzania made progress with CT issues. Following the March 2006 CT TWG visit, a supplemental TA visit was conducted in September/October 2006. During this visit, assistance was provided to the Ministry of Health (MOH) through the National AIDS Control Program (NACP) to finalize national PICT guidelines, and to adapt a draft CDC PICT training curriculum to the local context to be used in future PICT trainings.

Future TA visits will be supported in FY 2007 to enhance the capacity of a new CT partner, IntraHealth International, to assist NACP in the national roll-out of PICT in clinical settings. In the second quarter of FY 2007, TA assistance will focus on PICT training for health workers as well as training on couples counseling and testing for counselors already trained in VCT.

In the third quarter of FY 2007, members of the interagency CT TWG, including representatives from DOD and USAID, will return to observe settings where national PICT roll-out has occurred, as well as to monitor the progress made on their March 2006 recommendations, and make further recommendations as necessary. The CT TWG will pay particular attention to child counseling and testing issues.

A subsequent TA visit in the fourth quarter of FY 2007 will focus on the national progress of PICT, CT promotion, condom education and distribution, and other issues as requested by NACP and other partners. During this visit, assistance will also be given in the preparation of the FY 2008 COP.

During FY 2007, four interagency TA visits will be made to Tanzania to assist in national PICT roll-out as well as conduct site visits and assist in implementation of activities to address the CT TWG's March 2006 recommendations.

Targets

Target Target Value Not Applicable Number of service outlets providing counseling and testing
according to national and international standards Number of individuals who received counseling and testing for HIV
and received their test results (including TB) Number of individuals trained in counseling and testing according to
national and international standards

Table 3.3.09:

CDC Management and Staffing (GHAI account)

These funds will support two full time staff that will assist in coordinating activities within this program area as well as serve as technical leads for aspects of the work. The specific composition of the staffing is a senior and junior specialist, given the scope and magnitude of the treatment roll-out in Tanzania, and the evolving responsibility of the USG in the scale-up of these services given "regionalization".

In FY 2007, USG/Tanzania ART implementing partners will fully transition to the newly adopted regionalization plan designed by the Government of Tanzania (GOT). Under this regionalized plan, each USG partner will support the scale-up of ART services at all levels of treatment facilities within assigned geographic regions. In all designated treatment sites in each region, USG partners will provide some level of support, and will be integrated within the regional and district annual health budget and plans.

In support of this, both full-time staff members will work directly with implementing partners, both governmental and non-governmental, specifically providing technical assistance to the National AIDS Control Program (NACP) and USG ART partners. Field visits and attendance at regional authority meetings will be necessary. As USG/Tanzania plans to implement a more defined strategy of building linkages in FY 2007, one staff member, in addition to the focus on ARV Services, will help oversee the integration of non-ARV services such as prevention of mother to child transmission (PMTCT), TB/HIV and Care. In addition, this specialist, under the direction of the NACP, will help lead the design of a multi-dimensional strategic approach to pediatric HIV/AIDS.

CDC TA for ARV services Each year, it is important to call together all of the treatment implementing partners, the government of Tanzania and key members of the PEPFAR Treatment Technical Working Group (TWG) to share perspectives on effective service delivery, discuss challenges and possible solutions, and to map out a way forward to scale up services strategically and cost effectively. The Treatment TWG brings a fresh eye to service delivery in this resource challenged environment, bringing experiences and lessons learned from other countries in the region.

In FY2007, given the anticipated scale-up of services under regionalization this annual meeting wll be a critical component of our planning.

These funds will support the Headquarters staff who will attend the meeting and provide the in-country team and our host country counterparts technical assistance during the week of the meeting.

Targets

Target Target Value Not Applicable Number of service outlets providing antiretroviral therapy
Number of individuals who ever received antiretroviral therapy by
the end of the reporting period Number of individuals receiving antiretroviral therapy by the end of
the reporting period Number of individuals newly initiating antiretroviral therapy during
the reporting period Total number of health workers trained to deliver ART services,
according to national and/or international standards

Coverage Areas: National

Table 3.3.11:

Monitoring the impact of ART in Tanzania (SI)

This narrative relates to OPSS activity ID number 7778.

The majority of facility-based HIV/AIDS treatment monitoring systems implemented in Tanzania are based on chronic disease record-keeping for patient management and cross-sectional reporting of program-level output indicators for program management. The Government of Tanzania (GOT) information systems and very few regional partners have the human or technical resources to collect or analyze longitudinal information on individuals enrolled on antiretroviral treatment (ART). Current resources should be primarily focused on the scale-up of care and treatment and prevention services. However, information on the same individuals over time is needed to measure the impact of the national ART services program on HIV-related outcomes, such as the percentage of persons on ART who are alive and on ART at six and twelve months after initiation. National level evaluation of the quality of services is important to determine if the program is having the desired impact. By the end of 2006, Tanzania will have over 200 care and treatment centers at the zonal, regional and district levels. The National AIDS Control Program (NACP) plans to scale up the number of sites by implementing ART services at the health center level. This will bring the number of sites providing ARV therapy to over 500.

