TITLE: Expansion of PMTCT services in Dar es Salaam

NEED and COMPARATIVE ADVANTAGE: Mother-to-child transmission of HIV is a major problem among

pregnant women in Dar es Salaam (DSM), where 10.9% of the population is estimated to be HIV positive.

Service delivery gaps, including lack of trained personnel, insufficient space for counseling and testing, and

erratic supply of HIV rapid test kits, ARVs, and other essential commodities are being addressed but remain

challenges.

MDH, a collaboration between Muhimbili University of Health and Allied Sciences, Dar es Salaam City

Council, and Harvard School of Public Health, has been providing PMTCT services at eight large antenatal

clinics and seven labor wards in DSM. MDH has helped to ensure that laboratory facilities are functioning

well, a strong training base exists, patient monitoring and tracking loss to follow-up is in place, and that

health infrastructure is well developed. There is strong commitment from the city council authority for the

advancement of HIV prevention, care, and treatment services in DSM. By September 30, 2008, MDH will

expand PMTCT services to twenty antenatal clinics and fifteen labor wards within DSM. The population

served will include 47,000 new antenatal clients and 65,000 deliveries.

ACCOMPLISHMENTS: MDH has been supporting the provision of PMTCT services in eight sites within

DSM. By the end of FY 2007, approximately 41,000 pregnant women will be enrolled in comprehensive

PMTCT services. MDH has implemented best practices such as opt-out testing, testing at labor and

delivery, and male involvement in PMTCT. These practices resulted in fewer missed opportunities for

counseling and testing and increased uptake of PMTCT services. Activities to strengthen existing referral

networks and improve access to care and treatment services for HIV positive mothers, partners, and HIV-

exposed and infected infants are ongoing.

From October 2006 through June 2007, 23,219 women received HIV counseling and testing with test

results at the antenatal and labor ward; and 2,456 HIV positive pregnant women received nevirapine (NVP)

prophylaxis. Between January 2006 and May 2007, 209 health care workers (HCWs) were trained in the

provision of PMTCT services.

ACTIVITIES: MDH will scale-up PMTCT services from the current 14 sites to an additional six sites by

September 30, 2008. The new sites that MDH will include: Muhimbili National Hospital, Kimara, Tandale,

Kiwalani, Vijibweni and Kawe dispensaries. PMTCT services at these sites will be strengthened and

expanded.

In all existing and new sites, comprehensive and quality services will be provided. The following areas will

be our priority: 1) Train 250 HCWs using the revised national PMTCT training curriculum. A two-day

refresher course will be periodically provided to HCWs to further build capacity. PLWHAs will service as

facilitators in a panel discussion during the training;

2) Implement provider initiated opt-out counseling and testing at all MDH supported sites to decrease

missed opportunities for PMTCT service provision;

3) Train HCWs on the use of more efficacious ARV prophylaxis regimens and provide site assistance in the

procurement and distribution of ARVs. Provide single dose NVP to HIV-positive pregnant women at time of

HIV diagnosis to ensure mothers who deliver at home or do not return to ANC receive the minimum ARV

prophylaxis regimen. Initiate ART, or provide the most efficacious regimen available, in accordance with the

national guidelines;

4) Strengthen referral systems and integrate care and treatment clinic (CTC) activities with ante-natal clinic

(ANC) services. A nurse counselor and a clinical officer will be assigned to the ANC to initiate care and

treatment services and minimize missed opportunities. Nurse counselors will be responsible for CTC

enrollment and taking map-cues for home visits when required. A map-cue is a form used to capture

directions to a mother's home using landmarks and street addresses. HIV positive pregnant women will be

given a referral form, or will be physically escorted to the CTC, on the day they are given their results;

5) Transfer mother's PMTCT information from the ANC card to the infant's road-to-health (RHC) card after

delivery to ensure that HIV-exposed infants receive optimal care including cotrimoxazole prophylaxis and

immunization;

6) Provide infant feeding counseling at ANC, labor and delivery (L&D), CTC, and immunization clinics;

7) Offer PCR early infant diagnosis HIV-testing to all HIV -exposed infants at six weeks of age and six

weeks after the cessation of breastfeeding;

8) Address prevention messages for HIV-negative and HIV-positive pregnant women and their partners

during counseling sessions conducted at ANC, L&D and CTC;

9) Increase male involvement in PMTCT by providing invitation letters to partners of ANC clients; making

PMTCT services more male-friendly by fast-tracking PMTCT services for couples; and working with

community organizations to include male involvement messages into ongoing activities.

