TITLE: MoHSW Prevention of Mother to Child Transmission of HIV (PMTCT)

NEED AND COMPARATIVE ADVANTAGE: The Prevention of Mother to Child Transmission of HIV

(PMTCT) unit is under the National AIDS Control program (NACP) of the Ministry of Health and Social

Welfare (MOHSW). To date, the unit has received technical and financial support from the Government of

Tanzania's development partners and multilateral organizations to support, implement and coordinate

PMTCT services in the country. PEPFAR support has enabled the unit to implement PMTCT services and

coordinate activities conducted by PMTCT partners.

The PMTCT Unit is leading the regionalization of PMTCT services and partners in-line with the recent ART

regionalization in order to improve linkages to HIV care and treatment programs and rapidly increase

coverage of PMTCT services. The national PMTCT Unit will focus on its role of program coordination and

management and transition primary PMTCT service implementation and support to PMTCT and ART

partners by March 2008. With FY 2008 funds the MOHSW, through the PMTCT program, will improve the

national PMTCT policy environment and strengthen national coordination to scale-up quality PMTCT

services nationwide. Increased emphasis will also be placed on monitoring and evaluation of the national

PMTCT program in order to use data for decision-making and program improvement, improve the quality of

services, and monitor progress towards achievement of national PMTCT targets.

ACCOMPLISHMENTS: In FY 2007, the MOHSW revised the national PMTCT guidelines to include the

WHO tiered-approach for PMTCT ARVs, implementation of provider-initiated testing and counseling in

antenatal (ANC), labor and delivery (L&D) and postnatal wards, and provision of single dose Nevirapine as

per national guideline so as to ensure all HIV-positive pregnant women receive at least the minimum

PMTCT prophylaxis regimen. National PMTCT indicators and monitoring and evaluation tools (M&E),

including monthly summary forms and ANC and L&D registers, are being revised to reflect the new regimen

options and ensure referrals and linkages with other continuum of care services. The national PMTCT

training curriculum was revised to reflect the updated guidelines, indicators, and M&E tools, and ensure

implementation of revised policies and strategies. Supportive supervision visits were conducted in all

regions and districts implementing PMTCT, and 203 trainers and 2758 service providers were trained in

PMTCT service provision. Workshops were conducted for 24 district teams from four regions to include

PMTCT in district planning and budget documents. Information, education and communication (IEC)

materials are in development to address challenging issues in PMTCT implementation. The MOHSW also

contributed to national PMTCT commodities and drug forecasting.

ACTIVITIES: 1) Strengthen national coordination and integration of PMTCT into reproductive and child

health services (RCHS), integrated management of childhood illness (IMCI) programs, and HIV care and

treatment services; 1a) Coordinate the expansion of early infant diagnosis programs; 1b) Ensure infant-

diagnosis and infant-feeding preferences are captured in data forms and used for decision-making; 1c)

Ensure linkages with immunization services and that mother's PMTCT information is transferred to the child

immunization card; 1d) Work with partners to ensure provision of maternal and pediatric cotrimoxazole; 1e)

Work with implementing partners to devise innovative approaches to rapidly increase the percentage of HIV

-positive pregnant women that receive ARV prophylaxis or ART as eligible, initiate mothers to mothers

programs to promote adherence, follow-up care and psychosocial support.

2) Strengthen monitoring and evaluation of the national PMTCT program and use data for decision-making;

2a) Coordinate piloting and finalization of revised PMTCT M&E tools; 2b) Operationalize revised M&E tools

by coordinating roll-out and partner implementation; 2c) Lead the integration of PMTCT data with HIV care

and treatment systems and ensure HIV care and treatment systems track services provided to pregnant

women and their children; 2d) Use and disseminate data (via regular reports and stakeholders meetings) to

continuously review policies and strategies and make updates when needed; 2e) Coordinate expansion

plans to ensure national PMTCT targets are met; 2f) Oversee and manage the decentralization of

supportive supervision activities from regional to district levels in order to increase efficiency and promote

ownership of the program by the Council Health Management Team (CHMT). Supervision tools will be

disseminated and trainings on the importance of data use will be conducted; 2g) Train regional health

management teams (RHMT) on PMTCT service provision and data use for decision-making;

3) Strengthen commodity and test kit quantification, procurement, distribution and coordinate LMIS roll-out;

4) Coordinate updates to PMTCT training curricula and guidelines;

5) Increase male involvement in PMTCT; 5a) Collaborate with RCHS to add PMTCT to existing outreach

activities targeting men; 5b) Coordinate national IEC and advocacy work pertaining to PMTCT, and ensure

PMTCT messages are incorporated into existing IEC campaigns;

6) Coordinate a demonstration project with the national IMCI Community Own Resource Persons (CORP)

program to raise awareness of PMTCT in the community, and assist with the follow-up of HIV positive

women and their children. This will be done by sub-granting this community initiative to Health Focus

network, a NGO with vast experience in community outreach services in Tanzania;

