TITLE: SCALING UP COMPREHENSIVE PMTCT SERVICES IN A REGION (TBD)

NEED and COMPARATIVE ADVANTAGE: In Tanzania, PMTCT coverage remains insufficient with only

about 12% of all health facilities, mostly in urban areas, offering PMTCT services. Since 2004, African

Medical and Research Foundation (AMREF) has demonstrated a model of expansion of PMTCT services to

reach rural and underserved populations by integrating PMTCT into routine services with success in rolling

out to lower-level facilities. Additionally, AMREF has trained hospital-based PMTCT and infant-feeding (IF)

trainer of trainers (TOT) who conduct routine training of health care providers working at lower-level

facilities. AMREF has facilitated demand creation for PMTCT services through social marketing, local

community mobilization, sensitization, and enhancement of male involvement using community owned

resource persons (CORPs). Upon request from the USG to continue implementation of PMTCT programs

in collaboration with other partners and the GoT, AMREF will use its PMTCT model to scale up quality

comprehensive PMTCT services in a region to be determined by USG and MOHSW.

ACCOMPLISHMENTS: Working under the ANGAZA program, during the period October 2006 to June

2007, AMREF counseled, tested, and received results for 11,000 pregnant women. Of those individuals,

700 (6.3%) tested HIV positive and 400 received ARV prophylaxis according to national guidelines.

Roughly 1,500 male partners accessed care and treatment (C&T) at PMTCT service outlets. 75 health care

providers and 99 community workers were trained. AMREF has also worked with the Ministry of Health and

Social Welfare (MOHSW) to develop and pilot follow-up tools for HIV exposed children. AMREF, in

collaboration with various stakeholders, has developed standard operating procedures (SOP) and clinical

audit tools for PMTCT services.

ACTIVITIES: The USG has identified AMREF as the responsible partner for covering PMTCT in a region to

be determined that is not currently covered through the PMTCT regionalization Initiative. They will work

closely with USG and GoT treatment partners who are carrying out ART and PMTCT regionalization so that

activities are well coordinated and effective while avoiding duplication of services.

AMREF will increase the coverage of comprehensive PMTCT services by training health care providers on

provision of quality integrated PMTCT services using the curriculum formulated by the MOHSW. To

encourage men's participation in PMTCT services, AMREF will encourage training of at least one male

PMTCT counselor per health facility. The program will adopt and utilize national job aids to ensure

provision of quality service. The program will strengthen provider initiated ‘opt-out' C&T in antenatal clinics,

maternity waiting homes, labor wards, and during the postpartum period. HIV testing will be conducted per

the national guidelines (e.g., group counseling, individual HIV testing with same day results, and post-test

counseling). In addition, couples counseling and testing will be available.

AMREF will strengthen the integration of PMTCT into existing outreach reproductive health (RH) programs

and support minor renovations in debilitated health facilities to improve RH services. One mobile van and

at least two tents will be provided to hospitals to facilitate outreach. AMREF will support these programs

with essential supplies, equipment, and drugs including Cotrimoxazole. The program will strengthen

capacity of district-wide procurement systems in addition to providing training to districts on supply

management skills. AMREF will continue to access the PMTCT joint donation for Nevirapine and

Determine.

Other activities include; providing sustainable, comprehensive, and integrative quality PMTCT services with

quality antenatal and delivery services; encouraging deliveries in health facilities; orientation and

involvement of local government authorities on comprehensive provision of PMTCT services; TOTs in

community sensitization and mobilization in accessing integrated RH and PMTCT services. Additionally,

AMREF will promote male involvement as well as addressing cultural norms and behaviors hindering male

participation. The CORPs carry out household sensitization and mobilization on a routine basis and during

special events. Joint supportive supervision with council health management teams (CHMT) and refresher

training will be conducted biannually as part of on-job staff mentoring and quality assurance.

AMREF will adopt and implement National IEC/BCC materials and products produced for social marketing

of PMTCT in addition to utilizing media spots (e.g., local radio, television, and newspapers) to raise public

awareness of PMTCT services. AMREF originally developed these media spots to encourage male

participation in PMTCT programs. In an effort to have far-reaching implications, AMREF will collaborate

with MOHSW to explore the possibility of using local media to broadcast the spots.

