TITLE: Expansion of PMTCT-Plus Services in Three Regions of Tanzania

NEED AND ADVANTAGE: Columbia University (CU) will implement PMTCT services in three regions of

Tanzania (Kagera, Kigoma, and Pwani) where HIV prevalence ranges from 2% to over 7%. The main focus

in 2007 and beyond is ‘elimination of MTCT' by ensuring broader coverage, increasing uptake through opt-

out testing and counseling, and using more efficacious regimens. Focus will also be on expansion of the

early infant diagnosis program to all PMTCT sites.

By September 30, 2009, CU will support 21 district health authorities for PMTCT services in 59 new

facilities; approximately 50,600 pregnant women receiving CT; 3,300 pregnant women receiving ARV

prophylaxis; 450 health care workers (HCW) training in PMTCT services; and 300 trained in additional infant

feeding counseling.

In 10 health centers per region, CU will support establishment of the Reproductive Child Health (RCH)

platform which offers integrated CT and treatment services. An additional 30 health centers will provide HIV

CT services and clinical care; patients meeting criteria for treatment will be linked with treatment centers

and monitored to prevent loss to follow-up.

ACCOMPLISHMENTS: During FY 2006 and FY 2007, three innovative approaches were used to scale-up

PMTCT and enhance linkages to HIV care and treatment: 1) Integration of HIV CT within the RCH Platform

of services; 2) Use of partner invitation letters for PMTCT; and 3) The PMTCT+ district network. In FY 2006,

19,158 pregnant women received HIV CT, and 827 mother-infant pairs were provided NVP prophylaxis. In

FY 2007, approximately 9,720 pregnant women will receive HIV and 340 HIV positive women will receive

PMTCT prophylaxis. This takes into account the decreased number of CU supported service outlets due to

regionalization.

By June 30th 2007, 790 HIV-exposed infants (HEI) were identified at eight sites and 743 of these were

given cotrimoxazole prophylaxis; 161 HIV positive infants were diagnosed through polymerase chain

reaction (PCR) HIV-testing via dried blood spot (DBS) and referred to care and treatment clinics.

ACTIVITIES:

1) Expand PMTCT services to 59 new lower level facilities in Kigoma, Kagera and Pwani regions. 1a)

Partner with Council Health Management Teams (CHMTs) to plan, implement, and strengthen PMTCT

services in the district;1b) Continue support to 92 existing sites; 1c) Train approximately 280 health care

workers (HCW) using the revised national PMTCT curriculum; 1d) Procure HIV test kits and related

consumables; 1e) Support implementation of more efficacious PMTCT regimens where capacity allows

(NVP 813, AZT+NVP 380, ART 174); 1f) Conduct joint supportive supervision visits with CHMT members;

1g) Establish PMTCT rapid start-up teams in each district; 1h) Establish opt-out counseling and testing in all

points of service at RCH clinics and advocate for same-day test results; 1i) Increase male involvement in

PMTCT services by provision of partner invitation letters; 1j) Support renovations in the facilities to create

room for service delivery; 1k) Support communication and stationary required at the site; 1l) Sensitize

traditional birth attendants (TBA) and community-based organizations in each district to promote hospital

deliveries, counseling and testing, and to increase utilization of services; 1m) Hire 60 nurse counselors; 1n)

Train 300 staff on additional infant feeding counseling;

2) Create linkages to care and treatment. 2a) Establish HIV care clinics in 30 rural health centers. The care

clinics will provide services to HIV-infected mothers, their HIV-exposed infants and partners; 2b) Support

minor renovations and furniture; 2c) Purchase motorcycles for blood sample transportation; 2d) Supply adult

and pediatric cotrimoxazole for prophylaxis; 2e) Supply standard package of opportunistic infection drugs;

2f) Train approximately 280 staff on clinical staging and management of opportunistic infections; 2g)

Provide PCR early infant diagnosis HIV-testing via DBS for HEI identified in all PMTCT sites; 2h) Establish

two-way referal systems between PMTCT and care and treatment services;

3) Promote adherence to PMTCT regimens, retention into care, and linkages with other programs. 3a)

Support formation of family support groups for HIV positive mothers and their families; 3b) Establish

linkages with the community by partnering with community-based organizations {e.g. Tanzania

Development and AIDS Prevention (TADEPA) in Kagera region} for provision of psychosocial support and

home-based care (HBC) services; 3c) Train 10 peer counselors per district on adherence support; 3d)

Strengthen linkages with nutrition centers, family planning clinics, and malaria programs providing

insecticide treated bednets. CU will work with districts and facilities to identify organizations, such as World

Food Program, that can provide food support. Assessment will be based on growth monitoring and national

guidelines drawn from WHO; 3e) Establish linkages with PLWHA groups such as Zanzibar Association of

People living with HIV and AIDS (ZAPHA+) for promotion of services, psychosocial support, stigma

reduction, nutritional support and HBC services.

4) Support the national PMTCT program. 4a) Continue providing technical assistance on policy issues and

data use for decision-making; 4b) Provide technical assistance on finalization and roll-out of PMTCT

monitoring and evaluation (M&E) tools; 4c) Hire a M&E officer to support the PMTCT program at the

national level.

5) Funds will be used to expand the number of family support groups (FSGs) to 5 per region, and improve

client recruitment by introducing the buddy system for new HIV positive patients in ANC and Labor and

Delivery. Additionally, funds will support ICAP and other USG partners to expand FSGs and document and

share experiences across programs.

To improve information sharing and encourage an enabling policy environment for working with PLHAs in

the PMTCT program, ICAP will sponsor a DVC to bring together MOH, USG PMTCT partners and other

countries implementing FSGs. The program will engage the MOH officials to encourage development of

national guidelines and tools. Lastly, locally developed IEC materials with core messages pertinent in

PMTCT settings will support counseling sessions for PMTCT services and FSGs. Messages will focus on

basic knowledge on HIV transmission, adherence to care, infant feeding, partner disclosure, HIV testing,

importance of CD4 count, and positive living.

