The Goal of the national PMTCT programme is to expand PMTCT services in order to reduce the risk of transmission of HIV infection from infected mothers to their babies during pregnancy, child birth and during breastfeeding through integration of PMTCT services in routine reproductive and Child health services in all 21 regions. Since the national PMTCT program inception in 2000, PMTCT services roll-out has accelerated significantly. Currently 544 sites (10%) out of 5,379 in all districts are providing the core elements of PMTCT services including testing and counselling (TC), antiretroviral prophylaxis, and infant feeding counselling integrated in reproductive and child health services. This 10% coverage is low and as a result, by the end of 2005 only 11,435 (9%) of the estimated 122,000 HIV positive pregnant women were receiving Nevirapine prophylaxis. The MOHSW and USG have been concerned on the low uptake of antiretrovial (ARV) prophylaxis and are instituting several measures to improve this situation. Some of the key measures includes changing the PMTCT policy and allowing pregnant women to take home NVP the day they are diagnosed to be HIV positive, testing for HIV in both laboor and delivery wards and provision of ARV and supporting the impelemntation of more efficaciuos ARV regimen for HIV positive women in third trimester. Since facility delivery (which is low) may also influence ARV uptake, USG would like to pilot out how improved facility delivery interventions can improve ARV uptake in a district such as Njombe in Irnga. In spite of high attendance of at least one ante-natal care (ANC) of about 92%, only 47% of pregnant women currently deliver in health facilities (DHS 2004/05). As a result, there are many missed opportunities to identify HIV positive women since the labor ward is the place to capture women who missed HIV testing during ANC or delivery. The loss of these patients for testing of PMTCT translates directly into higher potential for transmission of HIV to the infant. Reportedly, many women do not want to come to the hospital for delivery because the quality of services and the actual facility are not satisfactory. This request for Plus Up funding is to address those issues, so as to improve ‘the environment in which delivery takes place'; ergo, increasing the possibility of sustain antenatal care visits and ensuring that women come to facilities for safe delivery. Specifically, low facility delivery is thought to be a result of several factors, including poor quality of services, poor state of equipment and commodities, poor hygienic conditions during delivery, insufficient staff skills in handling expectant mothers, a lack of a supportive attitude, to mention but a few. This Plus Up funding would be used to pilot a project that demonstrates how improved ante-natal services, increased facility-based delivery, and strengthened linkages between maternal and child health services with HIV/AIDS care, support and treatment services improves PMTCT services uptake. The main goal of this project is to stimulate and increase facility-based deliveries in Njombe district and provide timely integrated PMTCT, care, support and treatment services to HIV infected women delivering at facilities. The activity will take place in three Ministry of Health and Social Welfare (MOHSW) facilities in Njombe district in Iringa region. EngenderHealth will work in close collaboration with the MOHSW, regional and district authorities and USG Department of Defense (DoD). It builds on an activity from the FY2007 COP to develop PMTCT Plus services at the Iringa regional hospital. Arrangements have already been made with the US Department of Defense to construct a new maternity wing and a related maternity dormitory for women and their children who live far from the facility. This investment will be leveraged with training of staff for appropriate counseling and testing of pregnant women, providing for more infection prevention and safe delivery conditions, equipment, appropriate drugs, commodities and consumables. In addition, providers will have their skills in managing expectant mother improved (from the ante-natal stage to the delivery and post-natal stage). Efforts will be made to improve not only their clinical skills, but attitudes as well. PMTCT, care and treatment interventions will be provided by EngenderHealth working with the Treatment partner at the facilities (Deloitte/FHI). Other interventions will include: integration of Prevention of Mother-to-Child Transmission (PMTCT) of HIV into Reproductive and Child Health services, labor wards and maternity waiting homes in those three facilities; integrating VCT into family planning and under five clinics to reach more women at risk; Inter-facility referral for staging and screening for HAART eligibility, Peripartum ARVs for those not eligible to ARVs, safer obstetric practices, safer infant feeding counseling, availability of nutritional support for malnourished women, prevention and treatment of malaria in pregnancy including distribution of ITNs and follow up of HIV positive mothers and their exposed infants both at the facility and community level.