7) Strengthen linkages with family planning; 7a) Participate in the development of demonstration projects for

providing counseling and testing services at family planning clinics, and providing family planning services

and methods at ART sites. Activities will be implemented with the aim of preventing unintended

pregnancies in HIV+ women of childbearing age. Family planning plays several roles in helping to maintain

the health of individuals, families, and communities, and can be utilized as an entry point to counseling and

testing services; 7b) Work with partners to ensure integration of HIV and PMTCT messages into existing

family planning training curricula and service implementation;

8) Build capacity of district and regional supervisors and the national PMTCT coordinating unit; 8a) Maintain

equipment and staff for national PMTCT coordinating unit; 8b) Provide PMTCT related program

management training and relevant short-courses to PMTCT staff at district, regional, and national levels; 8c)

Coordinate quarterly national secretariat and subcommittee meetings, and advise the National Care and

Treatment Advisory Committee on PMTCT related policy decisions;

9) Coordinate an annual program review workshop involving stakeholders; successes, challenges, and

Activity Narrative: progress towards achievement of national targets will be discussed. Innovative approaches to ensure

increased coverage and quality of PMTCT services will be discussed and way forward will be decided.

LINKAGES: Linkages with implementing partners will be maintained and strengthened in order to increase

the coverage and uptake of PMTCT services. Linkages with ART services will be strengthened to ensure

HIV positive pregnant women are enrolled in care, assessed for ART, and provided ART if eligible.

Linkages with ART will also ensure HIV-exposed infants are receiving appropriate care and are tested for

HIV as soon as possible. In order to strengthen M&E of the national program, the PMTCT Unit will, in

collaboration with the NACP M&E Unit, HMIS and partners, update and rollout a revised national PMTCT

Monitoring system, support sub-national M&E efforts, provide PMTCT progress reports, and improve

PMTCT data quality and timely reporting. Linkages with RCHS will be strengthened to increase coverage

and uptake of PMTCT services and integrate PMTCT services within the expanded program of

immunizations (EPI). PMTCT will also be included in existing RCHS outreach activities. Linkages with

family planning will be strengthened to prevent unwanted pregnancies among HIV-positive women. To

ensure HIV-exposed infats receive home- and community-based care and support, linkages with OVC

programs will be developed.

CHECK BOXES: In-service training to health care workers at reproductive and child health clinics is a

capacity building activity. IEC materials and media to increase male involvement in PMTCT is a gender

related activity.

M&E: MOHSW will decentralize supportive supervision from regional to district levels and build sub-national

-level capacity. M&E activities will also involve managing and implementing a national PMTCT system that

reflects the national guidelines; improving data quality and reporting; training and supporting sub-national

levels on data use; and disseminating PMTCT program data and data quality reports.

SUSTAINABILITY: MOHSW will work with District Councils to include PMTCT activities in Comprehensive

Council Health Plans and support resource mobilization from Global Fund and other sources. Full

integration of PMTCT into RCH services will help to ensure sustainability. Capacity building of the regional

and council health management teams in program specific training, supportive supervision, and mentoring

skills will be included to ensure continuity of their supervisory roles and program ownership. Capacity

building at the national level will help to ensure continuity of program monitoring and evaluation for decision-

making.

TITLE: Advocacy and Social Mobilization for Behavior Change Communication

NEED and COMPARATIVE ADVANTAGE: NACP coordinates the Health Sector HIV/AIDS response in

Tanzania through planning and implementation of health related HIV/AIDS interventions in collaboration

with other partners. Social mobilization is crucial for community support and uptake of services being

provided through the various program areas of prevention, care, treatment, and support. These

interventions are implemented by five other units within NACP and are all linked for advocacy and behavior

change communication through the Information, Education and Communication (IEC) unit. The HSS

recommended incorporation of Behavior Change Communication (BCC) in addition to IEC. Evaluation of

whether these IEC activities lead to behavioral change towards safer sexual practices, abstaining, and

faithfulness has not yet occurred. In addition to creation of conditions that influence behavior, practices and

socio-cultural norms, IEC/BCC strategies must address gender and economic dimensions which influence

sexual relations.

ACCOMPLISHMENTS: NACP has supported the regions in the identification and selection of the Regional

AIDS Coordination Committees (RACCs), District AIDS Coordination Committees (DACCs) and Council

Multi-sectoral AIDS Committees (CMACs), including 14 regional facilitating agencies to implement IEC/BCC

strategies. NACP plans to implement the program in five regions including Dar es Salaam, Shinyanga,

Mwanza, Tabora and Singida.