10) Conduct home visits using a map-cue to track those lost to follow-up and ensure they receive PMTCT

services and HIV care and treatment;

11) Recruit a PMTCT coordinator in each district to enhance supervision, coordination, and exchange of

information across districts and sites. During supervisory visits and monthly review meetings, data and other

new information will be shared with HCWs at the sites;

12) Engage the labor ward in-charge, the RCH coordinator, and the PMTCT coordinator at each site to

improve provision of PMTCT services by organizing monthly review meetings to discuss accomplishments,

challenges, and opportunities; and

13) Increase PMTCT uptake through community awareness-building activities such as training community

leaders and PLWHA in PMTCT.

LINKAGES: MDH works under the National AIDS Control Program (NACP) by following the national

Activity Narrative: PMTCT and treatment guidelines. PMTCT services will be strongly linked with other HIV prevention, care,

and treatment activities, including links to CTC and family planning (FP) programs. The MDH CTC intake

form has been revised to allow for tracking of referrals and home-based care providers will track women

who have been lost to follow-up.

MDH will work with heath facility and district level management to support and link PMTCT and other

related services. There will be a PMTCT task force at each site comprised of people from CTC, expanded

program on immunization (EPI), and FP. MDH will work with District Councils to include PMTCT activities in

their Comprehensive Council Health Plans. MDH will also work with local NGOs and community leaders to

support and link PMTCT and other related services for PLWHA, including linkages with OVC programs. In

addition, MDH will work with other partners providing PMTCT services in DSM.

CHECK BOXES: Training will be provided to HCW to build human capacity. The effort to increase male

involvement in PMTCT is a gender related activity. The general population, and specifically pregnant

women, will be targeted in our testing activities; PLWHA will be used to strengthen linkages and prevent

loss to follow-up; and counseling services will focus on discordant couples. Local organization capacity

building will be addressed to strengthen the capacity of health facility and district level management, local

NGOs, and community leaders to be able to provide quality services on their own in the longer term.

M&E: MDH has established a strong data capturing, processing, reporting and utilization system. National

monitoring and evaluation tools (registers and monthly report forms) are used at all sites. Training on

monitoring and evaluation is included in the PMTCT curriculum. Monthly reports are used to provide

supportive supervision. Quarterly reports are generated for PEPFAR and NACP from the PMTCT

database. MDH also uses the database to analyze quality indicators as part of the larger MDH Quality

Management Program. This allows us to develop quality improvement activities, including training and

change in procedures. Feedback to the site coordinators is provided during monthly review meetings which

serve as a forum for monitoring process of program implementation. Strategies to improve data collection

and PMTCT services will be implemented. The monthly review meeting is approximately 13% of the total

PMTCT budget. We will also leverage resources from Care and Treatment where we have built capacity for

data entry, processing, analysis and reporting.

SUSTAINAIBLITY: The MDH PMTCT program is run by managers and staff who are fully integrated within

the government system. The capacity of health workers is being built on an ongoing basis by updating their

clinical skills through in-service and on-the-job trainings. The City Council is a partner of the MDH program

which ensures that all activities are carried out as per the needs and directions of the government system.

National guidelines will be used to ensure continuity of the implemented activities. MDH will work with

District Councils to include PMTCT activities in their Comprehensive Council Health Plans to further ensure

sustainability.

TITLE: Facility Based Palliative Care in Dar es Salaam

Harvard University is the primary treatment partner in Dar es Salaam, 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: Expansion and Integration of TB/HIV Services in Dar es Salaam

NEED and COMPARATIVE ADVANTAGE: TB and HIV co-infection is a major public health problem in

Tanzania, with Dar es Salaam among the most severely affected regions in the country. Our group has long

-standing collaboration in the provision of services to patients at TB clinics and in HIV/AIDS care and

treatment. We will extend our current integrated TB/HIV services from three clinics (based at the three

district hospitals) to an additional 2 health centers and 2 dispensaries where we currently have a functional

CTC.