In order to assess the quality of the national ART program, a few key de-identified patient level clinical and laboratory outcomes will be analyzed using routinely collected data from a nationally representative sample of ART care and treatment sites and patients who have been on antiretrovirals (ARV) for 12 months in Tanzania. This activity is a program evaluation and is modeled after the Rwandan evaluation of the quality of ART services. It will provide implementing partners and policy makers with information to enhance or prioritize components of the ART program. This evaluation will be conducted annually in future years.

In this evaluation, key patient-level characteristics will be analyzed with clinical, immunologic, and virologic outcomes, and adherence to ART clinical and program monitoring guidelines during the scale up will be assessed. Medical record abstraction will take place in the second and third quarters of 2007 for 4-6 weeks. Analysis of viral load from residual bloods will start at the same time but will take 8-12 weeks. As there are two components of this evaluation, multi-stage sampling will be performed. From a listing of all ART care and treatment centers, a representative sample of eligible facilities will be selected. A checklist will be administered at each participating facility to describe programmatically relevant characteristics such as facility staffing and management, other available health services, laboratory capacity, drug procurement and stocks, and program model. A retrospective sample cohort of eligible persons on treatment will be constructed to give results about 6- and 12-month outcome data on clinical outcome, weight, and CD4 cell count. The second component is a retrospective cohort based on laboratory testing for HIV RNA on residual blood from routinely collected specimens for CD4 cell counts on patients receiving ART. These data will not include any personal identifiers such as name or unique number. The residual bloods will be delinked from any specimen number and name. All analyses will be done on an aggregate level by cohort. It is not expected that the evaluation will introduce any risks to patients or providers as it is based on data collected routinely and routine laboratory testing which are delinked from any personal identifiers at time of data abstraction. Confidential, standardized data abstraction, storage, and access procedures will be followed. This evaluation will enable the GOT and USG to critically evaluate and improve treatment programs in country. The findings of this evaluation may identify components that could be addressed through future public health evaluation.

The activity will have collaborative oversight from USG Tanzania's Strategic Information and ART Services Thematic Groups, and the NACP with the ART Task Force comprised of members from USG, treatment partners, and other partners. A coordinator will oversee data collection and analysis with the assistance of a data manager. The evaluation will be implemented using teams of data abstractors through USG-funded treatment partners. The database will be owned by the Ministry of Health and Social Welfare (MOHSW) and shared with national and international partners for analyses. To ensure that the information will be used to inform overall Emergency Plan treatment program quality,

success, and improvement, results will be shared with US agencies. This evaluation will be implemented in a way that promotes the improvement of health records and treatment data systems and the development of human capacity in treatment-related strategic information.

The total funding level is based on the number of participating facilities, number of specimens tested, and the number of persons required to support the evaluation. In FY07, we are requesting $200,000. These funds will be used to pay for data abstraction, laboratory supplies, transport and testing of residual bloods, technical assistance, and for data analysis support. A master's level student from the Field Epidemiology and Laboratory Training Program will participate in the overall coordination.

Drivers and Barriers to male involvement in ART in Zanzibar It is documented in the literature that women more readily seek help for health problems than men in many geographic settings. In Kenya, it has been reported that men see sexually transmitted infections and reproductive health as women's issues and not affecting them directly. In Tanzania it has been observed that there are more women than men seeking treatment for HIV. In a recent program review with the Zanzibar AIDS Control Program (ZACP), it was reported that there is low uptake of antiretroviral treatment (ART) services among men in Zanzibar and that most public health services are oriented towards women and children making them not user-friendly to men. It is not known what are the drivers or barriers to treatment-seeking behaviors among men in the United Republic of Tanzania. Based on these discussions, ZACP proposed conducting a public health evaluation to identify potential barriers to men receiving treatment.

In FY07, we propose to conduct a public health evaluation with four components and triangulate the results to identify potential drivers and barriers for men in Zanzibar. General barriers that will be addressed include personal (denial of problem, fear or being overwhelmed), interpersonal (fear of losing a partner, lack of family support), societal (stigma attached to HIV), and program/structural barriers (costs associated with treatment, lack of men-oriented services, lack of flexible services (time and duration), or lack of program information or strategies to effectively reach men).

