ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In FY 2009, the Youth Health Corps (YHC) project will develop a specific strategy that will give a special

attention and support to the YHC who are head of households, as well as those cared for by the elderly to

ensure their completion of the preliminary course. The Pangea YHC project will continue to collaborate with

the local Most Vulnerable Children Committees (MVCC), as well as provide overall supervision of YHC

members to ensure adaptation of the national quality standard of health care services in 20 rural

communities in Mufindi District. This will be accomplished by participating in national OVC quality

improvement meetings to familiarize themselves with the developed standards, as well as linking identified

OVC and vulnerable caregivers to the full range of required health and support services. The YHC will also

provide follow up to those receiving care and services. Additionally, the project will develop strong linkages

with other health and social welfare training and service institutions (e.g., formal health worker training

organized through the USG-funded Touch Foundation at Bugando University College of Health Sciences—

BUCHS or other scholarships to be provided by I-TECH), to facilitate avenues for channeling YHC members

who successfully complete two years of service into formal training, higher education, and employment

opportunities in the health and social welfare sectors, aiming at contributing to the strengthening human

resources for health services.

*END ACTIVITY MODIFICATION*

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: 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.

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

including didactic, community pediatric, community/ clinical practical, 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).

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.

Activity Narrative: 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

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.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17802

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

17802 17802.08 HHS/National US National 7629 7629.08 $350,000

Institutes of Health Institutes of Health

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $15,609,953

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Counseling and Testing

Program Area Context FY 2009

HIV counseling and testing (CT) is critical in the fight against HIV/AIDS as it is the main entry point into HIV/AIDS treatment, care,

and support services. The Government of Tanzania recognizes the importance of CT services and strong national leadership has

encouraged all Tanzanians to learn their HIV status. On July 14, 2007, President Jakaya Mrisho Kikwete launched Tanzania's

national HIV testing campaign, which culminated in April 2008. More than 4.2 million Tanzanians were tested and received their

HIV results during a nine month period, and 194,149 persons (117,254 females and 76,895 males) were found to be HIV positive

and referred for clinical services. More individuals were tested in this nine month period than in 15 years before in the country.

This testing campaign was a historic step forward in Tanzania's efforts to increase the number of individuals that know their HIV

status and the USG, with direct funding support and partner participation, played a critical role in the campaign's success.

Additionally, USG's support of routine HIV CT services has substantially bolstered testing efforts in Tanzania. In 2007, the USG

directly supported CT services in approximately 240 sites throughout the country with an emphasis in high prevalence and

underserved areas. These sites represented a 15 percent increase from 2006 and 93 percent of the established annual PEPFAR

target. USG supported CT sites reached 723,848 clients in mainland Tanzania and in Zanzibar, which was 84 percent more

Tanzanians tested than in the previous year. In 2008, the USG goal was to increase the number of Tanzanians tested to

approximately 1.3 million. Semi-annual progress indicated that USG partners tested 1.4 million clients, reaching 110% of the

annual target after only six months. This reflects a significant increase in access and highlights the great strides made in HIV CT

over the past two years.

Advances in HIV testing methodologies and counselling approaches have made learning one's HIV status easier. In Tanzania, for

example, the government adopted a testing algorithm that is simpler and quicker to use (Bioline followed by Determine for

confirmatory testing and Unigold as the tie-breaker). This algorithm greatly assists testing accuracy and enables more clients to

get tested and know their status. The HIV test kits used in this algorithm greatly facilitate the use of finger-pricks to collect blood

for HIV tests. Finger-prick blood collection, instead of veinipuncture, is being used by a growing number of testing sites and GOT

is interested in expanding this method of blood collection. GOT has also championed the expansion of CT services that reach

Tanzanians in the places that they frequent most often and are convenient including health care settings, communities, and

workplaces. As a result of these efforts, there have been substantial increases in the number of persons testing and receiving HIV

results.