ACTIVITIES: The National AIDS Control Program (MOHSW/NACP) has responsibility for coordinating the

mainland Tanzania health sector response to HIV/AIDS. One component of the national response is to

encourage healthy behaviors that prevent HIV infection through the promotion of abstinence and

faithfulness. NACP, through its IEC/BCC unit, aims to enhance communication abilities of health care

service providers through behavior change communication and social mobilization trainings with a focus on

promoting abstinence among young people and encouraging faithfulness and stable sexual relationships

among adults. NACP's IEC/BCC unit maintains and supplies a range of innovative materials such as

booklets, leaflets and other audiovisual materials for low-literacy and rural populations and the general

public. In FY 2008, NACP plans to implement the following:

1) Continue to further promote the use of IEC/BCC materials and build the capacity skills of staff to address

AB HIV prevention effectively: This will be achieved by: 1a) conducting an inventory of existing information

resources; 1b) identifying information gaps and thereafter developing appropriate IEC/BCC materials

focusing on AB; 1c) training 2500 health care providers and media personnel on the appropriate use of

IEC/BCC.

2). Promote adequate production and distribution of culturally appropriate IEC/BCC materials that support

BCC and AB: 2a) produce and distribute 300,000 posters, 600,000 brochures, and 300,000 booklets

covering different aspects HIV/AIDS/STI in the context of AB; 2b) distribute the materials to all referral,

regional, district and ward level facilities and NGOs.

2 d) develop and disseminate reference materials for the Regional and District AIDS Control Coordinators

(RACCs and DACCs) and other partners to assist them in their IEC/BCC intervention activities.

3). Produce & print training materials and train CMACs, RACCs, & DACCs:

3a) develop training materials for service providers, conduct training of trainers (TOT) in communication

strategies for behavior change, and involve CMACs, RACCs and DACCs in IEC/BCC activities in the project

area. NACP expects to reach 121 DACCs and 21 RACCs;

3b) collaborate with zonal training centers (ZTCs) to train master trainers for the zones;

3c) conduct seminars with partners and media personnel for the promotion of partner reduction and

abstinence campaigns; 3d) conduct sensitization meetings with local leaders, local government authorities

(LGAs) and private stakeholders implementing abstinence and faithfulness interventions in the regions.

4). Collaborate with partners to develop and train partners on a BCC strategy to link with the planned

STRADCOM radio program: 4 a) Use Modeling and Reinforcement to Combat HIV/AIDS (MARCH), a BCC

strategy that integrates modeling through radio dramas and various reinforcement activities such as small

group discussions to target change at the interpersonal and community levels. 4b) Technical assistance will

be sought for developing and producing films and talk shows on different areas with emphasis on AB.

5). Assess level of behavioral change and communication:

5a) Promote culturally appropriate AB messages and strategies for the general public; 5b) Increase the age

of sexual debut; promote HIV testing through IEC/BCC strategies; 5 c) NACP IEC/BCC unit will conduct

routine process monitoring during the funding period. Indicators will focus on trainings delivered,

intervention quantities related to proposed activities, and IEC/BCC materials and programs produced

through various channels as a result of these efforts.

LINKAGES: NACP will work closely with the local government authorities in regions and districts (mainly

CMACs, RACCs and DACCs in Dodoma, Tanga, Morogoro, Coast & Lindi). The linkages will be continued

with other USG AB implementing partners including TAYOA, Ministry of Education and Vocational Training,

STRADCOM, TANESA, track 1 ABY partners, NGOs, and Media Institutions/Houses. 1) STRADCOM will

provide technical assistance and produce and air radio programs on different issues on HIV/AIDS/STIs in

the context of AB in collaboration with NACP. 2). TANESA is committed to working with RACCs, DACCs

and CMACs in community outreach campaigns and sensitization workshops. 3) NACP will work closely with

the track 1 ABY and MOEVT-TIE partners to disseminate the youth AB curriculum to adapt a standard

approach for AB life planning skills (LPS) training.

CHECK BOXES: The program will focus on IEC/BCC in the context of AB in different settings. NACP will

focus on building the capacity of local organizations in the respective regions. Training of key implementers

of HIV programs focusing on health workers at district level and community mobilization. The general

population will be targeted through community outreach activities on AB implemented by existing partners in

the regions

M&E: AB will be integrated into the health management information systems (HMIS). There will be training

on the use of M&E tools and support provided in the use of the tools in day to day operations. All supported

sites will use MOHSW daily registers and monthly summary forms. This will harmonize recording and

reporting of AB community outreach activities.

SUSTAINABILITY: This project will utilize existing knowledge on major obstacles to an effective HIV/AIDS

response, such as issues on stigma and discrimination against people living with HIV/AIDS, and gender

inequalities, particularly in the area of information access and utilization. Through the existing systems at

Activity Narrative: the regional and district levels NACP will build capacity of the CMACs, RACCs, DACCs and other local

leaders in the area of AB. In turn the trained CMACs, RACCs, DACCs and LGAs authorities will continue

educating and advocating for the correct AB interventions in their respective communities. NACP will work

with district authorities to include part of the programming in AB into the CMACs plans at the district level.