This activity will be conducted by ZACP in collaboration with USG-Tanzania and technical assistance from USG agencies headquarter staff and students from the public health department at the University of Zanzibar. There will be four different components to collect information on drivers and barriers to treatment seeking-behaviors in men. Data will then be synthesized. 1. Men attending a representative sample of voluntary counseling and testing sites will be asked to participate in an anonymous, unlinked exit interview survey. The questions on the survey will assess where men would go for treatment if they had an STI or if they were diagnosed as HIV-positive. 2. Facilitated focus groups will be held for men to discuss issues related to their health, including what motivates them to seek treatment and where they go for specific types of illnesses, e.g., if they had an STI. Men will be invited to participate in the discussion and reimbursed for their transport. Potential groups of men that will be targeted include fishermen, men working in public transportation, and men working at the Foordhani, a large social network area in Stone Town. 3. Men who are currently attending care and treatment centers will be invited to participate in an anonymous, unlinked survey which will assess factors that motivated them to attend the center and what they consider as barriers. 4. Lastly, health care professionals, pharmacists, and workers in "duka la dawas", local pharmacies, will be interviewed to determine their experiences with men clients and what their perceptions are of where men seek treatment for HIV infection, and if they do not, what the possible reasons may be. Baseline information on the percentage of male clients they see and type of services they provide will also be captured. For all four of these components, HIV prevention messages and information on health resources, including care and treatment centers, will be provided to participants where applicable.

The data from the four different surveys will be synthesized and triangulated to identify key drivers and barriers to treatment seeking behaviors, and to determine where men are seeking health care. The results will be used to develop appropriate targeted interventions to reduce barriers and enhance drivers to ensure men access care and treatment. Program and structural barriers will be addressed by ZACP and health facilities. Personal, interpersonal, and societal barriers will be addressed using USG partners and existing community-based organizations to target men.

The FY07 funds will be used to provide technical assistance to ZACP, hire students from the University of Zanzibar to coordinate the study, fund operational costs for this evaluation, including conducting focus groups and printing materials, and disseminate results.

Public Heatlth evaluation of the cost effectiveness of HIV treatment to support resource planning The resources required to meet PEPFAR's 2-7-10 targets are considerable, and the major portion of these resources is devoted to providing comprehensive antiretroviral treatment (ART) to treatment-eligible individuals. A full and accurate assessment of the cost and cost-effectiveness of ART will contribute substantially to resource planning and allocation. This activity proposes a public health evaluation in Tanzania to measure the costs and outcomes of selected ART programs supported by PEPFAR, and to evaluate the cost-effectiveness of these programs. The specific objectives of the analysis are 1) to estimate the average annual per-person cost of providing quality comprehensive ART for eligible adult and pediatric clients; 2) to evaluate the range of ART costs across settings; 3) to inform resource planning to meet the targets of the Emergency Plan; 4) to inform planning for long-term sustainability of ART in country; 5) to assess the relative cost-effectiveness of the differing program types and program delivery systems; 6) to provide an estimate of patient time and travel costs and their effect on treatment outcomes.

The cost of providing ART services in focus countries may be expected to vary significantly across settings, program types, and delivery approaches. In Tanzania, the delivery approach is through geographic regionalization of treatment partners supporting regions in all aspects of care and treatment. Accurate estimation of the cost of comprehensive ART in a range of settings will serve a number of purposes. First, the project will deliver robust estimates of per-patient treatment costs in representative programs. Second, comparative analyses across settings will reveal institutional and contextual factors that affect the cost of ART provision. Third, by providing an estimate of the program costs that might result from a particular set of circumstances, the project will inform resource planning as programs expand to meet PEPFAR's ambitious treatment goals and guide long-term sustainability planning.

This evaluation will identify and value the discrete cost components that comprise the cost of comprehensive HIV treatment within country, assist USG and country partners in assessing the potential reach of ART programs given available financial resources, inform the choice of approach used for provision of treatment services, and assist the programs in identifying those areas where potential efficiency gains could free-up resources to expand service provision. The sample of HIV treatment facilities utilized for this evaluation is to be selected in collaboration with local USG officials and other appropriate stakeholders based on Tanzania's regionalization model. For this activity, it is proposed that six treatment sites be included in the sample. Retrospective costing data will be collected in order to capture costs over a full-year period. The cost of comprehensive treatment will be estimated based on both facility-level data and on the associated management and operations (i.e., higher-level overhead) costs attributable to supporting treatment operations at the facility. Treatment costs will be collected to capture the full cost of operating the program, including both USG and other-than-USG sources of support, and will track the source of support for each cost component. In addition, patient non-medical direct costs for time and travel to access treatment will be estimated through patient surveys.

Concurrent with the assessment of HIV treatment costs will be an evaluation of treatment outcomes among patients in the same sample of treatment facilities. The methods that will be utilized in this proposed activity are designed to complement the collection and analysis of HIV treatment cost data and will take advantage of outcomes data already available through existing patient monitoring systems. These methods enable analyses that move beyond the basic indicators of how many people are receiving care and treatment and provide data that address key issues relating to treatment quality and effect. Additionally, the methods are designed to be applicable across settings with differing quality of patient monitoring data or laboratory capacity. The outcomes analysis will be based on a retrospective analysis of patient records at the selected sample of treatment facilities. Within each facility a sample of patients will be taken as representative of the total patient population under treatment, allowing comparisons both within and between facilities. De-identified patient-level outcomes data and demographic information will be collected from all patients in the sample. Patient-level treatment outcomes will be assessed using a hierarchical approach that takes advantage of the best available patient monitoring data. Data collection and analysis will involve standard set of indicators routinely available

through the abstraction of clinical records. Based on the ability to abstract common data elements, this set comprises all available indicators of treatment outcomes, including virologic (i.e. viral loads), immunologic (i.e. CD4) and clinical (e.g. incident OIs, weight change from baseline). A positive health outcome will be defined as a patient who, twelve months after initiation of ART, remains in the program and whose treatment might be considered successful based on the best available marker: undetectable viral load, if these data are available; if not, positive change in CD4 if immunologic data are available; if neither virologic or immunologic monitoring data are available, then clinical indicators will be utilized.

The cost-effectiveness of HIV treatment will be assessed in the selected sites, utilizing the cost and health outcomes data collected at each site. With appropriate selection of representative treatment sites that are to be included in the evaluation, the cost-effectiveness analyses will provide measures of how cost-effectiveness influenced by settings, facility types, and program model. Additionally, with the collection of information on patient time and travel costs, the effect of these costs as potential barriers-to-care will be assessed using health outcomes data. Evaluation findings from the cost, outcomes, and cost-effectiveness analyses will be shared with key stakeholders to inform the national program and other providers on the cost-effective approaches to HIV treatment.

Regional Health Authorities

HIV treatment services continue to expand in Tanzania. The government of Tanzania has increased the number of ART treatment sites from 96 to 200 with further expansion planned to health centers and dispensaries. The USG treatment partners are currently providing or planning to provide, by the end of FY2007, technical assistance to facilities in 19 of the country's 21 regions.

Under regionalization, where USG ART partners have been assigned specific regions within which to support the scale-up of ARV services, the USG approach in FY07 includes a much closer collaboration between the USG ART partners and regional health authorities in the planning and monitoring of treatment activities. The regionalization strategy is also an opportunity for the USG, and their partners, to help build the capacity of each Regional Medical Officer (RMO) to fulfill the responsibilities of their office, which is to coordinate and oversee all health programs within their region, including HIV/AIDS, as laid out in the 2003-2006 Tanzania Health Sector Strategy for HIV/AIDS (HSS).

The RMO leads the Regional Health Management Team (RHMT). The RHMT is composed of a Nursing and Health Officer (RNO and RHO) and a Regional Health Secretary. On behalf of the central government, the regional authorities, as described in the HSS, retain a supervisory function over the performance of the district authorities. It is well known that, at their current budget, staffing and training levels, most RHMTs lack the ability to serve as technical or managerial backstops to districts. For example, part of the RHMTs role is to organize and implement supportive supervision to the district facilities in their regions. However, most have not received basic training in the clinical management of HIV/AIDS or instruction on the use of a supportive supervision tool.

As part of USG Tanzania's focus on sustainability, our plan, through this activity, is to help strengthen the regional medical office. One vital strategy is to move away from indirect assistance provided by external US-based organizations toward direct funding of these regional health authorities. They would receive financial management support from the USG in managing this new funding relationship. With this direct funding, they would in turn fund activities to enhance their skills and to carry out basic coordination tasks.

These skill-enhancing activities would focus on institutional capacity building in HIV/AIDS Project management. This would comprise of instruction in: the planning and management of resources; the design of detailed plans to project human and financial resource requirements; monitoring and evaluation for the use of data to direct planning and managerial action at the regional level; strategies to link with the community, the use of consultative community structures and the organization of focused external technical assistance. Acquisition of these skills will help assure the quality and continuity of HIV/AIDS services.

These funds would also support short-term hiring of contract staff to support the RHMT for planning, financial management, and program management that would then be integrated into the regional budget after two years. In addition, critical stakeholder meetings and other coordination activities as required by the terms of the office will be supported.

A competitive request for proposals will be developed which will be aimed at regional health authorities nationwide. In the first year, two regions would be selected based on the strength of their application. If a selected region already has a USG ART partner, that partner would concentrate on ensuring that the RHMTs receive focused training on HIV/AIDS, such as clinical management and supportive supervision; they would involve the RHMTs within these supportive supervision visits, and consult with both the RHMTs and District Health Management Teams (DHMTs) in planning the expansion of services.

The services of other USG partners will be made available to these regional authorities. These include ITECH (OPSS, ARV) and AIHA (ARV, OPSS) in assuring quality of training and preceptorships respectively; and Pathfinder (OPSS, Care) and Deloitte and Touche (OPSS, ARV) for project planning and financial management.