Data from the 2008 THIS found that among 15-49 year olds in Tanzania, 37 percent of women and 27 percent of men have ever

been tested for HIV and received the results. In the four years since the 2004 THIS, the proportion of women and men age 15-49

who have undergone HIV testing has doubled (15 percent of women and men reported to have ever undertaken an HIV test in the

2004 THIS). Furthermore, 19 percent of women and men age 15-49 were tested for HIV and received the results at some time

within the 12 months prior to being interviewed, representing a nearly fourfold increase from the last THIS for women and about a

threefold increase for men. This means that more than half the population that has ever been tested for HIV in their lifetime has

done so within the 12 months of being interviewed.

Building on successes in FY08, USG and its CT partners will emphasize strategies that increase access to CT services,

particularly in high prevalence regions of Tanzania and with most at risk populations. Specific areas of focus include expansion of

services along transportation corridors and the use of mobile VCT services for hard to reach high-risk groups. Services will

continue to expand among the military, in residential worksites (e.g. mines and agricultural estates), and in high prevalence, high-

density locations such as border crossings. This expansion will be coordinated with future infrastructure enhancements

undertaken as part of the Millennium Challenge Compact. As USG considered program area budgets for FY 2009, Management

and Operations faced difficult decisions about how to realign funding to the various program areas given overall reductions in the

country's funding level. Ultimately, USG Management and Operations decided to levy a greater proportional cut to the CT budget

than other areas. Despite these cuts, however, it appears that CT partners will test as many or more persons in FY 2009 because

of greater efficiency in targeting and momentum generated from the national testing campaign.

In FY 2009, GOT will continue to expand best practices with technical assistance from the USG, including continued roll-out of

provider-initiated testing and counseling (PITC). The expansion of this modality is a high priority for both the GOT and USG to

significantly increase access to and facilitate "normalization" of CT services. The national PITC guidelines, developed in

collaboration with a USG partner, were approved by GOT in April 2008. Several USG partners will implement this approach in FY

2009. As more partners train providers to implement services in medical facilities, USG will continue efforts to assist GOT with

coordination and delivery of services. In addition, one CT partner implementing PITC will track referrals to care and treatment

using personal digital assistants (PDA). Staff at both CT and treatment sites in one region of Tanzania will be trained on this

technology to monitor how many clients that are referred actually report for their treatment appointments. Finally, a public health

evaluation funded in FY 2008 will assess the most effective CT service delivery models in clinical settings. This information will be

used to tailor PITC services in country and guide future programmatic decisions by GOT.

Home-based testing is another CT method that began implementation last year. Two USG partners were funded to initiate home-

based testing as a component of existing home-based care activities. The partners are providing home-based CT services in high

HIV prevalence regions. In FY 2009, both partners will work with GOT to introduce non-medical, lay counselors to facilitate better

management of client loads and to provide the bulk of pre-test and possibly post-test counseling. This task shifting will not only

reduce the burden on medical professionals, but will also allow home-based testing services to place more concentrated

emphasis on risk reduction counseling and individual risk redu ction planning. In addition, one partner is comparing client

acceptability and the impact of testing families through index patients versus door-to-door, home-based testing. The lessons-

learned will be used to guide the rollout and expansion to other partners.

In FY 2009, USG will begin to address several important issues that will ultimately improve the quality of CT services. One effort

will address the association between alcohol consumption and sexual risk using a brief alcohol assessment and motivational

interviewing implemented in post-test counseling sessions. Other USG partners also will begin implementing the intervention this

year, provided it is proven effective. In addition, emphasis will be placed on strengthening risk-reduction counseling to both

individuals who test positive and individuals who test negative for HIV. Knowledge of HIV status and risk-reduction counselling for

HIV positive individuals will likely encourage them to protect their sexual partners and further protect themselves from re-infection.

In addition, targeted prevention counselling for those who test HIV negative may assist these individuals to reduce sexual risk

behaviours and increase safer sex practices in order to remain HIV negative. There will be focus on strengthening referrals and

linkages to prevention interventions, social support, and treatment and care to all individuals being tested.