TITLE: Scaling-up Community Home-based Care/ Palliative Care in Tanzania

NEED and COMPARATIVE ADVANTAGE: The Tanzania Health Sector Strategy on HIV/AIDS includes

community home-based care (HBC) as one of the interventions under care, treatment, and support. HBC

refers to a broad spectrum of palliative care and has been recognized as one of the most effective ways of

mitigating the physical, mental, emotional, spiritual, and economic difficulties for people living with HIV/AIDS

(PLWHA) and their families. These services are provided by both healthcare workers and trained

volunteers, both within facilities and in the community. The Ministry of Health and Social Welfare (MOHSW)

established HBC services in nine districts in 1996. As of December 2006, the services reached 70 out of

127 districts across Tanzania. With expansion of care and treatment, the need for facility-based palliative

care increases as well.

While there are guidelines and standard training materials, implementation of palliative care is still

fragmented and uncoordinated. MOHSW, through the National AIDS Control Programme (NACP), is

responsible for coordinating services as well as ensuring that the services are accessible and of high

quality. NACP's Counseling and Social Support Unit (CSSU) sets standards, oversees and coordinates

implementation of the training of community HBC workers, and monitors and evaluates the implementation

of palliative care services provided to PLWHA.

ACCOMPLISHMENTS: FY 2007 was the first year that the USG requested Emergency Plan funding for the

CSSU of NACP. Those funds have only just been awarded; though NACP is proceeding with many

important aspects of coordinating palliative care services, strengthening the preventive care package,

improving quality of services and initiating an accreditation system for programs, and revising palliative care

guidelines. This upcoming support will also be very important for the initiation of work on a national

monitoring system of palliative care services that can be used as a management tool at both the national

and local level, and thereby proceeding with stronger coordination and quality efforts.

ACTIVITIES:FY 2008 will be an important year for exerting stronger leadership and significant expansion in

the area of palliative care. The CSSU has organized a care and support sub-committee of the National

Care and Treatment Task Force. This formal body will foster better partner coordination and

implementation under NACP's leadership. This initiative will focus on the quality and comprehensiveness of

palliative care. Several organizations will collaborate with NACP: Family Health International (FHI) for

organizational strengthening, the African and Tanzanian Palliative Care Associations, Mildmay, the

Foundations for Hospice in Sub-Saharan Africa, Columbia University/Ocean Road Cancer Institute, and a

twinning partnership with the Iowa Synod. Each of these organizations has expertise and innovative ideas

to help facilitate the expansion and improvement of standards of care, guidelines, and training curriculum.

The CSSU will ensure that providers of palliative care, especially HBC, convene regularly to discuss quality

issues, approaches, program content, and supervision. Attention will be paid to ensuring that implementers

create, in collaboration with NACP, a standard service package including nutrition counseling and

assistance, psychosocial/spiritual support, opportunistic infection (OI) and pain management,

cotrimoxizole/malaria prevention, referrals for malaria and TB diagnosis and treatment, access to safer

water, ART adherence counseling, and referrals to services in the community, such as income generating

activities (IGA), legal and human rights education, etc. Nutritional assessments will also be included as

appropriate. In addition, a prevention with positives package will be considered to reduce risky behavior,

provide access to family planning and condoms, and support disclosure. To ensure compliance with

quality standards, and verification that coordination reaches the community level, the CSSU will organize

biannual national level meetings and zonal biannual meetings. In addition, the CSSU will conduct

supportive supervision visits throughout the year.

In FY 2008, the MOHSW CSSU Unit and the Monitoring and Evaluation Unit at NACP will work with FHI

also develop and implement a national monitoring system for palliative care. The system will be developed

under the direction of NACP with input from stakeholders. The rollout of the system in FY 2008 will involve

training of HBC providers in the new system, and implementation will be accomplished with a project

management team. Supportive supervision will be built into the training to ensure quality data is collected

and that district level personnel understand how to use data for program planning, budgeted, managing,

and decision-making.

A key role that the CSSU of NACP plays is to coordinate the trainings and allocate trainers, while the

council health management teams (CHMT) will identify the facilities from which the health facility HBC

providers will be trained. This is particularly important where there is no USG partner working at this time.

These trained health workers will sensitize their respective communities to select additional resource people

(using the criteria set in the national guidelines) to be trained as HBC volunteers. Key components of the

training include community sensitization on HIV prevention, nursing care of PLWHA and other chronically ill

patients, management of OIs including pain management, basic counseling skills, adherence support,

referral, networking, and recording and reporting data. Trainings will be conducted in the districts with

support from national and district HBC trainers.

Funds will support copies of "Integrated Management of Adolescent and Adult Illnesses" caregiver booklets

and patients' flipcharts, to be provided as references and working tools for the HBC providers. In FY 2008,

the CSSU of NACP will be involved with USG partners in the review of publications to identify a collection

that are usable by all partners and other small organizations that provide HBC. These will be printed and

made available to all partners.

In order to address the service and coordination gap, NACP, in collaboration with the CHMT, will undertake

several additional activities. Approximately 160 district HBC trainers will be re-trained on palliative home-

based care, community directly observed therapy-short course (DOTS) for TB, monitoring and evaluation,

and preventive care. Fifteen new health center and dispensary level HBC providers will be trained in each

of the proposed districts. Thirty lay volunteers will be trained in each of the proposed districts.

