TITLE: Provider Initiated Testing and Counseling (PITC) Training and Scale-Up

NEED and COMPARATIVE ADVANTAGE:

Lack of testing and counselling services result in missed opportunities for HIV-infected individuals to obtain

needed treatment and support. Furthermore, the government targets for care and treatment are not

achievable without a shift from volunteer counselling and testing (VCT) to PITC given that there are only

1,027 VCT sites across Tanzania, PITC will lead to a higher uptake of testing, and increase in the number

of infected patients able to access care and treatment. IntraHealth International (IHI), with its experience in

capacity building, HIV/AIDS training and service delivery, and excellent relations with the GoTZ through its

existing CDC and USAID-funded projects in Tanzania, is the best partner to roll out PITC services and

improve referral systems to ART services nationally.

ACCOMPLISHMENTS: IHI has established itself in Tanzania by hiring competent and experienced

Tanzanians to manage the PITC project. IHI is currently supporting seven sites that provide PITC services

including training, mentoring, and supervision activities. IHI has facilitated and participated in the

development of national guidelines and training curriculum for PITC. IHI also was part of the Tanzanian

team that went to Botswana to study the implementation of routine HIV testing, and made recommendations

to the GoT on how to scale-up PITC services.

ACTIVITIES:

To expand its efforts, IHI will:

1) Establish PITC services in an additional 10 hospitals and 20 health centers to serve outpatients and

inpatients. More people will know their HIV status, be able to adopt appropriate preventive behaviors, and

initiate ARV treatment. This will be accomplished by: a) integrating PITC services into family planning clinics

in government hospitals; b) strengthening intra- and inter-facility referral systems and community/facility

referral networks, which will ensure that all those testing HIV-positive will be enrolled in the care and

treatment program; and c) procuring HIV test kits as a buffer stock for anticipated stock-outs in the 37

supported facilities.

2) Train PITC trainers, service providers, and Regional/Council Health Management Teams (R/CHMT).

District capacity to supervise and train trainers will be enhanced, and each health facility will have trained

staff to provide quality PITC services. Five PITC trainers will be trained per region, a total of 70 health

workers per hospital and 10 health workers per health centre will be trained in PITC, Twelve members of

RHMT per region and 10 members of CHMT per district will be trained in mentoring and supportive

supervision of PITC services.

3) Disseminate PITC policy guidelines in 38 districts to encourage district leaders, CHMT members and

health workers to endorse and use national PITC policy guidelines in their areas of work. IHI will print and

distribute 130,000 copies of the national PITC policy guidelines. In addition, IHI will provide one copy of the

guideline for each health worker undergoing training in PITC and develop and print a Q&A booklet on PITC

in Kiswahili. Orientations will be conducted with three Zonal Training Center teams and a one day

dissemination workshop for district leaders and CHMT members in each district.

4) In collaboration with WAMATA, IHI will advocate for task shifting in HIV testing and counseling services in

an effort to have more non-health workers and non-providers participate in the provision of HIV testing and

counseling services. To accomplish this activity, IHI will: a) develop an advocacy package for task shifting in

HIV testing and counseling that targets policy makers at national level and b) pilot-test the training of lay

counselors in Arumeru and Kasulu districts. Task shifting activities will be conducted with approval from the

National AIDS Control Program (NACP).

5) Provide mentoring and facilitative supervision to 37 health facilities providing PITC services. The PITC

services will comply with the national protocols for safety and human rights, and confidentiality will be

assured. In collaboration with respective R/CHMT, IntraHealth will provide mentoring and facilitative

supervision to each site on quarterly basis.

6) Produce patient information brochures and appropriate job aids for service providers.

