TITLE: Providing PMTCT services to Tanzania Peoples Defense Force

NEED and COMPARATIVE ADVANTAGE: The Tanzanian Peoples Defense Forces (TPDF) has a network

of military hospitals, health centers and dispensaries through out the country, supporting a total of over

30,000 enlisted personnel and estimated 60-90,000 dependants. Eighty percent of patients at these

hospitals are civilians living in the vicinity of the health facilities. The eight hospitals offer district-level

services with the largest hospital, Lugalo, located in Dar es Salaam, serving the role of a national referral

center for military medical services. The MOHSW goal is providing PMTCT service to 80% of the projected

HIV-positive mothers by September 2009. The national PMTCT coverage is still low, at 15%. Military

hospitals and health centers will play an important role in realizing MOHSW goals.

ACCOMPLISHMENTS: In FY 2004 the TPDF started offering PMTCT services at Lugalo Hospital. With

PEPFAR FY 2005, FY 2006 and FY 2007 funds, the TPDF and PharmAccess International (PAI) introduced

these services in the remaining seven military hospitals (Mbalizi, Mwanza, Mzinga, Monduli, Songea,

Mirambo, Bububu) and four health centers of Mwenge, Mbalizi, Mwanza and Tabora Hospital. In FY 2007, a

total of 1,260 pregnant women were tested in the last 12-month reporting period, of which 324 women

received ARV prophylaxis.

ACTIVITIES: 1) Expand PMTCT services to an additional 10 health for a total of eight hospitals and 14

health centers.

1a) Using the four-week national curriculum, carry out training of three health care workers per hospital (24)

and two per satellite health center (28).

1b) Renovation of counseling and delivery rooms at 10 new satellite sites/health centers.

1c) Train PMTCT service providers in staging of HIV+ mothers and provision of ART where capacity exist. If

capacity is not available on-site, then patients will be referred to nearest military, District or Regional

Hospital

2) Provide PMTCT services at 22 military health facilities:

2a) Support the role-out of the new national PMTCT guidelines (50% of the HIV+ women are expected to

receive NVP, 30% AZT+NVP, and 20% ART).

2b) provide services using the opt-out approach, based on the new national testing algorithm using rapid

test with results given on same day.

2c) Provide PMTCT to women in ANC and labor, delivery, and post natal wards.

2d) Promote infant-feeding counseling options (AFASS), linking mothers to safe water programs in the

region, and for those choosing to breastfeed, counseled to exclusively breastfeed with early weaning.

2e) Infant feeding and nutritional interventions during lactation period will be promoted.

2f) Train ANC staff in collection of dried blood spot (DBS) for infant diagnosis.

2g) Establish a formal referral system for HIV+ women and their HIV-exposed infants from the health

centers to TPDF hospitals or District and Regional hospitals for additional ANC services, infant diagnosis,

ART, and TB/HIV at CTC.

2h) Procure test materials and protective safety gear through the District Medical Offices (DMO) and

Medical stores department (MSD) under the national PMTCT program.

3) Promote and manage quality services.

3a) Lugalo Hospital will serve as the coordinating body for services, and oversee quality assurance

following national standards for follow-up at district or regional hospitals.

3b) Conduct ‘Open House' days and other awareness campaigns at each center distributing information

about the available services of the facilities, including PMTCT.

3c) Train volunteers/social support providers to conduct community education, home-visits, and assist in the

development of the organization of post-test.

LINKAGES: Expansion of PMTCT activities in FY 2008 will ensure a close linkage of military

implementation to national strategies and programs supporting MOHSW goals. Activities will be linked with

organizations of women living in the barracks for promotion and patient follow up at home. Linkages will be

established as well as referral for HIV+ individuals from the satellite sites to TPDF hospitals or public

regional and district hospitals for CD4, TB testing, and complicated cases. Linkage will be strengthened with

Prevention activities under the TPDF Program, including promotion and counseling of preventive measures

for HIV+ individuals, provider initiated testing and counseling (PITC,) C&T, TB/HIV and OVC programs.

Linkages will also be improved with reproductive child health (RCH) activities especially Malaria and

Syphilis in Pregnancy program, family planning, and nutritional and child survival program as these are all

provided in the military facilities. Furthermore, linkages with nearest by District and Regional Hospitals will

be established for referral of complex clinical cases and laboratory testing. PAI will continue to collaborate

with facilities supported, other USG treatment partners, and Global Fund.

CHECK BOXES: This funding will fully develop PMTCT services in the network of military hospitals and

satellite military health centers. Funding will support the introduction and/or improvement of PMTCT

services. More emphasis will be put into training of health care workers per hospital and from satellite health

centers, renovation or refurbishing of counseling and delivery rooms, community education, and providing

test materials and protective safety gear.

M&E: PAI will support the military facilities teams to collect and report PMTCT data based on the national

protocol, and provide feedback on tool performance to the NACP. PAI will work with these institutions to

strengthen and implement the PMTCT quality framework and provide regular supervision. PAI will continue

to support the district and regional teams with supportive supervision visits to monitor the collection of data,

reporting of the data, and the continued on-site training of facility staff. Data will be collected both

electronically and by paper-based tools. PAI will work with the MOHSW in rolling-out the revised PMTCT

M&E: patient-based registers, the Monthly Summary Forms for both ANC and L&D, and the commodity

logistic (LMIS) tools to all of the sites it supports. PAI, in collaboration with UCC, will train 52 health care

workers and provide technical assistance to 22 facilities. PAI will continue to promote the synthesis and use

of data by facility staff, and strengthen its use for decision-making for facilities and the district and regional

management teams.

