TITLE: Scale-up of Home-based Care Activities for People Living with HIV/AIDS in Tanzania

NEED and COMPARATIVE ADVANTAGE: HIV/AIDS remains the biggest public health challenge in

Tanzania. Community home-based care (HBC) is a critical component of the continuum of prevention,

care, support, and treatment for People Living with HIV/AIDS (PLWHA). HBC services aim to teach clients

to live positively while providing palliative care and support, in addition to linking individuals to health and

social services. HBC creates strong two-way referral linkages between the community and medical

facilities. HBC helps clients get the treatment and support required in order to live longer, healthier lives.

Pathfinder International (PFI) has been working in HBC in Tanzania since 2001 and has built strong working

relationships at the community level. PFI and its sub-partners are providing comprehensive home-based

palliative care services that include clinical, psychological, spiritual, and social care, as well as providing

insecticide treated nets (ITNs), water vessels, purification tablets, cotrimoxizole prophylaxis, nutritional

support/education, home counseling and testing services, and referrals.

ACCOMPLISHMENTS: PFI has supported 18,000 individuals with general HIV-related palliative care,

sensitized 120,000 community members on services and need for HBC, trained over 800 individuals, and

extended services to 67 wards. Over 3,000 HBC kits and 3,000 ITNs have been distributed. PFI has

conducted needs assessments for five implementing partners and is a member of the care and support

subcommittee of the National Advisory Committee on HIV/AIDS. PFI assisted the National AIDS Control

Programme (NACP) in coordinating and pre-testing supervision tools and in proposing a strategic

framework for HBC planning.

ACTIVITIES: With FY 2008 funding, PFI will:

1. Scale up coverage and strengthen provision of integrated, high-quality care and support for PLWHA in

five existing and two new regions. PFI will support and encourage community leaders to mobilize local

resources and enlist community involvement and ownership. Mapping of facilities will be done to identify

how partners will establish collaboration between facility-based and community HBC, entry-to-care points,

and other key services actors. The program will strengthen and formalize systems between local health

facilities, community-based organizations (CBOs), Council Multisectoral AIDS Committees (CMACs), and

community groups to support referrals, supervision, reporting, and follow-up for continuity and efficacy of

services.

2. Build the capacity of local government and civil society for sustainable delivery of services for PLWHA.

PFI will also provide input to NACP to strengthen programs and coordinate community HBC activities,

institutionalize technical monitoring, supervision systems, and tools. PFI will provide intensive institutional

capacity building (ICB) support for district health management teams (DHMT) and CBOs to expand

activities. Possible tailored support includes strengthening of financial, human resource, operational

management systems, as well as governance and strategic planning. An efficient, rapid, and flexible sub-

grant mechanism will work in tandem with capacity-building support for scaled-up service delivery in order

to develop intermediary organizations as key stakeholders in the national HIV/AIDS response.

3. Expand access and integrated service networks of PLWHA to the continuum of care and comprehensive

HIV/AIDS services, as well as preventive care and interventions and prevention with positives. PFI will

encourage local and national groups and committees (including PLWHA groups), to share their work and

raise implementation challenges with high-level stakeholders, institutionalizing mechanisms to

collaboratively address PLWHA and HIV-related issues. PFI will advocate for increased attention to

palliative care at all levels with policymakers and government representatives. PFI will provide clients with

comprehensive home-based palliative care services that include clinical, psychological, spiritual, social

care, and preventative services (ITN, water vessels, cotrimoxizole, nutritional support/education, counseling

and testing services, and referrals). By establishing linkages with antiretroviral therapy (ART) partners and

municipal facilities will aid in strengthened referrals. A critical aspect that will receive renewed attention is to

identify children in the household who may have been exposed to HIV and ensure they are tested and

referred as appropriate for care/treatment. PFI will also take advantage of home visits to ensure that

prevention messages are provided for those who are positive to reduce behavior that risks transmission,

offer condoms and family planning (as appropriate), and monitor adherence.

