TITLE: AIDSRelief Rapid Expansion of ART

NEED and COMPARATIVE ADVANTAGE:

HIV-prevalence in Mwanza, Mara, Manyara & Tanga regions ranges from 2-7%, with an estimated total of

350,000 HIV positive individuals. An estimated 70,000 individuals are in need for ARV. As of June 2007,

only 13% (8,974) were on active ART. Effective scale-up of care & treatment services requires improved

infrastructures, staff capacity building, strengthened supply chains & enhanced management systems. With

four regionally-based teams working closely with Regional and Council Health Management Teams

(RHMT), faith & community-based groups, AIDSRelief (AR) can provide technical support & material inputs

necessary to increase ART enrollment to reach at least 50% of patients requiring ART. AR has the

additional advantage of working through faith-based partners who are rooted in communities in order to

support the spiritual & psychosocial needs of people living with HIV.

ACCOMPLISHMENTS:

Since initiating our program in July 2004, AR has promoted a comprehensive package of support to HIV

care and treatment partners, enabling them to respond to the needs of patients along a continuum of care,

promoting the conditions necessary to achieve durable viral suppression. As of June 2007, 18 AIDSRelief-

supported HIV treatment centers are providing care to 18,822 patients. Of these, 8,974 patients, including

719 children, were on active ART.

ACTIVITIES:

AR will provide significant inputs to roll out HIV care and treatment to 87 health facilities located in Mwanza,

Mara, Manyara, & Tanga regions

1) On-site preceptorship & ongoing supportive supervision to 87 facilities to achieve the minimum criteria for

the delivery of ART;1a) Ensure staff at all 87 facilities receive training in ART care & treatment using NACP

or IMAI curricula, augmented by AR adherence training including education on prevention for positives &

site management leadership skills;

2) Direct technical & material support (when central supplies are not available) to 87 facilities, including 52

lower level health centers (two per district); 2b) Develop comprehensive facility-specific work-plans including

Provider Initiated Testing and Counseling (PITC) & PMTCT in all facilities providing ART, with emphasis on

local accountability for clinic growth & performance; 2c) Renovate & purchase basic laboratory & clinical

equipment.

3) Increased number of pregnant women and children on ART 3a) Integrate ART services with PMTCT, TB,

ANC, inpatient & out-patient services to improve pediatric referrals; 3b) Monitor use of cotrimoxazole for HIV

-exposed & infected infants, implement universal CD4 screening of pregnant women & expedite entry onto

ART for those eligible; 3c) Strengthen capacity through basic training & mentoring of non-pediatric health

workers to provide care & treatment for children;

4) Strengthen role of the RHMT/CHMTs in the provision of supportive supervision to all dispensing facilities;

4a) Ensure all RHMTs have adequate skills and knowledge of ART care and treatment protocols; 4b)

Facilitate regular supportive supervision by RHMT/CHMTs to all dispensing facilities; 4c) Promote regional

planning & resource management;

5) Conduct ongoing QA/QI activities to measure success of programs. Institutional Review Board and other

ethical committee review approvals will be gained as necessary before initiation of activities; 5a) Conduct

chart reviews at each partner site for improvement of clinical practices; 5b) Conduct Life Table Analysis to

identify factors associated with early discontinuation of treatment; 5c) Conduct Quality of Life analysis to

assess whether morbidity decreases over time;

6) Expand laboratory capacity at facility & regional level; 6a) Establish training laboratory at a regional

hospital enabling laboratory staff from other facilities to improve technical skills and knowledge; 6b) Ensure

all facilities have adequate resources & capacity to perform diagnostic testing using nationally recognized

standard operating procedures; 6c) Formalize & strengthen referral systems for transport & processing of

lab specimens from lower level facilities; 6d) Ensure adequate systems to procure, store & track laboratory

reagents & commodities;

7) Improve pharmaceutical management; 7a) Strengthen capacity in inventory control & forecasting,

including OI drugs & pediatric ARV formulation; 7b) install computers in 35 facilities 7c) Improve

infrastructure for pharmacy management, storage & dispensing;

8. Improve adherence to treatment; 8a) Strengthen referrals between HIV service points & provide

community-based support; 8b) Involve PLHA as lay counselors & treatment support partners; 9) Strengthen

financial & management systems of partner institutions.

LINKAGES:

AR's established relationships with regional & district government, including RHMTs, faith-based networks

& community based groups reinforce linkages for improved patient support. AR also has the ability of

provide a comprehensive continuum of care through PMTCT, TB screening, HBC & OVC activities as well

as linking with CRS' broad portfolio of programs which involve many of our 39 current partners. These

include water resource development, micro-enterprise, savings and small farmer programs supported by the

USG and other donors. OVC & nutritional support programs provide added opportunities for identification of

HIV-exposed & infected children. AR community outreach volunteers & staff will map facility catchment

areas & formal linkages will be established between CTCs & groups providing home based palliative care in

these areas. Outreach & adherence staff, using patient attendance data, will utilize these networks to follow

up missed appointments or patients lost to follow up. PLHA groups will assist with scale-up by performing

as lay counselors & adherence support partners & assist with stigma reduction & education of prevention for

positives through sensitization of ward, street and 10-cell leaders.

CHECK BOXES:

Activities related to renovation will be conducted in an effort to improve laboratory capacity at AIDSRelief

supported sites. Human capacity development activities revolve around in-service training of health care

Activity Narrative: workers. HIV testing and enrollment into treatment will focus on the general population with added

emphasis on pregnant women and children. Discordant couples will be given prevention messages in

counseling sessions. PLHAs will be utilized as lay counselors and treatment support partners. Wrap-around

programs include activities with HBC, agriculture, water sanitation and micro-lending.

M&E:

AIDSRelief will collaborate with the National AIDS Control Program (NACP)/Ministry of Health and Social

Welfare (MOHSW) to implement the national M&E system for care & treatment in Mwanza, Mara, Manyara

& Tanga regions. Data will be collected using national tools. AR staff accompanied by regional & district

MoH personnel will provide quarterly supportive supervision for M&E to 87 care and treatment CTCs). This

approach will build the capacity of MoH staff to provide supportive supervision for quality assurance. We

shall provide regular feedback to supported sites & build capacity at facility & regional level to utilize data to

inform patient management & district/regional planning. Computerization of paper-based information

systems at facility level enhances their ability to synthesize data & generate information that can be used for

improving patient management & reporting to NACP & other donors. The NACP facility-based CTC 2

database is currently in use at 19 AIDSRelief supported CTCs. This will be expanded to 35 CTCs by end FY

2008. SI Targets: Initial & refresher trainings in the use of revised care & treatment tools will be provided to

498 HCWs. Technical Assistance (TA) will be provided for four regional and 13 district offices as well as the

87 CTCs. 7% of project support is designated for M&E.

SUSTAINAIBLITY:

AR will lay a foundation for sustainable Regional & District management of care and treatment by: 1)

Ensuring all RHMT, District Health Management Teams & CTC's receive training using the national

curriculum & work towards the achievement of minimum criteria for the delivery of ART; 2) Integrating the

program into existing health infrastructure & decentralizing services to health center level; 3) Strengthening

laboratory & pharmacy supply chains & medical records; 4) Promote development of patient support

mechanisms within communities which educate people about their health and promote treatment

adherence; 5) Working with RHMTs & CHMTs to ensure a quality assurance/improvement plans provide an

evidence base for critical information used to manage HIV care and treatment. programs.