TITLE: Youth Health Corps for Community-based HIV care, Treatment, and Prevention for OVC and

Caregivers

NEED and COMPARATIVE ADVANTAGE: Tanzania has greatly expanded access to Antiretroviral Therapy

(ART). The overwhelming care and treatment need continues to deplete national supply, with less than

10% in need receiving care. Barriers to ART and other healthcare services include distance to clinics and

associated costs, stigma, and an acute shortage of trained healthcare workers. The situation is worse for

Orphans and Vulnerable Children (OVC) because often times the caregiver is either too old or too young to

support and ensure OVC access to quality healthcare. In Tanzania, most OVC are cared for by

grandparents who are either ignorant of infant diagnosis on HIV/AIDS symptoms, transmission, and means

of prevention or too overburdened to ensure the adherence of ART by the infected OVC (about 52%).

Another workforce issue tied to the epidemic is that many OVC are breadwinners caring for their siblings.

As a result, they leave school to earn money by whatever means possible, (e.g., engaging in work as bar

maids or plantation laborers, jobs that involve migration, social dislocation, (and especially for young

women) sexual exploitation, thereby increasing HIV risk. To improve ART access and prevent new

infections to the OVC and caregivers, the Youth Health Core (YHC) model aims to address both the critical

healthcare workforce shortage and young people's vulnerability to HIV. The program will be spearheaded

by Pangea Global AIDS Foundation (PGAF) team, along with Muhimbili University College of Health

Sciences (MUCHS) and the University of California at San Francisco (UCSF)-.

ACCOMPLISHMENTS: This new initiative has emerged from two years of formative research, and will be

rolled out as a pilot project with FY 2008 funding. Since 2005, the YHC team has examined barriers to

AIDS treatment including healthcare workforce constraints and factors placing young people, OVC, and

caregivers at risk for HIV. A workforce gap analysis was conducted to identify critical needs required for

effective prevention of HIV/AIDS and scale-up of ART and community pediatric care. Extensive qualitative

interviews were conducted among clinicians, community leaders, and youth in Mufindi District to assess

acceptability of the YHC concept. Relationships have been developed with stakeholders at all levels,

including the Ministry of Health and Social Welfare (MOHSW), and the refined model proposed here reflects

this input.

ACTIVITIES: 1. The program will recruit and employ 40 YHC members to serve an estimated 4,000

households in 20 villages in Mufindi District, Iringa Region. YHC members will provide service in five

principal domains: basic preventive, diagnostic, and curative primary care; linking infected OVC and

caregivers to higher-level facility-based care; community-based patient follow-up; coordinating referrals for

support needs; and supporting community-level data collection and reporting. In collaboration with the local

Most Vulnerable Children's Committees (MVCC), the program will recruit out-of-school former OVC females

and males aged 18-26 currently residing in the target communities and having completed a minimum Form

IV education. Two YHC members per village will be selected and employed through MUCHS. The YHC

will be linked to local health centers, most of which will soon be initiating HIV/AIDS care and treatment.

While serving in the YHC, members will be supervised by the clinician in charge at the local health facility to

which they are attached. Each YHC team will be required to attend a weekly meeting with their supervisor

to consult on cases, submit patient contact documentation, troubleshoot problems, pick up medication

refills, and receive new cases for community-based follow-up.

2. The program will provide training of YHC members. Initial training will be conducted for six-months,

including didactic, community pediatric, community/ clinical practica, and group/team project modules.

While the focus is on clinical skill building, key themes, including patient-centered care, ethics and

confidentiality, leadership development, and career planning run throughout each module. Nationally, the

program aims to have YHC members certified as community-based para-medicals. Upon successful

completion of two years of YHC service through the MOHSW/MUCHS Institute of Allied Health Sciences,

ongoing career guidance services will be provided, and graduates will be linked to training, education, and

employment opportunities in the health and social welfare sectors (e.g., formal health worker training

organized through the USG-funded Global Development Alliance at Bugando University College of Health

Sciences--BUCHS).

3. The program includes ongoing quality control, community input and continuous improvement. This will

ensure quality, consistency, and responsiveness. Measures include quarterly meetings with Community

Advisory Boards (CAB), quarterly performance reviews of each YHC member, and monthly meetings with

all YHC members. Quarterly meetings of the CABs, consisting of local representatives of the MOHSW,

village and ward-level health committees, clinical facilities, people living with HIV/AIDS, local service

providers, and a rotating YHC member will be used to gather continuing feedback on the model. In

addition, discussions regarding plans for changes as they occur and troubleshooting capability will also be

addressed should problems arise.

LINKAGES: This project will support the implementation of the OVC National Plan of Action and will

leverage Emergency Plan support with co-funding from the NIH and the Elizabeth Glaser Pediatric AIDS

Foundation. A Technical Advisory Committee (TAC) will meet quarterly to review progress of the pilot, and

identify a feasible scale-up and impact evaluation plan including long-term sustainable funding mechanisms.

TAC members will come from a wide variety of stakeholders. In addition, YHC can link to I-TECH's work

with the ZTC in Iringa. The program will link with the pre-service health worker training supported by the

USG at BUCHS in order to maximize utilization of training.

CHECK BOXES: Human Capacity Development/pre-service training: This activity will certify participants as

community based para-medicals through MUCHS. Economic Strengthening: This activity will place

otherwise unemployed youth in sustainable jobs, therefore making them less vulnerable to HIV/AIDS.