This activity links to activities HLAB MOHSW 7758, 7779 NIMR, 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/HIV7781, PMI, SCMS 8233, FHI 7712; SI NACP 7773, MOHSW 7761

Recognizing that well-equipped laboratories staffed by qualified personnel are essential in the fight against HIV/AIDS, the Ministry of Health and Social Welfare (MOHSW), with support from USG, in FY 2004, developed a plan to strengthen HIV/AIDS laboratory capacity. This included building laboratory infrastructure, developing skill capacity and laboratory quality systems to effectively support HIV/AIDS interventions, including VCT, PMTCT, ART, and HIV surveillance. In FY 2004, Emergency Plan funds were allocated to support the establishment of a network of zonal, regional, and district laboratories and provide capacity to diagnose HIV infection, disease staging of HIV/AIDS, and treatment monitoring. Also, with support of the USG, the MOHSW initiated efforts to establish a national HIV laboratory quality assurance system to meet international standards of Good Laboratory Practices (GLP). This resulted in the National Laboratory Plan in support of HIV/AIDS Care and Treatment Plan. The Laboratory Infrastructure Program works in collaboration with MOHSW and partners to impliment this plan. USG supported the renovation of 35 laboratories and started preparations for renovation of a National HIV Laboratory Training and Quality Assurance Centre. The four Track 1.0 ART awardees (Columbia University, Harvard University, EGPAF, and AIDSRelief) strengthened HIV/AIDS laboratory capacity in 3 of the 4 zonal referral hospitals with the fourth directly supported through Track 2.0 activities. In FY 2005, USG continued to support the development of the Quality Assurance and Training Centre. In order to fulfil PEPFAR goals the USG/HHS/CDC hired a senior technologist to provide technical assistance to MOHSW and ART partners and to assist in the introduction of the quality systems approach in Tanzania. HHS/CDC has continued to provide technical assistance to MOHSW and its partners in building capacity of laboratory services to support HIV/AIDS care and treatment. This support is provided by in-country and Atlanta-based Laboratory support teams.

In FY 2006, in order to facilitate the achievement of Emergency Plan goals, CDC-Tanzania recruited a senior laboratory specialist in addition to the existing senior laboratory technologist. These CDC Tanzania laboratory staff have collaborated and worked closely with DoD and CDC Atlanta lab team as well as other non-USG organizations that support the national laboratory plan such as WHO, AXIOS, JICA, AMREF and the Clinton HIV/AIDS foundation.

The laboratory staff has provided and coordinated technical assistance to MOHSW from US based partners CLSI, APHL, ASCP and in country based partners NIMR and Track 1 partners. The areas of technical assistance have included laboratory infrastructure renovation, equipment specification and procurement, laboratory information systems assessment and specification, training, quality assurance framework development and implimentation, assessment for provision of services for infant diagnosis, policy formulations and guidelines in various areas of laboratory based and affiliated services.

A training program for a training of trainers in basic laboratory procedures for CD4, chemistry, and hematology was conducted in which thirty five laboratory technologists working in all five zonal and eight regional laboratories were trained and have conducted the first roll out training to the regions. A total of 100 technicians in mainland Tanzania and Zanzibar have been trained on automated CD4, Chemistry and Haematology technologies. In FY06 USG supported the MOHSW in the development of material for the training of equipment users and facilitated the TOT training on first line equipment maintenace and trouble shooting. In FY 2006 USG through its partners supported a laboratory information system implimentation strategy with assessment for both software and hardware systematic requirements and staff capacity assessment.

In FY07, CDC Tanzania will continue to offer technical assistance and coordinate the USG supported training activities to cover service provision in the country. The training support will focus on training of trainers first followed by a national training roll out implementation that will cover areas such as rapid hiv testing, quality assurance, identification and diagnosis of infants and children exposed to and infected by HIV virus and standard of care testing. This strategy will ensure sustainability of initiatives by

building capacity for training in the different areas of HIV related laboratory medicine.

In FY 2007 USG will support the actual installation of the laboratory information system and training of staff for its utilisation both in the paper based form and the electronic version. At completion the electroninc system will cover 5 referral hospitals and 10 regional hospitals while the paper based system will be nationwide

The HH S/CDC staff will continue In FY07 USG to support the expansion of the EQA coverage to include Rapid HIV Testing, Haematology, Clinical Chemistry and HIV serology. This will include Private Health Laboratories through the Private Health Laboratories Board. USG will also assist MOHSW in the establishmentn of an efficient sample transportation system, conduct awareness on the need for laboratory auditing and laboratory accreditation

Proposed activities for FY 2007 will include the provision of technical assistance from USG to the MOHSW and other partners for implementing HIV prevention, care and treatment. This includes supporting the development of the National Laboratory Quality Assurance and Training Centre, protocols, training curriculum and monitoring and evaluation system for all program areas. The CDC Atlanta based Laboratory support team will support the field staff to develop systems including introduction of the Laboratory Quality System and expansion of HIV/AIDS testing and infant diagnosis to ensure that all ART sites access high quality laboratory services.

In FY 2007 with the continued support for the blood safety program and the initiation of infant diagnosis program as part of a comprehensive pediatric HIV/ AIDS care and treatment program, and the ongoing activities for laboratory infrastructure and capacity building, HHS/CDC Tanzania will recruit a blood safety program officer, a senior laboratory technologist and an infant diagnosis / pediatric care and treatment program officer. These HHS/CDC staff will contribute the overall human and institutional capacity building to combat the epidemic in line with the USG 5 year strategy and attaining the PEPFAR goals.