The FY 2008 funding will support two direct-hired HBC program officers at NACP to address the workload

described above. One only needs to envision an hourglass to understand the impact of too few staff to

significantly scale up services.

LINKAGES: As the coordinating body for all HBC services, NACP will play a key role in facilitating linkages

Activity Narrative: with other services such as care and treatment. NACP will develop and implement referral systems that will

be used to link counseling and testing patients to HBC and will include this in the monitoring system. Since

comprehensive care and support requires networking and referrals to link services and needs of PLWHA

and their families, linkages with care and treatment clinics (CTCs), reproductive health clinics, TB, and other

community-based services will be established. HBC providers will be oriented to these services during

training, as appropriate. In addition, this activity will have a critical linkage with all the palliative care

programs: those involved in systems strengthening, those developing innovations, and those on the ground

with significant caseloads.

CHECK BOXES: NACP's work will develop human capacity through in-service training of the clinical nurses

who will supervise the community HBC volunteers in the community. NACP will also promote task shifting

of HBC from trained nurses to non-medical personnel in the community.

M&E: NACP CSSU will work in collaboration with the NACP M&E unit, as well as with Family Health

International and all implementing partners, to develop and implement a database and related tools to

provide NACP with information to monitor, plan, and share results on progress of HBC in Tanzania.

Reports will be channeled monthly from the dispensaries and health centers to the districts and compiled to

be submitted quarterly to MOHSW. NACP will use data from the new system for program planning and

feedback to partners and the government on the progress and challenges of HBC in Tanzania. The data

will also be made available to local government authorities and the relevant NGOs so that data can be used

for planning, management, budgeting, and decision-making. In order to improve supervision, NACP will

develop a standardize tool (in collaboration with HBC partners) to use for data quality and for feedback to

HBC organizations on the progress and quality of their work. They will also work to build their capacity so

that the unit is able to manage data from the new system.

SUSTAINAIBLITY:It is critical for HBC to be integrated into the district comprehensive plans as a core

service. During establishment of the services in the districts, sensitization is conducted to emphasize that

the services are included in the district comprehensive plans. At the central level, the services have been

included in the HIV/AIDS Health Sector Strategic plan. However, it is well understood that there is lack of

resources and inadequate allocation of resources in the health sector budget. Training, capacity building,

and advocacy will ensure sustainability.

TITLE: Strengthening HIV Counseling and Testing Services for Mainland Tanzania

NEED and COMPARATIVE ADVANTAGE: The Ministry of Health and Social Welfare, through the National

AIDS Control Program (NACP), has the responsibility of coordinating the health sector response to

HIV/AIDS. The Counseling and Social Support Unit (CSSU) at NACP coordinates the Counseling and

Testing (CT) program through development of policies and guidelines, training protocols and manuals,

standard operating procedures and job aides. NACP also provides supervision and technical guidance to

implementing partners, strengthens training of counselors to secure the required quantity and quality of

services, and monitors the progress of implementation of CT activities through reports from district councils,

NGOs, and other stakeholders.

ACCOMPLISHMENTS: Recent NACP achievements include providing CT services and indirect support to a

combined total of approximately 681,000 clients and training of 23 health care workers in CT services. In

addition, CSSU worked with the Epidemiology Unit at NACP to revise the M&E tools for CT.

MAJOR ACTIVITIES:

FY 2008 funds will be used to:

1. Strengthen VCT services at 56 USG-supported sites within 10 regions;

2. Establish provider initiated testing and counseling (PITC) services at 25 health facilities within 16

regions;

3. Train 100 health care workers from 25 sites and retrain 50 counselors from 28 health facilities;

4. Procure HIV test kits and related commodities;

5. Provide mentoring and facilitative supervision to hospitals and health centers providing CT services;

6. Mobilize and sensitize communities for the uptake of CT services;

7. Design, develop and pretest IEC messages in collaboration with the IEC/BCC Unit;

8. Monitor the progress of CT activities through supportive supervision, monitoring and reporting;

9. Standardize the CT monitoring system, to capture both VCT and PITC data; and

10. Strengthen the managerial capacity of the Unit to coordinate CT services in Tanzania.

LINKAGES: For individuals testing HIV-positive, linkages will be made with various programs including

palliative care/home based care and HIV treatment. HIV-negative persons will be linked with resources

(e.g., post-test clubs) to help them maintain their negative status). Work will be completed in collaboration

with various implementing partners including JICA, GTZ, GFATM, and SIDA.

CHECK BOXES: Coordination of CT services, training of health care workers, service provision for VCT and

PITC and supporting the Council Health Management Teams (CHMTs) in the roll out of CT services.

Disseminate the CT guidelines and training materials to all partners implementing CT services.

M&E: NACP will continue to support integration of HIV CT in HMIS and training for M&E tools. NACP will

also provide support in the use of the tools in day to day operations. All supported sites will use MOHSW

daily registers and monthly summary forms, which will harmonize recording and reporting of CT services.

