TITLE: AED/T-MARC PMTCT Communications Initiatives

NEED and COMPARATIVE ADVANTAGE: According to the 2003/4 Tanzania HIV/AIDS indicator survey,

while almost 69% of women know that HIV can be transmitted from a mother to her child by breastfeeding,

only 17% know that there are special drugs that can reduce the risk of transmitting the virus to the baby. In

addition, while approximately 90% of pregnant women access antenatal care (ANC) services, the uptake of

ARV to prevent HIV transmission is approximately 12%. AED/T-MARC works with, and through community

partners with the most-at-risk populations (mobile business people, market women, sex workers, women

engaged in transactional sex, and people in communities where high risk behaviors occur) in the 10 highest

prevalence regions of Tanzania to communicate and motivate behavior change with regard to HIV

prevention. With reproductive health (RH) and child survival (CS) funding from USAID, AED/T-MARC is

also utilizes funding to implement a nationally-aired, well-established radio program (Mama Ushauri)

targeting women of childbearing age (WCBA). AED/T-MARC will continue to design appropriate messages

advocating increased PMTCT service, demand, and utilization among Tanzania's most-at-risk populations.

AED/T-MARC's community presence, communications expertise, current initiatives, and legitimacy with

most-at-risk populations provide an excellent framework for increasing knowledge and demand for PMTCT

prevention services for individuals who are most vulnerable.

ACCOMPLISHMENTS: AED/T-MARC did not receive funding for PMTCT in FY 2006 or FY 2007.

ACTIVITIES: AED/T-MARC will collaborate with USG PMTCT partners and the government of Tanzania

(GoT) to develop messages, materials, and tools to be integrated with T-MARC's current HIV/AIDS and FP

communication initiatives, targeted at the most-at-risk populations in Tanzania.

AED/T-MARC will develop behavior change communication messages including materials and tools (for

providers, outreach workers, and beneficiaries) on core PMTCT issues (e.g., the benefits of testing for HIV

when pregnant, the benefits of ARV and cotrimoxazole prophylaxis for both the mother and infant, family

planning options and exclusively breastfeeding for 6 months etc). These materials will be developed

specifically for most-at-risk populations.

In order to accomplish this task, AED/T-MARC will conduct a materials development workshop with PMTCT

partners and collaborate with an advertising agency to design initiative materials, complete pretest review,

and print finalized materials. Furthermore, AED/T-MARC will disseminate materials to partners for national

use. These materials will include PMTCT messages integrated into T-MARC's community-based HIV

prevention activities including Sikia Kengele: Tulia na Wako (Listen to the Bell, Stick with Your Partner)

faithfulness campaign. Sikia Kengele is targeted at communities where high-risk sexual activities occur -

particularly along the transportation corridors in the 10 regions with the highest HIV prevalence in Tanzania

(Mbeya, Iringa, Dar es Salaam, Mtwara, Mwanza, Kilimanjaro, Pwani, Shinyanga, and Ruvuma) and in and

around workplaces such as mines, plantations, and markets. It addresses multiple concurrent partnerships

while promoting faithful relationships between partners.

Sikia Kengele involves the implementation of community mobilization events (e.g., road shows and

edutainment theatre) and "bell ringers" implementing interpersonal communications activities (including peer

-education and outreach). Curricula to help faith leaders talk with their congregations about faithfulness and

teach faithfulness skills have been developed for both Christian and Muslim audiences. With PMTCT funds,

AED/T-MARC will coordinate with USG partners working in Kengele regions to ensure linkages with

appropriate services. Additionally, AED/T-MARC will implement Kengele interpersonal, community, and

mass media activities advocating a strong push to increase knowledge of, and demand for PMTCT

services. Some activities will focus on raising awareness of the benefits of getting tested.

PMTCT messages will be incorporated into the Christian and Muslim faithfulness curricula currently being

implemented by Word and peace organization (WAPO) and Tanzania Muslim Council (Baraza la waisilamu

Tanzania-BAKWATA) as part of Sikia Kengele. The curricula will target men, encourage them to be

supportive in asking their pregnant partners to get tested, and advocate strong support for HIV positive

pregnant women who need treatment. AED/T-MARC will conduct PMTCT awareness activities during the

National Uhuru Torch campaign, which includes a mobile festival that visits every district in the country and

reaches more than 1 million Tanzanians each year.

In order to successfully reach as many people as possible in Tanzania, AED/T-MARC will develop and

integrate a PMTCT storyline into the long-running Mama Ushauri (Mama Advice) radio program. Mama

Ushauri airs 6 times per week on three national radio stations. It targets WCBA with reproductive health

and child survival messages. With FY 2008 funds, AED/T-MARC will work with USG partners to develop

objectives and scripts for the integration of a strong PMTCT storyline into the Mama Ushauri program for

recording and utilization for one year. This will include a bi-monthly question and answer program regarding

PMTCT inquiries which will be evaluated with T-MARC's established M&E mechanisms (Steadman Media

research, T-MARC Knowledge Attitude Practice (KAP) study, and regular listener focus group discussions

(FGDs).

In addition, AED/T-MARC will develop and print PMTCT-specific messages to support the radio program

and provide resources for listeners to access additional information. PMTCT-specific informational material

will be distributed at clinics and public places with a high volume of WCBA.

LINKAGES: Since there are no PEPFAR indicators for outreach/communication to drive demand for

PMTCT services it is imperative that AED/T-MARC's activities are closely linked to the implementation

plans of USG and GoT entities responsible for PMTCT. AED/T-MARC's prevention communications

activities are strongly linked to prevention partners, particularly STRADCOM and Ujana. Activities are

implemented with the consultation and assistance of district and regional GOT officials: District Medical

Officers (DMOs), Regional Medical Officers (RMOs) and Community Health Management Teams (CHMTs).

AED/T-MARC's collaboration with the Tanzania Commission for AIDS (TACAIDS) and the National AIDS

Control Program (NACP) information education and communication (IEC) Unit will provide guidance on

program and materials design. Advertising agencies, graphic design firms, experiential media houses, and

other Tanzanian agencies will also have creative input into the design of the initiative. WAPO, BAKWATA

and other TBD NGOs/CBOs/FBOs grantees will play key roles in the implementation of this initiative on the

ground.

Activity Narrative: CHECK BOXES: Because Sikia Kengele addresses male norms, the PMTCT initiatives implemented by

AED/T-MARC will have a strong focus on the role of men in protecting their families. The training of NGOs

and their staff to implement PMTCT initiatives - as they are incorporated into Sikia Kengele - will be part of

the capacity building directed at NGO grantees, BAKWATA, and WAPO who implement the Kengele

curriculum. The program also targets adults 18 and over, mobile populations, women and men involved in

transactional sex, and HIV positive women. Messages regarding reproductive health are incorporated into

the Mama Ushauri radio serial drama program signifying a wrap-around activity.

M&E: Approximately 7% of AED/T-MARC's PMTCT funding will be devoted to M&E. In FY 2008, AED/T-

MARC will implement the second round of the T-MARC KAP study that will examine the reach and recall of

PMTCT messages incorporated into Sikia Kengele and Vaa Kondom (wear a condom), as well as other

initiatives. The KAP also examines reported behaviors and attitudes of the target populations and questions

about PMTCT can be incorporated. Through hired experiential media agencies and NGOs monthly-reach

data (on a tool developed for that purpose) will be submitted into the T-MARC Project monitoring database.

Steadman Media Group provides monthly statistics reflecting quantity of listeners to AED. AED will conduct

spot checks of activities in the field to check on data quality. Data will be reviewed and updated quarterly

according to revision standards set by the GoT. With FY 2008 funds, T-MARC expects to reach a total of 1

million individuals with Sikia Kengele community outreach activities and 1.5 million people monthly with the

Mama Ushauri radio program.

SUSTAINAIBLITY: AED/T-MARC will enhance implementation of prevention initiatives throughTanzanian

NGOs utilizing communication strategies. A major deliverable of the T-MARC Project is to create a

sustainable Tanzanian communications and marketing company capable of continuously implementing high

-quality initiatives. AED/T-MARC continue to provide technical assistance, marketing, and management

skills and will scale-up capabilities in these areas. USG/GoT partners will benefit from these increases in

technical and managerial skill-building.

TITLE: AED/TMARC Partner Reduction Initiatives

A reduction in sexual partners can have a dramatic impact on HIV prevalence as has been demonstrated in

Uganda and Thailand with similar data now from Zambia, Kenya, and Ethiopia. The 2005 Tanzania

HIV/AIDS Indicator Survey (THIS) identified that 5% of married and 10% of unmarried women; and 25% of

married and 32% of unmarried men had more than one partner in the 12 months before the survey.

Building on FY 2006 and FY 2007 efforts, AED will scale up through the Sikia Kengele: Tulia na Wako

(Listen to the Bell: Stick to your Partner) initiative. FY 2008 provides an opportunity to build on Kengele's

successes and go deeper and wider to reach individuals most at risk from HIV in communities along the

transportation corridors. AED will also address the link between alcohol and HIV as it relates to multiple

partner behaviors.

ACCOMPLISHMENTS: In FY 2006, AED launched Sikia Kengele targeting sexually active adults in high-

risk communities primarily along the transport corridors. Community mobilization, stakeholder involvement,

and supportive media (in collaboration with STRADCOM) activities were implemented, and a faithfulness

curriculum for Christian groups was drafted and tested. In FY 2007, Kengele will expand along the northern

transport corridor, develop a curriculum for Muslim groups, award NGO grants via Africare to keep Kengele

"alive" in communities, and with FY 2007 plus up funds, the program will expand to the lake zone.

ACTIVITIES: The kengele (bell) is a strong symbol in Tanzania as a call for change and reflection.

Kengele addresses perceived social norms supporting multi-partner behavior, such as nyumba ndogo (extra

-marital relationships) and trans-generational relationships; and challenges these norms via interpersonal

communication (IPC) "bell ringers", community mobilization "big bell events", advocacy efforts, and mass

media. AED will continue to strengthen Kengele, working with USAID prevention partners such as Ujana

and STRADCOM to implement "Safe Passages" (an initiative reaching high-risk youth), NGOs, and local

GOT entities to deepen the impact and expand the reach to additional audiences. Kengele activities will

continue to focus on the communities along the transport corridor. A strong link to locally available

counseling and testing services is also a key feature of Kengele in FY 2008. T-MARC AB activities are

implemented in the same communities where OP interventions take place.

Kengele is intended to be protective of the wider community, while OP activities for programs such as Dume

and Vaa Kondom target those practicing the highest risk behaviors. FY 2008 IPC activities will continue to

focus on male norms while community events will also address multiple concurrent partnerships in women

and sexually active youth. In FY 2008, Kengele will also address the contributing factors to multiple

concurrent partnerships, particularly alcohol use which is a major contributing factor to infidelity, sexual

violence, and gender inequalities. These activities include a rapid response capability, which can allow

them to be mobilized in support of specific workplace program requests.

In FY 2008, AED will:

1. Increase the frequency and prevalence of Kengele in communities along the transportation corridors.

1a. Implement 140 "big bell" activities in the ten highest HIV prevalence regions down to the level of district

towns to bring together communities in a public discussion of faithfulness, values, and norms. 1b. Award

grants to approximately 20 NGOs/CBOs/FBOs in Kengele communities to implement IPC activities via

outreach, peer education, edutainment theatre, and delivery of sermons. 1c. Use national events such as

the Uhuru Torch (a Mardi gras type festival that reaches every district in Tanzania), Nane Nane agricultural

fairs, and Saba Saba trade fairs to spread Kengele messages. 1d. Coordinate with Ujana and

STRADCOM initiatives to ensure involvement of sexually active youth and mass media support via the

"Safe Passages" initiative. 1e. Develop public-private partnerships (PPP) with Selcom (an SMS company

that supports all mobile phone companies in Tanzania) to support Kengele, taking advantage of widespread

presence of mobile phones along corridor (to send messages) and interest in radio contests (where

messages can be "texted" in).

2. Develop the next generation of Kengele tools and materials. 2a. In collaboration with Ujana and

STRADCOM, Kengele will lead the process of working with advertising agencies to develop umbrella tools

to be used by all partners. 2b. Print materials targeting adults and develop a dissemination plan to ensure

materials are used by NGO/CBO/FBOs, USAID/GOT partners, and the private sector. 3. Finalize and print

media regarding the faithfulness curricula, and train faith leaders in the Christian and Muslim communities

on the fundamentals of the curricula. 3a. Hold workshops with pre-test trainers and key faith leaders from

WAPO and BAKWATA to finalize curricula developed in FY 2006 and FY 2007. 3b. Layout and print 300

copies of each curriculum. 3c. Roll out training of curricula (linked to NGO/CBO/FBO grants and with

collaboration of WAPO, BAKWATA, and other national FBOs. 4. Increase link between Sikia Kengele

initiative and counseling and testing and PMTCT partners. (See AED CT and PMTCT submissions. 5.

Launch and implement HIV and alcohol initiative with Ujana and STRADCOM. 5a. Develop HIV and

alcohol strategy. 5b. Take lead role in working with ad agencies to develop creative concepts. 5c. Print

and disseminate materials for all partners. 5d. Integrate initiative into Kengele activities (grants, training,

mobilization, etc.) along transport corridor. (See concept note for additional details.) Also, implement a

limited number of HIV and alcohol events with the launch of initiative.

LINKAGES: AED's activities will be coordinated with other USAID prevention partners (e.g., STRADCOM

and Ujana for "Safe Passages"). T-MARC will link with other partners (Walter Reed, ROADS Project, and

C&T agencies). T-MARC will collaborate with district and regional GOT officials (district medical officers

(DMO), regional medical officers (RMO), and community health management teams) to ensure effective

implementation of programs. T-MARC's collaboration with TACAIDS and the NACP IEC Unit will provide

guidance on program and materials design. Advertising agencies, graphic design firms, experiential media

houses, and other Tanzanian agencies will have creative input into the design of the initiative. WAPO,

BAKWATA, and other TBD NGOs/CBOs/FBOs will play key roles in the implementation of this initiative on

the ground.

M&E: In FY 2008, AED will implement the second round of the T-MARC KAP study (the first was in FY

2005/FY 2006), which will examine the reach and recall of Kengele and reported behaviors and attitudes of

the target populations. Additionally, hired experiential media agencies, and NGOs/FBOs/CBOs working on

this initiative, will provide monthly reach data. This will be submitted into the T-MARC Project monitoring

database. AED will conduct spot checks of activities in the field to check on data quality. In FY 2008, T-

MARC will reach 925,000 with combined upstream and downstream activities, 500,000 of whom will be

reached via community mobilization.

SUSTAINAIBLITY: A major deliverable of AED is to spin off a Tanzanian communications and marketing

company that is sustainable and capable of implementing high quality initiatives. The T-MARC Company

Activity Narrative: "spun" off this project in April 2007 and AED continues to provide technical assistance to the company in

BCC. Other NGOs/CBOs/FBOs funded through this initiative will also benefit from technical and

management skills building activities.

TITLE: AED/T-MARC Project OP and Condom Initiatives

NEED and COMPARATIVE ADVANTAGE: In years past, the USG has been the largest supporter of

condom social marketing in Tanzania. Since FY 2004, AED has implemented USG's condom social

marketing efforts to promote branded condoms (male and female), as well as implement generic

communications initiatives that increase demand for condoms and their use. The audience for these efforts

is most-at-risk-populations (MARPs), especially mobile populations, workers in industry and agriculture, sex

workers, and people who live and work in communities where high-risk sexual behaviors are frequent.

AED's unique public-private partnership with Shelys' Pharmaceuticals, Ltd. forms the backbone of effective

social marketing initiatives. In order to effectively increase condom use, AED must also address

contributing factors such as alcohol use, sexual violence, and prevailing myths and misconceptions.

ACCOMPLISHMENTS: With FY 2006 funding, AED continued to expand the reach, relevance, and

desirability of Dume male condoms and Lady Pepeta female condoms. More than 10,000 new outlets were

reached and more than 8.8 million condoms were sold. In April 07, T-MARC launched the Vaa Kondom

generic initiative to promote correct and consistent condom use. A major accomplishment of both the

branded and generic initiatives was the implementation of more than 1000 bar and market interventions

along the transportation corridors. With FY 2007 funding, T-MARC is prepped to continue to improve these

efforts, adding a mass media component to promote the male condom brand and adding a grants program

for reaching sex workers with plus-up funding.

ACTIVITIES: 1.T-MARC will increase Dume's reach to district towns and rural communities in the 10 most

HIV affected regions of Tanzania and along the transport corridors. 1a) Build on Dume's base in non-

traditional outlets (bars, nightclubs, guesthouses) to go from 30% penetration to 70% penetration. 1b)

Recruit district wholesalers to uplift products to rural areas. 1c) Increase brand affiliation through

interpersonal communications (IPC) efforts, road shows in rural gathering places (bus stops, train stations,

etc.), and extend radio and outdoor media efforts. 1d) Reinforce business via trade activations and

rebranding in new and current outlets. 1e) Expand the institutional accounts outreach program to ensure

condom availability at workplaces (i.e. mining, construction). 1f) Collaborate with income generation

organizations to provide income-generation opportunities for subgrantees. 1g) Ensure audience is aware of

where they can get free condoms at government facilities.

2.AED will focus on nurturing Lady Pepeta's relevance among a core audience (sex workers, bar maids and

other most-at-risk women) in five regions with the highest HIV prevalence among women (Iringa, Mbeya,

Dar es Salaam, Tabora, and Pwani) and in regions with seasonal migration of sex workers (Arusha,

Dodoma, and Mwanza). 2a) Increase penetration in non-traditional outlets through highly targeted trade

activations. 2b) Implement face-to-face marketing activities in bars, brothels, and nightclubs targeting both

staff and sex workers. 2c) Via TBD NGOs, train bar maids to work as condom distributors. 2d) Expand the

institutional accounts outreach program for industries with female workers. 2e) Collaborate with Ujana,

ROADS, Walter Reed, and other USG prevention partners to take advantage of opportunities to promote

the female condom.

3.The Vaa Kondom generic initiative will take advantage opportunities to reach a vast and comprehensive

population through increased visibility in hot spots such as bars and guesthouses. This initiative will include

collaboration with other USG partners along the transportation corridors. 3a) Award 10-15 NGO grants to

implement IPC activities targeting mobile populations, workers in industries, sex workers, and others

engaging in high-risk sexual behaviors. 3b) Implement up to 1000 bar and guesthouse activations targeting

venues where high-risk sexual behavior occurs. 3c) Develop the next generation of Vaa Kondom tools and

materials - with special materials to be developed specifically targeting women. 3d) Increase "visibility" of

generic condom initiative via outdoor media, radio programming, in targeted communities. 3e) Develop

PPP with Selcom (the company that manages SMSing for Tanzanian mobile phone companies) to support

Vaa Kondom and take advantage of widespread presence of mobile phones along the corridor (e.g.

implement audience response contests on the radio - getting people to text answers to HIV-related

questions). 3f) Implement Vaa Kondom activities as part of the national Uhuru Torch campaign - a mardi

gras-type event that reaches all districts in Tanzania over four months - and nearly 1 million people - each

year. 3g) Link condom promotion to STI services and C&T activities (see AED C&T submission). 3h)

Implement Vaa Kondom in collaboration with Ujana and STRADCOM on joint high-risk youth prevention

initiative called "Safe Passages"

4.Continue and extend the sex worker grants program initiative started with FY 2007 plus-up funds. 4a)

Implement a competitive process to select three to five NGOs to implement IPC communities with sex

workers and women engaged in transactional sex. 4b) Provide grantees with technical assistance and

materials (developed in 07 to implement the initiative) to implement risk reduction activities. 4c) Provide

income opportunities for sex workers as condom salespersons. 4d) Provide appropriate referrals to

services (e.g. STI services, PMTCT, C&T).

5.Launch and implement HIV and alcohol initiative with Ujana and STRADCOM designed to raise

awareness of the role that alcohol plays in contributing to risky sexual behaviors and violence against

women. 5a) Develop HIV and alcohol strategy. 5b) Take lead role in working with ad agencies to develop

creative concepts. 5c) Print and disseminate materials for all partners. 5d) Link initiative into Dume and

Vaa Kondom activities (grants, training, small venue activities, etc.) along transport corridor. (See concept

note for additional details.)

Workplace programs can leverage all the activities listed above for their HIV prevention activities.

LINKAGES: AED's C activities will be coordinated with other USG prevention partners (esp. STRADCOM,

Ujana, ABCT, ROADS). T-MARC's involvement in the joint prevention initiative, "Safe Passages" will be

funded via this line item. T-MARC will collaborate with district and regional GOT officials (DMOs, RMOs,

and Community Health Management Teams) to ensure effective implementation of programs. T-MARC's

collaboration with TACAIDS and the NACP IEC unit will provide guidance on program and materials design.

Advertising agencies, graphic design firms, experiential media houses, and other Tanzanian agencies will

have creative input into the design of the initiative. PPPs include Shelys Pharmaceutical, Selcom, and

workplaces.

CHECK BOXES: This program addresses male norms and behaviors around condom and alcohol use.

Activity Narrative: Lady Pepeta marketing opportunities will provide women an opportunity for income generation activities.

The training of NGOs and their staff to implement T-MARC's initiatives will build the capacity of local

institutions to effectively address HIV prevention and will include, if necessary, training in financial systems,

M&E, and management of HIV prevention programs. The program primarily targets sexually active adults

18 and over, mobile populations, and women and men involved in transactional sex, women in prostitution

(including many who are HIV-positive) and the business communities of many towns and cities.

M&E: Approximately 7% of AED's C funding will be devoted to M&E. In FY 2008, AED expects to

implement the second round of the T-MARC KAP study (the first was implemented in FY 2005/ FY 2006)

which will examine the reach and recall of Dume, Lady Pepeta and Vaa Kondom and reported behaviors

and attitudes of the target populations. Through hired experiential media agencies and NGOs, monthly

reach data (on a tool developed for that purpose) will be submitted into the T-MARC project database. AED

will conduct spot checks of activities in the field to check on data quality. In FY 2008, T-MARC will reach

1.2 million people with upstream and downstream activities combined - 500,000 of whom will be reached

with community outreach activities.

SUSTAINAIBLITY: AED intends to enhance the ability of Tanzanian NGOs to implement prevention

initiatives, including those focusing on condom social marketing and promotion. A major deliverable of the

T-MARC project is to spin off a sustainable Tanzanian communications and marketing company that is

capable of implementing high quality initiatives. The T-MARC company "spun" off the Project in April 07

and AED continues to provide technical assistance to the company in marketing and BCC. Other NGOs

funded through this initiative will benefit from technical skills building (in BCC & marketing), as well as HIV

program management and M&E.