LINKAGES: CU will partner with community-based and faith-based organizations to support local

Activity Narrative: communities and work closely with PLHAs (especially HIV+ pregnant mothers); as they are key players in

promoting PMTCT services, reducing stigma and discrimination, promoting male involvement and

participation, and addressing other related maternal and child health issues. Linkages to care and

treatment, family planning, child survival, nutrition, TB/HIV, Malaria, RCH and OVC programs will be actively

strengthened. CU will continue to collaborate with districts supported by the Global Fund and will

strengthen linkages between facilities. CU provides technical assistance on implementation and creates

linkages for infected mothers, their infants, and partners to the care clinic and to the nutrition program

provided by ZAPHA+.

CHECK BOXES: Activities will include training of HCW, partnering with community-based organizations,

renovation of infrastructure, and strengthening M&E at the site and national level. The efforts to increase

male involvement in PMTCT is a gender related activity. The general population, and specifically pregnant

women, will be targeted in our testing activities; PLWHA will be used to strengthen linkages and prevent

loss to follow-up; and counseling services will focus on discordant couples.

M&E: a) CU will continue technical support to the National AIDS Control Program in revision and finalization

of national M&E tools. Once finalized, CU will work with partners to train, pilot, and implement the tools; b)

Data will be collected and reported using national PMTCT tools: ante-natal clinic and labor and delivery

registers, and monthly summary forms (MSF); c) CU will promote data synthesis & use at the site, district,

regional, and national level; d) Data quality will be ensured through CU and district teams conducting

regular site supervision visits with review of registers and consistency checks of MSFs; e) CU will train 150

HCWs and provide technical assistance to 92 facilities, 21 districts and three regional offices; f) CU will

support implementation of national PMTCT database; g) CU will assist PMTCT teams at supported facilities

to provide monthly, quarterly, and semi-annual/annual reports to the district, regional, and national levels as

appropriate. CU will provide reports to PEPFAR as required.

SUSTAINAIBLITY: CU will work with District Councils to include PMTCT activities in Comprehensive

Council Health Plans and support resource mobilization from Global Fund and other sources. Full

integration of PMTCT into RCH services will help to ensure sustainability. The implementation process will

involve existing management systems and human resources. National guidelines will be used to ensure

continuity of the implemented activities. Capacity building of the regional and council health management

teams in program specific training, supportive supervision, and mentoring skills will be included to ensure

continuity of their supervisory roles and program ownership. Capacity building at the national level will help

to ensure continuity of program monitoring and evaluation for decision-making.

Title of Study: Evaluation of the implementation of revised PMTCT guidelines incorporating more complex

PMTCT regimens and ART to HIV positive pregnant women. (A similar evaluation is being conducted at

Columbia University (CU)-supported sites in Mozambique).

Expected Timeframe of Study: Protocol development to completion: 2 years.

Local Co-investigator: TBD/Columbia University

Project Description: The Tanzanian national PMTCT guidelines were recently revised to recommend more

effective PMTCT regimens including zidovudine (AZT) from 28 weeks of pregnancy, AZT, lamivudine (3TC)

and nevirapine (NVP) in labour and AZT and 3TC for mother and baby post-partum. ART is recommended

for HIV positive pregnant women who are eligible for treatment. CU proposes to evaluate to what extent the

new guidelines are being implemented and identify programmatic and personal factors associated with the

uptake of more effective PMTCT regimens and ART in pregnancy. The PHE results would provide useful

feedback for the refinement of PMTCT programs by highlighting enablers/barriers to implementation.

Evaluation Question: The primary objectives are

1. To measure the proportion of HIV-infected pregnant women who receive single dose nevirapine (Sd-

NVP), or more complex regimen for PMTCT over a 12 month period after the implementation of the new

guidelines

2. To determine the proportion of pregnant women who initiate combination ART in pregnancy over a twelve

month period after the implementation of the new guidelines

3. To identify personal and programmatic enablers and barriers to women receiving PMTCT regimens or

initiating combination ART during pregnancy.

The secondary objectives are:

1. To determine variation in MTCT rates before and after revision of guidelines

2. To examine effectiveness of linkages between PMTCT and care and treatment programs

Methods: This will be a prospective study of patients attending for antenatal care (ANC) at selected CU-

supported PMTCT sites over a 12 month period after the change in guidelines. Interviews with HIV positive

women at selected time points will provide information on personal and programmatic barriers to accessing

the different PMTCT regimens or to starting ART, and adherence to those regimens. Data will be collected

on infant feeding practices, and HIV-exposed infants born to women enrolled in the study will be linked to

the Early Infant Diagnosis (EID) program to determine MTCT rates through HIV polymerase chain reaction

(PCR) testing from six weeks of age. Site characteristic data collected as part of CU routine reporting will be

used in the analyses of the impact of programmatic and site level data. There will also be a retrospective

component with chart reviews and data abstraction on PMTCT practices prior to the change in guidelines.

A challenging issue will be ensuring follow-up of women during pregnancy and the post-partum period and

funds will be set aside for active follow-up to determine final outcomes.

Population of Interest: All HIV positive pregnant women attending for ANC in the study period will be

included.

Information Dissemination Plan: Interim analyses will be conducted six months into the study and final

analyses at conclusion of follow-up. Results will be shared at site, district, regional and national levels, and

presented at stakeholder meetings. A PHE report will be disseminated to the National AIDS Control

Programme (NACP) and the Ministry of Health (MOH) and other partners and results will also be

disseminated through national and international workshops and conferences as well as peer-reviewed

publications.

Budget Justification: Salary/fringe benefits: $80,000

Equipment: $10,000

Supplies: $5000

Travel: $70,000

Participant Incentives: $5000

Laboratory testing: nil

Other: nil

Total: $170,000

TITLE: Scaling Up Availability of Palliative Care Services in Tanzania

NEED AND COMPARATIVE ADVANTAGE: Tanzania has an estimated 3.5 million people with incurable

illnesses who require palliative care. Out of these, 700,000 have HIV/AIDS. Many patients with end-stage

HIV/AIDS are taken care of at home as there are only four facilities nationally that have health care workers

(HCW) trained in palliative care, including pain management and symptom control. Columbia University

(CU) has supported the Ocean Road Cancer Institute (ORCI) since 2005. ORCI is the Ministry of Health

and Social Welfare (MOHSW) designated leader in the delivery of palliative care to HIV/AIDS patients in

Tanzania. CU is well positioned in collaboration with ORCI to further expand these services in FY 2008. In

addition, there is little home-based palliative care provided in the CU service regions of Kagera and Kigoma.

Services in Coast are provided through TUNAJALI (Deloitte), though this will transition to CU in the

regionalization process. CU is poised to initiate these services to link with facility based palliative care for

people living with HIV/AIDS (PLWHA).

ACCOMPLISHMENTS: In FY 2007, through ORCI, CU supported facility-based and home-based palliative

care services to 1,835 clients, over half of whom had HIV/AIDS. In addition, CU provided facility-based

palliative care to over 20,300 people by March 2007 in Kagera, Kigoma, Coast, and Zanzibar.

1. Expand access to palliative care through ORCI, the leading palliative care institution in Tanzania, in all

four zones and selected regional hospitals by:

a) strengthening ORCI's direct palliative care provision program with increased staff support, HIV AIDS

related basic equipment, and capacity for outreach services; b) rollout pain management and palliative care

services in collaboration with ORCI and with the approval of the National AIDS Control Programme (NACP).

This would include reaching all four zonal hospitals and selected regional hospitals to introduce pain

management, symptom control, and management of Kaposi's Sarcoma; c) train 250 HCWs and at least

250 community volunteers in four zones and selected regional hospitals in carrying out pain management

and symptom control services. The national curriculum developed by ORCI is available for this purpose

and can be piloted on a broader scale, and considered for inclusion in revised national guidelines through

NACP. Training will include pain management, opportunistic infection management, prevention, and

psychosocial counseling. Prevention with positives training will be included in the curriculum. Once a

site/district has trained personnel it will be certified to deliver palliative care services nationally; d) work with

NACP for the integration of the pain management training and certification into the routine palliative care

training; e) procure equipment and supplies required for pain and symptom control. This will include pain

relief and symptom control medications for the initiation of these services at newly approved sites; f)

conduct needs assessments in Dar es Salaam and selected upcountry regions on the existence of

palliative care policy, the existence of palliative care and home-based care services, importance of palliative

care, and the community perspectives. Assessments will also explore the availability and accessibility of

the health units, the number of staff at these facilities and status of equipment/supplies at these facilities. g)

provide for expansion of pain management by supporting growth of ORCI's national on-site training program

with short-term training scholarships and technical assistance. g) work with NACP to create awareness of

palliative care services using an information, education, communication package on palliative care services

that can be used by all implementing partners.

2. Deliver palliative care services through facility-based and home-based providers in Kigoma and Kagera

regions, and prepare for transition of services from the TUNAJALI program in Coast region.

a) provide treatment for opportunistic infections to all those who test positive through HIV counseling and

testing; b) ensure all PLWHA identified through routine counseling and testing have immediate access to

cotrimoxozole, treatment for opportunistic infection (OI), psychosocial support, adherence counseling, and

linkages for other key services in the community; c) strengthen home-based care (HBC) programs in

Kagera and Kigoma, where currently few services for basic care are provided through health facility

outreach or HBC workers. d) work with ORCI to capacitate all districts in Kagera and Kigomato, and

initiating sites in Coast, to ensure availability of holistic palliative care including pain management and

symptom control; e) establish palliative care point persons at each district to champion pain management

activities; f) link with organizations providing legal aid, OVC support, and preventive care package services.

g) establish linkages and partnerships with other organizations that can provide other components of the

preventive care package (e.g., safe water, condoms, insecticide treated bed nets, and family planning

methods).

LINKAGES: Linkages continue to be forged between CU, ORCI, the MOHSW/NACP, Family Health

International (FHI), and key palliative care providers including Pathfinder, Deloitte, the Department of

Defense programs, Pasada, and Selian. CU will work with the African and Tanzanian palliative care

associations (in which ORCI is the chair), FHI, and NACP to expand services and will bring USG care and

treatment partners into networks to ensure smooth implementation. In addition, the Princess Di Fund

currently provides support to ORCI for palliative care training and expansion, and CU is working closely with

Princess Di to ensure complementary support for a common goal. CU, with ORCI, will work closely with

regions with urgent need to introduce palliative care services. Facility-based services in Pwani and at ORCI

are being expanded under FY 2007 funding. With FY 2008 funding, zonal hospitals and up to four regional

hospitals will rollout palliative care programs. In regions where CU is primarily responsible for treatment

and PMTCT, CU will work closely with NACP and the regional and district authorities of Coast, Kagera, and

Kigoma to provide palliative care services - both facility-based and home-based. In Coast, CU continues to

work with Deloitte/Africare to expand home-based services and as the regional partner under

regionalization, will be the initiator of new home-based care programs in that region. Supplies of

cotrimoxizole and other OI drugs will be assured through Diflucan partnership, with MSD, Abbott, and CU.

CU will work with the USG, T-MARC, PSI, and MSD/SCMS to ensure an adequate supply of condoms,

family planning methods, bed nets, and safe water. CU plans to establish linkages and partnerships with

non-governmental organizations (NGOs) involved in the provision of home-based care where there is no

other partner. Because of the lack of HBC in Kagera and Kigoma, at least two NGOs will be contracted to

help deliver home-based care and to improve identification and care of homebound HIV patients, in addition

to supporting the HBC providers already part of the government of Tanzania (GoT) system. This will

additionally serve to provide family-based HIV testing and counseling and link more clients into the care

network. Exposed children and partners will be linked with the CU care and treatment clinics in the

respective communities.The activity is both aimed at training health care workers and upgrading their

palliative care skills, and to provide systems strengthening throughout the national program for palliative

care.

Activity Narrative:

M&E: CU will collaborate with the NACP/MOHSW to track palliative care services provision, utilization of

services, TB screening, diagnosis, and treatment at CU sites. CU will participate in the

planning/development of a national monitoring system for palliative care and the implementation once it is

completed. Support must be secured to ensure that local authorities will use the data for planning,

management, budget, and decision-making. In addition, it will be important that CU assist ORCI, NACP,

and the Tanzanian Palliative Care Association in the effective use of pain management drugs.

Columbia community based targets for individuals served for FY 09 will be 7012 in 47 wards. Facility based

palliative care targets will be 31017.

SUSTAINABILITY: CU will continue to build ORCI's capacity with the goal that they increasingly receive

direct funding from USG or other sources and build an even greater diversification of a funds base. ORCI

has recurrent funding sources (some paying clients, funds from GoT, and other sources), excellent facilities

in the first national hospital of Tanzania and solid leadership and staffing. It is envisioned that ORCI will

become another premier regional training institution for palliative care, and will expand its ability to offer

training services to other institutions and GoT staff at a fee. In the regions, CU will ensure sustainability of

these services by engaging local authorities in all decision-making processes, and by working closely with

leaders to integrate palliative care into existing healthcare services. CU will continue to build the technical

capacity of the HCWs at the health facilities and that of the local government authorities.

TITLE: Scaling up TB/HIV collaborative activities at Care and Treatment Centers (CTC) in Kagera, Kigoma,

Pwani and Zanzibar

NEED and COMPARATIVE ADVANTAGE: Columbia University (CU) supports comprehensive ART

services in Kagera, Kigoma, Pwani and Zanzibar where there is currently an estimated 51,603 patients in

need of ART. 10% of patients enrolled in care and treatment are estimated to have active TB while 50 -70%

of TB clients are likely to be HIV positive according to the Tanzania DHS 2004/5. HIV patients with TB

needs prompt TB treatment as a measure to reduce transmission amongst vulnerable HIV clients attending

care and treatment. Similarly, TB clients who are HIV positive will need to engage in HIV care and treatment

as a measure to reduce morbidity and mortality. CU has conducted intensified TB case-finding at many

supported sites, and is well positioned to further expand these services in FY 2008.

ACCOMPLISHMENTS: In FY 2007, CU supported ARV services in 24 hospitals and 1 Health Center.

Intensified TB case-finding was established at all care and treatment clinics using a 5-question symptom

screening tool that was developed by CU. Clients who were diagnosed as TB suspects based on the

screening tool were investigated according to the National TB diagnostic algorithm. Linkages were

established with the TB clinics and at all facilities in wards, and clients diagnosed to have TB were promptly

referred for TB treatment. Data from April - June 2007 show 69% of the 2,791 patients enrolled at CU

supported sites were screened for TB, and four were diagnosed to have active TB. Overall, 3% of the

11,099 patients who received care during the quarter were on TB treatment.

ACTIVITIES: 1) Provide technical assistance in collaboration with the Ministry of Health (MOH) through the

National Tuberculosis and Leprosy Program/National AIDS Relief Program (NTLP/NACP) in implementation

of Infection Control to other ART partners. 1a) update training guidelines for HIV/AIDS and for TB to include

infection control measures: 1b) organize training sessions with USG partners on TB infection control in CTC

settings; 1c) train additional health care workers (HCW) at select hospitals in training of trainers (TOTs)

programs for TB infection control at care and treatment clinics. 1d) print and disseminate training guidelines

for TB infection control through MOH. 1e) assist in development of job aids for HCW for infection control.

1f) print and disseminate job aides.

2) Decrease the burden of TB in PLHAs 2a.Strengthen intensified TB case-finding at existing CU supported

sites; 2b) Establish intensified case-finding at newly supported CU sites; 2c)Ensure, through renovation, TB

infection control measures are in place in 30 health care settings; 2d) Ensure all family members of PLHAs

with TB are actively screened for TB. 2e) Ensure linkages between HIV and TB clinics are established and

strengthened through regular information meetings and follow-up of referral forms. 2f) Train 176 HCW from

all CTC sites in the national TB/HIV training curriculum; 2g) Do refresher training for 40 lab technicians in

TB diagnostics;2h) Procure 30 microscopes and lab supplies required to strengthen TB diagnostics; 2i)

Establish care and treatment services for TB clients at 1 TB clinic in 1 district hospital (Kagera). This will

require employing HCW, training in the NACP curriculum, renovating the TB clinic for infection control

purposes; 2j) Roll out TB/HIV co-management in all 18 districts in Pwani, Kagera and Kigoma with some

support as needed in Zanzibar.

3) Decrease the burden of HIV in TB patients. 3a) Ensure all TB clients are offered HIV counseling and

testing at CU supported sites in Kagera, Kigoma, Pwani and Kigoma; 3b. Ensure all TB patients with HIV

are on cotrimoxazole therapy through improved use of CTC tools and through training of dispensers,

pharmacists and clinicians in essential use of cotrim for HIV+ individuals; 3c) Print laminated TB screening

tool for use in 21 regions in Kagera, Kigoma, Pwani and Zanzibar - provide training and hands on

mentoring in use of the tool; 3c)Distribute electronic and 200 printed copies of International Center for AIDS

Care and Treatment Programs' (ICAPs) TB/HIV integration booklet with evidence and instruction on use of

the screening tool; 3d) Ensure all TB clients with HIV are promptly engaged in HIV care and treatment by

carrying out Provider Initiated Testing & Counseling (PITC) with district hospitals and health centers

delivering TB services; 3e) Ensure all TB clients receive counseling on HIV preventive methods through

training at district and health center levels; 3f)Ensure linkages between the TB clinics and HIV clinics are

strengthened through two-way referrals and HIV management committees - use the referral forms

developed by ICAP and expert patients or HCW staff to accompany patients.

4) Establish mechanisms for TB/HIV collaboration. 4a)Coordinate with the NTLP, regional, district and

facility-based TB/HIV bodies in the implementation of TB/HIV activities 4b) Participate in the National

TB/HIV planning and share information at district, regional and site level through our annual stakeholder

meetings and regular support to the districts and sites. 4c)Participate in national TB/HIV M&E activities to

further refine TB management tools; 4d) support the Regional Health Management Teams (RHMT) to

increase integration of TB and HIV services at the regional level through improved supervision by carrying

out training and improving communication and technical assistance in clinical management and use of data;

4e hire a TB/HIV advisor under ICAP to strengthen activities and provide technical assistance and training;

4f) include TB/HIV integration as part of the Clinical Mentors (ICAP staff) core tasks in the 21 districts CU

supports; 4g) provide training and support to the regional TB member of the RHMT and the District TB

coordinators to support improved integration of services; 4h) work with other groups such as PATH (a

TB/HIV implementing partner) to improve linkages through regular communications and meetings.

LINKAGES: CU works closely with the NACP, NTLP and the MOH diagnostics unit in implementing TB/HIV

activities. CU will continue to utilize existing MOH referral and reporting mechanisms to assist with

identification and referral between TB and HIV clinics. HIV management teams which include TB and care

and treatment coordinators based in the facilities or districts will meet regularly to review data on the

referrals from all TB and HIV clinics and will be empowered to identify and trace those lost to follow up. In

Pwani and Zanzibar, CU will collaborate with PATH in the implementation of TB/HIV activities. Because of

our strong regional presence with offices in Kagera, Kigoma, Coast and Zanzibar we have a regularly

updated list of programs with wraparound services and regular contacts with groups working in HIV/AIDS

activities.

CHECK BOXES: The areas of emphasis were chosen because activities will include training of health

workers. Strategic information activities will help inform the program on its achievements and challenges.

The general population and PLHAs will be targeted through HIV or TB testing activities and the provision of

ART or TB therapy.

Activity Narrative: M&E: a) CU will collaborate with the NACP and NTLP to implement national M&E systems for TB/HIV

diagnosis and treatment in the 3 regions & Zanzibar; b) the TB Screening Questionnaire (TSQ) will be

implemented at all sites and 12,954 newly enrolled HIV patients screened for TB; c) TB/HIV referrals will be

documented using the 2 way referral form between CTCs and TB clinics; d) CU will provide technical

assistance (TA) at all 42 sites for implementation of TB/HIV M&E systems and share quarterly and semi-

annual/annual reports on TB/HIV integration at the site, district and regional levels; e) data quality will be

ensured through regular supervision visits; f). 126 HCWs will be trained in TB/HIV M&E and 42 CTC's, 21

districts & 3 regions will be supported.

SUSTAINAIBLITY: CU will continue to build the technical and financial capacity of the local staff at the

health facilities and that of the local government authorities. Capacity will be built through training of clinical

staff in the co-management of TB/HIV and through training local government authorities in conducting

needs assessments, determining priority sites and activities, work planning, budgeting and M&E programs.

Emphasis will be made in strengthening quality assurance of programs. Capacity will also be enhanced in

grant writing as well as technical and financial report writing.

TITLE: Expanding HIV Testing and Counseling in Kagera, Kigoma, Pwani and Zanzibar

NEED and COMPARATIVE ADVANTAGE: Columbia University (CU) supports comprehensive HIV/AIDS

care and treatment services in four regions of Tanzania - Kagera, Kigoma, Pwani and Zanzibar.

Additionally, national level support includes technical assistance and support to the Ministry of Health and

Social Welfare (MOHSW) and Bugando Medical Center (BMC) for national HIV early infant diagnosis;

support to ORCI for scaling up palliative care, including pain management and symptom control; improving

PMTCT M&E with NACP; and in 2008 support to the National Quality Assurance and Training Laboratory in

Dar es Salaam. Since 2005, CU has incorporated testing and counseling as part of case-finding for HIV-

positive individuals to link to care and treatment. With Regionalization, CU will continue to provide voluntary

counseling and testing (VCT) services, tailoring such services to the needs of the regions and populations.

ACCOMPLISHMENTS: From 2004 to September 2007, 401,610 people will have received testing and

counseling in CU-supported VCT, PMTCT, and care and treatment sites. CU has supported and

established 44 VCT sites, and ensured clients are linked to care and treatment through the district network

approach. CU has conducted mobile VCT services in hard to reach areas and for most at-risk populations

(MARPs).

ACTIVITIES: In FY 2008, CU will:

1) Expand HIV testing and counseling to MARPs through: a) Monthly CT outreach targeting fishing islands

where there is a known high HIV prevalence through GOT health center clinics in Kagera; b) Training and

funding to ZANGOC(Zanzibar NGO Cluster) for delivery of CT targeted to MARPs in Zanzibar; c) Providing

CT outreach to mining areas in Kagera and Kigoma through GOT or NGO; d) Supporting mobile CT as part

of community activities in Pwani region linked to care and treatment at nearest clinics; and e) Strengthening

referral systems between VCT and other ARV services through the district network approach. All activities

will be planned and implemented in collaboration with other CT partners to maximize resources and reduce

duplication.

2) Strengthen existing facility-based VCT service delivery at CU-supported regional and district hospitals

and selected health centers by: a) Supporting the training of 50 staff in VCT; b) Undertaking minor

renovations and repairs at CU-supported VCT health centers; c) Procuring additional HIV test kits and

expendable supplies to fill gaps and meet scale-up needs; and d) Supporting lay counselors and additional

staff where needed in 21 districts to intensify VCT linked to care.

LINKAGES: CU will ensure strong links with care and treatment services when initiating VCT and outreach

CT services in Kagera, Kigoma, Pwani and at Ocean Road Cancer Institute. ZANGOC will target MARPS

on Unguja and Pemba; ZAPHA+ in Zanzibar will target family members and partners of PLHAs for HCT. All

sites implementing VCT will ensure strong referral network system for PLHAs for nutrition, psychosocial

OVC support. CU will ensure PLHAs from remote islands in Kagera receive ‘wraparound services' for this

displaced group with high numbers of HIV+ women and their children. With MSD/Supply Chain

Management Systems (SCMS), CU will strengthen supply chain management systems for full supply of HIV

test kits and expendables. CU is working with FHI in Pwani to link those testing positive with home-based

care to receive adequate care and treatment services. CU will link with PSI and TMARC so that HIV+ and

HIV- to receive robust prevention supports (e.g., condoms, behavior change).

CHECKBOXES: CU will focus primarily on expanding VCT in all regional, district and health centers in the

four regions where it works - building local human and management capacity to manage the program.

Gender is a focus as more women than men receive care and treatment - CU will target men and MARPs

for HCT. Target populations include the general population on in patient wards, TB and STI clients.

MARPs are targeted especially on Zanzibar (MSM, IDUs, and youth) and also fishing villages and islands in

Kagera.

M&E: The national registers were launched in July 2007. CU will collaborate with the NACP/MOHSW to

implement the national CT M&E system across all CU-supported HTC sites using 8% of the budget. Data

will be collected in the national CT registers and summarized in monthly summary forms (MSFs). After the

national database is completed, CU will implement it at 20% of the sites. At CU, an Access database will be

developed for storage of MSFs from all CU-supported sites. Data quality will be ensured through regular site

supervision visits with review of registers and range and consistency checks of MSF's. Finally, CU will share

quarterly and semi-annual/annual reports with the HCT teams at the site, district and regional levels.

SUSTAINABILITY: The "district network approach" used by CU ensures sustainability of activities in the

public sector settings through direct engagement with existing district health systems. Agreements are

determined through discussion with the District Executive Director and District Medical Officer in each of the

21 districts where CU works. Funds are provided to the District for implementing activities. Regional health

authorities are engaged in supportive supervision, training, and oversight of activities. Existing NGOS and

FBOs are strategically selected to scale up HCT services.

TITLE: Expanding HIV Care and Treatment Services in Kagera, Kigoma, Pwani, Zanzibar

NEED AND COMPARATIVE ADVANTAGE

Columbia University (CU) supports ART services in Kagera, Kigoma, Pwani and Zanzibar (HIV prevalence

of 0.9%-7.2%) where currently there is an estimated 51,503 patients in need of ART. There is need to bring

services closer to PLHAs in order to reach all those eligible for ART. CU proposes to establish ART services

at lower level facilities. This will involve infrastructure rehabilitation, training of health care workers, and

establishing the systems that are necessary to support ART programs. CU has supported high quality

comprehensive HIV Care and Treatment services for adults and children in Tanzania since 2004, and is

well positioned to further expand these services in FY 2008.[* regional HIV prevalence]

ACCOMPLISHMENTS

In FY 2007, CU supported ARV services in 24 hospitals. By June 2007, CU had enrolled 20,321 clients in

care and initiated 8,102 on ART (64% females and 36% males). Over 550 children under the age of 15 are

receiving ART. 55 pregnant women have started ART since the onset of the program. Early Infant

Diagnosis activities at CU sites have identified 754 HIV-exposed infants, of which 680 received an HIV test.

117 were noted to be HIV-infected and 65 are receiving Care and Treatment.

ACTIVITIES

COLUMBIA University will use the additional funds to accomplish the original targets of rolling out ART

services at 61 health facilities in five regions. This will involve: increasing coverage of HIV Care and

Treatment services through decentralization.

1. Focus on children (15% of total): 1a) renovate health centers for ART provision; 1b) train 372 staff in IMAI

curriculum 1c) provide clinical mentoring to staff in the provision of ART and enhance health care

workers' (HCW) skill to treat children; 1d) ensure commodities and supplies related to adult and pediatric

ART provision and OI drugs are available on-site through capacity of the Council Health Management

Teams (CHMT) in forecasting and logistics, and gap filling; 1e) ensure clients not eligible for ART are

enrolled into care programs; 1f) ensure Pre and ART registers are used to monitor clients on Care and

Treatment; 1g) provide care, treatment, and support through OVC programs to HIV-exposed and infected

children. This includes screening for HIV; HIV testing by DNA PCR for infants; establishing referral linkages

for care, including cotrimoxazole prophylaxis, and adherence support by community health workers; 1h) in

collaboration with the Ministry of Health and Social Welfare (MOHSW), expand roll-out of the early infant

diagnosis program to all four zones in Tanzania; including training zonal trainers and health facilities; 1i)

implement PITC at pediatric inpatient and outpatient departments; 1j) implement active case-finding at

immunization clinics and ensure mother's PMTCT status is documented on the child health card.

2. Provide comprehensive services at HIV Care and Treatment sites: 2a) ensure CU supported sites

provide Pediatric ART, PMTCT, EID, TB/HIV, PITC and HBC services; 2b) ensure strengthened linkages

between services; 2c) establish sample transportation systems; 2d) provide prevention with positives

services to clients attending care and treatment; 2e) adherence support to clients enrolled into ART

programs 2f) establish partnerships with programs providing commodities, nutritional, psychosocial, and

income generating support; 2g) coordinate with existing palliative care programs; 2h) establish PITC at all

entry points in CU supported facilities.

3. Ensure high quality ART service provision at all CU supported sites: 3a) implement standards of care and

evaluate quarterly; 3b) strengthen paper-based systems at sites and with computerized data at 20 sites; 3c)

strengthen the capacity of sites, districts and regions in the collection, analysis, and interpretation of data

and empower in data ownership; 3d) conduct regular data feedback sessions 3f) hire additional data clerks

at high volume ART sites;

4. Ensure ART service delivery is sustainable: 4a) empower Regional Health Management Teams (RHMTs)

and CHMTs in planning, implementation, and supportive supervision, and ensure ART related activities are

all included in the Comprehensive Council Health plans; conduct supportive supervision with CHMT and

RHMT; 4b) support one local NGO in each region; utilize community groups to provide psychosocial

support, link PLHAs to community support groups, and conduct defaulter tracing. 4c) empower PLHA

groups (at least one per region) to conduct adherence support activities; 4d) address policy issues around

the use of lay counselors and task shifting amongst HCWs at national level;

5. Expand public-private partnerships: 5a) identify urban sites with shortage of health care providers; 5b)

identify private health care workers providing medical services in the same urban sites; 5c) engage local

authorities and private practitioners in dialogue regarding collaborative provision of services; 5d) train

private practitioners in the NACP ART training curriculum, mentor and supervise service provision; 5e)

document process and outcome and disseminate results to national stakeholders and other implementing

partners; 5f) explore working with private for-profit businesses to initiate and/or strengthen care and

treatment services as part of their package of health services to employees and dependents; leverage

resources in the provision of ART for employees at the work place, and support HIV counseling and testing

for the community with links to care where possible (NB This portion of the activity includes a rapid

response capability to be mobilized in support of specific workplace program requests); 5g) continue

providing training on clinical care and M&E to Kagera Sugar Hospital and other companies with on-site

health clinics. These clinics are staffed, managed, and stocked by their respective companies.

6. Strengthen regional laboratory network in 4 regions: 6a) upgrade14 laboratories and train 40 staff/region

on laboratory management, opportunistic infections diagnosis and good laboratory practices; 6b) upgrade

infrastructure in six new laboratories; 6c) upgrade 20 health center laboratories to perform hematology,

chemistry tests and diagnose opportunistic infections; 6d) create and provide minimum package of

laboratory equipments and reagents to the regional, district, and health center laboratories; 6e) create

sample transportation system between lower tier and higher tier laboratories; 6f) on-site training for the six

new labs on HIV monitoring; 6h) establish a communication system between laboratories to ensure

accurate reagents procurement, forecasting, and provide training on estimation of existing stock, sample

transportation, and data collection; 6g) establish laboratory data management system in 40 laboratories; 6h)

technical Assistance by in-country and regional CU lab Advisors

LINKAGES

Activity Narrative: PLHA organizations will be supported to assist in basic care and adherence support CU works closely with

the NACP, the diagnostics unit and the National TB and Leprosy Program (NTLP) in implementing

comprehensive HIV/AIDS activities. CU has created effective linkages with TADEPA, a local NGO in

Kagera providing community mobilization and defaulter tracing services. Further linkages will be formed

with the Kagera Zone AIDS Project to provide adherence support to PLHAs. Population Services

International, Mennonite Economic Development Associates in commodity provision. IEC/BCC partnerships

with STRADCOM. In Zanzibar, the Zanzibar Association of People Living with HIV/AIDS and Zanzibar non-

governmental organization cluster will provide adherence support to PLHAs. CU works closely with Clinton

HIV/AIDS Initiative on Zanzibar. New partnerships with private sector groups such as Interchick (Pwani),

Kagera Sugar, Uvinza Salt, Kabanga nickel mines, Nyaza Cooperative Cotton outgrowers will be explored.

CU will not provide food support directly, but will explore linkages with the World Food Program (WFP) and

faith-based organizations in order to leverage resources for nutritional support.

CHECK BOXES

General population, most at risk populations, and others will be targeted through testing activities and the

provision of ART. Patients on wards targeted through PITC. Employees will be targeted for job satisfaction,

increased retention. Activities related to renovation will be conducted in an effort to improve the capacity of

health centers to provide care and treatment services. Human capacity development activities revolve

around in-service training of health care workers. Workplace programs will be part of public-private

partnership (PPP) activities. CU will continue providing technical assistance to the MOHSW M&E unit.

M&E:

a) CU will collaborate with NACP/MOHSW to implement the national M&E system in all regions

b) Data will be collected & reported using paper-based and electronic National CTC tools. National and

OGAC reports will be generated

c) CU will promote site feedback and data use

d) A data quality assurance protocol for paper-based and electronic data will be implemented at all sites

with one QA supervision visit/quarter.

e) The NACP access database is currently implemented at six sites & will be scaled up to 20 sites by Sept

08 f) CU will train 126 HCW in M&E systems and provide technical assistance (TA) to all 61 CTCs

g) CU will support sites/districts/regions to share their data at stakeholder meetings, workshops and

conferences.

SUSTAINABILITY

This year's focus will be local governments, private sector engagement, and work with PLHA organizations

for sustainability and adherence.

TITLE: Establishment of systems to support National Infant HIV diagnosis program, National Laboratory HIV

Quality Assurance and Training Center and Mnazi Mmoja Hospital in Zanzibar

NEED and COMPARATIVE ADVANTAGE: HIV disease progression during infancy is extremely rapid

where over a third of children succumb to HIV by 12 months of age and one-half die by 24 months. Early

diagnosis of HIV is therefore critical and now possible in limited resource settings through use of dried blood

spot (DBS) sampling and DNA PCR testing. This intervention feasibly and effectively allows for case-

finding of HIV-infected children early and engaging them in life-saving HIV care and ART services. CU has

supported the establishment of a first DNA PCR laboratory at Bugando Medical Center that provides HIV

diagnosis services for infants for the lake zone and rest of Tanzania. CU will continue to support the

systems for expansion of Early Infant Diagnosis services in partnership with CDC, MOHSW, African Medical

Research Foundation (AMREF) and others to the rest of Tanzania. These include support of staff at the

national level, trainings, technical assistance, guideline and training curriculum development. QA/QC will be

established for DNA PCR to ensure the quality of the results delivered..

ACCOMPLISHMENTS: In FY 2007 the only center in the country providing PCR-DNA using DBS was set

up and is functioning at Bugando Medical Center in Mwanza. Early Infant Diagnosis (EID) program results

included procurement of lab equipment and consumables, development of standard operating procedures,

training of 186 health care workers in DBS collection; clinicians in pediatric care and treatment; pediatric

patient referral mechanisms to the clinics in 21 centers. Through this intervention, 750 HIV exposed infants

have been identified, 679 tested and 117 (17%) identified as positive and referred for care and treatment.

CU also helped support MOHSW to develop the Early Infant Diagnosis guidelines that were finalized in

August 07.

ACTIVITIES: Columbia University (CU) will support the national early infant HIV diagnosis program through

provision of Technical Assistance to the MOHSW on implementation of EID services; training and retraining

of health care workers on EID services in four zones; building the capacity of the Regional Health

Management Team (RHMT) and Council Health Management Team (CHMT) on supportive supervision (4

regions, 21 districts) on EID activities including QA/QC; . CU will hire additional staff to manage scaled up

EID national program including one staff seconded to the MOHSW and one CU staff.

CU will support the establishment of EID capability at the (NHLQALTC). This will include the hiring of a

PCR technician to oversee the services both at the NHLQALTC and nationally being responsible for EID

Quality assurance. CU will work with MOHSW to strengthen systems for forecasting and procuring related

consumables by providing technical assistance on methods of forecasting. CU will provide TA on a

quarterly basis by an external Advisor on EID

Cu will support the implementation of quality systems (QS) at Mnazi Mmoja Referral Hospital Laboratory

(MMH). MMH lab is a referral lab for Zanzibar lab services, and currently does not have capacity to support

the laboratory services network as a referral center for HIV/AIDS in Zanziubar. The laboratory recently

conducted SWOT analysis towards implementation of the twelve elements of quality system and came up

with a list of strengths and weaknesses checklist. In a yet another activity by Clinical and laboratory

standard institute (CLSI) the referral hospital labs were assessed for international accreditation by using

ISO 15189 in which a gap analysis was presented to the participating labs MMH lab being among them.

With FY 2008 funding, the gaps as identified in the QS and accreditation gap analysis will be addressed.

MMH will be assisted to establish and strengthen internal and external QA/QC systems for HIV diagnosis,

HIV monitoring tests and opportunistic infection diagnosis tests, establish schedules and support systems

for QA/QC site visits for all laboratories in Unguja and Pemba, provide training to all Laboratory staff and

non lab on specimen management, document and record, laboratory management tools for pre-analytical,

analytical and post analytical. Perform Continuous improvement and laboratory safety;

LINKAGES: CU-ICAP will partner with the MOHSW - Diagnostic unit and NACP, US Government partners

(FHI, Harvard, AIDS Relief, DoD, EGPAF), the RHMT and CHMT, MOHSW health facilities, faith based

hospitals to scale up the early infant HIV diagnosis, QA/QC activities in the region and a networking among

the regional labs. Close linkages will grow with USG partners in every region to roll out the Early Infant

Diagnosis Program and also with the Clinton HIV/AIDS Foundation who provide technical assistance for

forecasting and quantification and who will assist MOHSW with the procurement of reagents and supplies

for the EID program. With CHAI CU is collaborating with EID on Zanzibar and planning to partner closely as

the national program scale up with hopes that CHAI will support the national reagents supply and DBS

logistics, CU will support the programmatic training, Bugando Medical Center PCR laboratory and national

QA/QC; Other partners with the National Quality Assurance and Reference lab set up by CDC will be key

partners in the coming year to fully staff and capacitate this important center. CU will partner with the

MOHSW and ZACP in Zanzibar and strengthen regional HIV and OI diagnosis and monitoring QA/QC

systems and TA.

CHECK BOXES: Health systems will be improved through a regional network of laboratories that will ensure

a large menu of tests are provided and services are close to the clinics thus improving the local health

system capacity and elevate the overall quality of clinical laboratories in-country. Services will include

renovations, capacity building and establishment of laboratory management systems

M&E: M&E: a) 5% of the budget will be dedicated to M&E activities b) Data on number of lab tests

performed per month will be collected from lab registers at sites using the CU monthly data collection tool.

c) Data on the targeted tests for HIV(140,000),TB diagnostics(14,000), Syphilis tests (14,000) and HIV

disease monitoring(30,000) will be collated in excel sheets for quarterly & semiannual PEPFAR reports d)

Data quality will be ensured through regular site supervision visits and on-site training and re-training of lab

technicians who complete the lab registers. e) There will be regular feedback of data to the CU lab advisor

and CU will also share quarterly and semi-annual/annual reports with the lab teams at the site, district and

regional levels. QA/QC data management and monitoring will include the EQA activity for EID from Atlanta

in all labs working on EID

SUSTAINAIBLITY: Program is focused at both national level (EID program in Four Zones of Tanzania), and

the regional level (CU Treatment and PMTCT regions). At national level our support will strengthen

MOHSW management and implementation of the national EID program through staffing, technical

assistance, ongoing training and support. CU support for training in the zones will empower other USG

partners and the regional and district authorities to carry out the program beyond the initial training and

follow up. With other partners such as CHAI, AMREF also supporting the national EID network, our inputs

are likely to be more strategic and sustainable. At the regional level our work is in line with plans under the

Activity Narrative: MOHSW for laboratory networks and CU inputs will strengthening labs for not only HIV/AIDS services, but

for the wider health care needs.