SUSTAINAIBILITY: To ensure sustainability of CT services, NACP will support the training of CHMTs on

mentoring and supportive supervision of CT services (VCT and PITC) and in directly supports the overall

HIV Care and Treatment Plan. This activity will also strengthen the CHMTs to manage and supervise the

implementation of quality CT services at the council level through monthly/quarterly coordinating meetings.

It will also strengthen the referrals and linkages to care, as well as treatment and prevention activities in all

sites and the integration of CT services into other services.

TITLE: Coordination of ARV services and HIV care in Tanzania

NEED and COMPARATIVE ADVANTAGE:

The Care and Treatment Unit (CTU) is the National AIDS Control Program (NACP) focal point for

coordination, management and implementation of the National HIV/AIDS Care and Treatment activities in

Tanzania. The CTU works with other units of the NACP and partner organizations within and outside the

health sector to develop and implement comprehensive care strategies in public, private and community

based settings.

ACCOMPLISHMENTS:

The Care and Treatment program in Tanzania was initiated in 2004 with 32 health facilities and by the

beginning of FY 2007, there were 204 operational CTCs (all located in referral, regional and district

hospitals).

The NACP/CTU coordinated regionalization of all care and treatment services where each region was

assigned one supporting partner. This resulted in PEPFAR partners providing support to 19 out of 21 (90%)

regions in mainland Tanzania as well as to Unguja and Pemba Islands of Zanzibar. Regionalizing partner

support has enabled the NACP to rapidly decentralize support to regions and districts. The partners in turn

have been able to integrate with regional medical offices (RMO) thereby providing assistance in planning

and implementation of services.

In FY 2007, the NACP/CTU started to develop human and physical infrastructure needed to expand the

services to Primary Health Centers (PHC) to provide HIV care and treatment as initiation, refill or outreach

(satellite) centers. The plan was to have four PHCs per district to a total of 500 PHCs providing treatment

services in Tanzania. USG treatment partners have begun to implement these plans in the regions that they

support. By Sept 2008, approximately 274 (55%) PHCs will be support by USG partners.

Using existing funds from USG as well as funds from the Royal Netherlands Embassy (RNE) through

PharmAccess International (PAI), the NACP M&E Unit revised the Care and Treatment Centre (CTC)

monitoring and reporting system to include a facility-based monitoring & reporting component. This included

adapting the World Health Organization (WHO) facility-based chronic HIV/AIDS care registers to the

Tanzania situation and revising the paper-based longitudinal management patient record. In the CTC 2

form, it will function as the data source for the registers. Cross sectional and cohort reports were also

adapted for Tanzania. By March 31, 2007, the NACP M&E Unit in collaboration with PAI and USG treatment

partners had trained 261 regional, district and CTC staff in 11/21 regions on the use of these tools. The

revised CTC 2 forms have been distributed to all existing CTCs while the registers and reporting tools are

being distributed after completion of the training.

NACP M&E unit also contracted the University Computing Centre (UCC) through the Global Fund to

develop an electronic database based on the CTC 2 form. The CTC 2 database, which is capable of

generating national and PEPFAR reports for treatment services, is currently in use at 35 of the 204 existing

CTCs. UCC also developed for NACP, a central-level database (CTC 3) which has de-identified patient

level data on a subset of CTC 2 data elements. The CTC 3 database is electronically linked to other partner

-supported databases such as the Harvard system in Dar es Salaam (4 CTCs) and the DoD system in

Mbeya, Rukwa and Ruvuma regions with 15 CTCs.

Finally, by March 31, 2007, Tanzania had 71,584 patients actively on ART (96% supported by USG) and

1,457 HCWs trained on management of HIV including focused training on Pediatric HIV.

ACTIVITIES:

In FY 2008, the NACP CTU will coordinate the following activities in order to come up with quality

unduplicated ART services;

a) Coordination of partners implementing ART services in Tanzania including conducting regular meetings

with partners to discuss various issues including provision of policy and technical guidance, sharing best

practices and sharing M&E data to track progress against national goals and to improve program

implementation.

b) Coordinate the expansion of care & treatment services to PHCs.

c) Review training materials in collaboration with I-TECH and disseminate the revised training guidelines.

Since management of HIV/AIDS is very dynamic with progressive and frequent changes, the CTU plans to

review and finalize the national clinical guidelines, national training materials, and standard operating

procedures (SOPs) used at tertiary and secondary levels and the IMAI documents to be used at primary

health care levels.

d) For the sites to provide quality ART services, supportive supervision needs to be conducted frequently. In

a bid to decentralize supportive supervision, the NACP/CTU in collaboration with treatment partners will

empower Regional Health Management Teams (RHMTs) to conduct supportive supervision to districts and

facilities in their regions.

e) Ensure that on TB/HIV collaborative activities are well coordinate and linked between HIV and TB Clinics.

f) NACP/CTU will work with the NACP M&E Unit to coordinate the rollout of the revised M&E tools for care

and treatment and the expansion of electronic databases at facility level and central level. All USG

treatment partners have been funded to support the NACP implement these activities. The USG will assist

the NACP to build in-country capacity to regularly evaluate the impact of ART in Tanzania.

g) Continue maintaining the CTU unit at NACP including remuneration of program hired CTU staff and

procurement of stationary and other office supplies to ensure smooth running of the program.

h) Attend international conferences. To enable CTU coordinate ART activities, personnel need

strengthening/capacity building by attending relevant courses, workshops and conferences within and

outside the country.

