TITLE: Providing PMTCT services to Tanzania Police, Prisons and Immigration Department

NEED and COMPARATIVE ADVANTAGE: The Tanzanian Prisons Service, and the Tanzania Police Force

have a network of hospitals, health centers and dispensaries through out the country, supporting a total of

over 27,000 enlisted personnel and estimated 60-90,000 dependants for the Police, and 12,000 enlisted

personnel, plus an estimated 40-50,000 dependants and approx 45,000 inmates for the Prisons. These

hospitals do not only service the uniformed forces their dependents and inmates, but also civilians living in

the vicinity of the health facilities. In fact 80% of the patients are civilian. Five zonal Police and five Prison

hospitals offer district level services. The largest hospitals are, Kilwa Road (for the police) and Ukonga

Prison, both located in Dar es Salaam and serve as national referral centers for medical services. An

average HIV prevalence of 8.7% among pregnant women in the general population of Tanzania, and over

90% of the HIV infection in children below 15 years is attributed to mother-to-child-transmission (MTCT); the

rates are thought to be higher in the police and prison setting.

The MOHSW goal is providing PMTCT services to 80% of the projected HIV positive mothers by September

2009. The national PMTCT coverage is still low, at 15%. Based on previous support, PAI is poised to

continue to address the needs to improve coverage and access to strengthen and expand PMTCT activities

in the police and prison hospitals and health centers/satellite sites across Tanzania and ensure a close

service linkage of the HIV programs of the respective forces being implemented in line with the national

Health Sector HIV strategy.

ACCOMPLISHMENTS: Under FY 2007 funding, Police and Prisons offered PMTCT services at five zonal

Police and five zonal Prison hospitals in: Dar es Salaam, Moshi, Mwanza, Mbeya and Zanzibar.

ACTIVITIES: Eight Police and eight Prison health centers will start PMTCT services in FY 2008. A total of

10 hospitals (five police and five prisons) and 16 health centers (eight police and eight prisons) will then

serve as PMTCT sites. Testing will be opt-out based on the new national algorithm. Women will be tested

in ANC, LW, and post natal, with rapid test and results given on same day

Based on capacity, both single-dose NVP, and more complex regimens will be provided with the goal of

accessing more women to more efficacious regimen.

Police and Prisons personnel, their dependents, inmates, and civilians living in the vicinity of the hospitals

and health centers will be informed through prevention and awareness campaigns of each center.

Information about the available services of the facilities, including PMTCT, will be presented and promoted

to through drama, music and other presentations at different occasions, including Open-house days for

civilians living in the communities around the clinics.

1) Support the role-out of the new national PMTCT guidelines in the 10 hospitals and 16 satellite health

facilities. (50% of the HIV+ women are expected to receive NVP, 30% AZT+NVP and 20% ART. 50% of the

HIV-exposed infants will receive CTX)

2) Using the national curriculum, carry out training of three health care workers per hospital (30) and per

satellite health center (48)

Train PMTCT service providers in staging of HIV+ mothers and provision of anti retroviral therapy (ART)

where capacity exist. If capacity is not available on-site, then patients will be referred to the nearest

Police/Prison, District, or Regional Hospital

3) Renovation or refurbishing of counseling and delivery rooms at 16 new satellite sites/health centers

4) Conducting community education to increase access to services and partner testing.

5) Providing test materials and protective safety gear through the District Medical Offices (DMOs) and

Medical store department (MSD) under the national PMTCT program. Limited quantities of these materials

will be procured under this Program to prevent stock-outs. Kilwa Road Hospital and Ukonga Hospital will

serve as the coordinating bodies for services, and oversee quality assurance following national standards

for follow-up at district or regional hospitals.

6) Establishing a referral system for HIV+ women and their HIV-exposed infants from the satellite sites to

Police and Prison hospitals or District and Regional hospitals for additional ANC services, infant diagnosis,

ART, and TB/HIV at CTC, where needed.

7) Training of volunteers/social support providers, transport and incentives for home-visits, organization of

post-test clubs and other activities.

8) Provision of infant feeding.

LINKAGES: Expansion of PMTCT activities in FY 2008 will ensure a close linkage of implementation to

national strategies and programs supporting MOH goals of providing this service to 80% of the projected

HIV positive mothers by September 2009. Coverage will increase through the 10 hospitals and 16 health

centers. PharmAccess will ensure linkages with organizations of women living in the barracks. We

anticipate that these women will also operate as care providers within the barracks. No NGO or other

private social support organization or social support organization is allowed to work/operate within the

military barracks. However for clients in the surrounding communities, we anticipate to form linkages with

existing local NGOs operating in those communities to ensure continuum of care. In addition, linkages will

be established as well as referral for HIV+ people from the satellite sites to the Police and Prison hospitals

or district hospitals for CD4, TB testing, and complicated cases.

Linkage will be strengthened with Prevention activities under the Police and Prison Program, including

promotion and counseling of preventive measures for HIV+ persons, provider initiated testing and

counseling (PITC), C&T, TB/HIV and OVC programs supported by PAI. Linkage will also be improved with

reproductive and child health (RCH) activities especially Malaria and Syphilis in Pregnancy program, family

planning, and nutritional and child survival program, as these programs are all provided in these facilities.

Furthermore, linkages will be established with nearest District and Regional Hospitals for referral of complex

clinical cases and laboratory testing. PAI will continue to collaborate with facilities supported by the Partner

organizations and Global Fund.

