TITLE: Expanding PMTCT Services in Mara, Manyara, Mwanza, and Tanga

NEED and COMPARATIVE ADVANTAGE: AIDS Relief (AR), a 5-member consortium consisting of Catholic

Relief Services (CRS) (lead agency), Interchurch Medical Assistance World Health, Institute of Human

Virology, University of Maryland School of Medicine, Constella Futures, and Catholic Medical Mission

Board, has proven experience in ART and linkages to other HIV-related services. Existing complementary

programming supported by individual consortium members (e.g. OVC, HBC, agriculture, and fluconazole

partnership), represents a key comparative advantage of AR for scale-up and ensuring wrap-around

support to clients. In FY 2007, AR will partner with 29 facilities in four regions (Mwanza, Tanga, Manyara,

and Mara) where HIV prevalence ranges from two percent to over seven percent. By September 30, 2009,

AR will work in a further 19 health facilities providing training, supplies and equipment, opportunistic

infection (OI) and ARV prophylaxis and treatment, safe delivery kits, protective gear, and improved facilities

for counseling and delivery. AR will help sites reach national targets by providing counseling & testing to

90% of antenatal clinic (ANC) attendees and access to ARV prophylaxis for PMTCT to 85% of HIV-positive

mother-infant pairs either on-site or through care and treatment clinic (CTC) referrals.

ACCOMPLISHMENTS: To date, no accomplishments have been made. When FY 2007 supplemental

funding is awarded and disbursed, AR will support 13,300 PMTCT clients at 29 health facilities in 4 regions.

From October 2007 to February 2008, AIDSRelief will provide capacity building programs for PMTCT staff &

improve linkages to other HIV-related programs and the community. Partners will receive material inputs

including opportunistic infection drugs, ARV prophylaxis and treatment, test kits, safe delivery kits, CD4 test

reagents, and protective gear. Anticipated results include increased referrals to PMTCT, more births in

health facilities, more mother-infant dyads receiving a full course of ARV prophylaxis, and improved patient

tracking.

ACTIVITIES: 1) AIDSRelief will expand the availability of quality PMTCT services by training 192 health

care workers (HCW) to provide quality PMTCT services to mother & child. 1a) Train four HCW per site using

the revised national PMTCT training curricula 1b) Implement the WHO-tiered approach for ARV prophylaxis

to ensure HIV positive women and HIV-exposed children receive the most efficacious treatment, including a

multidrug regimen where possible. Provide single dose Nevirapine at time of HIV diagnosis to ensure all

HIV positive women receive at least the minimum ARV regimen; 1c) Provide on-site technical assistance to

initiate, implement, and improve provider-initiated (opt-out) testing with same day results for all pregnant

women attending antenatal clinics (ANC), labor and delivery (L&D) and postnatal wards; 1d) Work with

regional and district medical teams to conduct PMTCT supportive supervision at all levels of service

delivery.

2) Improve environment of PMTCT centers to motivate staff and ensure confidential services. 2a) Work with

site managers to refit waiting areas, counseling rooms, delivery rooms, and waste disposal facilities (e.g.

biological wastes or rubbish bins); 2b) Procure clinical and office equipment; 2c) Promote task shifting to

address human resources shortfall.

3) Strengthen linkages among health facility programs including PMTCT, community outreach, ANC,

maternal and child health (MCH), tuberculosis (TB), malaria, and adult and pediatric HIV care and

treatment. Providing follow-up of patients at different service points will increase utilization of the full-range

of PMTCT and continuum of care services. 3a) Ensure all PMTCT programs have two community workers

to conduct education activities and track PMTCT clients. 3b) Train community workers and PLWHA groups

to conduct patient monitoring and community education on prevention for positives, the importance of

prophylaxis for mother & child, benefits of delivering at health facility, HIV testing and care and treatment

services, as well as, the benefits of PMTCT and continuum of care services. Train community workers,

including PLWHA, on referral systems and making referrals; 3c) Provide supportive supervision of

community outreach activities; 3d) Promote HIV testing for partners of PMTCT clients, emphasize male

involvement in PMTCT, and emphasize prevention for positives in counselling sessions; 3e) Use national

registers to track HIV-exposed infants for follow-up care and treatment. 3f) Work with maternal and child

health (MCH) clinics to identify HIV-exposed infants during routine immunization visits, and refer infants to

CTC services. Mother's PMTCT information will be transferred to the child immunization card to assist with

identification of HIV-exposed infants.

4) Improve the laboratory and pharmacy capacity of PMTCT sites to prevent stock-outs and ensure quality

care is provided to mother and child. 4a) Work with Ministry of Health, Medical Stores Department (MSD),

and partners to improve forecasting of key reagents, PMTCT commodities, ARV prophylaxis, and OI drugs.

4b) Supply partners with adequate quantities of delivery kits, delivery beds, and protective gear. 4c) Train

PMTCT providers for referral of samples for infant diagnosis to Bugando Medical Center's early infant

diagnosis (EID) program. Collaborate with Columbia to ensure processing of samples and return of results;

4d) In line with national guidelines, offer cotrimoxazole prophylaxis to HIV-positive pregnant women as

indicated and all HIV-exposed infants from 4 weeks after birth until proven HIV-negative.

5) Strengthen program capacity to support the regionalization of PMTCT services. 5a) AIDSRelief

consortium will hire an additional four technical staff to train and supervise PMTCT sites; 5b) At site level,

AIDSRelief will fund one nurse as a PMTCT coordinator; 5c) Train 12 accountants and 52 coordinators in

finance, compliance regulations, and monitoring and evaluation (M&E) respectively.

LINKAGES: Within the health facilities, AIDSRelief will use its relationships with other HIV-related programs

to build linkages for a continuum of care. TB/HIV programs in the same health facilities will identify their

pregnant clients for referral to the PMTCT program. Linkages with community outreach activities and

PLWHA groups will be strengthened in order to ensure proper referrals are made and HIV-positive women

and HIV-exposed children are identified and receive care and treatment. AIDSRelief will also train service

outlets to refer patients from PMTCT to its care & treatment programs, many of which are located in the

same facility or a nearby district hospital. PMTCT staff will use national referral forms to refer HIV+ women

to the CTC, where registers will be used to track referrals. Pediatric clients will be referred to CRS

sponsored OVC programs within the same regions, whereby children may be eligible for nutritional support.

Linkages with reproductive child health, malaria, nutrition, child survival, and syphilis in pregnancy programs

will be developed. AR will continue to collaborate with Global Fund by assisting districts with sustainable

resource mobilization.

Activity Narrative: CHECK BOXES: The areas of emphasis were chosen because activities will include training of PMTCT

health workers, refitting infrastructure, and strategic information support. CRS will also provide wraparound

support through its PEPFAR-funded home-based care (HBC) and OVC programs which extend palliative

care, education and nutritional support. The general population will be targeted in the community outreach

activities to increase uptake of PMTCT services. Children under five and pregnant women will be targeted in

testing, treatment, and referral activities.

M&E: (7% of the budget) AR will collaborate with the National AIDS Control Program (NACP) and support

PMTCT sites in the improvement of data quality & reporting. PMTCT patient data will be compiled using

NACP electronic registers and paper-based longitudinal medical records. AR will assist sites with

implementation of the revised community logistic tools and national PMTCT monthly reporting forms for

ANC and L&D and promote data use culture in patient care and management. Feedback on tool

performance will be provided to NACP and partners. Continuous quality improvement committees will be

established at sites to manage and analyze data to measure quality and success of the program. This will

support PEPFAR and MOH objectives of monitoring and evaluating the availability, coverage and uptake of

PMTCT services.

SUSTAINAIBLITY: AIDSRelief will encourage Council Health Management Teams (CHMTs) to integrate

PMTCT activities in Council Health Plans and budgets at the district level. To improve administrative

capacity, AIDSRelief will work with regional and district authorities for better program coordination. To build

local authority's technical capacity, AIDSRelief will participate in Regional Health Management

Teams' (RHMTs) and CHMTs' supportive supervision activities including those for M&E. Clinicians from

RHMTs and CHMTs will be included in central trainings alongside the health facility staff to improve

technical skills and build collaboration across different levels of service providers. One hundred and thirty

health workers at district, regional, and health center level will receive ongoing training to support scale-up

of PMTCT services and promote sustainability.

