TITLE: PMTCT Services in Rukwa Region

NEED and COMPARATIVE ADVANTAGE: Rukwa has a recorded general HIV prevalence of around 6%

with prevalence at antenatal clinics recorded at 7%. To effectively scale-up services in Rukwa, ANC will

require significant infrastructure improvements, staff capacity building, strengthened supply chains and

enhanced management systems at the district hospitals and health centers. Located in the far west of the

country along the border with the DRC, regular interaction with zonal support through the Mbeya Referral

Hospital (MRH) and the National AIDS Control Program (NACP) in Dar is difficult. The poor conditions of

their roads isolates them even further, particularly during the rainy season in which they are impassible, and

makes oversight of services through out the region challenging.

ACCOMPLISHMENTS: Funding from FY 2006 was used to train six counselors at the ANC at each of three

facilities under USG support. Integration of PMTCT services as part of regular antenatal care at these sites

improved uptake of services with 3,000 pregnant women accepting counseling and testing and

approximately 150 of those women identified as HIV+ receiving ARV prophylaxis in a twelve month period.

ACTIVITIES: With PMTCT regionalization by the USG, PEPFAR funds will be awarded to DOD partners to

directly support PMTCT sites (both current as well as planned) originally served by funding through the

MOHSW. As a result, the existing referral system will be further developed so that HIV+ women identified

will be linked to nearby treatment centers.

1) Expand PMTCT sites to a total of 16 by September 30, 2009 covering 100% of NACP identified hospitals

and health centers in the region and several dispensaries. The number of service outlets supported in 2007

was three, but with 2007 plus-up funding the number of service outlets supported increased to 13 as DOD

transitioned into sites formerly supported by MOHSW.

1a) Train health care workers at each new site using a "full site" approach similar to Engender Health

whenever possible, ensuring at least four ANC staff per site are trained.

Adopt an opt-out counseling and testing policy in both ANC setting and labor ward and delivery.

1b) Renovate ANCs where needed to improve confidentiality.

1c) Procure commodities, such as rapid test kits, when not available through central procurement

mechanisms.

2) Strengthen PMTCT interventions and integration of PMTCT to ART services.

2a) Where ART is available; either at the same facility or a nearby service center, efforts will be made to

establish formal referrals from PMTCT services/sites with care and treatment clinic (CTCs) to support the

delivery of comprehensive HIV services.

2b) Evaluate HIV+ women for eligibility for full HAART and provide ARV regimens based on the new revised

guidelines following the WHO-tiered approach for ARV prophylaxis to ensure HIV positive women and HIV-

exposed children receive the most efficacious treatment (AZT and NVP or NVP only).

2c) Provided "prevention for positives" counseling package based on the USG developed approach in

Tanzania

2d) Encouraged HIV+ women to bring in family members for counseling and testing at either the ANC or the

hospital's VCT center

2e) 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.

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

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

2h) Send DBS to MRH which will be receiving equipment from the Clinton Foundation and technical

assistance from USG lab partners to conduct infant diagnosis for the entire Southern Highlands.

2i) Ensure all HIV exposed and infected children are initiated on cotrimoxazole prophylaxis as appropriate.

3. Build capacity of regional and district health teams to plan, execute and monitor PMTCT activities.

3a) Acquire technical support to regional and district authorities with the assistance of other USG partners

(such as Engender Health) to work with the Rukwa RMO in conducting site assessments and supportive

supervision

3b) Use data collected to work with District Health Management Teams to assess site specific services and

develop plan of action to address problems.

3b) Support DHMT to include PMTCT activities in council health plans.

LINKAGES: This activity is linked to activities under this partner in ART, TB/HIV, and palliative care. It is

also linked to other USG partner entries in the program area which can provide additional technical

assistance such as Engender Health or EGPAF.

Linkages for services will include pre and post-test counseling (group or individual). Those testing negative

are given education on protective measures and practices for avoiding infection while HIV+ are evaluated

for ART as described above. Both populations are linked to reproductive health RH services. In addition,

the Rukwa RMO will continue to promote outreach services from the facilities to the communities for HIV+.

Each facility will have lists of NGO's, CBOs and HBC providers involved in HIV/AIDS support, indicating

geographical coverage and types of services offered. These lists will be displayed in the CTCs and other

clinics/wards so health staff can refer clients to those organizations as necessary. These referrals, as well

as referrals from community organizations to the facility, will be further strengthened through facility staff

serving as POC for the community organizations.

CHECK BOXES: This funding will fully develop PMTCT services covering all the districts including health

centers and down to dispensaries as possible. Funding will support the introduction and/or improvement of

PMTCT services in the region. Emphasis will be put into training of health care workers in district hospital

and health centers and dispensaries; renovation counseling and delivery rooms and commodities for

services when not available through central procurement mechanisms.

M&E: Quality Assurance/Quality Control (QA/QC) of services will be provided by Rukwa RMO staff

conducting quarterly site assessments (more frequently for new sites). Technical assistance will also be

sought by other USG PEPFAR partners such as Engender Health which is executing a successful "full site"

approach to PMTCT and is initiating PMTCT support in the nearby region of Iringa in FY 2008.

Activity Narrative: Data will be collected using both paper-based tools developed by MOHSW and adaptation of the electronic

medical record system (EMRS) (see DOD SI entry) to incorporate PMTCT data. On site electronic data

entry will take place. All sites will have laptops with a data base and output functions as developed by UCC

for the National C&T program. Data clerks will be retrained, and the data collected will be reported NACP

and the USG.

SUSTAINABILITY: Rukwa RMO in ensuring sustainability through capacity building of health care facilities

and its staff, sensitization of community members and advocacy through influential leaders. This is also

accomplished by strengthening "systems", such as the improved capacity of Regional AIDS Control

Program the DHMT, and through regional supportive supervisory teams as part of already existing zonal

support and routine MRMO functions. Most of this funding will be spent at the district level and health facility

level thereby building capacity and sustainability at the level where the services are provided.

TITLE: Expanding and Integrating TB/HIV activities in Rukwa Region

NEED and COMPARATIVE ADVANTAGE:

According to the National Tuberculosis and Leprosy Program (NTLP), TB /HIV dual infection contributes to

17.5 % of the total disease burden in Tanzania (Ministry of Health and Social Welfare (MOHSW), Manual of

National Tuberculosis and Leprosy Program in Tanzania, Fifth Edition, 2006). Currently, the Rukwa

Regional Medical Office (RMO) has been providing ART and TB services to patients in three district

hospitals and one health center and plans to provide TB/HIV services to up to additional 7 health centers

where we currently have a functional Care and Treatment Center (CTC). This integrated approach will

further strengthen collaboration between TB care and HIV/AIDS care, reducing the burden of TB among

PLWHA and reducing the burden of HIV among TB patients, resulting in more effective control of TB among

HIV-infected people.

Rukwa RMO supports the implementation of prevention and care and treatment programs throughout its

region, overseeing funding and supervision to the regional hospital and district level facilities. As a DOD

partner and a region under the support of the Mbeya Referral Hospital, roll out of TB/HIV in this region

mirrors that in Mbeya and Rukwa.

ACCOMPLISHMENTS:

Currently, over 1,300 patients from the three district hospitals and one of the health centers in the region are

on ART. The Rukwa RMO will continue to strengthen the monitoring of HIV patients who are on TB care.

Monitoring TB patients through the use of clinical forms with TB screening questions has been key to

ensuring the screening and referral of all HIV and TB patients. Patients referred both ways have been well

documented in the care and treatment clinics. Integration of HIV care and treatment and the TB diagnosis,

as well as treatment and follow up will be strengthened further in FY 2008.

ACTIVITIES:

Using a "cluster" approach, the region has been divided based on the three primary districts (Sumbawanga

Urban included as part of Sumbawanga Rural), using the hospitals supporting high density areas in these

districts as the primary points of support and moving out from those facilities to health centers. The Rukwa

RMO will expand TB/HIV services and support to a total of three hospitals and eight primary health care

facilities in the region covering all districts.

1) All HIV infected patients receiving HIV care and treatment will be screened for TB disease routinely and

those suspected will access TB diagnostic services. Those found positive for TB disease will be

immediately referral to the TB clinic to initiate an uninterrupted treatment using direct observation therapy

(DOT).

1a) Support the making of clinical forms with TB screening tool.

1b) Clinicians at each site will be trained on TB/HIV collaborative activities including use of modified clinical

forms to routinely identify underlying TB signs and symptoms for all clients attending at CTC.

1c) Develop a referral system for access of HIV-infected TB suspects to laboratory diagnosis and treatment

for TB.

2) TB infection control practices will be implemented in the care and treatment clinics to prevent

transmission of TB among PLWHA as well as health providers.

2a) CTC staff at each site will be trained on TB infection control practices. Ensure ventilation in Care and

Treatment clinics.

3) Strengthen existing laboratory services needed to implement TB/HIV program activities.

3a) Supplement supply of X-ray films.

4) Support outreach ART services to remote TB clinic in the regions.

LINKAGES: This activity is linked to activities under this partner in PMTCT, treatment, and palliative care as

well as those of the other regions in this zone (Mbeya and Ruvuma). It is also linked to the DOD

submission under SI and other USG treatment partner submissions providing expertise in areas of pediatric

care and TB infection control.

The Rukwa RMO will continue to promote outreach services from the facilities to the communities. Each

facility has/will have lists of NGO's, CBOs and HBC providers involved in HIV/AIDS support, indicating

geographical coverage and types of services offered. These lists are displayed in the CTCs and other

clinics/wards so health staff can refer clients to those organizations as necessary. These referrals, as well

as referrals from community organizations to the facility, will be further strengthened through facility staff

serving as points of contact (POC) for the community organizations.

CHECK BOXES:

The areas of emphasis will include: initial and refresher training of staff in TB/HIV co-management, infection

control, provision of supplies and medications, and capacity building. Community Health Management

Teams (CHMTs) will be supported in planning and incorporating TB/HIV activities in Council

Comprehensive Health Plans (CCHPs)..

M&E:

M&E data activities for all the CTCs under the Rukwa RMO are supported by technical assistance (TA)

from the DOD SI team based at the Mbeya Referral Hospital. All efforts will be made to capture all the HIV

care and treatment related data from both the CTCs and TB clinics using NTLP data collection, recording,

and reporting tools. Data at each CTC is collected using standardized forms based on the National AIDS

Control Program (NACP) and facility data needs. It is entered into the electronic medical record system

(EMRS) and transported to the DOD data center located at Mbeya Referral Hospital for synthesis,

generation of NACP and USG reports as well as to provide feedback to CTC teams for use in patient

management.

SUSTAINABILITY:

Using a "cluster" approach, the region has been divided based on the three primary districts (Sumbawanga

Urban included as part of Sumbawanga Rural), using the hospitals supporting high density areas in these

districts as the primary points of support and moving out from those facilities to health centers.

Activity Narrative:

In order to sustain our efforts in integrating and expanding the TB/HIV services, MRMO will continue

working very closely with the National TB/Leprosy Control Program. The MRMO will ensure sustainability

through capacity building of health care facilities and its staff, sensitization of community members, and

advocacy through influential leaders. This is also accomplished by strengthening "systems," such as the

improved capacity of District Health Management Teams (DHMT), the regional supportive supervisory team

and the zonal weekly ART meetings as part of already existing zonal support and routine MRMO functions.

TITLE: Expansion of ART Services in Rukwa Region

NEED and COMPARATIVE ADVANTAGE:

The Rukwa Regional Medical Office (Rukwa RMO) supports the implementation of prevention, care, and

treatment programs through out its region, providing funding and supervision to the regional hospital and

district level facilities. As in other regions, Rukwa will be scaling up treatment in the districts through the

health centers. As a DOD partner and a region under the support of the Mbeya Referral Hospital, roll out of

ART in this region mirrors that in Mbeya and Ruvuma.

ACCOMPLISHMENTS:

Currently, over 1,300 patients from the three district hospitals and one of the health centers in the region are

on ART. Over 75 staff members have been trained in ART provision. Two district laboratories at the Nkasi

and Mpanda District Hospitals have been renovated, equipped, trained, and are up and running performing

their own hematology and chemistry assays. Provider initiated testing and counseling (PITC) of HIV/AIDS

has been implemented in all the hospitals in the region and supportive supervisory teams have now been

extended to facilities below the district level to expand ART services at all health centers in the region.

ACTIVITIES:

To effectively scale-up services in Rukwa, care and treatment centers require significant infrastructure

improvements, staff capacity building, strengthened supply chains and enhanced management systems at

the district hospitals and health centers. Located in the far west of the country along the border with the

DRC, regular interaction with zonal support through the Mbeya Referral Hospital and the NACP in Dar is

difficult. The poor conditions of the roads isolate them even further, particularly during the rainy season

when they are impassible. This makes oversight of services through out the region challenging. The DOD

is exploring mechanisms for stationing personnel in Rukwa to work more closely with the RMO, the District

Medical Officers (DMOs), and Regional and District Health Management Teams (RHMT and DHMT) to

provide direct technical support and material inputs necessary to improve site capacity.

Using a "cluster" approach, the region has been divided based on the three primary districts (Sumbawanga

Urban included as part of Sumbawanga Rural), using the hospitals supporting high density areas in these

districts as the primary points of support and moving out from those facilities to health centers. This allows a

systematic expansion of services to new sites, increasing overall ART enrollment in Rukwa while

maintaining quality of services through strengthening of tiered supportive supervision from the zonal

hospital to the RMO to the DMO to the health centers. Technical assistance and input from other USG

treatment partners will continue to play a factor in scaling up treatment services in this region such as CU's

expertise in applying the district network model approach.

Under FY 2008 funding, the Rukwa RMO and DOD will provide significant inputs to roll out HIV care and

treatment to eight additional health centers bringing the total number of facilities to 11 by September 2009,

with 100% of NACP identified facilities in this region supporting ART and ensuring services are available in

all four districts in the region.

1. Expand services and support to a total of three hospitals and eight primary health care facilities in the

region covering all four districts. This will be at a rate of two to four health centers per district.

1a. Based on NACP health center assessments and strengthening reports, work with DHMT in initiating

ART services in the eight new health centers.

1b. Work with the DHMT and facility directors in developing facility-based work plans and implementation of

these plans.

1c. Renovate space at most of the facilities to support CTC.

1d. Train an additional 38 health providers/clinical staff in ART and TB/HIV co-management.

1f. Assist in the acquisition of reagents, medications and clinical supplies through local distributors when not

available through central mechanisms.

1g. Work with facility pharmacists in improving capacity in forecasting, stock management and ordering.

2. Continue to improve the quality of care and treatment service.

2a. Strengthen and reinforce implementation of SOP for clinical services, laboratory monitoring and

maintenance of patient records.

2b. Expand mentoring and supportive supervision down beyond the district level facilities through regional

medical teams.

2c. Participate in weekly zonal ART meetings with the Mbeya referral hospital to discuss treatment roll out,

identify areas of need, determine solutions and coordinate resolution.

2d. Improve patient record/data collection, working with DoD, DHMT and facility staff to analyze data to

inform improvement of services.

3. Reinforce and expand PITC to all facilities.

3a. Train 75 staff in inpatient wards and outpatient clinics in HIV CT, actively promoting provider initiated

counseling and testing for all patient contact points.

3b. Continue to sensitize hospital staff and clients in CT as a regular part of all out patient services,

including the TB clinic.

3c. Reinforce sensitization through rotation of staff from the HIV CTCs to assist regular hospital staff in

patient identification and provision of this service.

4. Increase the number of women and children on ART.

4a. Promote and support routine counseling and testing of mothers and their children at all contact points in

the health facilities, including ante-natal clinic (ANC), labor and delivery wards, immunization clinics, and

female and pediatric inpatient wards.

4b. Continue to improve and strengthen referrals between ANC PMTCT services and CTC for evaluation of

HIV+ mothers for treatment.

4c. Train ANC and CTC staff in the collection of dried blood spot (DBS) for infant diagnosis.

4d. Send DBS to MRH which will be receiving equipment from the Clinton Foundation and technical

assistance from USG lab partners to conduct infant diagnosis for the entire Southern Highlands.

4e. Ensure all HIV exposed and infected children are initiated on cotrimoxazole prophylaxis as appropriate.

5. Reinforce comprehensive nature of clinical services.

Activity Narrative: 5a. Strengthen referral systems for services within a facility among wards and clinics.

5b. Use site coordinators to conduct daily checks on registers in outpatient clinics, in-patient wards, MCH

and the TB clinic to keep track of patients referred to the CTC.

5c. Strengthen prevention for positives counseling among all staff providing CT services and care and

treatment at CTC.

5d. Strengthen and formalize referrals to and from CBO, NGO and FBO serving patients in their

communities through facility social workers.

LINKAGES:

This activity is linked to activities under this partner in PMTCT, TB/HIV, and palliative care as well as those

of the other regions in this zone (Mbeya and Ruvuma). It is also linked to the DOD submission under SI

other USG treatment partner submissions providing expertise in areas of pediatric care and TB infection

control.

The Rukwa RMO will continue to promote outreach services from the facilities to the communities. Each

facility has/will have lists of NGOs, CBOs and home-based care (HBC) providers involved in HIV/AIDS

support, indicating geographical coverage and types of services offered. These lists are displayed in the

CTCs and other clinics/wards so health staff can refer clients to those organizations as necessary. These

referrals, as well as referrals from community organizations to the facility, will be further strengthened

through facility staff serving as POC for the community organizations.

CHECK BOXES:

The areas of emphasis will include: initial and refresher training of staff in ART and CT; significant

infrastructure improvement for existing and new sites; provision of equipment, supplies and medications;

strengthening linkages with TB/HIV, PMTCT and community groups.

M&E:

QA/QC for clinical services is conducted through the zonal and regional supportive supervisory teams

discussed above.

M&E data activities for all the CTCs under the Rukwa RMO are supported by TA from the DOD SI team

based at the Mbeya Referral Hospital. Data at each CTC is collected using standardized forms based on

NACP and facility data needs, entered into the electronic medical record system (EMRS) and transported to

the DOD data center located at Mbeya Referral Hospital for synthesis, generation of NACP and USG

reports, as well as to provide feedback to CTC teams for use in patient management. The number of CTCs

supported by Rukwa RMO will be 10 and 11 by September 2008 and September 2009 respectively.

SUSTAINABILITY

Rukwa RMO in ensuring sustainability through capacity building of health care facilities and its staff,

sensitization of community members and advocacy through influential leaders. This is also accomplished by

strengthening "systems", such as the improved capacity of District Health Management Teams (DHMT), the

regional supportive supervisory team, and the zonal weekly ART meetings as part of already existing zonal

support and routine Rukwa RMO functions.