Activity Narrative: CHECK BOXES: This funding will fully develop PMTCT services in the network of police and prisons

hospitals and satellite health centers. Funding will support the introduction and/or improvement of PMTCT

services. More emphasis will be put into training of health care workers per hospital and from satellite health

center, renovation or refurbishing of counseling and delivery rooms, community education, and providing

test materials and protective safety gear.

M&E: PAI will support the police and prisons facilities teams to collect and report PMTCT data based on the

national protocol and provide feedback on tool performance. PAI will work with these institutions to

strengthen and implement the PMTCT quality framework and provide regular supervision. PAI will continue

to support the district and regional teams with supportive supervision visits to monitor the collection of data,

and the continued on-site training of facility staff.

Data will be collected both electronically and by paper-based tools. PAI will work with the MOHSW in rolling

out the revised PMTCT M&E: the patient-based registers, the Monthly Summary Forms for both ANC and

L&D, and the commodity logistic (LMIS) tools to all of the sites it supports. Electronic data entry will take

place. All sites will have laptops with a data base and output functions as developed by UCC for the

National C&T program. To that end, PAI, in collaboration with UCC, will train 52 health care workers and

provide technical assistance to 26 facilities.

PAI will continue to promote the synthesis and use of data by facility staff, and strengthen its use for

decision-making for facilities and the district and regional management teams.

Data will be provided to Regional and District Health Management Teams, the National AIDS Control

Program (NACP) and PEPFAR for reporting purposes and stakeholders meetings.

SUSTAINAIBLITY: PAI will encourage the Office of the Director Medical Services of the Police, and of the

Prison Service to integrate PMTCT activities in their respective Health Plans and budgets at the facility and

national level. To improve administrative capacity, the PAI will work with Prison and Police authorities to

build local authority's technical and managerial capacity to manage the program.

The facilities provide staff and health infrastructure. Most costs of this program are for training and for

infrastructure improvement. Investments are done at the start-up phase of the Program It is therefore

expected that the costs per patient will decrease dramatically over time. In the Police and Prison setting,

turnover of medical staff is low.

Health facilities of the Prison Service is under the administration of the Ministry of Home Affairs and the

Police Force under the Ministry of Public Safety and Security, not under the Ministry of Health. This PMTCT

program will be implemented under the rules, regulations and guidelines of the National AIDS Program.

Training, treatment, treatment guidelines, M&E etc is all part of one large program.

TITLE: Providing HIV/AIDS Prevention programs for the Tanzania Police Forces, Prisons Service and

Immigration Department

NEED and COMPARATIVE ADVANTAGE:

The HIV prevention and awareness-raising activities under this program concentrate on 30,000 police

officers (including 2,500 recruits per year), 30,000 prison officers (including 2,500 recruits per year), 5,000

immigration officers (400 recruits per year), their dependants and thousands of civilians living in the vicinity

of the police and prison health facilities. The program is a continuation of the program started under FY

2007 funding, as well as FY 2007 plus-up funds, which devoted resources specifically to looking at critical

gender issues, such as gender based violence (GBV) among this target population. Tools and materials

developed under the DOD/PAI/TPDF program can be used for all police, prisons and immigration

departments and vice versa.

GBV can be defined as any unlawful act perpetrated by a person against another person on the basis of

their sex that causes suffering on the part of the victim and results in among others, physical, psychological,

and emotional harm or economic deprivation. Attention is increasingly being directed at the possible role

military personnel could play in preventing HIV/AIDS within their ranks and in the civilian communities they

come in contact with. The Tanzania Police Forces, Prisons Service and Immigration Department, like any

other uniformed services groups are grappling with how to best stem the spread of HIV/AIDS among its

workers.

ACCOMPLISHMENTS: This activity is scheduled to begin in the middle of FY 2007, with 0207 plus-up

funding.

ACTIVITIES: A core activity of the initial funding is to develop a comprehensive HIV/AIDS education

program, based on life-skills modules which were developed by the Tanzania Peoples Defense Forces

(TPDF) through Emergency Plan funding with PharmAccess. A critical component to this work is to assure

that the module that is developed to specifically assess and address a host of issues related to HIV, gender

and other critical topics, as they relate to newly recruited policemen and policewomen as well as new

recruits into other uniformed services in Tanzania.

Specific materials to work with the uniformed services to address GBV issues will be developed and

implemented including materials to increase positive male involvement, to reduce alcohol abuse that leads

to high risk behavior, and to reduce the acceptance and practice of GBV among uniformed personnel.

Materials will be distributed to appropriate locations such as police stations, prisons, border crossings, and

park ranger stations targeting all such personnel working in Tanzania. Training specific to GBV will be

conducted throughout Tanzania; both sensitization throughout the general forces, as well as specific

prevention and counseling training with medical personnel to create an environment conducive to reporting

and addressing such issues.

Specific activities include: 1) Develop and distribute new IEC and life skills materials, as well as newly

designed materials and prevention components on GBV, positive male involvement, and issues around

alcohol abuse. 2) Provide prevention IEC and life-skills materials and services to all service members, their

dependents, and the communities in the vicinity of police and prison health facilities. 3) Special efforts will

be put on counseling of HIV+ persons to raise awareness about the risks of HIV transmission. USG funding

will support the (re-) training of approximately 100 clinicians and HIV counselors of approximately 25 health

facilities. 4) Establish post-test group sessions of HIV+ persons. 5) Re-train 60 TOTs and train 1200 peer

educators, at least two per police station or prison. Activities will be directed to all police stations, prisons,

and offices of the immigration department.

6) Enhance the awareness of HIV/AIDS by training commanders so that they consistently give high visibility

to HIV/ AIDS in their proceedings and activities.

LINKAGES: The 16 new health facilities where counseling, testing, and care and treatment services will be

provided will be linked with:

1) Nearby regional and district hospitals for ELISA and CD4 testing and for referral of late-stage AIDS

patients. 2) Organizations of women living in the barracks around these police stations and prisons. Two

hundred women will be trained and involved in providing HIV/AIDS IEC and life-skills materials in and

outside the barracks. 3) NGOs and other community support organizations to do home-visits, provide home-

based care and other support functions to HIV+ persons living in the vicinity of these heath centers and

outside the barracks.

CHECK BOXES: The emphasis is to keep personnel of Police, Prisons and Immigration Services (TPPI or

the Forces), their dependants, and civilians living in the vicinity of the health facilities of these Forces free

from HIV infection. The areas of emphasis were chosen because activities include providing prevention

education, materials and services to all service members, their dependents and the communities in the

vicinity of police and prison health facilities, equipping new recruits with the necessary knowledge and skills,

and provide ongoing access to information and services to prevent HIV/AIDS among themselves and other

youths in and outside these Forces and lastly enhancing the awareness of HIV/AIDS by training peer

educators and commanders so that they consistently give high visibility to HIV/ AIDS in their proceedings

and activities.

M&E: Data will be collected and reported by the management of the health facilities. Management will be

trained and instructed for that purpose to guarantee as much standardization as possible in reporting.

PAI will prepare a written M&E plan and will begin implementation no later than receipt of FY 2008 funds.

The plan will outline procedures for data collection, storage, reporting, and data quality, and will outline

plans for data use for decision-making within the organization and with stakeholders. PAI will allocate 7% of

FY 2008 funds to M&E. PAI, as they develop and revise data collection tools, will work to harmonize with

other PEPFAR AB and OP partners, as appropriate.

SUSTAINABILITY: 1) Most costs of this program are for training and for developing and distributing IEC

materials. Investments are done at the start-up phase of the program. It is therefore expected that the costs

per patient will decrease dramatically over time. 2) Turnover of medical staff is low. Training is needed.

Once trained, this capacity will stay within the Forces. 3) Health facilities of the uniformed forces are under

the administration of their respective ministries, not under the Ministry of Health. This prevention program

will be implemented under the rules, regulations, and guidelines of the National AIDS Program. Training,

treatment, treatment guidelines, and M&E etc are all part of one large program.

TITLE: Providing HIV/AIDS Prevention programs for the Tanzania Police Forces, Prisons Service, and

Immigration Department.

The HIV prevention and awareness-raising activities under this program will concentrate on 30,000 police

officers (including 2,500 recruits per year), 30,000 prison officers (including 2,500 recruits per year), 5,000

immigration officers (400 recruits per year), their dependants, and thousands of civilians living in the vicinity

of the police and prison health facilities. The program is a continuation of the program started under FY

2007 funding. Tools and materials developed under the DOD/PAI/TPDF Program can be used for all police,

prisons, and the immigration department and vice versa. Immigration officers are linked to police and prison

health facilities for treatment. Over the next several months, PharmAccess International will explore the

possibility of extending services to prisoners through a partnership with the United Nations Office of Drug

and Crime.

ACCOMPLISHMENTS: The Prevention program for the police, prison and immigration forces is expected to

start in the second half of 2007, funded by PEPFAR/USAID.

ACTIVITIES: With FY 2008 funding, PharmAccess will be involved in the following activities:

1) Developing and distributing of new IEC and life skills materials by dedicated taskforces for each of the

police, prison and immigration services.

2) Providing prevention IEC and life-skill materials and services to all service members, their dependents,

and the communities near police and prison health facilities.

3) Equipping new recruits with the necessary knowledge and skills, and provide ongoing access to

information and services, to prevent HIV/AIDS among themselves and other youths in and outside the

uniformed forces.

4) Special efforts will be put on counseling of HIV-positive persons to raise awareness about the risks of

HIV transmission. USG funding will support the (re-) training of 104 clinicians and HIV counselors of 26

health facilities.

5) Establishing post-test group sessions of HIV-positive persons

6) Re-training of 60 TOTs and training of 1200 peer educators, at least two per police station or prison.

Activities will be directed to all police stations, prisons and offices of the immigration department.

7) Enhancing the awareness of HIV/AIDS by training commanders so that they consistently give high

visibility to HIV/AIDS in their proceedings and activities

8) Training of groups of women living within the barracks and near the police stations and prisons to

advocate HIV testing and less risky behavior.

9) Distributing condoms as well as carrying out education services on prevention efforts and as part of CT

services at all police stations, prisons, and offices of the immigration department. Condoms will be obtained

through District Medical Officers in the respective districts. In incidental cases, when the public system

does not deliver and when stock-outs may occur, condoms will be procured and distributed through

Tanzania Marketing and Communications company (T- MARC).

LINKAGES: The 16 new health facilities providing counseling, testing, and care and treatment services will

link with nearby Regional and District hospitals for Elisa and CD4 testing and for referral of late-stage AIDS

patients, organizations of women living in the barracks around these police stations and prisons. 200

women will be trained and involved in providing HIV/AIDS IEC and life-skills materials in and outside the

barracks. In addition, the facilities will link with NGO's and other community support organizations to do

home-visits, provide home-based care, and provide other support to HIV-positive persons living in the

vicinity of these heath centers and outside the barracks.

CHECK BOXES: The emphasis is to keep employee police, prisons, and immigration services (TPPI or the

Forces), their dependants, and civilians living near the health facilities of these forces free from HIV

infection. Activities include providing prevention and education materials and services to all service

members and their dependents within communities near police and prison health facilities. In addition,

Pharmaccess will equip new recruits with the necessary knowledge and skills (and provide ongoing access

to information and services) to prevent HIV/AIDS. Lastly, Pharmaccess will enhance HIV/AIDS awareness

by training peer educators and commanders so that they consistently give high visibility to HIV/AIDS in their

proceedings and activities.

M&E: Data will be collected and reported by the management of the health facilities. Management will be

trained and instructed to guarantee as much standardization as possible in reporting procedures.

PAI will prepare a written M&E plan and will begin implementation no later than receipt of FY 2008 funds.

The plan will outline procedures for data collection, storage, reporting, and data quality in addition to

outlining plans for data use for decision-making within the organization and with key stakeholders. PAI will

allocate 7% of FY 2008 funds to M&E and will harmonize with other PEPFAR AB and OP partners to

develop and revise data collection tools.

SUSTAINAIBLITY: 1) Most costs of this program are for training and for developing and distributing IEC

materials. Investments are pledged at the start-up phase of the program, therefore, it is expected that the

costs per patient will decrease dramatically over time.

2) Medical staff turnover is low, therefore upon completion of training, this asset and capacity will remain

with the forces to ensure sustainability.

3) Health facilities of the uniformed forces are under the administration of their respective Ministries. This

prevention program will be implemented under the rules, regulations, and guidelines of the National AIDS

Control Programme. Training, treatment, treatment guidelines, and M&E are all part of one large program.

TITLE: Providing comprehensive TB/HIV diagnoses and treatment at Police and Prisons health facilities

NEED and COMPARATIVE ADVANTAGE: The PharmAccess International (PAI) Police, Prisons and

Prisoners Service has a network of hospitals, health centers and dispensaries through out the country,

supporting a total of over 39,000 enlisted personnel and estimated 100,000 dependants.

PAI will work with Police, Prisons and the Immigration Department to provide comprehensive quality care

and treatment services in five Police and five Prison hospitals and 16 health centers/satellite sites.

ACCOMPLISHMENTS: FY 2007 was the first year that the USG requested Emergency Plan funding for

PharmAccess (PAI) Police and Immigration Forces. Those funds have only just been awarded; though PAI

is proceeding with many important aspects of coordinating initiation and development of work plan for

TB/HIV program.

These hospitals and health centers do not only service personnel from these forces and their dependents,

but also civilians living in the vicinity of the health facilities. The hospitals offering district level services with

the largest hospitals, Kilwa Road Police and Ukonga Prison Hospital, are both located in Dar es Salaam,

and serve the role of national referral centers for these forces. With an average HIV prevalence of six to

seven percent, Tanzania is amongst the hardest hit countries in Africa. The rates are thought to be higher in

the Uniformed Forces. PAI is poised to continue to address the needs to improve coverage and access, and

to strengthen and expand care and treatment activities in the Police and Prison hospitals and health

centers/satellite sites across Tanzania for their personnel and civilians, including inmates. PAI's

contributions ensure a close service linkage of the HIV program of these forces being implemented in line

with the national Health Sector HIV strategy.

A HIV/AIDS Policy to make HIV testing an integrated part of the yearly medical check-up for all Police,

Prisons and Immigration personnel is expected to be authorized within 12 months. Consequence of the

policy will be that large numbers of personnel will be tested and that an extensive increase of HIV+ and TB+

persons who need care and treatment can be expected.

Approximately 40-50% of TB patients are HIV-infected and, conversely, it is estimated that roughly one-third

of HIV-infected patients develop clinically-overt TB. Expanded case identification and treatment of TB is

needed in order to reduce morbidity and mortality associated with HIV infection. In addition, aggressive HIV

counseling and testing of TB patients represents an important public health strategy which will be key in the

further identification and treatment of other HIV-infected individuals. The program is planned to start in

September 2007.

ACTIVITIES: 1) Assesments/reassessments, refurbishing, furnishing of patient counseling rooms at 16 new

satellite sites/health centers

2) Training/retraining of staff at five Police hospitals and eight of their satellite sites/health centers and five

Prison hospitals and eight of their satellite sites/health centers will be organized. Four clinicians and two

laboratory technologists from 10 hospitals along with two clinicians and one laboratory technician from 16

health centers (60 + 48 = 108 in total) will undergo two to four week trainings. Health care providers of the

counseling and testing centers (CTC) will be trained on TB diagnostic methods to increase detection and

referral of TB cases among their HIV positive patients. Health care providers of the TB-Units will be trained

on provider initiated HIV testing and counseling of all confirmed TB positive patients.

These trainings will be organized in collaboration with the TB Unit of the National AIDS Control Program

(NACP) and the National TB and Leprosy Programme (NTLP).

3) Providing microscopes for TB diagnosis, lab-materials and protective safety gear and support to improve

laboratory capacity for TB diagnosis at all 26 health facilities. Kilwa Road Police and Ukonga Prison

Hospital will serve as the coordinating bodies for services and oversee quality assurance following national

standards for follow-up at district or regional hospitals.

4) TB/HIV patients will receive cotrimoxazole prophylaxis administered in accordance with existing NTLP

guidelines.

5) Establishing a referral system for HIV+ persons from the 16 health centers to the 10 Police and Prisons

hospitals and/or to nearby Regional and District hospitals: for CD4 testing and for care and treatment of

complicated cases.

6) Conducting community education and Open House days to increase access to services and partner

testing. Military personnel, their dependents and civilians living in the vicinity of the hospitals and health

centers will be informed through ‘Open House' days and other awareness campaigns for each center.

Information about the available services of the facilities, including HIV-screening, PMTCT and TB treatment

will be presented and promoted through drama, music and other presentations.