LINKAGES: IHI, through its PITC project, has established working relationships with CDC-funded NGOs

providing technical support for care and treatment services. These include EGPAF, AIDSRelief,

Columbia/ICAP, and FHI. These agencies will ensure that optimum-quality care and treatment services will

be accessed by patients tested at their facilities, and referred for ART. We will collaborate with R/CHMTs in

mentoring and facilitative supervision of PITC services. Joint visits will be made to maximize the cost

effective use of resources, especially transport. To enhance a transparent partnership, IHI will sign a

comprehensive memorandum of understanding with each respective region.

CHECK BOXES: The 15 districts that were chosen for introduction of PITC services are densely populated,

with very few VCT sites. PITC services will be introduced in each facility with a focus on family planning

clinics, STI clinics, under-five clinics, and in-patient wards. The project also plans to introduce a workplace

component targeting one military facility and one facility serving Ngorongoro conservation area in Arusha

region.

M&E: All supported sites will use Ministry of Health (MOH) daily registers and monthly summary forms for

PITC services. This strategy will harmonize recording and reporting of service statistics. Quarterly reports

will be used to analyze trends towards achieving project targets and provide feedback to each site.

IntraHealth will collaborate with NACP and other partners in developing an electronic tool to capture HIV

testing data. The PITC project has allocated 8% of its budget for M&E related activities.

SUSTAINABILITY: To maximize ownership and ensure sustainability of PITC services, each region will

have its own trainers. This means that even at the end of the project, PITC trainers will remain behind to

further train other service providers. R/CHMTs will be trained in mentoring and supportive supervision of

PITC services. As the Government puts more emphasis on decentralization, all project districts will be well

prepared to manage PITC services including the integration of PITC services into annual comprehensive

council health plans. This will result in re-training of health workers and procurement of test kits by each

Activity Narrative: district through its basket grant or other sources of health financing.

TITLE:Integrated management of adult illness (IMAI)-based standards on personal digital assistants (PDAs)

to promote quality of care and ARV rollout.

NEED and COMPARATIVE ADVANTAGE: The continued expansion of HIV care and treatment in Tanzania

will rely on delivering standardized care through the rigorous use of medical protocols. Standards of care

enable task shifting of routine tasks to less trained health workers in order to address the acute shortage of

clinicians, especially in rural areas. Standards of care also simplify data collection and thus promote

supervision and program management.

Our sub-partner has developed and tested a handheld-computer system to guide health workers through a

clinical assessment derived from the Integrated management of adult illness (IMAI) guidelines. The system

indicates which clients should be referred to a clinician, as well as which routine lab tests are required.

Current work in South Africa suggests this can shift client screening to less trained staff without sacrificing

quality and with the added benefit of point-of-service data capture.

ACCOMPLISHMENTS: IntraHealth International (IHI) has established itself in Tanzania by hiring competent

and experienced Tanzanians to manage the Provider Initiated Testing and Counseling (PITC) project. IHI

has facilitated and participated in the development of national guidelines and training curriculum for PITC

IHI was part of the Tanzanian team that went to Botswana to study the implementation of routine HIV

testing and made recommendations to the Government of Tanzania (GoT) on how to scale-up PITC

services. IHI also actively participated in the development of the health sector strategy for HIV/AIDS 2007-

2012.

ACTIVITIES: The goal of project activities for COP 08 is to develop a fully functional PDA based set of

clinical standards that can be rolled out more widely to CTC sites in 2009.

1. Adapt and pilot system for delivering standardized care in CTC clinics on PDAs to help screen clients and

make better use of limited clinical staff. This will provide a tool for use throughout Tanzania and an

assessment of its feasibility and its ability to improve quality of care for a rapid rollout.

1a Hire necessary staff including project manager and local staff.

1b Conduct initial trial at 1-2 CTCs supported by ICAP.

1c Pilot system at 5-10 sites supported by ICAP.

1d Produce a written evaluation of system.

1e Work with MOHSW, NACP, NIMR, and service delivery partners to reach consensus on protocols and

procedures for PDA system.

1f Form working group to focus on PDA based clinical care standards for HIV+ children.

2. Develop software needed for initial trials and program roll out of IMAI clinical care standards. This will

enable pilot activities as well as provide a platform for future delivery of protocols for TB, reproductive

health, etc.

2a Develop open source software code that provides IMAI algorithms on PDA in easy to use format.

2b Improve capacity of University Computing Centre to develop and maintain PDA software.

2c Develop data storage and synchronization methods to link client information on PDA with external

electronic medical record system.

2d Develop tools for generating reports on client status, clinic outputs and inputs and management data

3. Develop training materials, operations manuals and dissemination. This step will support the rollout and

help maintain high quality care across diverse service partners and locations.

3a Develop standardized operating procedures and manuals for rollout.

3b Develop quality assurance systems for rollout to ensure that all clients receive care according to

evidence based standards of care.

3c Develop training curriculum and methodology for health workers and data managers.

3d Develop technical support systems for hardware and software and identify local institutions that can

provide necessary services.

3e Document experience to date for use nationally.

SI Targets HCWs trained - 150 Local organizations given TA - one (1)

LINKAGES: Our sub-partner will engage the NACP, WHO, MOH, and all partners to solicit input, and to

converge on a set of standards for screening clients. They will also work closely with ICAP to pilot the

system. They will form a working group from the partners and GoT to specifically address how this system

can best work for HIV+ pediatric patients. This fits in well with our sub-partner's work in Mtwara with Ifakara

Health Development Research and Development Centre (IHDRC) to field test a computerized version of the

integrated management of childhood illness (IMCI) protocols for child health. They will work with University

Computing Centre (UCC) to improve their capacity for PDA applications and I-TECH to develop training

materials. They will also work with National Institutes of Medical Research on evaluating task-shifting

outcomes. They plan to develop PDA-based standards of care in many areas including TB, Child Health,

Reproductive Health, Chronic Disease and other problems of developing countries.

CHECK BOXES: Human Capacity Development/Training and Task-shifting: this project will support task

shifting and simplify training by providing standards of care in an easy to learn/easy to use format.

Local Organization Capacity Building: our sub-partner is working with UCC to develop their ability to support

PDA based programs and training.

Strategic Information (M&E, HMIS, Surveys/Surveillance, Reporting) This project will facilitate the collection

of information by entering client data at the point of care in an electronic format.

TB: will be included in the screening protocols.

M&E: In addition to data captured on the PDA, our subpartner will develop a quality assurance system for

client care and measure clients who are correctly or incorrectly screened using the PDA IMAI protocols. We

expect to spend about 7% on M&E.

The following measures will be tracked:

1. activity measures

1a. activities completed

1b. number of providers trained to use PDA system

2. output measures

Activity Narrative: 2a. Number of patients seen using electronic algorithms

2b. Number and % of patients who have NO COMPLICATIONS

2c. Number and % of patients seen by clinician whom CLINICIAN felt were NOT necessary to refer

2d. Number and % of patients seen by clinician whom clinician felt should have been referred sooner.

2e. Number of patients NOT seen by clinician whom clinician felt should have been referred, found from

review of clinical summary.

3. outcome measures

3a. Number and % of patients seen by clinician

3b. time needed for each client encounter using PDA

SUSTAINAIBLITY: Financial sustainability: There is evidence from Tanzania to suggest that the use of

PDAs to collect client data is both cost effective and practical. In the context of CTCs, the cost of using

PDAs will be offset by the use of nurses and nurse assistants rather than clinicians for client triage. The cost

of capturing and reporting data will be reduced by entering data at the point of care rather than the use of

data entry clerks. The identification of missed appointments defaulters and adherence problems will reduce

drug resistance and the need to use second line treatment regimens.

Institutional sustainability: our sub-partner is developing the capacity of University Computer Centre to

develop and maintain PDA based systems. They are also integrating the IMAI screening with other

screening protocols such as IMCI, reproductive health, TB, and malaria for use throughout the health

system.