M&E: Rigorous M&E activities will assess the YHC model's feasibility, acceptability, scalability, and potential

for impact and cost-effectiveness. These data will ensure ongoing project improvement in addition to

securing and supporting future replication, expansion, and national scale-up of the model. Using both

qualitative and quantitative measures, the YHC team will monitor the project for continuous improvement of

the model. Project monitoring will facilitate the setting of appropriate targets for numbers of patients served

in a variety of service categories for the subsequent scale-up phase. This concept includes an outcome

evaluation at three levels using an observational pre- and post-test design to examine the model's potential

for impact. Throughout the project, the team will collect cost data on program activities for a projection of

Activity Narrative: cost per community member served, and cost per YHC member trained, to model potential cost-

effectiveness for the scale-up phase.

SUSTAINAIBLITY: This model is sustainable on many levels. YHC members will be employed and

supervised by the public healthcare system. They will be certified for entrance into the workforce upon

completion. The YHC provided integrated primary healthcare services, the approach endorsed by the

MOHSW, rather than vertical disease-specific care. Most importantly, the YHC model is explicitly focused

on developing healthcare and social welfare career opportunities for at-risk youth, which should result in

both decreased vulnerability to HIV infection and a strengthened future workforce.

TITLE: Strengthening Skills of Health Workers in HIV/AIDS

NEED and COMPARATIVE ADVANTAGE:

The tremendous shortfall of skilled health workers to address the needs of HIV/AIDS patients requires

focused training above and beyond the normal pre-service training in Tanzania. The Fogarty International

Center (FIC) of the U.S. National Institutes of Health has funded 23 AIDS International Training and

Research Program (AITRP) Centers for more than ten years, including several African countries and can

make an important contribution to addressing the clinical training needs in HIV/AIDS care in Tanzania.

ACCOMPLISHMENTS:

This has not previously been funded by PEPFAR/Tanzania.

MAJOR ACTIVITIES:

The primary goal of this program is to build multi-disciplinary biomedical, behavioral, and social science

capacity for the care and treatment of HIV/AIDS and HIV-related conditions HIV/AIDS-affected adults and

children in Tanzania. AITRP makes provisions for training in the United States, in other countries, as well as

the home country itself. Though the primary focus of the AITRP grants has been on research capacity, the

Fogarty International Center has expressed interest in broadening the human capacity focus to clinical

service delivery.

The AITRP supports long-term (two to three years) MPH, PhD, and postdoctoral training in HIV/AIDS

research at Duke University and Baylor College of Medicine for health-professionals from Tanzania. Short-

term U.S. based-training of health professionals also is conducted.

In the case of Baylor, FY 2008 funding would support professionals who might benefit from focused training,

primarily in pediatric HIV/AIDS care and treatment. Baylor can host trainees with nursing degrees and

medical degrees. Another training model Baylor is set up to use is shorter term "attachments" to one of the

Baylor Pediatric AIDS Centers of Excellence (COE). For example, two to four week training programs can

be done with groups of physicians or nurses to a Center of Excellence in Botswana, Swaziland, or Malawi.

This model has been successful with trainees from other African countries because a) the learners do not

have to travel so far, b) they can do whatever length of attachment works for them based on how long they

can be away from their primary job, and c) the clinical training and guidance they receive is likely to be more

relevant to their home context than if they traveled to the US for short-term training.

In an attachment training experience, Tanzanian trainees (doctors, nurses, pharmacists, social workers, and

others) would have the opportunity to observe and work within an Africa-based care and treatment program

that is successful and thriving. They will learn about Antiretroviral therapy: when to start, when to stop,

when to switch, what to do about known or suspected resistance, etc. They will have the opportunity to talk

through difficult cases, and observe a multi-disciplinary team in action. This has been a very valuable

experience for those who have been through it.

The Duke University AITRP can also provide training opportunities in the care of persons living with HIV

infection. The Duke University AITRP has trained over 50 Tanzanians in the past four years in HIV/AIDS-

related disciplines, including physicians, researchers, nurses, pharmacists, laboratory technologists, social

workers and community members. With FY 2008 funds, programs can be created with an individualized

teaching focus to meet their specific training needs. The Duke University AITRP would offer additional

training for key personnel involved in supporting care, especially nursing leadership and laboratory

technologists. Duke University's principal collaborator in Tanzania is the Kilimanjaro Christian Medical

Centre (KCMC). Together they have established a state of the art Microbiology Laboratory at KCMC which

is used for training and the support of clinical research. The Duke-KCMC collaboration has studied or is in

the process of intensively studying the relationship of HIV and co-pathogens, especially Mycobacterium

tuberculosis. The focus of these studies has included defining the prevalence and incidence of HIV/TB co-

diagnosis, enhancing screening for both diseases among newly diagnosed persons, optimal strategies of

TB diagnosis, molecular diagnostics, TB susceptibility patterns, predictors of disseminated tuberculosis,

drug interactions between Nevirapine and Rifampicin, and the immediate versus delayed initiation of

antiretroviral treatment in patients newly diagnosed with TB and HIV. This ongoing work with Duke would

offer other excellent clinical training opportunities.

LINKAGES:

This training would be linked with other activities ongoing at KCMC through the Elizabeth Glaser Pediatric

AIDS Foundation.

CHECK BOXES:

Training; pre-service.

M&E:

A comprehensive monitoring and evaluation plan will be developed once the program begins. This plan will

capture information on who receives training, what they have been trained on, and how their skills have

improved

SUSTAINAIBLITY:

The training will help to develop a strengthened platform of trained health workers with very specific clinical

experience.