Anticipated project outputs will include (i) increased number of women delivering at the three MOHSW facilities by 30%; (ii) increased number of pregnant women identified HIV positive by 30% and (ii) increased number of pregnant women accessing ARV prophylaxis by 30%.By combining all these interventions, the project will build strong linkages between maternal and child health services and care and treatment services so as to develop an integrated comprehensive approach to HIV/AIDS services through maximizing uptake of PMTCT services, reduced missed opportunities, improved facility deliveries for HIV positive women, strengthen referral and linkages to CTC, following up exposed infants and linking them to CTC.

Targets

Target Target Value Not Applicable Number of service outlets providing the minimum package of 4  PMTCT services according to national and international standards Number of pregnant women who received HIV counseling and 8,840  testing for PMTCT and received their test results Number of HIV-infected pregnant women who received 1,150  antiretroviral prophylaxis for PMTCT in a PMTCT setting Number of health workers trained in the provision of PMTCT 200  services according to national and international standards

Table 3.3.02: Program Planning Overview Program Area: Abstinence and Be Faithful Programs Budget Code: HVAB Program Area Code: 02 Total Planned Funding for Program Area: $ 12,353,695.00

Program Area Context:

USG supports Abstinence and Be Faithful programming in Tanzania through technical assistance for standardization of messaging at both the mass media and community-based outreach levels, as well as appropriate training to support these efforts. USG works with a wide variety of implementing partners spanning the public and private sectors. In FY 2007, the USG program will build upon the success of its existing AB prevention activities with youth, and will significantly strengthen programming for B messaging with the adult male population, thus supporting Tanzania's documented epidemiological profile.

Results from the 2003-2004 Tanzania HIV/AIDS Indicator Survey indicates a 7% national prevalence rate, although there are wide regional variations. While progress is being made in key prevention indicators, as evidenced by an increase in age at first sexual intercourse (from almost 17 in 1999 to just under 18 in 2003), recent data presented at the Annual PEPFAR Conference in Durban on the spread of HIV through sexual networks illustrates the potential vulnerability to such gains. The data in Tanzania support the need for faithfulness interventions targeted at adult males. Infection rates increase steadily with age from 2.1% positive under the age of 19, to 5.2% positive between 20 - 24, to 8.3% positive between 25- 29, and to over 10% positive between the ages of 30 - 44. When coupled with the fact that 50% of women have had sex by the age of 18 and more than 9% of women aged 15-19 have had non-marital sex with a partner at least ten years older in the last 12 months the risk to younger woman to be infected by older men in clear. In addition, multiple partnering and trans-generational sex are common and socially accepted norms, making partner reduction, particularly among adult male population, a key prevention intervention for Tanzania.

USG is currently implementing an AB portfolio that operates on multiple levels: supporting GOT to improve the national-level coordination of behavior change activities and messages; supporting behavior change through media campaigns and community- level interventions with NGOs and FBOs; and weaving prevention messages and skill-building throughout the prevention to care continuum. The FY 2006 Semi-Annual Report states that from October 2005 through March 2006, 1.65 million individuals were reached, and 8,634 individuals were trained to provide HIV/AIDS education on AB prevention. When framed against their annual targets, these key results indicate that AB implementing partners are on track to achieve their annual projections.

In FY 2007, USG will continue to expand its AB portfolio to fill programmatic gaps which were identified in the FY 2006 and FY 2007 planning processes, and will expand activities to proactively address challenges. USG efforts complement the existing efforts of NACP, TACAIDS, UNAIDS, and other donor partners including the Global Fund, to assure that prevention is a strong component. Examples of this collaboration are the finalization of the National HIV AIDS Communications and Advocacy Strategy, and USG's participation in Tanzania's "Acceleration of HIV Prevention Efforts" which is part of UNAIDS call to intensify prevention action for the Africa region in 2006. Our youth-focused programs are providing increased national coverage, but there is a continuing need to assure documentation and utilization of best practices and an overall coordination of interventions to avoid duplication of effort. Continuing engagement of the broad variety of stakeholders at all levels will be a necessary component in addressing this potential pitfall. A number of important social norms, such as partner reduction and faithfulness among adult males, need further emphasis. USG/T will identify a new implementing partner to spearhead appropriate interventions and to act as a technical resource for male involvement issues as appropriate.

A number of strategic activities have been identified to build on USG program's successes while addressing barriers and gaps. Coordinating and maximizing the contribution of all USG efforts, including the growing number of local sub-grantees and the large number of central awardees, remains a challenge. In FY 2007, this will be addressed by continuing to use an existing USG youth program to promote coordination among partners. A Coordinating Committee for Youth Programs (CCYP) has been established to minimize implementing partners' efforts, and ensure that all partners have the capacity to implement and evaluate

effective behavior change and communication programs. CCYP serves as a forum to share and disseminate ideas, research, and best practices. These efforts are embraced by partners and government but have been sporadically implemented, and will be addressed more systematically. There has been a growing realization that among the large, and growing, number of local sub-grantees, several are working with a number of different prime partners. USG and prime partners are in discussion to address this issue, and ensure that activities avoid duplication.

For AB in FY 2007, USG Tanzania is striving to build a broad portfolio of implementing partners to strategically achieve our targets: Two GOT partners will work at regional and district levels to expand behavioral interventions through school and local government; eight NGOs of varying sizes will continue to work with geographically-concentrated behavior change interventions at the community level; two NGOs will continue to work at a national level to assure coordination, promote policy-level dialogue and appropriate change, and to conduct community-level behavior change through sub-grants; two partners will work specifically with faithfulness messaging and activities with the adult male population to identify factors that influence multiple partnering in Tanzania to engage men in promoting fidelity among their peers, and to address social norms to discourage multiple partnering and cross-generational sexual practices; and a new implementing partner (TBD) will provide support to all implementing partners to increase and improve knowledge through radio messaging. In addition, Peace Corps will continue to place volunteers throughout Tanzania to work with HIV/AIDS prevention activities.

Implementing partners will employ a range of approaches to reach out with AB messages. To assure broad messaging is achieved, strategies such as the HIV helpline will be expanded, and a variety of "edutainment" methods such as soap operas, PSAs, and call in shows will be used. This broad messaging will be reinforced through specific community outreach efforts utilizing peer educators and the engagement of gatekeepers (parents, teachers, community, political and religious leaders) to share information effectively, create motivation, build skills, make service referrals to help bring about sustained behavior change, provide age-appropriate advice to in-school youth to build life skills, and foster gender equity and changing social norms related to gender and sexual behavior through the incorporation of the innovative Program H, a project that fosters gender equity and promotes changing social norms related to gender and sexual behavior. Specific methods may employ folk media, drama, song, dance and youth groups to work with both in- and out-of-school youth.

Lastly, the Prevention Working Group in Tanzania recognizes the vital importance of promoting prevention throughout the prevention to care continuum. The USG/T Prevention Working Group and implementing partners will reach out to all implementing partners within the Country Operating Plan to discuss and influence the ongoing integration of prevention messages and activities into all HIV and AIDS services.

Program Area Target: Number of individuals reached through community outreach that promotes 1,640,140 HIV/AIDS prevention through abstinence (a subset of total reached with AB) Number of individuals reached through community outreach that promotes 7,384,850 HIV/AIDS prevention through abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention programs 36,189 through abstinence and/or being faithful

Table 3.3.02:

Strengthening Treatment and Preventive Services Linkages

This activity relates to activities under treatment (#7705), (#7701), and (#7771)

In the development of the USG/Tanzania's care and treatment portfolio, the need has become apparent for greater linkages between and among important clinical services to ensure effective case finding for adults and children, ongoing adherence, prevention of mother-to-child-transmission (PMTCT), and treatment at the lowest possible level to promote ease of access for patients. There has been limited experience in Tanzania with PMTCT Plus programs, but the idea of developing strong linkages between treatment and maternal and child services holds considerable promise, especially when implemented by an organization with a strong track record in maximizing uptake of PMTCT, engaging male partners in being tested, promoting family planning services, and following exposed children.

With FY2007 funds, EngenderHealth Tanzania plans to implement an activity to strengthen and integrate care and treatment with prevention of mother-to-child transmission (PMTCT) of HIV, other maternal and child health (MCH) services, and other support services in 35 Ministry of Health and Social Welfare sites in 4 districts in Arusha region (Karatu and Ngorongoro), in the Manyara region (Babati and Mbulu), and in one district of Iringa (Njombe). Each of these facilities already has a Government of Tanzania Care and Treatment Clinic (CTC), though there are no USG-funded treatment partners presently working in them (with the exception of Njombe, which will be a special case). EngenderHealth's strength in facilities and operations management, with a strong systems approach, will be focused on technical assistance to the CTC. It will assure that: 1) the CTC meets the service standards of the National AIDS Control Programme, 2) services are efficiently rendered, 3) laboratory and pharmacy support is appropriate, and 4) records are maintained in compliance with the national system for monitoring care and treatment. Just as important as that function will be working with the MCH program at the hospitals to develop a PMTCT service with strong linkages to the CTC, and also a follow up program at the MCH outpatient facility for exposed infants. EngenderHealth will also work with the family planning clinic and the under-five clinics, pediatric wards, labor wards, and maternity wards to identify adults and children at risk of HIV. In addition, the project will collaborate with the district hospitals to conduct mobile PMTCT services targeting hard to reach (nomadic) population in Ngorongoro district. Other interventions will include follow up of HIV positive mothers and their exposed infants both at the facility and community level using community health workers. The only exception to the "full service" approach will be in Njombe in Iringa. The Deloitte/FHI consortium has just started providing technical assistance to the CTC at the large Njombe District Hospital. EngenderHealth will work with Deloitte/FHI to develop a model program with strengthened referrals to the MCH and PMTCT services that can be documented and applied in other hospitals in the regions that Deloitte/FHI serve.

The EngenderHealth program will also build capacity of health care providers and community health workers in support of PMTCT and on reducing stigma and discrimination related to HIV/AIDS among health care workers using a whole site approach and quality improvement activities that have been used for PMTCT services. In addition, the project will introduce facility and community based interventions to address barriers that have hampered many PMTCT programs in the developing world. One unique aspect of the project will be building strong referral networks of health facilities and existing community structures to provide support and follow-up of HIV positive mothers and their infants, post-partum and linking them to CTC.

The project will build upon EngenderHealth's successful PMTCT project, building on key lessons and experience from integrating PMTCT into 22 sites in Arumeru, Arusha Municipality and Monduli districts in Arusha region. For this work, they have been a sub-grantee of the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). For FY2007, they will turn those 22 sites to EGPAF, and will focus on expanding the depth and breadth of their work in HIV/AIDS. EngenderHealth will identify those key success factors from their experiences in setting up successful PMTCT and reproductive/child health programs to apply to a broader spectrum of service, including care and treatment. The PMTCT interventions will be complemented by components that enhance prevention on the one side and longer-term care and treatment on the other. Through its highly successful

quality improvement tool known as Client-oriented, Provider-efficient (COPE) methodology, which has been specifically adapted for PMTCT and VCT services, EngenderHealth will determine shortcomings at the CTC and other areas of the health facility and community levels that hamper better utilization of HIV/AIDS services and develop strategies to overcome them. The program will apply the basic principles of human rights and gender equity to promote sustainable and continuous prevention, care, support and treatment adherence and referral for related services for HIV infected women, their partners and children.

In order to fully support women's access and choices, the project will actively involve male partners (through the men-as-partners (MAP) approach), families and other key members of the community, all of whom influence decision making, and will mobilize communities and health staff to reduce HIV/AIDS-related stigma. Efforts to involve men will include special education sessions for men in the community and targeting men who accompany their wives for ANC visits or those who come to visit and pick their wives from health care facilities after delivery.

The project will build on and adapt best practices and other lesson learned from EngenderHealth's previous PMTCT projects. This will include participatory planning with district-level Council Health Management Teams and Regional Health Management Teams, integration of interventions into comprehensive Council health plans for sustainability, whole-site training approach for service providers, using COPE to improve quality of clinical services, follow up of HIV positive mother-infant pairs, strengthening referral linkages to and from the CTC and integration of HIV/AIDS into family planning services and other RCH services.

Since October 2003, EngenderHealth has been receiving USAID field support to assist the MOHSW expand access to and the utilization of reproductive health services in Tanzania. Presently EngenderHealth, through the ACQUIRE Project, works in 400 sites in 10 regions, including Arusha and Manyara regions. This project will build onto systems already built in the proposed sites through the ACQUIRE project.