TITLE: Expanding comprehensive ART services in six regions and other under-served areas in Tanzania.

NEED and COMPARATIVE ADVANTAGE:

There are approximately 2 million Tanzanians living with HIV and close to a cumulative 800,000 AIDS cases

have been reported.

HIV prevalence is higher in urban areas (10.9%) than in rural areas (5.3%) and it varies in different regions.

In our current four regions, Kilimanjaro, Arusha, Tabora and Shinyanga, it is estimated that 100,823,

68.527, 123,689 and 182,363 people are infected respectively who will need care and ART services at

some point. It is now estimated that only 7% of People Living with HIV/AIDS (PLHA) from these regions

have accessed care by end of March 2007. The percentage is much lower in Mtwara and Lindi regions

where EGPAF will extend support in FY 2008. With a strong commitment and support from the government

and local authorities, EGPAF will play an important role to ensure optimum accessibility to care and

treatment services.

ACCOMPLISHMENTS:

As of March 2007, 20,026 patients have been enrolled into HIV care, 9,477 initiated on ART including 1,090

(11.5%) children in 26 hospitals. However, 95,000 patients are estimated to be in need for ARV. About 300

health workers have been trained to provide comprehensive ART care including patient monitoring. Quality

of care has been improved in the facilities through integration with PMTCT, infrastructure improvement and

supply of equipments and other commodities such as office, laboratory and pharmacy supplies.

ACTIVITIES:

1) Provide support to four lower level facilities (Health Centers) per district in current four regions (total of

124 sites) 1a) Support planning, training, mentorship and supervision by district teams. Ensure HIV is

included in Comprehensive Council Health Plans 1b) Improve referral system between facilities and

facilitate transport for mentorship and supervision and specimen testing 1c) Minor renovations and supply of

equipment

2) Provide continuum of care through integration and linkage between Care &Treatment and PMTCT and

TB services and community based services 2a) All ART supported sites will offer PMTCT services.

Strengthen mechanisms for referral of HIV+ women from PMTCT to care and treatment by promoting use of

referral slips and/or physical escorting and registers to countercheck 2b) Train PMTCT health care workers

(HCW) to carry out clinical staging of HIV+ mothers and partners and keep them at Reproductive & Child

Health (RCH) clinic for basic care services till they are eligible for ART 2c) Support community liaison

person at each site to link enrolled patients to CBO's for non-medical care and support 2d) PLHA groups

will be supported to provide peer-led adherence counseling, tracking of defaulters and for strengthening

prevention among positives. Condoms and other contraceptives will be provided in facilities where religion

is not a constraint.

3) Support and expand provider-initiated testing and counseling (PITC) to all health facilities 3a) Train

Health Care Workers (HCW) in Provider Initiated Testing and Counseling (PITC) using the National

curriculum 3b) Provide HIV test kits when central supply is not available 3c) Conduct community

sensitization meetings to increase demand and uptake of testing.

4) Increase the number and percentage of children enrolled to care and receiving ART 4a) Train HCW on

routine testing, basic care and referral of children attending RCH clinics and in-patient wards. 4b) Sensitize

and disseminate the revised child health cards with HIV exposure identification. 4c) Train health care

workers on early infant diagnosis including use of dried blood spot (DBS) for PCR testing. 4d) Mentor health

workers on pediatric ART. 4e) Provide care and treatment to HIV exposed and infected children through

OVC programs; 15% of total patients on ART will be children; 4f) Implement PITC at all points where

children come in contact with the health care system. This includes offering HIV testing to children and their

mothers at outpatient clinics, reproductive and child health clinics, and inpatient wards. EGPAF is part of the

USG initiative to increase identification of HIV exposed and infected children among those attending normal

immunization clinics. A demonstration project for integrating identification and referral of HIV exposed

children within immunization services is being implemented in two EGPAF sites, two Columbia sites, and

two Harvard sites, with EGPAF providing overall coordination.

5) Continue support for ART services in the current 38 health facilities. 5a) Provide trainings for back up

teams and focused pediatric training 5b) Support activities for continuous quality improvement. 5c) Recruit a

laboratory technician to assist with quality assurance (QA) at EGPAF supported sites in collaboration with

MOHSW. EGPAF will follow MOHSW standard operating procedures for QA. 5d) Strengthen data

collection, on-site utilization and reporting.

6) Expand support for both PMTCT and ART to underserved areas in Lindi and Mtwara regions in close

collaboration with Clinton Foundation in response to a request by the Ministry of Health.$2,078,236.

LINKAGES:

We will strengthen collaboration with NGOs (like PATHFINDER, MILDMAY, Word Food Program (WFP),

World Vision, KIWAKKUKI and MARTEA) that support other programs for PLHA, to ensure they (PLHA)

receive a combination of clinical, psychological, spiritual, social, & preventive services to optimize quality of

life. The CTC community liaison person will coordinate with CBO's and PLHA groups in follow-up and

tracking of clients. The program will promote active participation of community resource persons and

structures, and will use wrap-around programs for nutritional support (like WFP, World Vision) and the

Emergency Hiring Plan for human resource support. Continue partnership with Mkapa Fellows Foundation

for placement of critically needed human resource cadres in our supported facilities. Public-Private

Partnerships: EGPAF currently supports five private hospitals (Tanzania Sugar Plantation Corporation,

Mwadui Diamond mines hospital, Ithna Asheri hospital, and Arusha International Conference Centre

hospital) which are owned, staffed and run by private companies. The GoT provides ARV drugs to these

hospitals and EGPAF supplements the Governement's efforts with HIV-related supplies when central

supplies are not available. In addition, EGPAF supports 13 Faith Based Organization hospitals.

CHECK BOXES

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

Activity Narrative: training of health care workers. HIV testing and enrollment into treatment will focus on the general

population

M&E:

EGPAF will collaborate with NACP/MOHSW to implement the National M&E system for care and treatment

in Arusha, Kilimanjaro, Shinyanga, Tabora, Mtwara and Lindi regions. Data will be collected using paper-

based systems and where possible entered into the National CTC2 database. District teams will be

supported to perform M&E supportive supervision to their respective sites. EGPAF will provide the required

National and PEPFAR reports. In order to promote data use culture, we shall provide regular feedback to

supported sites and promote data utilization at sites through the Quality Improvement program for better

patient management. Data Quality Assurance: District teams will be supported to perform M&E supportive

supervision to their respective sites. Scale-up of electronic database: Currently, 15 facilities have the CTC2

database. This number will increase to 38 by September 2008. At the EGPAF Semi-annual partners

meetings, partners will share best practices, motivation and recognition of top performing sites will occur

and operational practices will be standardized across all sites.

SUSTAINABILITY:

EGPAF Tanzania works closely with the Government in the implementation of activities to ensure that the

plans are aligned with the National strategy. Local capacity building is ensured by improving physical

infrastructure, training and mentoring local Tanzanian health workers and using local Tanzanian technical

officers in project implementation. Systems are developed that rely heavily on local inputs and personnel.

External TA will gradually decrease over time, and in the next year training from Baylor and UCSF will

concentrate on refresher training, training of trainers, and mentorship. District teams will be empowered to

do supportive supervision and provide TA to lower level facilities.