TITLE: AIDSRelief Facility Based Palliative Care

AIDSRelief is the primary treatment partner in Mwanza and Mara, and provides palliative care to most of

those registered in their Care and Treatment Clinics (CTCs). This includes both patients on Anti-Retroviral

Therapy (ARTs) and not yet eligible on ARTs. Patients receive WHO staging, provision of cotrimoxazole in

accordance with national guidelines, diagnosis and management of opportunistic infections, including

tuberculosis screening and referral and cryptococcal infection, nutritional assessments/counseling (and

referrals), symptom and pain management (for outpatients, pain management is currently restricted to non-

opioid medicines such as ibuprophen and paracetamol), and psychosocial support. General counseling

addresses disclosure of HIV status, adherence to care and treatment, behavior change counseling for

prevention of HIV transmission, and other individual specific issues, as appropriate. Pediatric formulations

of cotrimoxazole are available for children.

In FY 2008, after an assessment of nutritional supplement options are evaluated, an expanding number

may receive nutritional support. A growing number of people living with HIV/AIDS are involved as peer

counselors and in assisting with linkages to local organizations that can help to promote adherence, provide

psychosocial support, and to handle referrals for community services (e.g. income generating activities and

legal service).

An important linkage is between facility-based palliative care and community home-based care (HBC). This

link is critical as all palliative care cannot be done at the facility. There are two-way referrals from the CTC

to the community HBC program and from the community HBC program to the CTC. The program strives to

have 100% of patients registered in Care and Treatment be referred to a community home-based care

program.

Total palliative care targets are de-duplicated at the national program level for patients who receive facility-

based services from this partner and home-based services from other USG-supported partners.

TITLE: Scale up of TB/HIV collaborative services in Mara, Manyara, Mwanza, and Tanga

NEED and COMPARATIVE ADVANTAGE: There have been government efforts toward universal access to

quality TB care and treatment services, particularly for those co-infected with HIV, yet targets are still unmet

due to minimal entry points to TB services from other HIV-related programs. To maximize entry points for

HIV diagnosis, treatment and screening for TB, AIDSRelief plans to strengthen links between Anti Retroviral

Treatment (ART) and TB services through its network of partners providing quality HIV care and treatment.

AIDSRelief uses this network to link and strengthen referral systems, thereby creating a bi-directional entry

into HIV prevention, care and treatment services. Using its 37 ART partners in Manyara, Tanga, Mara and

Mwanza regions, a total of 27,162 patients from care and treatment centers (CTC) will be screened for TB.

Those found to be TB/HIV co-infected (approximately 10%) will be referred to a TB clinic for care. The

TB/HIV co infected patients referred from TB clinics will be received at a CTC, and provided with quality

care and treatment services. AIDSRelief will scale-up TB screening services to a total of 37 sites by end of

February 2009, up from 31 sites in 2008.

ACCOMPLISHMENTS: With FY 2006 and FY 2007 funding, 30,719 clients (including TB patients) who

were referred to volunteer counseling and testing units (VCT) received counseling and testing at VCT. Of

those, 6,183 (20%) tested positive. Among HIV infected clients, 59% were screened for TB. In order to

strengthen TB/HIV services, AIDSRelief provided training on HIV counseling and on management of TB/HIV

co-infection to 16 health care providers. AIDSRelief also improved referral methods and linkages among

TB, ART, VCT, and Prevention of Mother to Child Transmission (PMTCT) services to reduce missed

opportunities for diagnosis and care and treatment. Improved referral methods and linkages resulted in a

higher acceptance rate (96%) for testing after counseling, and increased referrals among VCT, ART and TB

services.

ACTIVITIES: 1) Decrease the burden of TB among people living with HIV and AIDS attending AIDS Relief

supported sites 1a) Strengthen intensified TB case-finding at existing AIDSRelief supported sites 1b)

Establish intensified case-finding at newly established AIDSRelief supported sites. Needs assessment will

be conducted at 31 current TB/HIV sites and 6 new sites to identify areas for scale-up.