SUSTAINAIBLITY: In the military setting, turnover of medical staff is low. Once trained, this capacity will

stay within the forces. Health facilities of the Military Forces are under the administration of the Ministry of

Activity Narrative: Defense, not under the Ministry of Health. PAI will encourage the Office of the Director Medical Services to

integrate care and treatment activities in military health plans and budgets at the facility and national level.

To improve administrative capacity, the PAI will work with military authorities to build local authority's

technical and managerial capacity to manage the program, as well as incorporate data collection and

analysis as part of regular health service planning and management.

TITLE: Providing HIV/AIDS Prevention programs to TPDF

NEED and COMPARATIVE ADVANTAGE: The HIV prevention and awareness-raising activities under this

program aim to reach: a target of approximately 4,000 recruits at basic TPDF training centers; 3,000-4,000

men and women under the National Services; 25,000 other servicemen and -women and their dependents;

tens of thousands civilians from the communities around the military hospitals, health centers, and military

camps by September 2009. Prevention efforts within the TPDF will continue to focus on military hospitals,

health centers/satellite sites, basic training, special detachment camps, border camps, and the training

camps of the National Services. Service members are highly at risk for HIV/AIDS since they are often

stationed outside their residential areas for long periods, which usually range from 6 to 24 months. Included

in these critical prevention efforts are addressing gender issues, especially gender-based violence (GBV),

and this target population.

GBV can be defined as any unlawful act perpetrated by a person against another person because of their

sex that causes suffering on the part of the victim and results in physical, psychological, and emotional

harm or economic deprivation among other criteria. Attention has been increasingly directed at the possible

role military personnel could play in preventing HIV/AIDS within their ranks and in the civilian communities

they come in contact with. The Tanzania People's Defense Forces (TPDF), like any other African military,

is grappling with how to best stem the spread of HIV/AIDS among its officers. The TPDF serves 35,000

service members in addition to thousands of civilians living near eight military hospitals. A workplace

prevention model has been adopted by the TPDF as the most effective tool for combating HIV/AIDS in the

military as it provides a standardized approach to prevention, awareness, peer education, and critical issues

of gender such as GBV and care and treatment while enhancing force readiness.

The military arena provides a unique setting for reaching people with information on these themes. This is

because military personnel are a relatively captive audience while in the military and are used to receiving

new information and in-service training and upgrading of skills education.

ACCOMPLISHMENTS:

With FY 2007 plus up funds, PAI will support assessments of the policy environment and development of

IEC materials specifically related to issues of GBV at 36 military sites. These activities will cover about

20,000 military personnel and civilians, and 40 peer educators will be trained. Currently, a dedicated TPDF

task force has been formed to develop IEC and life skills materials. A video, a card game, and several

other printed life skills materials have been produced and distributed to all camps and health facilities, many

of which were supplied through UN programs for militaries. Twenty-four TOTs and 480 peer educators

have been trained. Condoms are procured by Tanzania Marketing and Communications company (T-

MARC) and MSD and distributed to 86 outlets. Prevention for positives counseling through health facilities

for HIV-positive persons on the risk of HIV transmission has been initiated under FY 2007 funds. This AB

component of PAI's program will be done in conjunction with their OP activities.

ACTIVITIES:

Pharmaccess believes that additional information about the extent of GBV in TPDF and enabling policy

environment is needed to assist with further decision-making. 1) Developing and distributing new IEC and

life skills materials, as well as newly designed materials and prevention components on GBV by a dedicated

TPDF taskforce. 2) Special efforts will be focused on counseling of HIV-positive persons to raise

awareness about the risks of HIV transmission, with an additional emphasis on partner reduction and being

faithful. USG funding will support the training of 102 clinicians and HIV counselors of eight military hospitals

(three per site), nine health centers, 16 training camps, and 14 training sites of the National Service (two per

site).

3) Re-training of 24 TOTs and training of 480 peer educators, at least two per military, navy, and air force

camp, with particular emphasis on gender issues, such as GBV, as well as alcohol abuse and their

relationship to HIV transmission. The peer educators will be supported in continued prevention/outreach

efforts throughout their period of military service. Activities will be directed to all military hospitals,

detachment, training and border camps, and the training camps of the National Services. 4) Establishing

post-test group sessions of HIV-positive persons with referrals to critical care and treatment services.

LINKAGES: PAI and the TPDF will link activities in this program area with clinical service and VCT activities

undertaken by the military. It will also link with organizations of women living in the barracks who will be

trained in social support and home-based care for HIV-positive persons in and outside the barracks. Links

will also be made with existing local NGOs operating in communities surrounding barracks to coordinate

and collaborate on broader prevention programs. Condoms will be obtained through MSD and District

Medical Officers in the respective districts. Prevention outreach will be linked to counseling and testing,

PMTCT, and care and treatment activities in support of the continuum of care. Expansion of prevention

services in FY 2008 will ensure a close linkage of the HIV/AIDS programs of the TPDF to national strategies

and programs implemented under the Ministry of Health and Social Welfare (MOHSW).

CHECK BOXES: Funding will support establishing post-test group, training of counselors and peer

educators, executing education activities, and the distribution of condoms.

M&E: Quantification of the effect of prevention activities is not yet standardized. TPDF management will

collect and report data and will have adequate training to guarantee as much standardization as possible in

doing so. PAI will prepare a written M&E plan and will begin implementation upon receipt of FY 2008 funds.

The plan will outline procedures for data collection, storage, reporting, and data quality, and will outline

plans for data use for decision-making within the organization and with stakeholders and will work to

harmonize with other PEPFAR AB and OP partners as appropriate.

SUSTAINAIBLITY: In a military setting, staff turnover is low. Once trained, this capacity will stay within the

forces. Based on the outcomes and findings of this pilot, the PAI will encourage the Office of the Director

Medical Services to integrate services in military budgets at the barracks and at the national level. To

improve administrative capacity, the PAI will work with military authorities to build local technical and

managerial capacity to manage the program as well as incorporate data collection and analysis as part of

regular health service planning and management.

TITLE: Providing HIV/AIDS Prevention programs to TPDF.

NEED and COMPARATIVE ADVANTAGE: The HIV prevention and awareness-raising activities under this

program aim to: reach a target of approximately 4,000 recruits at basic TPDF training centers; 3,000 to

4,000 men and women under the National Services; 25,000 other servicemen and -women, their

dependents; tens of thousands of civilians from the communities around the military hospitals, health

centers, and military camps by September 2009. Prevention efforts within the TPDF will continue to focus

on military hospitals; health centers/satellite sites, basic training, special detachment,border camps, and

training camps of the National Services. Service members are highly at risk for HIV/AIDS as they are often

stationed outside their residential areas for periods, which usually range from six to 24 months.

ACCOMPLISHMENTS: A dedicated TPDF task force has been formed to procure and develop IEC and life

skills materials specific for military populations. A video, a card game, and several other printed materials

have been produced and distributed to all camps and health facilities, many supplied through UN programs

for militaries. Twenty-four TOTs and 480 peer educators have been trained. Condoms are procured by

Tanzania marketing and communications (T-MARC) and MSD and distributed to 86 outlets. Prevention for

positives counseling through health facilities for HIV-positive individuals concerning the risk of HIV

transmission has already been initiated under FY 2007 funds.

ACTIVITIES: 1) Adapt and distribute new IEC and life skills materials obtained from the UN and other

African military program by a dedicated TPDF taskforce.

2) Execute prevention programs targeting high-risk behavior: 2a)Re-training of 24 TOTs and training of

480 peer educators,(at least two per military, navy, and air force camp): 2b) Support peer educators in

continued prevention/outreach efforts through commodities, printed material, and coordinated planning

sessions to allow an exchange of lesson learned by peer educators; 2c) Train women's groups living within

the barracks near the TPDF hospitals and camps to advocate HIV testing and less risk full behavior; 2d)

Ensure all military hospitals, detachment, training border camps, and the training camps of the National

Services are reached with these services.

3) Strengthen prevention for positives component: 3a) Train 102 clinicians and HIV counselors of 8 military

hospitals (3 per site), nine health centers, 16 training camps and 14 training sites of the National Service (2

per site); 3b) Establish separate post-test group sessions of HIV-negative and HIV-positive persons for

targeted prevention messaging.

4) Distribute condoms and include prevention education as part of counseling and testing services at

post/camp treatment clinics, basic training centers, special detachment, and border camps. Condoms will

be obtained through District Medical Officers in the respective districts. In incidental cases, when the public

system does not deliver and when stock-outs may occur, condoms will be procured and distributed through

T- MARC.

LINKAGES: PAI and the TPDF will link activities in this program area with clinical service and VCT

activities undertaken by the military. It will also link with organizations of women living in the barracks who

will be trained in social support and home-based care for HIV-positive persons in and outside the barracks.

Links will also be made with existing local NGOs operating in communities surrounding barracks to

coordinate and collaborate on broader prevention programs. Condoms will be obtained through MSD and

District Medical Officers in the respective districts. Prevention outreach will be linked to counseling and

testing, PMTCT, and care and treatment activities in support of the continuum of care. Expansion of

prevention services in FY 2008 will ensure a close linkage of the HIV/AIDS programs of the TPDF to

national strategies and programs implemented under the MOHSW.

CHECK BOXES: Funding will support establishing post-test group, training of counselors, and peer

educators. Funds will also support executing education activities and the distribution of condoms. It is

expected that these HIV prevention activities will reach: a target of approximately 4,000 recruits at basic

TPDF training centers; 3,000-4,000 men and women under the National Services; 25,000 other servicemen

and -women; their dependents; and tens of thousands civilians from the communities around the military

hospitals, health centers, and military camps by September 2009.

M&E: Quantification of the effect of prevention activities is not yet standardized. Management of the TPDF

camps will collect and report on the data. TPDF management will be trained to guarantee as much

standardization as possible in reporting procedures. PAI will prepare a written M&E plan and will begin

implementation no later than receipt of FY 2008 funds. The plan will outline procedures for data collection,

storage, reporting, and data quality, and will outline plans for data use for decision-making within the

organization and with stakeholders and will work to harmonize with other PEPFAR AB and OP partners as

appropriate.

SUSTAINAIBLITY: In the military setting, staff turnover is low. Once trained, this capacity will stay within

the forces. Based on the outcomes and findings of this pilot, the PAI will encourage the Office of the

Director Medical Services to integrate services in military budgets at the barracks and national level. To

improve administrative capacity, the PAI will work with military authorities to build local technical and

managerial capacity to manage the program as well as incorporate data collection and analysis as part of

regular health service planning and management.

TITLE: PharmAccess Facility-based Palliative Care for the TPDF

PharmAccess is the primary treatment partner for the TPDF, and provides palliative care to most of those

registered in their Care and Treatment Clinics (CTCs). This includes both patients on Anti-Retroviral

Therapy (ARTs) and not yet eligible on ARTs. Patients receive WHO staging, provision of cotrimoxazole in

accordance with national guidelines, diagnosis and management of Opportunistic Infections, including

tuberculosis screening and referral and cryptococcal infection, nutritional assessments/counseling (and

referrals), symptom and pain management (for outpatients, pain management is currently restricted to non-

opioid medicines such as ibuprophen and paracetamol), and psychosocial support. General counseling

addresses disclosure of HIV status, adherence to care and treatment, behavior change counseling for

prevention of HIV transmission, and other individual specific issues, as appropriate. Pediatric formulations

of cotrimoxazole are available for children.

In FY 2008, after an assessment of nutritional supplement options are evaluated, an expanding number

may receive nutritional support. A growing number of people living with HIV/AIDS are involved as peer

counselors and in assisting with linkages to local organizations that can help to promote adherence, provide

psychosocial support, and to handle referrals for community services (e.g. income generating activities and

legal service).

An important linkage is between facility-based palliative care and community home-based care (HBC). This

link is critical as all palliative care cannot be done at the facility. There are two-way referrals from the CTC

to the community HBC program and from the community HBC program to the CTC. The program strives to

have 100% of patients registered in Care and Treatment be referred to a community home-based care

program.

Total palliative care targets are de-duplicated at the national program level for patients who receive facility-

based services from this partner and home-based services from other USG-supported partners.

TITLE: Providing comprehensive TB/HIV diagnoses and treatment to Tanzania People's Defense Forces

(TPDF)

NEED and COMPARATIVE ADVANTAGE: The Tanzanian Peoples Defense Forces (TPDF) has a network

of military hospitals, health centers and dispensaries through out the country, supporting a total of over

30,000 enlisted personnel and an estimated 60-90,000 dependant. TPDF hospitals do not only service

military personnel and their dependents, but also civilians living in the vicinity of the health facilities. In fact

80% of the patients are civilian. The eight hospitals offer district level services. The largest hospital, Lugalo,

located in Dar es Salaam serves the role of a national referral center for military medical services. With an

average HIV prevalence of six to seven percent, Tanzania is amongst the hardest hit countries in Africa.

The rates are thought to be higher in the military setting. PAI is poised to continue to address the needs to

improve coverage and access, and to strengthen and expand care and treatment activities in the military

hospitals and health centers/satellite sites across Tanzania for military personnel and civilians, and ensure a

close service linkage of military HIV program being implemented in-line with the national Health Sector HIV

strategy.

A concept HIV/AIDS Policy to make HIV testing an integrated part of the yearly medical check-up for all

TPDF personnel has been written by a dedicated TPDF Task Force. Authorization of the Policy by HQ is

expected in the last quarter of 2007. The consequence of the new Policy will be that large numbers of army

personnel will be tested and that an extensive increase of HIV+ and TB+ persons who need care and

treatment can be expected. PharmAccess will work with TPDF to provide comprehensive quality care and

treatment services in eight military hospitals and 25 health centers / satellite sites.

Approximately 40-50% of TB patients are HIV-infected and, conversely, it is estimated that roughly one-third

of HIV-infected patients develop clinically-overt TB. Expanded case identification and treatment of TB is

needed in order to reduce morbidity and mortality associated with HIV infection. In addition, aggressive HIV

counseling and testing of TB patients represents an important public health strategy which will be a key to

further identification and treatment of other HIV-infected individuals. Military hospitals are small with limited

medical staff. The same clinicians see TB and HIV/AIDS patients.

ACCOMPLISHMENTS: A training for three clinicians and nurse counselors from the eight military hospitals

in June 2007 was the start of harmonization of the HIV/AIDS-TB under the DOD/PAI/TPDF Program. A

dedicated TB-laboratory and a container with rooms for TB counseling have been refurbished in June and

July. Referrals to and from the TB-Unit and the CTC started then.

Data-handling to keep track of referrals from the TB-Unit to the CTC and vice versa need to be put in place

now at all military hospitals.A total of 226 patients were tested for HIV in the period January - June 2007.

115 were HIV+, 82 were referred to the TB-Unit; 26 have been reported TB+.

ACTIVITIES: It is expected that a total of 550 of the 5,000 HIV-infected patients from the CTC's of the eight

military hospitals and their satellite sites will require treatment for clinically-overt TB illness in FY 2008. It is

also expected that a total of 700 of the 6,300 HIV-infected patients from CTC's of the 8 military hospitals

and their satellite sites will require treatment for clinically-overt TB illness in FY 2009. Approx 2000 will then

receive prophylaxis for opportunistic infections (OI). It is also anticipated that 95% of the TB positive

individuals attending the wards or Out Patient Department (OPD) of the TPDF health facilities will undergo

counseling and testing for HIV in that period.

1) Strengthening HIV/TB services among TPDF facilities, expanding services to an additional 10 health

centers: 1a) Renovate and furnish patient counseling rooms at 10 new satellite sites/health centers; 1b)

train staff from eight hospitals and 25 satellite sites/health centers in TB diagnostic methods to increase

detection and referral of TB cases among their HIV positive patients; 1c) train additional health care

providers of the TB-Units at Lugalo and Mbalizi in provider-initiated HIV testing and counseling of all

confirmed TB positive patients; 1d) procure microscopes for TB diagnosis at each site and procure lab-

materials when not available through the central mechanism; 1e) provide cotrimoxazole prophylaxis to HIV+

persons testing positive for TB, in accordance with existing NTLP guidelines.

2) Improve TB infection control practices in the CTC and in patient wards to prevent transmission of TB

among HIV+ persons as well as health providers: 2a) CTC staff will be trained on TB infection control

practices; 2b) assess and modify CTC to ensure ventilation; 2c) provide protective safety gear to clinic and

laboratory staff, and support in proper use.

3) Strengthen the continuum of care for TB/HIV services: 3a) Establish a referral system for HIV+ persons

from the 25 health centers to the eight military hospitals and/or to nearby Regional and District hospitals for

CD4 testing and for care and treatment of complicated cases; 3b) conduct community education on TB/HIV

co-infection and co-management during "Open Houses" at each of the eight hospitals; 3c) train women

(many who are spouses of soldiers) from organizations serving the barracks in directly observed therapy

(DOT) for follow up and provision of home-based services for both TB and ART treatment.

LINKAGES: Administration of the hospitals and health centers of the TPDF is not under the MOHSW but

under the Ministry of Defense. TB/HIV services under this program will ensure a close linkage with national

HIV/AIDS and TB strategies and programs of the TB Unit of the NACP and the National TB and Leprosy

Programme (NTLP). Coverage will increase through the eight military hospitals and 25 health centers. All

HIV-infected men and women will be referred for further evaluation and qualification for TB treatment and

ART within the facility. Linkage will be strengthened with prevention activities under the TPDF Program,

including promotion of and counseling on preventive measures for HIV+ persons, provider-initiated

counseling and testing (PITC), C&T, PMTCT, TB/HIV and OVC.

Linkages will be established as well as referral for HIV+ persons from the satellite sites to TPDF hospitals or

district hospitals for CD4, TB testing and complicated cases. PharmAccess will ensure linkages with

organizations of women living in the barracks. We anticipate that these women will also operate as care

providers within the barracks. No NGO or other private social support organization or social support

organization is allowed to work/operate within the military barracks. However for clients in the surrounding

communities, we anticipate to form linkages with existing local NGOs operating in those communities so as

to ensure continuum of care.

Activity Narrative: Linkages have been and will be established with the Regional and District Health Management teams for

supportive supervision purposes, and technical assistance.

CHECK BOXES: The areas of emphasis were selected because the activities will include support for

training of medical staff, purchase of TB-specific laboratory diagnostic equipment and reagents,

consumables for HIV confirmatory diagnosis and isoniazid (INH) and cotrimoxazole for treatment and

prophylaxis purposes. It is expected that a total of 2,000 people, representing approximately 50% of the

4,000 HIV-infected patients who will be on care or treatment by September 2009, will be found to be co-

infected with TB and will require TB services.

M&E: Data will be collected both electronically and by paper-based tools. All sites use the paper forms

developed by National TB and Leprosy Program (NTLP) and NACP. TB screening and HIV-screening

registrars need to be adapted to keep track of TB+ patients referred for HIV-screening and HIV+ patients

referred for TB-screening. Registrars need to be checked by a member of the referring clinic to ensure that

referred patients are reached.

On-site data entry will take place. All sites will have been provided with PCs, a database and output

functions as developed for the National C&T program. 66 Data clerks from the eight hospitals and the 25

health centers will be all trained by, or in collaboration with the Ministry of Health's Unit of Control and

Coordination (UCC). PAI and UCC will provide supportive supervision and the hospitals will support the

satellite sites. Data will be provided to NTLP, NACP and OGAC for reporting purposes.

SUSTAINAIBLITY: PAI will encourage the Office of the Director Medical Services to integrate HIV/AIDS TB

harmonization activities in military Health Plans and budgets at the facility and national level. To improve

administrative capacity, PAI will work with military authorities to build local authority's technical and

managerial capacity to manage the program.

The facilities provide staff and health infrastructure. Most of these program costs are for training and for

infrastructure improvement. Investments are done at the start-up phase of the program. It is therefore

expected that the costs per patient will decrease dramatically over time. In the military setting, turnover of

medical staff is low. Once trained, this capacity will stay within the forces.

TITLE: Providing Care and Support for Orphans and Vulnerable Children (OVC) of Military Personnel in

Mbalizi, Mbeya.

NEED and COMPARATIVE ADVANTAGE: Family of military service members are required to leave the

barracks when the service member passes away. Spouses often have no relatives nearby to support them,

since service members are transferred to and from various camps throughout their enlistment. When both

parents pass away, their children often do not have relatives to take care of them. Many community groups

are reluctant to provide services to these children, as they are not seen as coming from the community.

The management of Mbalizi Military Hospital in the Mbeya region has reported that approximately 200 OVC

of military personnel have been identified. Unfortunately, about half of these children are living on the

streets, and the remainder are residing with older stepparents in extremely poor households. This facility

has advocated for the need to address military involvement in supporting OVC from their "ranks" and will

serve as a pilot to determine feasibility of this type of program.

ACCOMPLISHMENTS: Care for OVC is a new activity for PharmAccess International (PAI) and the

Tanzanian People's Defense Force (TPDF). This activity will support a pilot project for OVC military in

Mbalizi.

ACTIVITIES: 1) Provide services to military OVC in Mbalizi, Mbeya: 1a) Using the Department of Social

Welfare (DSW) identification tool, work with the local most vulnerable children committees (MVCCs) and

KIHUMBE (an organization providing support for OVC in nearby wards), to identify OVC of military

personnel in Mbalizi; 1b) Refurbish and furnish a support center for approximately 200 children near the

barracks of Mbalizi military hospital;

1c) Contract and train ten support staff to look after the children in the afternoon thereby providing a respite

for caregivers; 1d) Train 20 foster families in proper care of OVC; 1e) Provide all OVC with psychosocial

support through individual and group counseling; 1f) Depending on outcomes of the needs assessment

conducted as part of the identification process, prioritize services needed by individual OVC for educational

support (fees, uniforms, and supplies), shelter, and nutritional assessment and assistance; 1g) Train staff

and caregivers in the identification of HIV related illness for proper referral of children who may be HIV

infected.

2) Conduct assessment of military associated OVC care at seven other barracks: 2a) Using the DSW

identification tool, work with the local MVCC and non-government organizations (NGOs) to identify OVC of

military personnel at seven other military facilities; 2b) With the MVCC and the local DSW representative,

map other OVC services in the communities to ensure comprehensive services of military OVC.

3) Determine feasibility of reintegrating OVC within their original communities and extended family

members: 3a) In collaboration with local social workers and the DSW, assess human resource (HR)

requirements of the TPDF to execute linkages through local DSW offices ; 3b) Review TPDF statistics on

service personnel and accuracy in assisting to identify home-of-record and kin for linkages; 3c) With the

DSW, evaluate the safety of this approach for OVC (it has been reported that some widowed women leave

their children in the communities of their spouse's last post to increase their chances of remarrying once

they have returned to their childhood communities).

4) Develop a strategy for TPDF involvement in OVC support: 4a) Convene a task force to evaluate data

from site and HR needs assessments; 4b) Initiate discussions on gaps to be addressed within the TPDF

and feasible support for OVC through either direct services or improving linkages with community based

groups and/or reintegration with original community/extended family members.

This project will include delivery of services to OVC and a feasibility study to link OVC back to their original

communities. The program will also assess the need for such support at seven other military hospitals in

Dar es Salaam, Mzinga, Monduli, Mwanza, Mirambo, Songea, and Bububu (Zanzibar).

LINKAGES: The program implementation will contribute to the MVC National Plan of Action (NPA). It will

be organized in close collaboration with Mbalizi Military Hospital (counseling and testing, and medical

services, including pediatric AIDS treatment), schools in Mbalizi town, a woman-run NGO living in the

barracks of Mbalizi military hospital, the local MVCC, local government, and KIHUMBE. Collaboration will

occur on all levels to support the reintegration of the children to their original families and fostering of the

children whose original lineage cannot be traced.

CHECK BOXES: This funding will develop services for OVC in one military hospital, as well as a needs

assessment of TPDF capacity to link OVC to their original communities. Also included are the introduction

of these services in one site, training of staff for a day-care center, and renovation and refurbishing of the

center.

M&E: This activity will use the national Data Management System tool to collect data for the targeted

beneficiaries and caregivers trained and feed to the national OVC data. M&E activities will be coordinated

with the MVCCs and KIHUMBE, which provides OVC support to some of the wards surrounding Mbalizi.

Close collaboration will ensure that duplication of services will not occur in providing assistance and support

to OVC.

SUSTAINAIBLITY: Staff turnover is low within a military setting. Once trained, individuals providing support

in this capacity will stay within the forces. Based on the outcomes and findings of this pilot, the PAI will

encourage the Office of the Director of Medical Services to integrate services in military budgets at the

barracks and national level. To improve administrative capacity, the PAI will work with military authorities to

build local technical and managerial capacity to manage the program as well as incorporate data collection

and analysis as part of regular health service planning and management. While the initial start-up costs are

relatively high per child, this initial expenditure will pay off in the long term once sustainable services are

developed.

TITLE: Expanding CT and Provider Initiated Counseling and Testing Services within the TPDF

NEED and COMPARATIVE ADVANTAGE: Though unconfirmed, the prevalence is thought to be higher in

the military than that of the general population (7%, Tanzania HIV/AIDS Indicator Survey 2003-2004) due to

their mobility, long periods of separation from their families, and special standing in the community placing

them at greater risk. Continued aggressive measures are needed to reach this mostly young and sexually

active portion of the population that can serve as a bridge for HIV transmission to the population at-large.

This activity will support ongoing efforts in providing CT and identification of HIV+ individuals among the

military for both target prevention and linkages to services. Started under FY 2005 funding by the Tanzanian

Peoples Defense Forces (TPDF) with assistance from PharmAccess International (PAI), this activity will

focus on increasing provision of CT services to military personnel and to communities surrounding military

posts and health facilities.

ACCOMPLISHMENTS: The TPDF expanded CT services to eight military hospitals with 2,568 people

tested in the last six month reporting period. A total of 2,327 persons were tested at the largest facility,

Lugalo Hospital in Dar es Salaam, in the last 12 months of which 548 were found to be HIV+. A recent

"Open House" in Mbeya held by the TPDF tested over 1,000 military and civilians in a two day period

showing a 20% prevalence among those tested.

ACTIVITIES: A draft HIV/AIDS Policy which will make HIV testing an integrated part of the annual military

medical check-ups has been written by a TPDF Task Force. Authorization of the Policy by TPDF HQ is

expected in the last quarter of 2007. An outcome of the new Policy will be that all sites where annual

medical check-ups are performed need to be prepared to provide CT.

Supportive supervision will be conducted by teams of experts of Lugalo, the National Military Referral

Hospital in Dar es Salaam, and PAI. These visits will be used to assess the capacity of the sites, develop

strengthening plans, plan and oversee refurbishments, trainings, M&E, and establish relationships with

District and Regional Health Management Teams for strengthening referrals with public facilities.

1) Expand CT services with TPDF static sites: 1a) Deliver CT at all eight TPDF hospitals and 30 health

centers; 1b) Refurbishing of 3-4 counseling rooms for the 15 new sites; 1c) Strengthen provider initiated

testing and counseling (PITC) as part of routine hospital services in out patient clinics (including TB) and in

patient wards; 1d) Provide CT to all new recruits and individuals deploying on peace keeping missions; 1e)

Retrain/train of a total of 164 clinicians, nurse-counselors, lab technicians and pharmacists or pharmacy

assistants: four from each hospital (32), and three from each satellite site (96); 1f) Procure test kits and

safety gear (gloves, materials for safe disposal of sharps and other wastes) when not available through the

central mechanism; 1g) Provision of condoms organized through linkages with TPDF and District Hospitals.

2) Provide mobile CT services to border camps and surrounding communities: 2a) Procure two mobile

centers; 2b) Train 15 staff in CT and diagnosis of expected TB cases (and provision of treatment where

appropriate); 2c) Conduct bi-monthly visits to 12 border camps.

3) Develop community linkages to improve service up take and strengthen prevention component of CT: 3a)

Conducting training for nurse-counselors from each CT site for home visits to discuss and offer CT to

relatives of HIV+ index patients; 3b) Organize post-test clubs (separate ones for negatives and positives);

3c) Provide prevention messages targeted to the clients HIV status upon testing, encouraging negatives to

remain negative and prevention with positives counseling as an initiation into care and treatment;

3d) Organize HIV/AIDS sensitization campaigns, advocating CT, through home-visits and "community

events" in the barracks; 3e) Train women's groups working within the barracks in execution of these

campaigns.

LINKAGES: Expansion of CT activities in FY 2007 will be accompanied by strengthening of referral

systems, particularly where none exists (annual medical exams). ART, PITC, HIV/TB services under this

partner will be executed with the focus of creating close linkages among the activities. HIV-infected men

and women will be referred for further evaluation for TB and malaria screening and treatment and ART

within the facility or the nearest TPDF or public regional/district hospital. Linkages will be strengthened with

Prevention activities under the TPDF HIV/AIDS Program including prevention for positives counseling. PAI

will ensure linkages with organizations of women living in the barracks for follow up and reinforcement of

prevention messages. For clients in the surrounding communities, linkages with existing local NGOs

operating in those communities will be formed as to ensure continuum of care. PAI will continue to

collaborate with Regional and District Health Management teams and with other USG partners in CT, for

supportive supervision purposes, and technical assistance.

CHECK BOXES: With the new TPDF HIV/AIDS Policy making HIV testing an integrated part of the annual

medical check-ups to be authorized soon, special efforts will be put on establishing and preparing health

centers and dispensaries for HIV-testing within the military. It is anticipated that this will increase the

number of military who are HIV+ requiring evaluation for treatment. This will require focusing more effort on

strengthening referral systems between CT and ART.

M&E: Data will be collected both electronically and using paper-based tools and registries. All sites use the

paper forms developed by MOHSW. On site electronic data entry will take place with all sites equipped with

laptops containing a data base and output functions as developed by UCC for the National C&T program.

By supporting the National CT MS, PAI builds local capacity and helps to strengthen the national M&E

system. Supportive supervision of these sites includes data collection, management and storage of data

(registers and forms) reporting of data to district-level. National CT guidelines and training materials will be

used to strengthen M&E capacity in these facilities. Data will be provided to NACP and USG for reporting

purposes.

SUSTAINABILITY:

In the military setting, turnover of medical staff is low. Once trained, this capacity will stay within the Forces.

Health facilities of the Military Forces are under the administration of the Ministry of Defense, not under the

Ministry of Health. PAI will encourage the Office of the Director Medical Services to integrate care and

treatment activities in military Health Plans and budgets at the facility and national level. To improve

administrative capacity, the PAI will work with military authorities to build local authority's technical and

Activity Narrative: managerial capacity to manage the program as well as incorporate data collection and analysis as part of

regular health service planning and management.

TITLE: Providing comprehensive care and treatment services to the TPDF

NEED and COMPARATIVE ADVANTAGE:

The Tanzanian Peoples Defense Forces (TPDF) has a network of military hospitals, health centers and

dispensaries through out the country, supporting a total of over 30,000 enlisted personnel and estimated 60-

90,000 dependants. Eighty percent of patients at these hospitals are civilians living in the vicinity of the

health facilities. The eight TPDF hospitals offer district level services with the largest hospital, Lugalo,

located in Dar es Salaam, serving the role of a national referral center for military medical services.

PharmAccess International (PAI) has been working with the TPDF on health issues since 2003 and is

poised to continue to address the needs to improve coverage and access to treatment in the military

facilities across Tanzania.

ACCOMPLISHMENTS:

TPDF initiated ART services in 2003 at Lugalo Hospital, Dar es Salaam. As part of FY 2004 and FY 2005

PEPFAR funding, Lugalo Hospital expanded care and treatment services to 2,800 HIV+, and ART services

to more than 1,800 soldiers, dependents and civilians. Since 2006, ART services have been expanded to all

eight military hospitals and three satellite sites. In 2007, this will be expanded to an additional nine health

centers along with VCT and PMTCT services. As of April 2007, 2,536 have been initiated on ART.

ACTIVITIES:

A draft HIV/AIDS Policy which will make HIV testing an integrated part of the annual military medical check-

ups has been written by a TPDF Task Force. Authorization of the Policy by TPDF HQ is expected in the last

quarter of 2007. It is anticipated that this will lead to the identification of a large numbers of army personnel

requiring care and treatment in addition to those regularly identified through VCT and as part of medical

services. This will require preparing facilities for a possible large increase in patient load as well as prepare

more health centers to assist in delivery of these services.

1) Increase the total number of health facilities under the TPDF to a total of eight hospitals and 28 health

centers.

1a) Renovate patient counseling and treatment rooms at 13 new satellite sites/health centers.

1b) Conduct initial and refresher ART training of 48 medical personnel from the eight military hospitals, 84

from the 28 satellite health centers.

1c) Train 108 (three health staff of each of the 36 facilities) on HIV/AIDS pediatrics (222 in total since

initiation of program).

1d) Train 200 barracks volunteers in basic home-base care to assist in patient follow up and at home-

management.

1e) Conduct community education and mobilization through "Open House" days at each facility to increase

access to services and partner testing.

1f) Strengthen the referral system between the health centers and hospitals as well as public District and

Regional hospitals for additional ANC services and adult and infant diagnosis, ART and TB/HIV at CTC.

2) Provide ART to a total of 7,200 individuals through TPDF facilities.

2a) Include prevention for positives counseling as a critical aspect of all HIV services.

2b) Evaluate patients for malnutrition and offer nutritional counseling and support.

2c) Procure medications for OI when not available through central mechanism.

2d) Reinforce provider initiated counseling and testing (PICT) as a regular part of all out patient services.

2f) Continue to improve patient record/data collection, working with TPDF HQ and facility staff to collect,

record and analyze data to inform improvement of services.

2g) Monitor quality of services at the hospitals through linkages with regional supportive supervisory teams

and Lugalo Hospital as well as through quarterly TPDF ART meetings (attended by all chief ART staff).

2h) Monitor services at the 28 health centers based at military camps, including border camps, through four

mobile centers consisting of a team of a clinician, nurse counselor, and a lab technician.

3) Ensure proper lab capacity is developed at all eight hospitals for patient monitoring and OI diagnostics.

3a) Provide CD4 equipment to the five remaining hospitals.

3b) Provide standard operating procedures and training in QA/QC; 3c) Train technicians in proper

equipment maintenance.

3d) Procure lab reagents and consumables when not available through central mechanisms.

LINKAGES:

All HIV-infected patients will be referred for further evaluation and qualification for TB treatment within each

facility. Linkages will be strengthened with Prevention activities under the TPDF Program, including

promotion and counseling of preventive measures for HIV+, PITC, C&T, PMTCT, TB/HIV and OVC. Formal

referrals will be established from the health centers to TPDF hospitals or public regional and district

hospitals for CD4, TB testing and complications. PAI will ensure linkages with organizations of women living

in the barracks for home-based support and adherence counseling. For clients in the surrounding

communities, linkages will developed with existing local NGOs operating in those communities to ensure a

continuum of care. PAI will continue to collaborate with Regional and District Health Management teams

and with USG treatment partners for supportive supervision purposes, and technical assistance.

CHECK BOXES:

The areas of emphasis will include initial and refresher training, infrastructure improvement, providing

equipment and drugs, HBC services and community support to accomplish the much-needed continuum of

care in the TPDF program.

M&E

PAI will continue to support the district and regional teams with supportive supervision visits to monitor the

collection of data, and the continued on-site training of facility staff.

Data will be collected both electronically and by paper-based tools. PAI will work with the MOHSW in rolling

out the revised the patient-based registers (paper based and electronic) to all TPDF ART facilities across

Tanzania. All sites will have laptops with a database and output functions as developed by University

Computing Center (UCC )for the NACP. To that end, PAI, in collaboration with UCC, will train 66 health care

workers, develop SOPs and provide supportive supervision to 33 facilities. Data will be used for patient and

program monitoring purposes. PAI will continue to promote the synthesis and use of data by facility staff,

Activity Narrative: and strengthen its use for decision-making for facilities and the district and regional management teams.

SUSTAINAIBLITY:

In the military setting, turnover of medical staff is low. Once trained, this capacity will stay within the Forces.

Health facilities of the Military Forces are under the administration of the Ministry of Defense, not under the

Ministry of Health. PAI will encourage the Office of the Director Medical Services to integrate care and

treatment activities in military Health Plans and budgets at the facility and national level. To improve

administrative capacity, the PAI will work with military authorities to build local authority's technical and

managerial capacity to manage the program as well as incorporate data collection and analysis as part of

regular health service planning and management.