4. Train and equip service providers for quality service provision. PFI will conduct training of trainer (TOT)

courses for new areas and refresher courses for existing TOTs in new technical areas. PFI will train new

community home-based care providers (CHBCPs). Existing providers will have refresher training which will

include provision of home-based care for HIV-positive children. PFI will facilitate coordination between

health training centers and lead agencies to promulgate palliative care training. It will be important to

expand successful purchase of supplies allowing management of supplies with district medical stores

officers who are provided with community HBC kit stock management training. All providers will be given

HBC kits after trainings.

5. Work with NACP and key HBC partners to develop, print, and disseminate behavior change

communication/information, education, communication (BCC/IEC) material and best practices. They will

also develop different communication materials to increase utilization of services, inform, and educate the

public on community HBC and other HIV/AIDS issues. Success stories and project experiences will be

documented, published, distributed in country, and presented at appropriate international learning

conferences.

6. Pilot the use of solar-powered handheld electronic devices to connect community and facility levels for

palliative care referrals, linkages, and back-up support. In remote areas, this will allow more effective

transmission of data.

LINKAGES: As one of the large HBC implementing partners, PFI will provide input and feedback to the

Tanzanian Commission for AIDS (TACAIDS) and NACP on policy, standards, M&E, and coordination

related to HIV/AIDS prevention, care, treatment, and impact mitigation. They will also participate in HBC

technical and coordination groups. To ensure access to and use of quality of services, the project will

develop strategic partnerships and build linkages with existing governmental and non-governmental

organizations at all levels. They will collaborate with existing structures to build local capacity and access

Activity Narrative: wraparound programs including food security, education and vocational training, safe water, ITNs linked

with the President's Malaria Initiative, and income-generating activities (IGA). The project will work closely

with USG and non-USG funded HIV/AIDS and health projects to expand breadth and depth of service

coverage especially for counseling and testing, PMTCT, ARVs, opportunistic infection prevention and

treatment, and wraparound services. Under the regionalization process, Pathfinder will specifically

coordinate the activities of other implementing partners to avoid duplication of effort and to ensure good

communication to the CMACS and local government.

CHECK BOXES: The project will be implemented in seven regions and will target PLWHA and the general

population. Both urban and rural areas will be targeted for service provision although areas with referral

facilities will be given preference to allow for linkages and wraparound services. Through ICB activities,

DHMTs and implementing partner's managerial capacities will be strengthened to improve program quality.

The project will strive to ensure that every individual in the operational area in need of HBC service is

accessing services through trained providers.

SUSTAINAIBLITY: PFI will promote sustainable activities by building capacity of existing DHMTs, CBOs,

coordination bodies, and CHBCPs and have formal agreements stipulating each party's roles,

responsibilities, and expectations in order to support incorporation of HBC activities in comprehensive

district plans. Sub-grantees will be strengthened in internal governance, financial sustainability, and

management information systems. Programmatic sustainability will be strengthened by upgrading skills

through step-down training by intermediate organizations.

TITLE: Tutunzane Integrating Community Program for Orphans and Vulnerable Children (OVC).

NEED and COMPARATIVE ADVANTAGE: Tanzania has approximately 2.5 million Orphans and

Vulnerable Children (OVC). Previously, orphanhood did not pose a problem to existing coping

mechanisms. However, the increasing numbers of OVC have overburdened traditional coping

mechanisms. In response, Tanzania has developed different strategies to improve and scale up services to

assist OVC and families affected by HIV/AIDS. Pathfinder International (PFI) has worked in Tanzania since

2001, building strong working relationships at the community level and providing home-based care to

people living with HIV/AIDS (PLWHA). This provides an opportunity to do case finding for HIV-exposed

OVC and provide services to them. The home-based care program, called Tutunzane (which translates to

"let us take care of each other"), will be expanded to include support for OVC, leveraging its relationships

with communities and expertise in home-based care.

ACCOMPLISHMENTS: Tutunzane already serves 18,000 PLWHA. Its key sub-partner, the Axios

Partnership in Tanzania (APT) also has considerable expertise working with OVC and communities. With

Abbott funding, APT served 4,698 OVC in paralegal cases; 15,000 in medical and psychosocial support;

11,000 with nutritional support; 1,148 with birth certificate registration; 165 with income generation activities

(IGA); and trained 811 volunteers. APT also built capacity for vocational training, worked with school health

programs and district OVC management teams, developed a business coalition model, produced guidelines

for institutional care, and developed an exit strategy for mature OVC to transition from institutions into the

community.

ACTIVITIES: With FY 2008 funds, Tutunzane will collaborate with APT as a sub-partner to scale up the

OVC National Plan of Action (NPA) by applying the national OVC identification process and provision of

comprehensive, effective, and high quality services. Tutunzane will build on existing local initiatives and

programs to establish interventions that are culturally appropriate in care giving and suitable to the

communities. Emphasis will be placed on ensuring that OVC receive better care within communities than in

institutions. This project is proposed to be implemented in the regions where Tutunzane is already active, in

addition to expanding to seven districts of Shinyanga Region. It will operate both in urban and rural areas,

with preference for areas with referral facilities for wraparound services. The program is expected to reach

9,800 OVC.

By the end of year one, PFI and APT will have completed a baseline survey, including an identification of

the OVC, and a market analysis of micro enterprise opportunities; trained project staff in psychosocial

outreach to OVC; and solidified project partnerships for rollout. PFI will provide educational support to OVC

identified by the community during the baseline assessment. Methods of operation will also be established,

laying out procedures to identify children who have been exposed to HIV so that they are referred for testing

and care/treatment, if necessary. OVC served during this period will include those children and adolescents

already identified by communities through other community-based organizations (CBOs) and local Most

Vulnerable Children's Committees (MVCCs). Established indigenous and other organizations will receive

necessary training in order to carry out project activities, and MVCC will be supported in building capacity to

provide oversight. Lessons learned and insight gained from this process will be used to inform, encourage,

and facilitate replication to other communities. In subsequent years of the project, PFI will work with

established partners to rapidly take to scale, model interventions, and mentor newly identified CSOs to

replicate the project and share relevant experiences. The programmatic responses will be complemented

and supported by implementing activities that strengthen the policy and program environment to adequately

address the needs and interests of OVC.

The Tutunzane Program will train community home-based care providers (CHBCPs) on the provision of

psychosocial support (PSS) to quickly catalyze and coordinate community PSS for OVC. Cultural,

recreational, and life-skills activities will be accessible to all children and adolescents in the community, with

a particular emphasis on the inclusion of OVC. Educational opportunities for OVC will be facilitated in

partnership with local CBOs through activities such as awareness raising by CHBCPs; provision of

scholastic materials to OVC; and teacher training on PSS. Vocational and life skills training for adolescents

will be developed following the program baseline survey and market surveys. Tutunzane will link with

community programs for food provision, coordinated by sub-grantees, to reduce food insecurity felt by

households caring for OVC. CHBCPs will provide nutritional education both inside and outside the home.

Tutunzane will collaborate with other OVC programs to ensure that child protection, social welfare, and

succession programs will be in place to bridge the gap between law and traditional practices, strengthen

child protection capacity at district and community level (to protect children from abuse and exploitation),

and provide a focal point to link all OVC related interventions.

Throughout the project intervention, particular attention will be given to child protection and minimizing girls'

vulnerability to exploitation and abuse. CHBCPs will ensure that those girls identified as being particularly

vulnerable to sexual exploitation are actively recruited for vocational training.

LINKAGES: This activity will link with all USG-funded OVC activities, especially through the OVC

Implementing Partner Group network. It will also be closely aligned with the PFI home-based care activity.

Basic mapping will be accomplished in program regions to identify other programs for potential wraparound

activities. Replication of the national OVC IPG activities at district and regional levels will be encouraged in

order to enhance linkages, reduce duplication, and support the districts' social welfare capacity to

coordinate OVC activities. PFI will also link with Peace Corps to strengthen nutritional and economic needs

of OVC households.

CHECK BOXES: The project will be implemented in five regions and the target populations are OVC. Both

urban and rural areas will be targeted for service provision with preference for areas with referral facilities

for wraparound services. Tutunzane will also assist to the MVCCs and CBOs to strengthen managerial

capacities in order to improve program quality and ensure compliance with the national programs. The

project will strive to ensure that every individual in the operational area in need of OVC service has access

to the services, with particular attention given to child protection and minimizing girls' vulnerability to

exploitation and abuse.

M&E: Tutunzane will adopt the national Data Management System, and will use that system for monitoring

and evaluation. They will ensure that sub-grantees are responsible and accountable for inputting

Activity Narrative: information about identified OVC. Tutunzane will also ensure that the data from the local level feeds not

only into the national system, but is also available to MVCCs at the local level for planning, decision making,

and monitoring. Tutunzane will also work with FHI to build capacity of the district social welfare and M&E

officers and purchase them computers to ensure data quality and integrity. In addition, PFI will conduct

quarterly field visits to assess the quality of services provided, collect data, and provide onsite refresher

training as needed. Lastly, PFI will support CBOs that are implementers at the district level to ensure

correct monitoring of the Emergency Plan program. Monthly data will be compiled, reviewed, and

aggregated from all districts/regions on a quarterly basis, to be shared with stakeholders and the USG.

SUSTAINAIBLITY: Tutunzane will support capacity development of the MVCCs, district social welfare

officers, and local CSO sub-grantees to ensure sustainability. Tutunzane will have memoranda of

understandings with council health management teams and implementing partners stipulating each party's

roles, responsibilities, and expectations, including the stipulation that OVC activities be included in

comprehensive district plans. At village levels, households will be strengthened through training and

income generating activities and entrepreneurship skills. With the support of district leaders, MVCC and

community leader's strategies will be developed to leverage local food production to create community

reserves for the child and elderly headed households. Tutunzane-supported CSO will be offered training in

project proposal development to open other grant opportunities.

TITLE: Scaling up HBCT within Tutunzane Program in Five Regions

NEED and COMPARATIVE ADVANTAGE: A limited number of Tanzanians know their HIV serostatus,

which hinders individual access to appropriate care and support and limits the proven preventive effect of

testing for HIV-negative individuals. VCT is a cost-effective method for increasing the number of Tanzanians

who know their HIV serostatus and reducing high-risk sexual behavior and preventing HIV transmission. It

has been estimated that VCT offered to 10,000 Tanzanians would avert 895 HIV infections at a cost of $346

per infection averted and $17.78 per disability-adjusted life year (DALY) saved. One strategy for scaling up

VCT services is the integration with community home-based care (CHBC). Home counseling and testing in

conjunction with CHBC programs will serve as an efficient way to scale-up counseling and testing in

targeted communities by utilizing existing volunteer CHBC providers with established networks for referral

and care and support.

ACCOMPLISHMENTS: PathFinder International (PFI ) began piloting home-based counseling and testing

(HBCT) in FY 2007 after a team from NACP, CDC, USAID, FHI and PFI learned how HBCT is being

implemented during a study tour in Uganda. PFI held several consultative meetings with key implementing

partners, including NACP and DMOs in Arumeru and Temeke. Finally, project site selection was completed

in collaboration with District authorities.

ACTIVITIES:

PFI plans eight key strategies to scale up HBCT.

1. Increase coverage and strengthen provision of counseling and testing at the community level in selected

regions from two existing districts in two regions to 18 districts in seven regions.

1a) Community sensitization and mobilization meetings will be conducted with leaders and stakeholders at

all levels. Meetings will focus on all aspects of project implementation will serve to build community

acceptance and garner support for community and home based counseling and testing (CT).

1b) CT outreach services will be conducted for hard to reach populations (e.g., mining and plantation

workers) in partnership with CBOs and FBOs implementing counseling and testing services.

2. Expand access and integrated service networks through partnerships, referrals and linkages.

2a) Orientation meetings will be conducted at regional and district levels with administrative and health

facility staff. Meetings will cover all aspects of community and home based CT implementation to engage

leaders in support of the activity and to plan specific activities that they can carry out to build community

acceptance.

2b) Additional orientation/sensitization workshops will be conducted for regional and council health

management teams in the selected districts - to link the services to the health facilities.

2c) Conduct mapping exercise with NACP/MOHSW to identify care and support services within Tutunzane

operation areas and advise the program on how best to establish functional referral systems.

2d) Identify laboratory facilities for quality assurance of test results.

3. Implement prevention with positives activities to avert new infections.

3a) Counsel individuals in order to increase disclosure of HIV status to partners when there is no

foreseeable harm to the client. Staff will also provide counseling on several key prevention issues, including

sexual risk reduction, adherence and reduction of alcohol consumption.

3b) Establish a referral system to care and treatment, PMTCT, STI and RCHS/family planning clinics.

3c) Develop IEC materials with prevention messages for HIV positive persons (e.g., proper use of condoms,

family planning, STI prevention).

4. Train and equip service providers for quality HBCT service provision.

4a) PFI will train 72 laboratory staff from 36 health facilities in 18 districts in collaboration with the MOHSW

Diagnostic Unit. Training will include the new national rapid test algorithm and quality assurance and

control issues. It is anticipated that every tenth positive and fiftieth negative test result will be sent to the

nearest designated laboratory for confirmatory testing.

4b) PFI also will train 350 lay counselors and 150 new supervisors (health personnel) in expanded areas.

The trained personnel will be responsible for the actual testing and the lay counselors will be involved in the

provision of counseling services.

4c) Finally, PFI will conduct refresher training for lay counselors and supervisors, as needed.

5. Procure commodities and supplies to support the HBCT program. PFI will procure and distribute 4400

Bioline, 165 Determine and 28 Unigold test kits (the new algorithm) and supplies (e.g., gloves, safety boxes)

through MSD.

6. Develop, print and disseminate BCC/IEC material and best practices.

6a) PFI will develop a variety of print communication materials to facilitate community awareness about

HBCT, the testing process and benefits.

6b) Working in collaboration with HBCT partners, PFI will adapt job aides and pocket guides. These will be

used to provide clear step by step instructions on community/home based counseling and testing for HCT

providers. The aides will be durable and portable to allow providers to carry them during visits.

7. Maintain equipment and vehicles. A portion of funds will be used for fuel for vehicles and motorcycles,

maintenance and other running costs.

8. Hire new project staff to support planned activities. New staff will include supervisors (72) and lab

personnel (36) to assist in supervision and quality assurance issues.

LINKAGES: PFI is committed to ensuring continuum of care through networking with other organizations

implementing HIV programs. Effective linkages have been created throughout Tutunzane operation areas

and include collaborations with health facilities, care and treatment clinics for ARV and PMTCT Programs

like Tunajali and CCBRT among others. Other linkages are to family planning programs and TB clinics. In

addition the Tutunzane program in which HBCT is incorporated will serve as a platform for supporting HIV

positive identified individuals with services like supportive counseling and nutrition counseling. Furthermore,

HIV positive individuals will be linked to other care and support services provided by FBOs and CBOs in

their community. Tutunzane will also foster collaboration with legal associations like WLAC and TAWLA for

Activity Narrative: legal aid in case of gender violence related to disclosure of HIV status.

CHECK BOXES: General population and human development capacity are chosen as counseling and

testing will be accessible on consent to everyone while training activities will be included to build the

capacity of providers for quality service provision. Geographical coverage will be in line with Tutunzane

program areas. The project will strive to make sure that every individual in need of testing is accessing the

services. Agreements for wrap around services will be developed with several appropriate partners

M&E: The M&E system developed in the pilot phase builds on existing tools and local capacities, allowing

for necessary adaptations. It reports achievements against the project's results, and monitors qualitative

and quantitative indicators. The approach is participatory and interactive, encouraging joint accountability

and specific outcomes and responsive to needs and capacities of local partners; and provides ongoing

feedback. To extract and analyze data, Tutunzane employs a number of methods, including, but not limited

to service delivery statistics, monitoring visits and program meetings. Monthly data will be compiled,

reviewed, and aggregated from all districts/regions and shared with DHMT, NACP, other stakeholders and

CDC on a quarterly basis. PFI will work in collaboration with NACP and other actors to develop relevant

tools for monitoring the program.

SUSTAINAIBLITY: PFI through its Tutunzane program will promote sustainable activities by building the

capacity of existing DHMTs, CBOs, coordination bodies and CHBCPs. PFI also will have MOUs with them

that stipulate each party's roles, responsibilities and expectations and support incorporation of HBC

activities in comprehensive District plans. Sub-grantees will be strengthened in internal governance,

financial sustainability, and management information systems. Programmatic sustainability will be

strengthened by upgrading skills through step-down training by intermediate organizations.