This activity links to activities HLAB MOHSW 7758, 7779 NIMR, 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 FY 2006, in order to facilitate the achievement of Emergency Plan goals, CDC-Tanzania recruited a senior laboratory specialist in addition to the existing senior laboratory technologist. These CDC Tanzania laboratory staff have collaborated and worked closely with DoD and CDC Atlanta lab team as well as other non-USG organizations that support the national laboratory plan such as WHO, AXIOS, JICA, AMREF and the Clinton HIV/AIDS foundation.

The laboratory staff has provided and coordinated technical assistance to MOHSW from US based partners CLSI, APHL, ASCP and in country based partners NIMR, , Track 1 partners and the CDC Atlanta based laboratory Support team. The areas of technical assistance have included laboratory infrastructure renovation, equipment specification and procurement, laboratory information systems assessment and specification, training, quality assurance framework development and implimentation, assessment for provision of services for infant diagnosis, policy formulations and guidelines in various areas of laboratory based and affiliated services.

The CDC Atlanta based Laboratory support team will support the field staff to develop systems including implimentation of the Laboratory Quality System and expansion of HIV/AIDS testing, laboratory monitoring of care and treatment and infant diagnosis to ensure that all ART sites access high quality laboratory services.

Assistance will be provided to MOHSW in the development of a National Training Plan which will include the training on rapid HIV testing. The Technical assistance will focus on the customization of training materials and development of strategy for rolling out of HIV rapid testing in Tanzania to meet the recruitment goals for care and treatment. The training package has been developed but it needs to be customized to the Tanzanian context, trainers trained and the training rolled out to meet the scale up targets for recruitment into care and treatment while ensuring the quality and accessability of rapid HIV testing. The rapid HIV test will be performed by both lab workers and non lab health workers. The technical assistance will involve the initial development of a strategy and then follow up with additional training for supervisors and qualtiy assurance.

The technical assistance will be used to develop a concept paper to be presented to Ministry of Health and Social Welfare and the Multisectorial Team for the creation of the National Quality Assurance and Training Centre as an executive agency of the Ministry of Health and Social Welfare with specific HIV Reference Public Health Laboratory functions. Currently there is no functional public health laboratory in the country and the quality assurance and training centre will fill in this gap The quality assurance and training centre is being renovated and will be completed by December 2007.

Tanzania is providing anti retroviral therapy (ART) to adults but lags behind on provision of art to infants due to lack of diagnostic strategy and program for infant diagnosis. There is need to coordinate the different programmatic areas into one Comprehensive Pediatric Care and Treatment National Program. CDC Atlanta Laboratory support team will provide Technical Assistance in the establishment of the laboratory component of the infant diagnosis program.

Technical assistance is requested to assist with evaluation and validation of HIV tests for use in USG supported programs and build capacity for the MOHSW to continue conducting evaluation of rapid tests and ELISA tests. The laboratory support team will utilize the forum to facilitate discussion on sample panel selection, test kits evaluation, data analysis, selection of HIV tests and diagnostic algorithm.

Technical assistance is also required for the training on technology to implement and analyze data from BED-CEIA using generic training materials created by the Atlanta Laboratory Support Team.

These HHS/CDC staff will contribute to the overall human and institutional capacity building to combat the epidemic in line with the USG 5 year strategy and attaining the PEPFAR goals

The National Quality Assurance Laboratory is scheduled for completion in the summer 2007. Additional funds are needed to complete the project and address contract modifications.

Table 3.3.12:

CDC SI Management and Staffing

CDC Management and Staffing in strategic information (SI) will be used to support CDC agency specific staffing needs in Tanzania as they relate to ensuring that the goals and objectives of the Emergency Plan are met.

The FY07 funds will support seven full-time equivalent staff that will coordinate activities in strategic information. The composition of the staffing includes the following: 1) SI and Capacity Development Program Director, a direct hire, who will oversee all CDC specific SI and Human Capacity Development activities. She will work closely on USG SI-related activities; 2) SI/HMIS (Health Management Information Systems) Senior Advisor, a contractor, who will coordinate all CDC specific activities related to surveillance, and information systems, including program monitoring; 3) HMIS Advisor, a contractor, who will provide support and technical expertise in developing, implementing, and maintaining information systems for the Government of Tanzania, and within CDC and USG ; 4) Monitoring and Evaluation Senior Advisor, a local hire, who will coordinate all CDC specific activities related to internal and external M&E and oversee target setting for OGAC indicators for CDC partners. This advisor will work closely with the Ministry of Health and Social Welfare (MOHSW), Zanzibar AIDS Control Program (ZACP), and other CDC partners to standardize and strengthen M&E capacity to ensure sustainability; 5) Surveillance Advisor, a contractor, to replace the exiting Surveillance ASPH (Association of Schools of Public Health) fellow, who will provide technical assistance for the development and implementation of HIV surveillance activities related to PEPFAR, including antenatal clinic surveillance, drug resistance threshold surveys, and behavioral and biological surveys among most at risk populations. S/he will also provide trainings and participate in technical working groups to build capacity within the ministries of health; 6) M&E Advisor, a local hire, to replace the exiting M&E ASPH (Association of Schools of Public Health) fellow. The M&E Advisor will support the senior advisor in performing M&E activities for CDC and its partners. S/he will work closely with CDC program officers to build their capacity in program monitoring; 7) USG SI liaison, a contractor, who will coordinate the SI activities across all USG agencies in Tanzania and liaise with OGAC on SI related matters. Funds will support a short-term consultancy that will be required to support two public health evaluations related to monitoring the national impact of ART services in Tanzania and treatment-seeking behaviors of men in Zanzibar. All SI personnel will be members of the USG Strategic Information Thematic Group.