Scale-up of services will be a major priority for AMREF in FY 2008. Activities in this area include facilitating

care and support for HIV-infected women and their infants, including early infant diagnosis and pediatric

care. Individuals testing HIV positive will be referred to care, treatment, and support services and the

AMREF Post-Test Club model will be used in all new sites. The PMTCT members will organize formal self-

governed groups for support. Furthermore, AMREF will strengthen linkages to other RH services such as

Family Planning; low-cost cervical cancer screening services where available; STI, care and treatment clinic

(CTC), TB screening; and other care and support interventions. AMREF will facilitate early infant diagnosis

and follow-up for pediatric care and support, including safe IF practices.

Finally, in order to evaluate practices, a pilot will be conducted for a model of community support for HIV-

infected women and their families including ensuring access to PMTCT services for home deliveries. This

will include supporting USG and GoT partners to establish a psychosocial support network of PMTCT

clients, their spouses, and families.

LINKAGES: AMREF will continue to work closely with MOHSW, all USG partners, and the local government

to scale-up PMTCT services. AMREF will encourage integration of PMTCT services and foster linkages

with other clinical services including home-based care for a comprehensive continuum of care.

Orientation will be facilitated for CHMT on PMTCT services management in addition to strengthening

supportive supervision of routine districts using the MoHSW guidelines. This will include linking PMTCT

services with Council Comprehensive Health Plans. Consistent collaboration with relevant stakeholders,

including academia and civil society organizations, will aid effective continuation of sustainable PMTCT

services implementation. AMREF will continue to strengthen public-private partnerships (PPP) down to the

district level by empowering and supporting sub-grantees, the local government, and other partners.

AMREF will continue to link with community structures with gender sensitive practices in order to utilize

Activity Narrative: services, as well as providing support to women and families.

CHECK BOXES: The interventions will target the general population, but with efforts to increase both men

and women's access to PMTCT services. Emphasis will be on linkages with other services and continuum

of care for PLWHA and training of health care providers for implementation of PMTCT services.

M&E: AMREF will build the capacity of partners by utilizing nationally approved monitoring and reporting

tools with PMTCT indicators for accurate and timely reporting. AMREF will train and support partners on

management skills and utilization of PMTCT information. Quarterly, semiannual, and annual reports will be

submitted to USAID per guidance of the USG. AMREF will use a clinical audit tool recently developed in

collaboration with a drafted facility-based SOP for enhancement of the quality of services for PMTCT

initiatives. AMREF is field-testing the draft SOP that were developed in collaboration with various

stakeholders and approved by the MOHSW. AMREF will empower partners in collection, reporting, and

utilization of community-based data in order to strengthen community-based health information systems.

Six percent of the budget will support M&E.

SUSTAINAIBLITY: AMREF will continue to work through partnerships and in collaboration with MOHSW

and district councils to ensure participatory planning, monitoring, and proper utilization of supervision tools,

as well as in skill development. AMREF will also support USG and GoT partners to ensure the inclusion of

PMTCT activities in comprehensive district health plans. In FY 2008, AMREF will encourage local partners

to participate in numerous activities including: planning, procurement, running of services, and other

community-based and mobilization activities. AMREF will coordinate with partners to address health

systems' challenges in relevant platforms, including human resources challenges. AMREF will also work on

a task-shift model through lay counselors and CORPs in Songea Rural district. This is a potential model for

replication.

The African Medical and Research Foundation (AMREF) Counseling and Testing (CT) program (also called

ANGAZA meaning ‘shed light') was founded in 2001 with USAID support. In FY 2006, AMREF employed a

combination of strategies to implement the program including the provision of sub-grants to partners who

run either stand alone and/or integrated CT services; VCT services to rural and underserved population

through mobile clinics; and social marketing campaigns to create demand for services through promoting

the ANGAZA brand. Through these strategies, cumulatively, AMREF trained 838 counselors and reached

364,387 people with VCT services in FY 2006. Despite the above efforts, AMREF encountered several

barriers that affected utilization of CT services. C&T coverage is still inadequate and does not reach the

entire population. While there are significant numbers of facilities and organizations providing various forms

of counseling and testing (approximately 975) this represents only 1/5th of all the health facilities in the

country. Other barriers include inadequate number of counselors to provide services; high counselor turn-

over in some sites; ‘longer' counseling sessions (protocol dependant); and delays in adopting provider

initiated testing and counseling due to lack of a National PITC policy document. Funding for FY 2006

activities has recently been received and since AMREF's cooperative agreement comes to an end in June

2007, initially, "zero funds" were required to reach the goals proposed in this narrative. In FY 2007, AMREF

will deploy several strategies to address the barriers mentioned above and to improve C&T coverage. It will

continue to provide CT services through the existing 65 static and 11 mobile sites. The program will

increase accessibility to CT services through additional sub-grants to FBOs, NGOs and Governmental

organizations, resulting in a total of 75 sub-grantees being supported by AMREF in FY 2007. As part of its

work with sub-grantees in FY 2007, AMREF will prepare them for hand-over to the new TBD partner

(activity #8656). PITC will be expanded in clinics through integration into services such as TB, STI and MCH

and inpatient settings, following national guidelines, protocols and training curriculums to be developed by

the Ministry of Health and Social Welfare (MOHSW). As a participant in the national CT working group,

AMREF will advocate for links with care and treatment, family planning services, and home-based and

palliative care. Subsequent to the development of national training curriculums, the program will carry out

PITC training for 240 providers, including updates in strategies for testing children, C&T for the disabled,

and lay counselors. Access to C&T will be improved and expanded through an increase in mobile services

provided via vans, motorcycles, and bicycles. Through leasing, AMREF will introduce a boat with a mobile

VCT clinic on Lake Victoria to access hard to reach fishing communities on the several islands on the lake.

In keeping with the MOHSW guidance, AMREF will support the use of "lay counselors" and work with sub-

grantees to implement this new initiative. AMREF will continue to create demand for Counseling and

Testing services through innovative social marketing techniques and community mobilization methods. The

program will continue to promote and advocate for couples counseling and disclosure, engage churches,

mosques and other religious setting, and facilitate premarital counseling and testing. The communication

tool to facilitate couple disclosure developed during FY 2006 will be scaled-up to other ANGAZA sites.

AMREF will work with the MOHSW in phasing out the old (Capillus and Determine sequential testing using

veneous blood draw) and adopting of the new, to be determined, HIV testing algorithm and will engage/rely

on the new SCMS mechanism to procure and distribute buffer stock of test kits and other commodities.

Psychosocial support to clients diagnosed as HIV infected will continue to be provided through Post Test

Clubs (PTC), ensuring linkages for continuum of care including referral to care and treatment clinics (CTC)

for assessment, staging and consideration of antiretroviral therapy as well as the provision of prophylaxis for

opportunistic infections. Monitoring and evaluation (M&E) will be strengthened to ensure quality services

and efficient reporting. AMREF shall collaborate with VCT district supervisors to conduct mystery client and

client exit survey in the selected sites. AMREF will liaison with MOHSW/CDC to ensure the quality of HIV

testing is maintained according to national standards. In order to enhance sustainability, the program will (i)

ensure sites with VCT activities supported by AMREF are integrated in the district's Comprehensive Council

Health Plans (CCHP), so that the financial support to these services is picked up by the local authorities;

and (ii) work with districts to decentralize the supervision of these services to the Council Health

Management Teams (CHMTs). This will ensure districts take over management oversight of the services.

Through these strategies, AMREF anticipates that a total of 311,278 individuals will access VCT services in

FY 2007; however, as these were captured in FY 2006, targets here are zero. Through the ANGAZA

program, AMREF has extensive experience training and implementing a range of interventions including

capacity building, social marketing and provision of VCT services. The NACP has recently adopted the

Provider Initiated Testing and Counseling approach in an effort to strengthen and broaden opportunities for

clients to access HIV services. The MOHSW is now in the process of developng new technical guidelines,

protocol and manuals with a view of rolling out the program at a national level. The USG has identified

AMREF as one of several partners to assist MOHSW to rapidly pilot the training phase of this approach.

Plus up funds will be used under the leadership of MOHSW and in close collaboration with other USG

partners to pilot the PITC training materials. AMREF will utilize its two training classrooms at its

headquarters, experienced trainers (2 clinical and 4 laboratory technicians) and other resource persons to

support the Ministry with the pilot. They will run two classes of 25 participants each for five days and

through 4 training sessions and in total will train over 200 participants. In carrying out the pilot training, the

AMREF team will keep track of the training process, document issues and questions that arise so that it can

provide inputs to the national roll-o