7) Nutritional support and infant feeding.

8) IT, Data management and data-handling for M&E and patient and program monitoring purposes

9) Project management.

LINKAGES: Administration of the hospitals and health centers of the Uniformed Forces is not under the

MOHSW but under the respective Ministries of these Forces (Defense, Security and Home Affairs). TB/HIV

services under this Program will ensure a close linkage with national HIV/AIDS and TB strategies and

programs of the TB Unit of the NACP and the National TB and Leprosy Programme (NTLP).

Coverage will increase through the 10 military hospitals and 16 health centers. All HIV-infected men and

women will be referred for further evaluation and qualification for TB treatment and ART within the facility.

Linkage will be strengthened with prevention activities under the HIV/AIDS Program of Police and Prisons,

including promotion and counseling of preventive measures for HIV+ persons, provider-initiated counseling

and testing (PITC), counseling and testing (C&T), PMTCT, TB/HIV and OVC.

Linkages will be established as well as referrals for HIV+ patients from the satellite sites to Police and

Activity Narrative: Prison hospitals or District and Regional hospitals for CD4, TB testing and complicated cases.

PharmAccess will ensure linkages with organizations of women living in the barracks. We anticipate that

these women will also operate as care providers within the barracks. No NGO or other private social

support organization or social support organization is allowed to work/operate within the military barracks.

However, for clients in the surrounding communities, we anticipate forming linkages with existing local

NGOs operating in those communities to ensure continuum of care.

Linkages have been, and will be established with the Regional and District Health Management teams for

supportive supervision purposes and technical assistance.

CHECK BOXES: The areas of emphasis were selected because the activities will include support for

training of medical staff, purchase of TB-specific laboratory diagnostic equipment and reagents,

consumables for HIV confirmatory diagnosis and isoniazid (INH) and cotrimoxazole for treatment and

prophylaxis purposes. It is expected that a total of 1,500 people, representing approximately 50% of the

3,000 HIV-infected patients who will be on care or treatment by September 2009, will be found to be co-

infected with TB and will require TB services.

M&E: Data will be collected both electronically and by paper-based tools. All sites use the paper forms

developed by National TB and Leprosy Program (NTLP) and NACP. TB screening and HIV-screening

registrars need to be adapted to keep track of TB+ patients referred for HIV-screening and HIV+ patients

referred for TB-screening. Registrars need to be checked by a member of the referring clinic to ensure that

referred patient reached.

On-site data entry will take place. All sites will be provided with PCs, a database and output functions as

developed for the National C&T program. 52 Data clerks from the 10 hospitals and the 16 health centers will

be all trained by or in collaboration with UCC. PAI and UCC will provide supportive supervision and the

hospitals will support the satellite sites. Data will be provided to NTLP, NACP and OGAC for reporting

purposes.

SUSTAINAIBLITY: PAI will encourage the Office of the Director Medical Services of Police and of Prisons to

integrate HIV/AIDS TB harmonization activities in their Health Plans and budgets at the facility and national

level. To improve administrative capacity, PAI will work with the respective authorities to build local

authority's technical and managerial capacity to manage the program.

The facilities provide staff and health infrastructure. Most costs of this program are for training and for

infrastructure improvement. Investments are done at the start-up phase of the program. Turnover of

medical staff is low. Training is needed. Once trained, this capacity will stay within the forces.

Health facilities of the Military Forces are under the administration of the Ministry of Defense, not under the

Ministry of Health. This HIV/TB program will be implemented under the rules, regulations and guidelines of

the National AIDS Program and NTLP. Training, treatment, treatment guidelines, M&E etc is all part of one

National Care and Treatment Program.

TITLE: Providing Insurance to Strengthen Households with Orphans and Vulnerable Children (OVC).

PEPFAR Tanzania has worked with the Government of the Netherlands to apply an integrated plan to

provide direct support to HIV/AIDS-impacted people, while simultaneously investing in the development of a

robust private sector health care capacity. Recent studies show that at the country's current level of

development, the private sector must be leveraged to assist in health care provision if the government is to

realize its goal of ensuring access to health care services to all who need it.

This activity collaborates with an innovative public-private partnership designed to provide basic employer-

provide health insurance to 50,000 low-income wage earners by leveraging the in-place program to offer

insurance benefits to caregivers and their families who are willing to take in OVC. The program provides

insurance premium subsidies, which the private sector in-country insurer matches by agreeing to take only

3%, profit rather than the standard 18% (resulting in a 15% insurer contribution).

ACCOMPLISHMENTS: new activity

ACTIVITIES: The USG/Tanzania has linked with the Dutch Government to implement an integrated plan to

provide direct support to HIV/AIDS-impacted people while simultaneously investing in the development of a

robust private sector health care capacity. This activity will extend the basic health care coverage package

by covering the care costs associated with households who are willing to take in OVC. The care will be

provided in certified private, non-governmental health facilities, as well as through home-based care

providers. The arrangement will have the dual effect of increasing household support for families caring for

OVC, while also encouraging the development of a parallel private sector health care network designed to

encourage and support employer-sponsored health care coverage. No targets have been set because the

beneficiaries will be served by USG-funded implementing partners and will be reported under those

partners programs.

LINKAGES: This activity links to the other insurance program activities in treatment and the on-going

activity in counseling and testing. Collaboration on the pilot programs will occur with Deloitte TUNAJALI

OVC activities, and possibly with other USG-funded OVC implementing partners.

CHECK BOXES: The program will serve OVC and their households, strengthening the household and

contributing to economic security.

SUSTAINAIBLITY: By building interest in health insurance, the program is expected to strengthen families

and develop the practice of using health insurance to strengthen health services.

TITLE: Counseling and Testing Services at Police and Prison Health Facilities

NEED and COMPARATIVE ADVANTAGE: With more than 65,000 police, prison, and immigration officers,

this population constitutes high-risk because of their age, the migratory nature of their work, lack of family

support during assignments, as well as the ‘power of the uniform', etc. HIV/AIDS and STI prevention, ABC,

other ‘life-skill' education messages and advocacy for counseling and testing will be targeted at all

employees, with a special focus on recruits, those who are transferred to service outside their region, those

sent on missions, and those sent to training camps. A HIV/AIDS policy introducing yearly HIV testing

(mandatory) and safeguarding the position of those HIV+ persons is currently being considered by the

management of these forces.

ACCOMPLISHMENTS: PharmAccess has managed to initiate VCT services in eight health facilities for

these forces (four for the police and four for the prisons) with funds from Global Fund. One hundred and

forty persons from the police, prisons, and from the surrounding communities of the respective health

facilities have been HIV+ at these sites. PAI has started providing nutritional supplements to 100 PLHA in

these sites. This activity is funded by Global Fund round four and subcontracted by PAI to Counsenuth

ACTIVITIES: PharmAccess provides services through the police and prison health facilities and links

immigration officers and employees to these sites.

With FY 2008 PEPFAR funding PharmAccess will:

1) Initiate counseling and testing services at four additional police and prison facilities and eight police and

prison facilities under FY 2009. Provider-initiated testing and counseling (PICT) will be offered free of

charge to servicemen and women, their dependents, and civilians living in the communities surrounding

these facilities. Civilians make ample use of the health services of the forces. Testing for new conscripts is

mandatory. Only conscripts who test HIV-negative join the police and prison forces. Testing and counseling

will be in accordance with the latest MOHSW algorithm and guidelines, including simple provision of blood

samples (needle prick rather than blood draw), same day testing and results, parallel testing with SD

Bioline, and confirming with HIV Determine. All sites will be provided with test kits and safety gear (gloves,

materials for safe disposal of sharps and other wastes, etc.). HIV-screening will be linked with prevention

activities and will be used as entry point activities related to gender-based violence (GBV) for both offenders

and victims. 2) Capacity building is a key element of the program. Four week PICT trainings will be

organized, following the curricula of the National Care and Treatment Program. Four medical officers, nurse

counselors, and laboratory technologists from the 16 new health centers will be trained and four from the

sites which started already will be retrained for a total of 96 health care workers. 3) Refurbishing of 3-4

counseling rooms for the 16 new sites is needed so that confidentiality for HIV-screening and for treatment

counseling is ensured, proper testing can take place, and stocks of medicines and laboratory materials can

be adequately stored. 4) Organize HIV/AIDS sensitization campaigns; organize home-visits and home-

based care services etc. in the barracks. Police and prison officers will be trained and organized to operate

as home-based care, nutritional and other support providers within the barracks. No NGO or other social

support organization is allowed to work/operate within the military barracks. For civilians living in the

surrounding communities, we anticipate to form linkages with existing local NGOs operating in those

communities so as to ensure continuum of care. 5) Organize post-test clubs and conduct counseling for

HIV+ individuals on the prevention of HIV transmission. Distribute life-skills and IEC materials to all who test

negative or positive. 6) HIV+ persons will receive care and treatment services at the facilities. Patients will

be referred for TB-testing within the site and will be referred to nearby regional and district hospitals for CD4

-testing and start of ARV treatment. When patients are stable on ART they will be referred back to the

health center. 7) Conduct community education and open—house days to increase access to services and

partner testing. Police and prisons personnel, their dependents, and civilians living in the vicinity of the

hospitals and health centers will be informed through ‘open house' days and other awareness campaigns of

each center. Information about the available services of the facilities including HIV-screening, ART, PMTCT,

and TB treatment will be presented and promoted through drama, music, and other presentations. 8)

Supportive supervision: teams of experts of the police and prisons HQ, referral hospitals, and PAI will

assess the capacity of the sites, develop strengthening plans, plan and oversee refurbishments, trainings,

M&E, relate with district and regional HMTs and regional partner organizations in close collaboration with

staff from the sites.

LINKAGES: Administration of the hospitals and health centers of the uniformed forces is not under the

MOHSW but under the respective ministries of these forces. TB/HIV services under this program will ensure

a close linkage with national HIV/AIDS and TB strategies and programs of the TB unit of the NACP and the

National TB and Leprosy Programme (NTLP). HIV-infected men and women will be referred for further

evaluation and qualification for PMTCT, TB, and malaria screening and treatment and ART within the

facility. Linkage will be strengthened with prevention activities under the HIV/AIDS program of police and

prisons, including promotion and counseling of preventive measures for HIV+ persons. Linkages will be

established as well as referral for HIV+ from the satellite sites to police and prison hospitals or district and

regional hospitals. For clients in the surrounding communities, linkages with existing local NGOs operating

in those communities will be formed as to ensure a continuum of care. Linkages have been and will be

established with the regional and district health management teams for supportive supervision purposes

and technical assistance. PharmAccess will explore linkages with the UN Office of Drug and Crime in order

to be able to extend these services to prisoners in the future.

M&E: The sites PAI work will use CT registrars and the national CTC monitoring system. By supporting the

national CT MS, PAI builds local capacity and helps to strengthen the national M&E system. An electronic

system will be developed by PAI at the facility-level in collaboration with UCC and NACP, as has been done

for the DOD/TPDF Program. National CT guidelines and training materials will be used to strengthen M&E

capacity in these facilities.

SUSTAINABILITY: PAI will encourage the Office of the Director Medical Services of Police and of Prisons to

integrate HIV-screening activities in their health plans and budgets at the facility and national level. To

improve administrative capacity, PAI will work with the respective authorities to build local authority's

technical and managerial capacity to manage the program.

TITLE: Treatment Buy-In to Insurance Fund PPP

PEPFAR Tanzania has developed an integrated plan to provide direct support to HIV/AIDS-impacted

people while simultaneously investing in the development of a robust private sector health care capacity.

Recent studies show that, at the country's current level of development, the private sector must be

leveraged to assist in health care provision if the government is to realize its goal of ensuring access to

health care services to all who need it.

This activity collaborates with an innovative public-private partnership designed to provide basic employer-

provide health insurance to 50,000 low-income wage earners. The program provides insurance premium

subsidies of 50% - 90% of the total cost to ensure affordability. The private sector match comes in the form

of the employee payment (10% - 50%) plus the private sector in-country insurer agreement to take only 3%

profit rather than the standard 18% (resulting in a 15% insurer contribution).

This activity will extend the basic health care coverage package by covering the treatment costs associated

with all eligible workers and their families within the 50,000 covered workers. The treatment will be provided

in certified private, non-governmental health facilities which will have the dual effect of increasing national

testing capacity while also encouraging the development of a parallel private sector health care network

designed to encourage and support employer-sponsored health care coverage. Studies show that for

countries in which less than 20% of GDP is collected in taxes (a dual measure of formal sector maturity and

sophistication of governmental monitoring infrastructure), resources for ‘government-only' health care are

insufficient to provide popular protection and the system must be augmented with a private sector health

care system designed to service ‘those who can pay'.

The initial target of 50,000 workers will focus on several geographically-centralized groups, including a large

coffee cooperative in Moshi and the micro-entrepreneurs at the Kariakoo market and the fish market in Dar.

Additional groups will be added once identified as meeting the program entrance criteria.

The funding will be provided to an existing partner organization, PharmAccess, who will in term pass it

along to the Dutch fund as a subgrantee. The funding is intended to spur the development of a private-

provider network of HIV/AIDS focused health professionals geared to service employer-sponsored plans

here in Tanzania. It is also intended to blaze a path for our focus countries to follow in teaming with the

innovative health insurance fund. We will initiate discussions with the O/GAC public-private partnership

group to monitor and evaluate program success and to determine feasibility of program extension within

and beyond Tanzania.

The initial workers targeted to benefit from this innovative fund are a coffee cooperative in Moshi,

creditworthy microfinance loan holders from the National Microfinance Bank (NMB), and stall holders at

both of the major markets in Dar es Salaam; the fish market and Kariakoo. The workers share some of the

key requisite attributes, including representing the lower wage earning end of the engine of commerce in the

country, and being formalized enough so that they can form a risk pool and have their wages garnered for

premium payments.

ACCOMPLISHMENTS:

ACTIVITIES:

PEPFAR Tanzania has developed an integrated plan to provide direct support to HIV/AIDS-impacted

people while simultaneously investing in the development of a robust private sector health care capacity.

Recent studies show that, at the country's current level of development, the private sector must be

leveraged to assist in health care provision if the government is to realize its goal of ensuring access to

health care services to all who need it.

LINKAGES: The other activities leveraging the insurance fund

SUSTAINAIBLITY: PPP

TITLE: Care and Treatment Services at Police and Prisons Health Facilities

NEED and COMPARATIVE ADVANTAGE: The Police and the Prisons Service have a network of hospitals,

health centers, and dispensaries throughout the country, supporting a total of over 39,000 enlisted

personnel and estimated 100,000 dependants, 40,000 prisoners, and tens of thousands other civilians. The

hospitals offer district level services with the largest hospitals, Kilwa Road Police and Ukonga Prison

Hospital in Dar es Salaam serving the role of national referral centers for these Forces. To date, none of

the Police or Prison sites are fulfilling the minimum criteria for HIV/AIDS Care and Treatment as defined by

the Ministry of Health and Social Welfare (MOHSW). Currently only one Police (Kilwa Road) and one Prison

Hospital (Ukonga) participate in the National Care and Treatment Program (NCTP). Prisons Service started

antiretroviral therapy (ART) in two hospitals and nine health centers without the necessary laboratory

capacity, staff training, assessments, M&E, etc, as required by the NCTP.

The hospitals and health centers of Police and Prisons service personnel from these Forces and from the

Immigration Department, their dependents, prisoners, and civilians living in the vicinity of the health

facilities. In fact, 80% of the patients are civilian. With an average HIV prevalence of 6-7%, Tanzania is

amongst the hardest hit countries in Africa and the rates are thought to be higher in the Uniformed Forces.

A HIV/AIDS policy to make HIV testing an integrated part of the yearly medical check-up for all Police,

Prisons, and Immigration personnel is expected to be authorized within 12 months, and is expected to drive

up demand for quality ART services. PharmAccess International (PAI) is poised to continue to address the

needs to improve coverage and access to strengthen and expand care and treatment activities in the Police

and Prisons hospitals and health centers/satellite sites across Tanzania for their personnel and civilians,

including inmates. PAI's contributions ensure a close service linkage of the HIV program of these forces

being implemented in line with the national Health Sector HIV strategy. Because PharmAccess has an

existing arrangement and a memorandum of understanding with Police, Prisons, and Immigration

Departments, they are well positioned to provide comprehensive quality care and treatment services in 13

zonal police and 13 zonal Prison hospitals by the end of FY 2008.

ACCOMPLISHMENTS: The program is just being initiated now, with a new award from USAID.

ACTIVITIES: Key activities for FY 2008 include:

1) Conducting site assessments and development of strengthening plans of eight Police and eight Prison

health centres;

2) Initiating ART services to 650 patients by the end of FY 2008 and 1500 patients by the end of FY 2009.

3) Refurbishing and furnishing Care and Treatment Clinics and laboratories. 3a) Laboratories of the Police

and Prison hospitals will be equipped for HIV and STI services. Patients will be referred to nearest

Regional and District hospitals for CD4 and routine monitoring lab tests, if not available on site.

3b) Procuring routine laboratory assays, safety materials, water sterilization equipment, a refrigerator,

medication for opportunistic infection (OI) treatment, and office supplies, including computer hardware for

each site.

4) Training 64 and re-train 60 health care workers in ART management.

5) Developing linkages between Police and Prison sites to nearby Regional or District Hospital for referral of

complicated cases. Establish linkage between Prison sites to Regional or District Hospital to ensure strong

referrals of inmates before they are released, to guarantee follow-up services.

6) Promoting linkages between ART and Prevention of Mother-to-Child Transmission (PMTCT) and TB

services, including through community education and open—house days to increase access to services and

partner testing. Police and Prisons personnel, their dependents, and civilians living in the vicinity of the

hospitals and health centers will be informed through ‘Open House' days and other awareness campaigns

of each center. Information about the available services of the facilities, including HIV-screening, ART,

PMTCT, and TB treatment will be presented and promoted through drama, music, and other presentations.

7) Conduct nutritional assessment as a part of routine clinical visits. Providing, when necessary, nutritional

support through prescription for up to six months. Linkages will be identified for other nutritional support

that can be distributed through organizations of women living in the barracks, organized to provide

nutritional and social support to HIV+ and AIDS patients.

8) Developing patient monitoring systems, using the national CTC monitoring system.

9) Inititiating provider-initiated testing and counseling (PITC) for all non-servicemen and women who are

dependents, inmates, and other civilians. Consequences of the Police and PITC will be that large numbers

of personnel will be tested and that an extensive increase of HIV+ persons who need care and treatment

can be expected.

LINKAGES: Because administration of the hospitals and health centers of the Army, Police and Persons is

not under the MOHSW but under the respective Ministries of these Forces (Defense, Public Safety and

Security and Home Affairs), linkages will have to be strong between these ministries and the program. In

addition, care and treatment services under this Program will be closely linked with the national HIV/AIDS

program coordinated by the National AIDS Control Programme (NACP) and the National TB and Leprosy

Programme (NTLP), as well as with other USG-funded treatment partners.

Linkages will be strengthened with prevention activities under the HIV/AIDS Program of Police and Prisons,

including promotion and counseling of preventive measures for HIV+ persons, PITC, counseling and testing,

PMTCT, TB/HIV and OVC. Linkages will be established as well as referral for HIV+ from the satellite sites

to Police and Prison hospitals or District and Regional hospitals for CD4, TB testing, and complicated

cases. PharmAccess will ensure linkages with organizations of women living in the barracks. PAI

anticipates that these women will also operate as care providers within the barracks. No NGO or other

private social support organization or social support organization is allowed to work/operate within the

military barracks. However, for clients in the surrounding communities, we anticipate to form linkages with

existing local NGOs operating in those communities so as to ensure continuum of care.

Activity Narrative:

Linkages have been and will be established with the Regional and District Health Management (RHMT and

DHMT) teams. PAI will continue to collaborate with Regional and District Health Management teams for

supportive supervision and technical assistance.

CHECK BOXES: The areas of emphasis were selected because the activities will include initial and

refresher training, infrastructure improvement, providing equipment and drugs as well as providing HBC

services and community support functions to accomplish the much needed continuum of care in the

program. We anticipate that 600 new patients will start ART under FY 2007 and 1000 under FY 2008

funding. In case that the new HIV/AIDS Policy (to make HIV testing an integrated part of the yearly medical

check-up for all personnel) will be introduced in the next 12 month, we expect that a total of 2,250 new

patients will be on ART in FY 2008. Target populations include military personnel and their dependants,

incarcerated populations, as well as members from surrounding communities.

M&E: PAI will collaborate with the NACP/MOHSW to implement the revised national M&E system for care

and treatment at all its hospitals and health centres. Data will be collected using paper-based tools and

managed electronically using the national database which will then generate the required NACP and USG

reports. For data quality assurance, PAI will continue to support DHMTs/RHMTs to provide supportive

supervision visits to sites including on-site training of facility staff and will develop Standard Operating

Procedures for record and report handling. Feedback reports will be provided to Regional and District

Health Management Teams and to facility staff for program and patient. All 33 sites will have laptops to

manage patient data using the national database. PAI will, in collaboration with University Computing and

NACP, train 66 health care workers in both paper and electronic systems, and provide technical assistance

to 33 facilities. PAI will perform regular data analyses and present findings at National and International

stakeholder meetings, workshops, and conferences.

SUSTAINAIBLITY: The training and infrastructure investments through this program will help to establish a

sustainable program for the Uniformed Forces. Turnover of medical staff is low in the Uniformed Forces,

therefore training is needed. Once trained, this capacity will stay within the Forces. Health facilities of the

Uniformed Forces are under the administration of their respective Ministries, not under the Ministry of

Health. This Care and Treatment program will be implemented under the rules, regulations, and guidelines

of the National AIDS Programme and the Leprosy Program, ergo strengthening the ongoing linkages

between NACP and the Uniformed Forces programs for quality ART services.