All of the CDC SI staff described will work directly with the MOHSW on the Mainland and the ZACP to provide ongoing technical assistance and building capacity among the respective Epidemiology Units. They will work with CDC's partners to establish and maintain health information systems, and monitor CDC's partners and their activities. This includes the development and implementation of national and USG databases for HIV/AIDS, specifically ART monitoring, counseling and testing, home-based care, PMTCT, and TB/HIV linkages where feasible and appropriate. It also includes building capacity in monitoring and evaluation and managing and analyzing surveillance data. Trainings for Epi Info, data use and activity planning and monitoring will be conducted for both CDC program officers and CDC's partners.

The FY07 funds will also support international (trainings, meetings, and conferences), and domestic travel (USG strategic planning meetings, partner meetings, workshops, and partner site visits).

This activity will contribute to developing the human and institutional capacity building within CDC-Tanzania and its partners, USG agencies, and the Ministries of Health in the United Republic of Tanzania.

CDC Technical Assistance

CDC technical assistance (TA) funds in SI will be used to support CDC agency specific TA requests for the USG in Tanzania as they relate to ensuring that the goals and objectives of the Emergency Plan are met. The proposed funds will support the procurement of temporary duty assistance (TDY) from CDC headquarters to provide expert technical assistance to field staff in strategic information activities. This includes the assistance in developing or implementing information systems for USG-supported Ministry of Health and Social Welfare (MOHSW) programs in the following areas: laboratory, blood safety, counseling and testing, care and treatment, and prevention of mother to child transmission. TDYs will also be sought to support surveillance activities, such as antenatal clinic (ANC) and most at risk populations (injecting drug users, men who have sex with men, and commercial sex workers). They will also be requested to ensure that quality data are collected and used in USG supported programs.

Technical assistance will be requested in the implementation of a pilot of the use of personal digital assistants (PDAs) for supportive supervision. Training on the use of PDAs will be conducted for the National AIDS Control Program, CDC Country Staff, and CDC's partners participating in the pilot. For the implementation of the HIV incidence assay: BED-CEIA, training will be conducted for NACP, the National Institute of Medical Research, and CDC Country Staff.

This activity will contribute to developing the human and institutional capacity building within the Tanzanian MOHSW, CDC-Tanzania and its partners, and in-country USG agencies.

Targets

Target Target Value Not Applicable Number of local organizations provided with technical assistance for 7  strategic information activities Number of individuals trained in strategic information (includes 39  M&E, surveillance, and/or HMIS)

Table 3.3.13:

FY 2007 funds will support one full time equivalent contract staff who assists in coordinating activities for this program area as well as serves as technical lead for aspects of the work, including provision of direct TA in systems strengthening to the Ministry of Health and Social Welfare, National AIDS Control Programme, and CDC partners. Primary implementing counterparts include the National Institute for Medical Research (NIMR), the International Training and Education Center for HIV/AIDS (I-TECH), the American International Health Alliance Twinning Center (AIHA), and Pathfinder International. The contractor oversees AIHA and I-TECH activities across program areas, as well as human capacity development activities within CDC, across program areas. She is also the Thematic Group Lead for OPSS.

This activity links to: Activity ID 7830 -CDC Management & Staffing - Base Funds Activity ID 9093 - CDC Cost of Doing Business - Base Funds Activity ID 8920 -CDC Cost of Doing Business - GHAI Funds

HHS/CDC Tanzania estimates the cost to manage and support the HIV program in Tanzania to total $4,104,809 for the FY07 COP. This includes costs associated with the management, administration and operations of the HHS CDC HIV program for the establishment and expansion of quality-assured national systems in the areas of Strategic Information, Prevention of Mother to Child Transmission (PMTCT) of HIV, human capacity development, laboratory services, blood safety and blood transfusion, Antiretroviral (ARV) Therapy, patient care and prevention programs. Activities supported by CDC are funded through cooperative agreements and are performed at the national and field level in direct partnership and collaboration between CDC Management, program staff and with USG and Tanzanian governmental and non-governmental organizations.

CDC personnel and travel costs total $1,652,525. Most of the funding for these costs will come from CDC base funds. The remainder will be cover by GHAI funds.