Title of Study: Comparing Cost-Effectiveness of Three Different Methods of Condom Distribution in

Tanzania: Free Through Public Health Facilities, Traditional Social Marketing and Private-Public Partnership

Expected Timeframe of Study: Two years

Local Co-investigator: Mwanza Research Centre of the Tanzania National Institute for Medical Research

Project Description: Over the past three years, many PEPFAR countries, including Tanzania, have

switched from a traditional model of social marketing HIV-related products (such as male condoms) to a

public-private partnership (PPP) model of shared responsibilities (for warehousing, distribution, etc.)

because of anticipated cost and opportunity benefits. Countries receiving PEPFAR support now need to

identify the most cost-effective interventions for HIV prevention to optimize the use of their own limited

resources. This study seeks to examine the cost-effectiveness of three methods of condom distribution to

high risk groups in Tanzania—free distribution through public health facilities, traditional social marketing,

and private-public partnership—to find ways to increase the cost-effectiveness of each approach and also to

explore the benefits, challenges and strengths of each method in achieving HIV prevention goals.

Evaluation Question: The primary questions are as follows:

1. What is the most cost-effective method of reaching high risk groups with condom interventions in different

segments of the affected population?

2. What are the costs and opportunity benefits associated with the public-private partnership model for

social marketing of HIV-related products as compared with the traditional model of social marketing?

3. What will be the relative saving to USG in using one method versus another?

Methods: Our team will develop a spreadsheet tool using Bernoulli and proportionate change models to

estimate the relative cost-effectiveness for the three HIV prevention interventions designed to change risk

behaviors of individuals—public free distribution of condoms, traditional social marketing, and public-private

partnerships. The team will also conduct sensitivity analyses to assess patterns of the cost-effectiveness

across different populations using various assumptions.

General Approach to Cost-effectiveness Estimation

The overall goal of this study is not to place one approach against another, as each of these complementary

approaches is important and targets different at-risk populations. Instead, the findings will demonstrate

ways to increase the cost-effectiveness of each approach.

The potential for real or perceived bias emanating from AED/T-MARC being involved in implementing the

PPP model in Tanzania will be avoided by collaboration with the Mwanza Research Center, a local research

institution entirely independent of T-MARC's activities. In collaboration with an external consultant, the

Mwanza Research Center staff will collect, analyze and report cost information from the three institutions.

The independent, external economist who will compile cost data and perform the cost effectiveness

analysis, will be made aware of all potential bias including the one of AED/T-MARC being one of the

implementing agencies. The team will work with PSI and GFTAM in selecting the external consultant for

this study.

The cost-effectiveness will be assessed by analyzing program/method costs which will include all resources

(purchased, donated, or volunteered) used to implement the intervention, but excludes any cost incurred by

the participants, unless they are reimbursed. The data will be obtained from financial and operational

reports of the T-MARC Company, Populations Services International (PSI) and The Global Fund to fight

AIDS, Tuberculosis and Malaria (GFATM) program in Tanzania. These are the only three major programs

for which reliable financial and operational costs data exist. The T-MARC project uses the PPP model,

GFATM uses both free distribution and traditional social marketing, and PSI uses traditional social

marketing exclusively.

The total number of HIV infections prevented includes those directly prevented by the intervention (primary

infections) and an estimate of the number of infections prevented in sex partners (secondary infections).

The secondary infections prevented are estimated by considering the prevalence of HIV in the sex partner

pool, multiplied by the number of sex partners and the risk of sexual transmission. The effectiveness of

each method will be estimated by the potential number of HIV infections prevented, and the cost is the

program cost of reaching people with a particular method. The cost-effectiveness ratio is Total program

cost of an intervention/Number of HIV cases prevented = Cost per HIV case prevented.

Estimates of HIV Infections Prevented

The estimate of the number of primary infections prevented will be based on subtraction of an estimate of

the number of HIV infections that would have happened if the prevention program had not been in place

from an estimate of the number of HIV infections that would have happened even with the program in place.

Applying the commonly used mathematical model, the Bernoulli model, each sex act is treated as an

independent event with a small, fixed probability that HIV is transmitted between members of a couple who

are discordant in their HIV status. From this per-act probability, the model then estimates the cumulative

probability that an uninfected individual with given sexual behaviors (number of partners, frequency of sex

acts) would become infected during a specified time period. The number of new HIV cases is determined by

the size of the population with given behaviors, the estimated number of discordant partnerships, and the

cumulative probability of transmission within these partnerships. Parameters measuring the effectiveness of

the interventions, such as changes in condom use or number of sex partners, will be drawn from selected

studies which report the type of condom used and sources of condoms, sexual practices and perception of

risk. We will explore other ways of apportioning the effectiveness based on an early desk review. The study

will take into account the potential overlap of activities performed by the three agencies. There are a

number of areas where this overlap is minimal. It is also possible to apportion the effectiveness based on

the volume of condoms distributed, using a mathematical model that controls for overlap in the distribution

and other variables such as distribution systems and behavior change communication intensity.

Estimates of Costs: Each method's costs will be considered as the total cost to the public health system to

implement the intervention. The final parameter to be used will be the program cost per person reached.

Costs will be broken down into capital costs, annualized and discounted across their life span, and recurrent

costs (direct costs of the program, and shared costs, appropriately apportioned using either budget

Activity Narrative: headings, total volume of product or total sales calls by agents).

The consultant and the Mwanza Center will conduct in-depth interviews with program staff. They will also

review financial reports and costing literature from elsewhere for quality assurance.

Comparisons of Cost-effectiveness and Sensitivity Analyses

We will first calculate the cost-effectiveness of each method using population figures from the Tanzania

AIDS Commission, Demographic Health Surveys (DHS) or data from the Adult Morbidity and Mortality

Project (AMMP). To have some comparability across the methods, we will standardize the duration of effect

to one year (2007) and assume that the effect found at the study end point (if it were less than one year)

would be sustained for one year. If the effect can only be measured at a follow-up time greater than 12

months, we will interpolate the benefit in a linear fashion to estimate the effect after 12 months.

Population of Interest: This will be a retrospective study of costs for the three programs described and will

not involve a traditional sampling strategy.

Information Dissemination Plan: Information dissemination and communication are critical to us and an

Information Resource Center (IRC) is soon to be developed to fulfill this role. The IRC will broker

information and serve as an access point for results. AED/T-MARC will also give presentations and

workshops at national and international AIDS conferences. A local final dissemination meeting will include

a wide audience of government, international organizations, and local organizations concerned with HIV

prevention.

Budget Justification: Staffing: The two-year total is $213,875; a 10 percent rate will add $21,387. This

includes: one pooled AED/T-MARC Company Senior Level Monitoring and Evaluation Staff for 100 days per

year in Years 1 and 2, daily rate $146. Two senior staff, one Economist/cost analyst Consultant and one

field Research Officer from Mwanza Center for 100 days per year for Years 1 and 2. The Economist/cost

analyst has a daily rate of $378 and the Research Officer has a daily rate of $154. A Senior Technical

Advisor will provide technical consultation as needed for 30 days per each year daily rate $1,304.

Travel: $25,840; general office supplies total $3600 at $150 per month plus 4 PDAs and car chargers $660;

additionally, T-MARC charges $750 annually for facilities and computer usage, totalling $1500. T-MARC

charges a 2% fee of $4,580 brings the total required budget to $271,772 for two years. All taxes and

service fees are included in the costs.