Activity Narrative: LINKAGES:

In Tanzania, the NACP/CTU provides technical guidance on referals and linkages and collaborates with all

ART partners implement Care and Treatment program. CTU ensures that there are linkages between ART

program and Home based care, TB and PMTCT programs. Linkages with the National TB and Leprosy

Control Program (NTLP) will be strengthened in order to track referals and ensure continuum of care.

CHECK BOXES:

The general population benefits the quality and accessible ART Services.

M&E:

Tanzania has a national standardized care & treatment M&E paper-based tools that are used at almost all

facilities. The system consist of; CTC 1 - a patient appointment card; CTC 2 - a patient management record;

CTC 3 - a monthly identifier-stripped patient-level report (soon to be discontinued); Pre-ART and ART

registers which are manual longitudinal patient record transcribed from CTC 2 forms; monthly cross

sectional and quarterly cohort reports. The CTC 2 and CTC 3 databases are electronic formats of CTC 2

and CTC 3 forms respectively capable of generating all the NACP and OGAC reports. The Harvard and

DoD are partner developed systems with links to the national systems for report generation.

With financial and/or technical support from RNE/PAI, USG, Global Fund and UCC, the NACP M&E Unit on

behalf of the NACP/CTU will continue to coordinate the implementation, scale-up and maintenance of these

systems. The NACP will also provide leadership in promoting data use culture at facility, district and

regional; coordinate regular outcome evaluation to track the impact of ART in Tanzania and conduct

regular data sharing workshops to disseminate findings

SUSTAINAIBLITY:

NACP/CTU is committed to sustainability and plans to: work with authorities from regional and district level,

to implement the program to empower local authorities and create ownership, putting the responsibility of

sustainability into their hands; Involvement of RHMT and CHMT to conduct supportive supervisors and plan

and budget for the gapes identified; Integrate ART activities in to the Districts Comprehensive Health Plans.

TITLE: Support for SI capacity, surveillance and program area monitoring systems within NACP

NEED AND COMPARATIVE ADVANTAGE: The National AIDS Control Program (NACP) in Tanzania

coordinates the Health Sector response to HIV/AIDS Epidemic. The Unit has primary responsibility for all

strategic information for NACP, including: a) surveillance and surveys including Ante-Natal Clinic (ANC)

based sentinel surveillance for HIV, HIV drug resistance threshold surveys and participation in national

population-based surveys such as the Tanzania HIV Indicator Survey (THIS); b) monitoring HIV/AIDS

interventions, including the development/adaptation and maintenance of electronic data-collection-tools

systems; training on paper-based tools and synthesis to move from data collection to reports; supportive

supervision to ensure data quality and timeliness of reports and data and report flow, c) capacity-building on

M&E to other units within NACP and d) compiling health sector response data for HIV/AIDS and reporting

these to the Tanzania Commission for AIDS (TACAIDS). This unit also links with TACAIDS to provide

information on the "Third One" for the Health Sector Response to the HIV/AIDS epidemic in Tanzania.

ACCOMPLISHMENTS: In the five years of collaboration between the NACP and the USG, there has been

substantial progress in the implementation of national HIV surveillance activities. Coverage for antenatal

clinic (ANC) surveillance has grown from 24 sites in six regions (2001/2002) to 128 sites in all 21 regions

(2007/2008) of mainland. The methodology of ANC surveillance has also improved substantially. For

instance, the use of dried blood spots (DBS), which are easily transportable, has enabled coverage to

remote sites with no lab capacity. During FY 2006, NACP piloted HIVDR threshold survey in six sites in Dar

es Salaam region, and in FY 2007, NACP carried out HIVDR threshold survey in Mwanza and Mbeya

regions.

ACTIVITIES: FY 2008 funding will support surveillance activities and capacity building for strategic

information.

1. Surveillance: ANC, HIVDR Monitoring

a. ANC Sentinel Surveillance

For the 2008-2009 round of ANC surveillance, NACP will maintain full coverage of all 21 regions in

mainland Tanzania, covering six sites per region. A total of 128 ANCs will participate in data collection for a

period of three consecutive months according to the standard protocol. ANC surveillance activities will

include maintenance of the surveillance workgroup; training of ANC and lab staff on protocols, procedures

and quality assurance; distribution of supplies; data collection; periodic supportive supervisory visits; HIV

testing of collected dried blood spots (DBS); data management, analyses, report preparation and

dissemination. During supportive supervisory visits, sites will be provided with funds for shipping of DBS

and data forms to the testing laboratory. Surveillance staff will be given a token during the three months of

data and specimen collection.