1c) Train Health Care Workers (HCW) at the new sites on TB/HIV collaborative services using the national

TB/HIV training curriculum. Print and distribute TB screening tool and job aids. Conduct refresher training

for HCW from 31 existing sites. 1d) Provide ongoing supportive supervision to ensure proper linkages

between HIV-related services and improved quality. 1e) Screen all family members of PLHAs who have

been diagnosed with active TB 1f) Strengthen referral methods and linkages between HIV and TB clinics at

AIDSRelief supported sites through regular information exchange meetings of HCW from HIV and TB sites.

1g) Conduct refresher training for laboratory technicians/personnel in TB diagnostics and quality assurance.

1h) Implement infection control measures to all CTC sites. 1i) Receive all TB/HIV co-infected patients from

TB clinic.

2) Establish mechanisms for TB/HIV collaboration. 2a)Collaborate with the National Tuberculosis and

Leprosy Program (NTLP), National AIDS Control Program (NACP), Program for Appropriate Technology in

Health (PATH) and other NGOs, regional, district and facility based TB/HIV bodies in the implementation of

TB/HIV activities. 2b) Participate in the National TB/HIV planning and share information at the district,

regional and site level through annual stakeholder meetings and regular support to the districts and sites.

2c) Participate in national TB/HIV monitoring and evaluation activities to further refine TB management

tools. 2d) Support the Regional and District Health Management Teams (RHMT & DHMT respectively) in

planning the integration of TB/HIV activities, supervision by training RHMT and DHMT members on TB/HIV

collaborative services. 2e) Work with other TB/HIV implementing partners such as PATH and NTLP to

improve linkages through regular communications and meetings.

LINKAGES: Within the health facilities, AIDSRelief will use its relationships with other HIV-related programs

to build effective linkages for TB/HIV co-infected patients' continuum of care. All PLHA from CTC, VCT, and

PMTCT who will be screened for TB and found to have active TB will be referred to a TB clinic for

management, according to the national guidelines. Working in collaboration with NTLP and PATH, all HIV-

infected TB patients referred from TB clinics will be received at CTC and provided with quality care and

treatment services; feedback will be provided to the referring clinic staff. Those facilities without TB

diagnostic services will refer all PLHA suspected to have TB to TB clinics for management, which includes

sputum smear microscopy and X-ray. Patients will be linked to other HIV and non-HIV related services in

the district/region e.g HBC, legal assistance, spiritual support, food support services etc. AIDSRelief

supports 47 ART centers in the 4 regions, and will collaborate with other partners implementing TB/HIV in

the same region such as PATH in Mwanza and NTLP in Tanga, Mara and Manyara to ensure smooth

referral, linkages and follow up of patients.

CHECK BOXES: The areas of emphasis were chosen because activities will include training for TB and HIV

health workers along with on-site strategic information and technical assistance. The general population will

be targeted in HIV counseling and testing activities to increase uptake of VCT services. Persons living with

HIV will be targeted in TB screening and referral activities.

M&E: a) AIDS Relief will collaborate with the NACP and NTLP to implement national M&E systems for

TB/HIV collaborative services in the 4 regions of Tanga, Manyara, Mwanza and Mara b) The TB Screening

tool will be implemented at all 47 existing, and 6 new sites and c) TB/HIV referrals will be documented using

the 2-way referral form between CTC and TB clinics d) AIDSRelief will provide technical assistance at all

sites for implementation of TB/HIV M&E systems and share quarterly and semi-annual/annual reports at the

site, district, regional and national level e) Data quality will be ensured through regular supervision visits f)

70 HCW will be trained in the TB/HIV M&E system in the 4 regions supported by AIDSRelief.

SUSTAINAIBLITY: TB/HIV program will be sustained by integrating the services into the existing health

system, by involving regional and district health management teams, incorporating the activities in the

district health plans, building capacity of local authorities, coordinators, and health care providers on TB/HIV

collaborative activities through training. Training of local authorities will improve capacity to manage

integrated TB/HIV programs from both an administrative and a technical stance.

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:

AIDSRelief will use the additional funds to accomplish the original targets of rolling 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.