TITLE: Strengthening and Expanding Counselling and Testing Services in the Lake Zone.

NEED and COMPARATIVE ADVANTAGE: The burden of HIV in the Lake Zone is quite high in comparison

to national statistics (12% vs. 7%). The situation is worse in some isolated areas (e.g., fishermen

communities and small business centres) where prevalence of 20% has been documented. There are few

sites providing counseling and testing (CT) services, and most are located in hospitals that are not easily

accessible to the larger population. The Bugando Medical Centre (BMC) began addressing access to these

counseling and testing services by training health care workers to offer HIV CT. Experience has shown that

most people in the hospitals and communities are willing to test for HIV if given pre-test information. Given

the success and acceptability, there is a need to strengthen and expand provider-initiated testing and

counseling (PITC) by training more health care workers and involving PLHA and lay counselors to conduct

PITC. BMC, being a pioneer in PITC, has got cooperative advantage to execute this work. In an effort to

reach individuals who do not regularly seek medical care, BMC will also conduct community testing at

market areas and special events in areas of high prevalence in the Lake Zone.

ACCOMPLISHMENTS: BMC established PITC services in both outpatient and inpatient wards. As of June

2007, a total of 12,772 patients have accessed HIV testing. BMC has also conducted 34 community

outreaches where a total of 14,849 clients have accessed HIV testing. In both settings, the acceptability for

testing is very high and referrals to care and treatment are made for those found to be HIV positive. Finally,

BMC trained 45 health care workers from the hospital and several community groups on VCT.

ACTIVITIES:

For FY 2008, BMC will strengthen and expand CT activities in the Lake Zone with the following activities.

1. Initiate a PITC program for all patients who use outpatient and inpatient services in six regions and four

districts hospitals. This will be accomplished by training 104 health care workers in PITC, and coordinating

CT partners in respective regions to ensure patients successfully receive test results and referrals.

2. Involve lay counselors and PLHA in provisional delivery of PITC services especially conducting

counseling sessions at the medical facilities. This task-shifting is a strategy to address the HR constraints

and will involve training 80 lay counselors, including PLHA from different HIV organizations in Mwanza

region, on the provision of the counseling sessions to clients at the medical facilities.

3. Strengthen and provide technical support to community testing efforts in the target areas of high

prevalence of HIV in the Lake Zone. To accomplish this activity, BMC will hire 12 community counselors

who will conduct outreach and link HIV-positive individuals with care and treatment services. BMC also will

purchase a new vehicle for ferrying counselors and the tents used for community volunteer counseling and

testing (VCT) outreaches. This activity will be conducted in collaboration with other partners and CBOs

conducting CT services in the Lake Zone.

LINKAGES: BMC is ensuring a continuum of care with other programs in Mwanza, including AIDSRelief,

which supports the care and treatment clinic, and Columbia University which deals with Infant Diagnosis.

BMC also collaborates with CBOs such as Nyakato AIDS, Mwanza Outreach Group, Archdiocese of

Mwanza, Care Tumaini-ELCT, Shalom Care House, and Uzima Centre Bukumbi.

CHECK BOXES: The areas of emphasis were chosen because human capacity development will target

health care and community providers. HIV test will target all age groups in the general population and

patients seeking care.

M&E: BMC will use both paper-based and electronic tools to monitor CT (VCT and PITC) activities. The

paper-based system will consist of registers, outreach report, and quarterly report. Monthly report will be

compiled into quarterly report, and will be analyzed to show programmatic strengths and weaknesses, this

will be also shared by other stakeholders. Both paper-based and electronic systems will comply with

national tools and reporting requirements.

SUSTAINABILITY: BMC, in collaboration with regional partners, will ensure sustainability by building

capacity in regional and districts health facilities and gradual task shifting through regular supportive

supervision and mentoring. Council Health Management Teams (CHMT) will be encouraged to incorporate

counseling and testing activities in their comprehensive council health plans in their respective districts.

TITLE: Strengthen and Expand comprehensive ART services in 6 regions of the Lake Zone.

NEED and COMPARATIVE ADVANTAGE: Lake Zone is estimated to have about 900,000 PLWHA, of

these 180,000 require anti retroviral treatment. Hitherto, not more than 10,000 PLWHA are on antiretroviral

treatment. The ART need gap is quite big, the training need of health care workers (HCW) is a challenge.

BMC as a referral hospital, with highly trained national trainers, and an exemplary and innovative care and

treatment clinic, has a comparative advantage to address this challenge through training and supportive

supervision. Indeed, BMC has pioneered scale-up of ART to primary health facilities, introduction of a Pre-

ART patient preparation course a network model with strong linkages with PLWHA support groups and

community home based care programs in Mwanza. Thus, BMC is better placed to spearhead scale-up of

quality ART service through training for ART delivery in the Lake Zone.

ACCOMPLISHMENTS:

1. BMC has been responsible for training initial and back-up teams for provision of ART services in all

districts, regions, and FBO hospitals in the Lake Zone. As of 31st March 07 a total of 431 Health Care

Workers (HCW) were trained in comprehensive HIV care, and 73 HCW were trained as Trainer of Trainers

on Integrated Management of Adult Ilnesses.

2. Developed a pre-ART patient preparation course.

3. Developed a network model of ART delivery with strong community links.

4. Introduced integrated HIV care with PMTCT and TB services.

5. Provided supportive supervision and mentoring to four regions in collaboration with Ministry of Health

Social Welfare (MOHSW) and partners.

ACTIVITIES:

1. To strengthen and build human capacity for provision and scale-up of ART in the Lake Zone. 1a. Train

120 HCWs from primary health facilities using the Integrated Management of Adult and Adolescent Illnes

(IMAI) curriculum. 1b. Train 80 HCP from 35 districts and six regional hospitals on HIV pediatric care. 1c)

Train 80.HCW in regional hospitals, district hospitals in Dried Blood Spot (DBS) specimen collection for

infant diagnosis. 1d) Train 126 HCWs from six regional and 15 district PMTCT teams on HIV/AIDS care

using the national curriculum, to enable them deliver ART at PMTCT sites. This is crucial to increase

women's access to initiation of care and treatment. 1e. Train 36 Regional Health Management Team

(RHMT) and 120 Council Health Management Team (CHMT) members on comprehensive HIV/AIDS

management and supervision to strengthen their capacity to supervise HIV/AIDS services in their respective

regions and districts. 1f) Training of 120 HCWs on new National algorithm for Rapid HIV testing to non-

laboratory personnel.

2. Recruit staff to strengthen existing capacity for ART training, mentoring, and supervision. 2a. Recruit one

pediatrician to oversee training on pediatrics HIV/ADS care. 2b. Recruit four clinicians to help on ART

trainings, precept ring at BMC HIV Clinics, supervise together with CHMTs and regional ART partners.

3.Strengthen linkages, networking, and referral with PLWHA support groups and communities

(CBO,HBC,CMACs, Community leadership).This is crucial to ensure continuum and complementarity's of

care, and to harness community resources to support HIV/AIDS care. 3a. Support monthly networking

meetings between BMC and community stakeholders in Mwanza for joint planning, referral and networking.

3b. Conduct sensitization workshops for 80 community religious leaders, council members on HIV-related

stigma and discrimination as major barriers to access care. It is important to enlist these community

gatekeepers as agents of change to fight HIV-related stigma and discrimination. 3c. Train 60 PLWHA,

community care givers on adherence, counseling, and treatment support. 3d.Conduct workshop for 50

traditional healers on basic HIV/AIDS sciences, prevention, and care and treatment.

4. Strengthen systems for quality assurance of HIV/AIDS care and treatment services in the lake zone.

4b.Conduct supportive supervision and mentoring to the six regional hospitals in collaboration with RHMTs

and regional USG partners. 4c. Conduct an annual workshop to share experiences and best practices in

implementing ART program in the lake zone.

LINKAGES:

Effective linkages have been established with: Mwanza Regional Health Management Team (RHMT) and

CHMTs of the 7 Mwanza districts which oversee and implement HIV/AIDS services at the regional and

district hospitals. (They also implement TB, and STI, RCH, EPI services which are important entry points to

HIV/AIDS care and treatment.); The Mwanza Roman Catholic archdiocese, which supports five home based

care programs in collaboration with several funding agencies. (We and also have links with other faith

based organizations like ELCT Kagera and Muslim health services (BAKWATA health centre); Regional

USG partners AIDS Relief, Columbia University and EGPAF who are supporting Mwanza and Mara, Kagera

and Tabora regions respectively; BMC oversees HIV/AIDS services in the health sector on behalf of

NACP/MOHSW; PLHIV Support groups, local and national, which provide ART adherence, support, and

mobilization for the fight against HIV; Kivulini provides legal support to women. and provides OVC nutrition

support.

CHECK BOXES:

Human capacity strengthening in terms of in service, training, and recruitment of required personnel to meet

HIV and TB training, mentoring, and supervision needs. To strength systems for quality Assurance of

HIV/AIDS care. Training will target health care workers in the Lake Zone..

M&E:

BMC caters for all program areas: (care & treatment, counseling & testing and laboratory services). Both

paper-based and electronic tools will be used to capture trainees' profiles and addresses. The paper-based

system will consist of training reports, and reports on mentoring and supportive supervision. We shall have

an electronic database of all training activity. Standard quality assurance tools for quality checks will be

ensured. Recruitment of two M&E personnel, purchase of six computers, networking of computers,

furnishing an M&E office, experience sharing visits/ meeting are important for improvements. Also, follow-up

training and on-site mentoring will be conducted by trainers periodically, and refresher training will be done

geared to needs.

SUSTAINABILITY:

Activity Narrative: BMC will ensure sustainability by training RHMT and CHMT to conduct supportive supervision, and train

regional and district trainers to sustain HIV care at lower facilities. All trainings will use MOHSW training

system. Periodic mentoring will ensure gradual task shifting.

TITLE: Laboratory infrastructure and capacity building at Bugando Medical Center (BMC)

NEED and COMPERATIVE ADVANTAGE. Bugando Medical Centre (BMC) laboratory is a referral center

for six lake zone regions: Mwanza, Shinyanga, Mara, Kagera, Tabora and Kigoma. The catchment's area

for Bugando referral center comprises of six regional labs and 35 district hospital laboratories with about

150 laboratory personnel. BMC Laboratory is a referral laboratory for HIV diagnostic, and ART monitoring

testing, Tuberculosis, and also the first lab offering infant diagnosis services. The BMC laboratory is in the

process of establishing and fully implementing quality system from FY 2007 funding. The BMC lab is also

on the route to accreditation and will use the FY 2008 funding to address the gaps identified during the gap

analysis exercise conducted by the Clinical and Laboratory Standards Institute using the ISO 15189

standards and Tanzanian Health laboratory Standards documents.

ACCOMPLISHMENTS: BMC laboratory was funded in FY 20O7 to implement a Quality System at the

center and become center of excellence model for the lake zone. The BMC lab has conducted Strengths,

weaknesses opportunities and treats (SWOT) analysis against the twelve elements of Quality System

identified gaps, and proposed priority areas for improvements. The priority areas are organization,

personnel, equipments, process control, specimen management, documents and records and laboratory

safety issues.

ACTIVITIES: To fully implement the 12 elements of Quality system at Bugando laboratory; will implement

the Quality system activities proposed by the gap analysis team conducted by MOHSW and CLSI against

the ISO 15189. BMC will produce a laboratory quality manual, and a laboratory safety manual which are

requirements for laboratory Quality systems as well as for Accreditation. BMC laboratory will disseminate

these manuals to all laboratory staff and make copies available for ease of reference.

BMC will train 15 laboratory personnel on equipment preventive maintenance. Laboratory technicians and

technologists will be trained on planned preventive maintenance and equipment maintenance logs to

ensure that all equipment at the center are functional at all times to reduce down time.

BMC will develop and maintain laboratory management documentation with MOHSW, put in place

laboratory management tools like laboratory registers, request forms, temperature charts, equipment

monitoring logs, analytical charts, and Standard Operational Procedures..

BMC will conduct training on specimen management to lab staff and all hospital workers handling lab

specimen. Specimen management is an important function of laboratory quality management. Laboratory

personnel will be trained on proper specimen management and since in most case in inpatient specimen

collection is done by non-laboratorians, all people who collect or handle specimen will be trained on proper

collection, transportation to the laboratory so that a quality sample is always available for testing. The zonal

laboratory has a role to support the lower level regional, district and testing sites to this end BMC laboratory

will facilitate specimen referral mechanism from the lower level.

BMC will develop and implement QC/IQC protocol at BMC laboratory. As part of QS implementation BMC

will have in place a documented process to validate all laboratory process from pre-analytical, analytical,

and post analytical phases and will train all laboratory personnel on QA practices and good laboratory

practices (GLP). BMC will conduct continuous improvement activities to continuously seek quality

improvement of the laboratory services and customer satisfaction by meeting with laboratory and clinical

staff

LINKAGES: BMC Laboratory links with MOHSW, AMREF and other USG laboratory Implementing partners

like CLSI, working on the laboratory standards and zonal labs accreditation, ASCP training of in-service for

laboratory standard of care tests like CD4, Chemistry and hematology, APHL assisting with lab information

system. AIHA a twinning organization which has arranged partnership between regional hospital

laboratories and Boulder Colorado Community hospital in US. The laboratory component is closely linked

with the ART services in BMC and at national level. National TB Reference Laboratory, MOHSW diagnostic

services for Laboratory and zonal training center. AMREF for laboratory training. Columbia University for

infant diagnosis support and AIDS Relief..

CHECK BOXES: Target is to equip BMC Lab. Staff with adequate knowledge and skills on laboratory

quality assurance to enable the BMC to be able to support the lower level and become Centre of Excellence

for the Lake Zonal ( 6 regions 35 districts, with 41 hospitals for both laboratory and non Lab services

M&E: Monitoring forms for HIV/AIDS services at BMC currently do not have a representative laboratory

component. BMC Laboratory will collaborate with CDC and USG partners working in the site to develop

good quality indicators to guide and monitor implementation of quality system and road to accreditation for

BMC laboratory. BMC will utilize the checklist developed by MOHSW to monitor its progress.

SUSTAINAIBILITY: All of the program activities are implemented by BMC personnel with technical

assistance from CDC Tanzania and USG laboratory partners for capacity building purposes. This ensures

promotes program and staff integration in the day to day hospital management committees. Involving top

management level at the facility creates ownership and recognizes value of the quality laboratory services.

This in turn will stimulate interest and attract support as well as strengthening the Quality agenda during

planning.