HIV testing of the collected ANC samples will be done in four referral hospital labs namely, Muhimbili

University College of Health Sciences-HIV Reference laboratory, Bugando Referral Hospital, Mbeya

Referral Hospital and Kilimanjaro Christian Medical Center (KCMC). For quality assurance, 10% of all

specimens will be retested at the National Quality assurance laboratory in Dar es Salaam. The surveillance

advisory group will analyze data, and prepare and disseminate reports.

b. HIV drug resistance monitoring

With the rapid scale-up of the National Care and Treatment program and increased access to ARVs, the

prevalence of acquired resistance should be examined. The emergence of some degree of HIV drug

resistance in ART programs is inevitable, but can be exacerbated by failure to optimize support for

continuing access, adherence, and continuous drug supply, by inadequate prescribing practices, and by

baseline (pre-ART) drug resistance. Routine ART program evaluation to monitor these factors and their

relationship with drug resistance should be instituted early in ART roll-out, utilizing standard minimum-

resource methods.

With FY 2008 funding, NACP expects to pilot HIVDR monitoring in four sites (private, faith-based/NGO

referral, regional) in four regions: Mtwara, Mbeya, Iringa, and Kilimanjaro. A cohort of 400 treatment-naïve

individuals (100 persons per site) will be monitored for a 12 to 15-month period to assess development of

acquired (primary) drug resistance. A national protocol for HIVDR monitoring will be developed and site

assessment will be conducted, to determine readiness and identify any gaps to be strengthened prior to

data collection. Data collection forms will be developed and will be revised based on pre-testing of tools.

Data will be evaluated for important lessons which can be generalized to other clinical sites, as HIVDR

monitoring is expanded to other ART sites.

2. Strengthening SI Capacity at NACP

a) Strengthening capacity in the M&E Unit

In FY 2008, the USG will provide funding and technical assistance to strengthen the infrastructural and

human capacity required to enable the Epidemiology and M&E Unit to carry out surveillance activities, build

M&E capacity, and provide information to TACAIDS on HIV interventions.

Funds will cover maintenance and/or recruitment of new staff and logistical support to enable personnel to

perform their duties as required. For staffing in the unit, six cadres of staff have been identified: 1) an

epidemiologist in charge of the unit; 2) an M&E officer to oversee activity planning, monitoring and

reporting, as well as capacity-building, data use and program evaluation activities; 3) a surveillance officer

to coordinate all surveillance activities; 4) three program monitoring officers in charge of all sub-national

level program monitoring activities including data quality assurance, training and supportive supervision; 5)

two data managers to maintain all central-level databases; 6) three data clerks to enter data as required.

The Unit currently has staff who are full-time MoHSW employees as well as contract staff supported by

donors, including the USG. FY 2008 funding will be used to maintain the existing USG-supported personnel,

as well as to fill vacant positions (officers in charge of M&E, surveillance, and counseling and testing

program monitoring).

b) Revision of the Health Sector M&E framework and coordination of reporting to TACAIDS

The USG will continue to support NACP in revising the health sector M&E framework to monitor and

evaluate the health sector's response to the HIV/AIDS epidemic. This framework plans to develop and/or

strengthen existing linkages between the different interventions, provide a comprehensive set of indicators,

Activity Narrative: standardize the reporting health information up to TACAIDS, and provide guidelines for developing work

plans, monitoring programs, and reporting all HIV/AIDS intervention activities. The M&E Officer will provide

oversight for the development of the framework including collaborating with the World Health Organization

(WHO) Resident M&E Advisor in the development and implementation the framework. The NACP and WHO

M&E Advisors will coordinate packaging, dissemination, and training on the framework. The M&E officer will

also coordinate the health sector information reporting to TACAIDS.

c) Building capacity of use of Personal Digital Assistants (PDAs) for data collection

Supervision is one of the keys to the success of a quality program. Supportive supervision at the regional

and district levels to health facilities are one of the integral components of program monitoring within NACP.

Currently, most regional supervision programs keep paper management records. They report their findings

to the national level. The introduction of new data collection methodologies will assist in ensuring that

quality data are collected and used in real time. PDAs will be used for data collection and dissemination of

findings and feedback.

LINKAGES: NACP works with other government organizations in the implementation of M&E activities,

including Tanzania Commission on AIDS (TACAIDS), National Bureau of Statistics (NBS), National Institute

for Medical Research (NIMR) and other Ministry of Health and Social Welfare departments. NACP also

works with Japan International Cooperation Agency (JICA), PharmAccess International (PAI), Global Fund

to Fight AIDS, Tuberculosis and Malaria (GFATM) and WHO.

SUSTAINABILITY: This activity builds capacity of national, regional, district and facility-level staff. It

supports the NACP M&E unit, programmatic units of NACP, local organizations, and laboratories. Supports

of SI capacity of the M&E unit will strengthen capacity of activity monitoring within program areas in NACP

including Counseling and Testing, Home Based Care, ART.