Existing Staff: Twenty-five existing staff support the management, administration and operations of the CDC program including a) two US direct hires (Country Director and Deputy Director) and a locally employed staff (Budget, Management and Operations Chief) providing technical leadership and overall management; b) three locally employed staff (IT Chief, Systems Manager, and Senior Prevention Advisor) and a contractor (Special projects advisor) providing technical advice and program management; c) three financial and budget staff (Finance Manager, Financial Planning Officer, Accountant) monitoring and overseeing CDC country budget and providing financial consultancy to government and non-government partners; and d) fifteen administrative personnel (Administrative Manager, two Administrative Assistants, three Secretaries, an Executive Assistant, two Computer Management Specialist, a Motor Pool Supervisor, five Drivers) to support program and management operations.

The attributable costs for the twenty-one existing technical advisors (non-Management) staff are located in the respective program areas (2 Prevention/AB, 1 Blood Safety, 2 PMTCT, 1 Counseling and Testing, 2ART Services, 1 HIV Care, 1 TB/HIV, 3 Laboratory Services (note 1 proposed not included but outlined below), 7 Strategic Information, and 1 other policy and system strengthening). The technical assistance and capacity building provided by the CDC/HHS to Government of Tanzania, Ministry of Health and other key partners will ensure a long-term sustainable system for providing HIV/AIDS Care, Prevention and Treatment services to Tanzanians.

FY2007 Staff: While staffing levels have stabilized in the past year, additional staff will be necessary for effective program implementation and oversight. Specifically, two new US direct-hire staff are being requested. One position is Associate Director for Science. This person would oversee all aspects of public-health evaluation work being conducted by CDC-Tanzania including development and adherence to protocols, human subjects issues,and coordination of work being done by evaluation-implementing partners. In addition, this person would assure coordination of PEPFAR-funded activities with PMI. The second position is for a technical public health advisor to provide oversight of CDC-Tanzania cooperative agreements. To help assure sustainability, CDC-Tanzania is increasingly providing direct funding to regional health authorities for them to fund and oversee treatment activities in district hospitals and clinics. This work will require more intensive technical and administrative oversight, which would be provided by the person hired into this new position. While the approval and hiring process for these positions will take approximately 6-9 months, CDC will bring on contract staff to provide technical advice and systems development in these areas including 1) review, establish and improve cooperative agreement management systems to improve links with HHS/CDC headquarters entities, technical advisors, management, and in-country partners and to enhance monitoring of USG requirements and work plans; 2) establish tracking and suspense systems for management. 3) review and enhance existing financial and internal controls systems.

Newly proposed technical staff includes hiring a locally employed staff to provide technical advice for infant diagnosis (proposed funding for this position will be under laboratory services). Additionally, CDC plans to convert the two existing Strategic Information fellows into a contractor position for surveillance activities and a locally employed staff/FSN position for monitoring and evaluation.

Other Staffing: CDC Tanzania continues to make progress with converting contract staff into locally engaged staff. Most of the local Tanzania staff will be converted to LES positions under the Embassy's HR system by December. This will help to explain differences in the staffing matrix from the version CDC submitted last year (7 technical contractors converting to FSN). Other noted differences were among staffing categories among administrative and program management staff and an oversight in including a projected blood safety advisor. Corrections are noted on supporting documents.

This activity relates to ID 9093 -CDC Cost of Doing Business - Base Funds; ID 7830 -CDC Management & Staffing - Base Funds; ID 7840 -CDC Management & Staffing - GHAI Funds

The operations budget (e.g. cost of doing budget) is estimated to be $2,452,284, mostly supported with GHAI funds. Since CDC is co-located on a Government of Tanzania facility, there are nominal costs for general operating expenses, including IT, utilities, communications, and service contracts. Other operations costs include field travel for site inspection of renovation projects and cooperative agreements, and motor pool operations including vehicle maintenance and fuel.

ICASS constitute $459,040 whereas $63,278 is for Capital Security Cost Sharing. CDC is in discussions with the US Embassy regarding consolidation of motorpool operations with ICASS. There may be increases in the CDC ICASS budget in FY2007, however, this may be offset with reductions in expenses associated with management of the CDC motorpool.

Funding is also included for staff development to enhance locally employed staff's knowledge and expertise in overseeing and supporting USG requirements for effective program management include financial monitoring, internal controls management, simplified acquisitions, supervisory skills, project management and documentation requirements. Where possible, CDC will work with programs in neighboring countries to cost-share or co-sponsor training opportunities to reduce transportation and training fees. Funding is included for a management and staff retreat to improve operations and planning.

CDC will use innovative approaches to improve management and operations while minimizing costs. Innovative approaches include: 1) outsourcing to entities where capacity exists (e.g. utilizing USAID IQC and SCMS procurement systems); 2) providing financial and IT consultancy to partners and grantees; 3) facilitating in-country technical support and oversight of small and large infrastructure improvement projects for partners (including utilizing existing senior project advisor to liaise with technical team and coordinate projects with RPSO resulting in duplicate services being provided by in-country partners for infrastructure improvement projects).

Table 3.3.15: