TITLE: PMTCT Services in Ruvuma Region

NEED and COMPARATIVE ADVANTAGE: Similar to the Rukwa Region, Ruvuma has a recorded general

HIV prevalence of a little over 6% with prevalence at antenatal clinics recorded at 9.9%. Expansion of

PMTCT under direct MOHSW funding was slow and not well implemented. To effectively scale-up services

in Ruvuma, ANC will require significant infrastructure improvements, staff capacity building, strengthened

supply chains, and enhanced management systems at the district hospitals and health centers.

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

funded sites executing ART. Integration of PMTCT services as part of regular antenatal care and ART

services improved uptake of pregnant women for counseling and testing at these sites with 2,200 accepting

counseling and testing and approximately 150 women receiving ART 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 24 by September 30, 2009 covering 100% of National AIDS Control

Program (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 4 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 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) Encourage 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 Ruvuma 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 Ruvuma 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 Ruvuma 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 FY2008.

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

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

and the USG.

SUSTAINABILITY: Ruvuma 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 RMO functions. Most of this funding will be spend 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 Ruvuma 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 Ruvuma Regional Medical Office (RMO) supports ART and TB services

in three district hospitals and two health centers and plans to provide TB/HIV services to an additional 10

health centers where we currently have a functional Care and Treatment Centers (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.

Ruvuma 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: Over 1,400 patients are on ART at each of the three district hospitals and two

health centers in the region. The Ruvuma 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 TB

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

ACTIVITIES: The Ruvuma RMO will expand TB/HIV services and support to a total of four hospitals and 12

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 will be immediately

referred to the TB clinic to initiate an uninterrupted treatment using Directly Observed Therapy (DOT) 1a)

Support the making of the 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 supplies and medications, and capacity building. Council Health

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

Comprehensive Council Health Plans (CCHPs).

M&E: M&E data activities for all the CTCs under the Ruvuma 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 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, and providing feedback to CTC teams for use in patient management.

SUSTAINABILITY: As with other DOD partners in the Southern Highlands of Tanzania, the Ruvuam RMO is

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 Ruvuma RMO functions.

TITLE: Expansion of ART Services Ruvuma Region

NEED and COMPARATIVE ADVANTAGE:

As in Rukwa, the Ruvuma Regional Medical Office (Ruvuma RMO) supports the implementation of

prevention, care, and treatment programs throughout its region, overseeing funding and supervision to the

region at hospital and district level facilities. 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 Rukwa.

ACCOMPLISHMENTS:

Over 1,400 patients are on ART at all three district hospitals in the region with 100 staff trained in service

provision. The laboratories at the Mbinga and Tunduru District Hospitals have been renovated, equipped,

and technicians are trained and are running hematology and chemistry assays. Provider initiated testing

and counseling (PITC) is being implemented in all the hospitals in the region and supervisory teams have

now been extended to facilities below the district hospital level to introduce of ART to health centers. ART

services will be expanded to a total of 12 facilities by September 2008, ensuring 50% coverage of facilities

in the region.

ACTIVITIES:

To effectively scale-up services in Ruvuma, health facilities require significant improvement in infrastructure,

development of staff capacity, strengthening of supply chains and enhanced management systems at the

district hospital and health center level. Similar to the Rukwa region, this region is geographically isolated

with poor road access. This, in addition to an almost one year lag in receiving government of Tanzania

(GOT) ARVs to initiate programs, has influenced the slower progression of roll out of ART services in this

region. To improve and increase the rate of implementation and roll out, DOD is exploring mechanisms for

stationing personnel in Ruvuma to work closely with the RMO, District Medical Office (DMO), and Regional

and District Health Management Teams (RHMT and DHMT), faith-based organizations (FBOs) and

community-based organizations (CBO) to provide direct technical support and material inputs necessary to

expand and increase ART enrollment in Ruvuma. Technical assistance from and collaboration with other

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

Columbia University (CU's) expertise in applying a district network model approach and Elizabeth Glaser

Pediatric AIDS Foundation (EGPAF's) experience in the nearby isolated southern regions of Mtwara and

Lindi.

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

treatment to 12 additional health centers, bringing the total number of facilities to 24 by September 2009

with 100% of NACP identified facilities supporting ART in the region.

1. Expand services and support to a total of three hospitals and 21 primary health care facilities in the

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

1a. Work with DHMT expanding services to 12 new health centers for the introduction of ART services,

using NACP health center assessments and strengthening reports as a reference.

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 48 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 provider initiated counseling and testing to all facilities.

3a. Train 100 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 clinics (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.

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,

maternal and child health (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 CBOs, NGOs and FBOs serving patients in their

Activity Narrative: 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 Rukwa). 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 Ruvuma RMO will continue to promote outreach services from the facilities to the communities. Each

facility will have lists of NGOs, 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:

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;

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

M&E:

Quality assurance/quality control (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 Ruvuma 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 Mbeya RMO will be 12 and 24 by Sept ember 2008 and September 2009 respectively.

SUSTAINABILITY:

As with other DOD partners in the Southern Highlands of Tanzania, the Ruvuam RMO ensures

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

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

"systems", such as the improved capacity of DHMT, the regional supportive supervisory team, and the zonal

weekly ART meetings as part of already existing zonal support and routine Ruvuma RMO functions.