Muhimbili Dar es Salaam and Harvard (MDH) is well placed to continue doing these activities for various

reasons. MDH has established a unique relationship between the Harvard School of Public Health (HSPH),

Muhimbili University of Health And Allied Sciences (MUHAS) and the Dar es Salaam City Council (DCC),

and which has been ongoing for past 15 years - especially in training and research. The health

infrastructure is well developed - the lab facilities are functioning well, there is a strong training base and

patient monitoring and tracking loss to follow-up is well placed. There is strong commitment from the Dar

City Council as well as the three municipalities for the advancement of the HIV care and treatment services

in the Dar.

ACCOMPLISHMENTS: TB/HIV services were initiated recently, and currently three sites (Temeke, Amana

and Mwananyamala hospitals) are involved. As of June 30, 2007, a total of 1,961 TB/HIV patients were

enrolled, of which 1,083 have been initiated on ARV and 878 are on care. On average, 324 patients are

enrolled per month from the three sites.

ACTIVITIES: In order to rapidly expand an integrated TB/HIV services in Dar the MDH program has been

involved in strengthening TB/HIV activities at three sites. Considering the large burden of TB/HIV in the

region, MDH will further expand the services to four more sites within the proposed funding period - Sinza

and Buguruni health centers, Mbagala Rangi Tatu dispensary and at the Infectious Diseases Center (IDC).

By improving the uptake at the current three sites, and with the addition of four more sites, we expect to

expand enrollment to a total of 5,000 TB/HIV patients from the current 1,961 by the end of September 2008.

All the TB/HIV activities will be conducted in close collaboration with the National Tuberculosis and Leprosy

Program (NTLP) and the National AIDS Control Program (NACP). The innovative initiatives proposed will

enhance the ability of TB clinics to identify HIV patients, and for the CTCs to detect more TB cases among

HIV patients, provide seamless referral to TB clinics, and deliver excellent care to TB/HIV co-infected

patients with documented monitoring and evaluation (M&E) of all these activities.

We will continue the efforts to improve communication between TB and CTC units, hold regular monthly

meetings to build team moral, have a holistic approach to patient management, and identify challenges and

plan for common solutions. Efforts will continue to bring improvements in provision of HIV counseling and

testing to all TB patients, on-going TB screening for all HIV-infected patients, provide all HIV-infected TB

patients with HIV care and treatment, and enhance TB diagnosis and therapy for all HIV-infected TB

suspects.

The program will implement an infection control plan through work practice, administrative and

environmental control measures by training of health care workers.

In order to carry out these activities, optimal number of staff will be recruited, trained and placed at the

TB/HIV sites.

We will continue using national guidelines and curricula to train health workers on the various aspects of TB

and HIV co-infection including TB/HIV indicators and strategic information systems, data documentation and

analysis and reporting in collaboration with the NTLP and NACP. All patients attending care and treatment

clinics will be screened for TB. Those diagnosed with active TB will be referred to TB Clinic for

management. MDH will continue training TB clinic staff, strengthen lab diagnostics related to TB and

ensure that regular quality assurance/quality control of lab activities at the sites will be done by the central

lab at MUHAS.

Funds from the COP will used to pay for the MDH staff. Moreover, we intend to provide essential equipment

such as mobile chest x-rays machines and the necessary supplies to the TB/HIV clinics.

LINKAGES: MDH works very closely with the MOH NACP and NTLP. Maximal linkages are being

established between the HIV care and treatment programs and the TB diagnosis, treatment and follow-up

clinics at each site. Additionally, tracking patients lost to follow-up will be conducted through the HBC

patient tracking teams.

A referral system has been established between TB and CTC clinics for patients who are referred to TB/HIV

clinics and those who are referred to CTC upon completion of anti-TB courses. The referral system will use

registers and intake forms.

CHECK BOXES: Emphasis will be on strengthening the linkages and referral systems between the TB

clinics and CTC, so that HIV care and treatment services are made maximally accessible and available to

TB patients.

M&E: The MDH TB/HIV program utilizes TB/HIV forms on all TB patients enrolled at the TB/HIV clinic.

Nurses at TB/HIV clinics document HIV diagnostic counseling and testing (DCT) data in the TBLP registers

and the TB/HIV form. TB/HIV co-infected patients are enrolled at the CTC during their second visit to the

TB/HIV clinic. Data from TB/HIV co-infected patients will be collected and monitored at each subsequent

visit using a MDH TB/HIV form and the MDH CTC data collection forms. The TB/HIV form collects

information on TB treatment outcomes, while the MDH CTC forms collects information on TB screening,

diagnosis and management Data will be entered daily by data clerks into Access databases developed on-

site. Monthly evaluations of the data will be performed. Examples of parameters to be measured include a)

the proportion of TB patients enrolled in TB centers receiving DCT b) the proportion of patients in CTC who

are screened and subsequently diagnosed with TB, Quarterly reports will be forwarded to the NTLP,

NACP and CDC. At least one data clerk will be trained from each of the seven TB/HIV sites in electronic

data processing.

Activity Narrative:

SUSTAINAIBLITY: In order to sustain our efforts in integrating and expanding the TB/HIV services, MDH

will continue working very closely with the National TB and Leprosy Control Program and NACP. All the

plans and implementation of the program will be according to the National Strategic Plans. Sustainability is

the core of our program. We will continue to build local capacity through on-going training and by

developing locally feasible, sustainable SOPs in collaboration with health care providers to enable them to

conduct these services effectively. All effort will be made to build the capacities of the public health system

in effectively running TB/HIV programs.

TITLE: Scaling up of the ARV services and HIV care in Dar es Salaam

NEED and COMPARATIVE ADVANTAGE:

Out of the 2.5 million population in Dar es Salaam region, 272,000 (10.9%) are estimated to be the people

living with HIV/AIDS (PLWHA). Of these it is estimated that 54,000 (20%) will need ART.

MDH is a collaboration between the Harvard School of Public Health, Dar es Salaam City Council and

MUHAS which has been ongoing for more than 15 years in training and research. This collaboration has

improved the health system including space, laboratory facilities, training base, patient monitoring and

tracking loss to follow up. There is strong commitment from the local authorities to advance HIV care and

treatment services.

ACCOMPLISHMENTS:

By end of FY 2007, 25 sites will be providing comprehensive care and treatment services. The 25 sites

include three district hospitals, an Infectious Disease Clinic, three refilling health centers upgraded to initiate

ART, Muhimbili National Hospital and 17 private facilities, to boost public-private partnership. A total of

15,000 (30% of eligible in Dar) patients will be actively on ART, of which 3,750 (25%) will be children. The

male to female ratio would be 1:1. Additional 8,000 clients not on ART will be on care.

ACTIVITIES:

Harvard will use the additional funds to accomplish the original targets of rolling out HIV care and treatment

in 34 sites within three municipalities and activities will include:

(i) Expansion of comprehensive ART services including prevention among positives:

Additional five sites (Kimara, Tabata, and Tandale dispensaries. Mnazi Moja and Kigamboni health centers)

will be included. Thus, MDH will put 5,000 more patients on ART; and by end of FY 2008, 20,000 (40% of

eligible in Dar) patients will be actively on ART and additional 10,000 not on ARVs will be on care using pre-

ART registers.

(ii) Staffing support -MDH will support the human resource requirements in the city through recruitment and

hiring of necessary staff within the government system, creating a conducive working environment, training

and career plan to ensure job satisfaction and retention.

(iii) Strengthening pediatric AIDS care and treatment - pediatric enrollment will increase from 10% to 25%.

MDH will strengthen linkages between PMTCT (using ANC and immunization care to identify HIV exposed

infants), maternal & child health clinics, inpatient and care and treatment centers (CTC). Sick children

attending immunization clinics will be evaluated and referred for HIV testing. Improving infant HIV diagnosis

through DNA-PCR will be emphasized. Practice of pediatric only day for patients under 15 years will be

promoted. All health care workers (including non-pediatricians) will be trained to provide care and treatment

for pediatric AIDS patients including co-trimoxazole prophylaxis.

(iv) Procurement and provision of various non-ARV medications - MDH will support sites in procuring and

stock managing non-ARV drugs for treatment of opportunistic infections including pediatric preparations.

(v) Laboratory services - MDH lab support will be coordinated and synchronized with the national program

- the Ministry of Health and Social Welfare (MOHSW) and the national referral lab. We will support

procurement of essential Lab equipments, reagents and supplies for the 30 sites. We will support quality

assurance & quality control programs as well Lab automation. MDH will also continue to build capacity of

human resource within the labs by hiring and training.

(vi) Quality management program (QMP) - MDH has indicators incorporating PMTCT, care & treatment

and TB/HIV programs to collect data and make use of this information for monitoring the quality of patient

care. QMP will cover all the existing as well as new sites. All the national M&E indicators are included in our

QMP.

(vii) Tracking patients lost to follow up: MDH has a patient tracking system to trace those missed their

scheduled visit, lost to follow up and with abnormal laboratory results. Currently the team has 30 nurses and

additional 40 will be recruited. We will also involve PLWHA and volunteers on ART in the tracking system.

MDH will strengthen linkages with organizations providing home based care.

(viii) Training: In order to continuously build the capacity of all the MDH health care providers and the district

health management team, a cascade of year round training sessions (intro and refresher) on the full

spectrum of HIV treatment and care will be conducted using the national curricula. On site training and

follow up, supportive supervision together with District Health Management (DHM) teams (monthly),

preceptorship, system strengthening and logistical improvement will be prioritized. In consultation with the

DHM, further training opportunities for selected MDH staff will be offered.

(ix) Nutrition: Currently, MDH is providing nutritional information and counseling to all patients. It is proposed

that nutritional supplements (plumpynut) be given to the severely malnourished patients (BMI <16) on care

and ART (10% of 38,000) for three months. A nutrition coordinator and assistant will be recruited. One

nutritionist per site (total of 14) will also be recruited and trained.

LINKAGES:

MDH will map and document available services for PLWHA. Referral systems will be strengthened to

enable patient's access to various levels of services provided by the health facilities and other organizations

particularly those of PLWHA and OVCs that provide clinical, psychological, spiritual, social, preventive and

palliative care in the communities. Linkages within health facilities particularly between CTCs, TB, PMTCT,

outpatient and inpatient departments will be strengthened. Provider initiated counseling and testing (PICT)

will be strengthened to minimize missed opportunities. Patients will be linked with various wraparound

programs - nutrition, reproductive health/family planning, malaria control, water and sanitation.

CHECK BOXES:

Human capacity development activities revolve around in-service training of health care workers. HIV

testing and enrollment into treatment will focus on the general population with specific emphasis on

pregnant women and children. Linkages with PLHA groups will be formed and/or strengthened.

Activity Narrative: M&E:

MDH will collaborate with the NACP/MOHSW to implement the national M&E system for care & treatment.

Patient records at all sites will be managed electronically using a well-developed electronic medical record

system linked with the National CTC3 database for generation of NACP and USG reports. In order to

promote data use, MDH will provide regular feedback to CTCs and build capacity to synthesize data to

inform patient management and district/regional planning. We will support training of 50 HCWs in SI and

provide TA to all 34 CTCs, three district offices and one regional office. MDH will regularly perform data

analyses to evaluate treatment outcomes and to document the lessons learnt which will be shared through

various forums including conferences and publications.

SUSTAINAIBLITY:

MDH is working with regional and district authorities in the day to day activities of the program within the

existing system. Planning, implementation and monitoring of the activities are done jointly with the district

staff. All MDH activities will be in line with the Council Health Plans. MDH will continue with district capacity

building in infrastructure and human resource. Financial and program management system capacities will

be strengthened through training and technical assistance.