Specific areas of heightened focus include strengthening CT programming at blood donation sites, increasing the identification of

discordant couples, and screening for gender-based violence during CT sessions. Currently, there are 7 zonal blood transfusion

centers in Tanzania and Zanzibar. Historically, there has been very little coordination between this program area and CT. USG

plans to address this void by enhancing staff training at transfusion centers and strengthening the HIV counseling component of

this program. Clients who test negative in CT settings will also be encouraged to donate blood in effort to bolster national blood

donation activities. As our partners encourage couple HIV counseling and testing services, partners will also need to strengthen

screening and care for gender based violence victims through HIV pre- and post-test counseling and make appropriate referrals to

safe shelters for women, support groups in the community, and referrals to legal services. Using findings from a recently

completed targeted evaluation, we will be able to identify barriers to self-disclosure of HIV positive status, adequately address

these disclosure issues, and increase CT services for couples and families. Special emphasis will also be placed on providing CT

services for men, particularly since CT is a core component of the planned male circumcision demonstration project.

One USG supported radio communication partner will provide assistance with mobilization of these priority groups and

communicating information to the public about these priority issues. This partner will continue to focus on "testing literacy",

location information, as well as addressing stigma and discrimination as barriers to testing uptake. Promotion of testing to adult

men will be a critical element for linkages with male circumcision activities and increasing male up take of this service.

Additionally, couples counseling and disclosure of HIV serostatus will be prominently addressed in the communication campaign.

At the community level all service delivery partners have included mobilization as a key strategy with one partner exclusively

focusing on the engagement of faith communities.

Essential support to achieve the aforementioned includes: ensuring commodities (test kits and lab supplies); working with GOT

on coordination strategies; providing assistance on policies/guidelines (e.g. HBC and lay counselors); fostering synergy and

collaboration among PEPFAR, GOT and other stakeholders to create an environment in which best practices and lessons learned

may be exchanged; and advocating for the adoption of practices that will streamline CT in Tanzania, including the use of lay

persons or paraprofessionals to conduct testing.

Despite great accomplishments and progress, opportunities for strengthening CT services in Tanzania remain and the USG and

its partners will play an important role in addressing the challenges. In FY 2009, both the GOT and the USG will maintain an

emphasis on training and building capacity to collect accurate, timely, and complete CT data. In FY 2008 GOT introduced new

M&E tools, which capture data at both community and clinical CT settings. Prior to the use of the new tools, the national data

system did not collect testing information outside of VCT services. USG will continue to support efforts to more fully capture and

report the numbers of individuals tested, counseled, and receiving results through VCT and other CT services. In addition, USG

will investigate previously unexplored variables so that information is available on such things as what proportion of CT clients are

repeat testers and whether they are accessing CT services in health settings or community venues. Furthermore, data collected

through mapping activities led by USG will greatly assist with analyzing CT site locations and will permit the team to better

describe geographic and population CT coverage.

Another opportunity for strengthening national CT services is to prioritize and address the challenges associated with pediatric

CT. As in many countries, currently there are no guidelines or policies for testing and counseling children in Tanzania. USG

plans to work with GOT through a recently established pediatric working group. The group, which hopes to draft appropriate

policy for pediatric CT, is comprised of USG partners from CT and clinical services and representatives from GOT.

Finally, developing strategies to promote continued sustainability for CT is an area that has not received great attention in

previous years. However, in FY 2009, the USG team will work with public and private partners to promote efforts to maintain CT

longevity. Approaches to achieve this goal will include communicating with Regional and District Medical Officers to advocate for

increased financial support in regional and district plans for CT, pursuing opportunities for public/private partnerships, and

supporting regional training centers to enhance in-country capacity.

USG activities will be implemented through partnerships with 21 prime partners, 1 of which is new to the portfolio. Both

governmental and non-governmental entities will be supported, engaging FBOs, CBOs and the private sector. This will include

partners working at the national level to improve logistics for test kit procurement, improve monitoring for quality assurance and

national reporting, increase service uptake through messaging, and develop policies to expand services including the use of lay

counselors and home-based testing. In addition, partners will work at the local level at points of service through both static as well

as mobile VCT units. Lastly, numbers of individuals receiving USG supported CT will be augmented through USG activities and

partners described in the TB and treatment sections. Approximately 1.2 million clients will be tested by the USG CT partners at

more than 925 sites with funding provided in FY 2009, bringing the overall cost per beneficiary to $19. A preliminary mapping

exercise highlighted the scope of USG CT services, which are in every region and are concentrated along transport corridors

where high risk activities are known to occur.

Table 3.3.14: