New Peer support activity for PMTCT

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 02 - HVAB Sexual Prevention: AB

Total Planned Funding for Program Budget Code: $17,723,605

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Program Area Context

Sexual Transmission (HVAB & HVOP)

COP 2009

PEPFAR Tanzania's COP 2009 prevention portfolio reflects a significant shift in strategic focus to better align with new data and

state-of-the-art programmatic priorities. The USG's objective is to implement a more technically sound, programmatically effective

portfolio to achieve long-term behavior change and significant reductions in new infections. Prevention partners will amplify their

efforts in geographic and venue-specific hotspots with comprehensive programming for adults and high-risk youth, while

continuing to build on gains made in delaying sexual debut. The USG will emphasize program quality and impact, scaling-up

efforts in high-risk locations and with high-risk populations through evidence-based interventions. Prevention activities will be

incorporated into all PEPFAR-funded program areas, to maximize opportunities and reach.In April 2008, the USG held a

Prevention Strategic Results Unit Strategy Meeting to develop a focused approach that reinforces Government of Tanzania (GoT)

priorities, reflects the nature of the Tanzanian HIV/AIDS epidemic, and integrates state-of-the-art prevention strategies. The USG

held a COP 2009 Strategic Planning Retreat in June 2008, furthering efforts to realign the prevention portfolio. Through this

ongoing strategic process, the Prevention SRU determined that the sexual prevention portfolio will address the following:- Risk

behaviors: multiple concurrent partnerships (MCP); transactional and commercial sex; low and inconsistent condom use; early

sexual debut and trans-generational sex; gender inequity and gender-based violence (GBV); and sexual risk taking associated

with alcohol and drug use.- Target populations/high-risk groups: adults engaged in MCP; mobile men with money (e.g., truckers,

fishermen, agricultural workers); discordant couples; HIV-positive individuals; sex workers and their clients; IDUs; bar maids;

those engaged in transactional sex; young men in urban slum areas; high-risk youth; uniformed services; prisons; and STI

patients. - Geographic areas/hot-spot venues: high prevalence areas with dense populations and/or concentrations of high-risk

industries (e.g. mines, agricultural estates); transportation corridors; trading towns; and areas of high concentration of sex workers

and IDUs.Supporting strategies will be used to more effectively address the needs of the individual, family, community, and

society including efforts to create safe and supportive environments that encourage sustained behavior change, promote complex

messaging that supports individuals' risk reduction, address the communication needs of couples, and reinforce healthy gender

norms. An example of complex messaging is the promotion of MCP reduction within counseling and testing (CT), and condom

promotion and distribution with high-risk populations. Throughout its activities, the USG will work to achieve program scope and

scale in geographic and venue-specific hot spots and coordinate mass media and interpersonal activities to support a

comprehensive approach ("air and ground war"). Activities will be coordinated with the broader USG portfolio through the

integration of prevention messaging in care and treatment activities; referrals for HIV-negative men to male circumcision (MC)

patient and partner education services; improved linkages between care and treatment programs on prevention with positives

(PWP) activities; and through wrap-around programming with the Millennium Challenge Corporation (MCC), Education, Natural

Resource Management (NRM) and Economic Growth activities funded with non-PEPFAR resources. The strategic review process

was supported by the release of preliminary data from the 2007-2008 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS),

following up on the 2003-2004 Tanzania HIV/AIDS Survey (THIS). The THMIS suggests a slight decrease in national prevalence

(6% overall; 7% for women and 5% for men), compared to the THIS (7% overall; 8% for women and 6% for men). HIV prevention

knowledge appears relatively high: seven in ten women and three in four men know that condoms can reduce the risk of

contracting HIV; eight in ten women and nine in ten men know that risk is reduced by having sex with only one uninfected partner

who has no other partners. This data presents a key challenge: How can Tanzania build on its efforts, which have increased

HIV/AIDS awareness, to make meaningful decreases in the rate of HIV infection through sustained behavior change?To address

this challenge, the portfolio will focus on the geographic areas, populations, and behaviors which data suggests are driving the

Tanzanian epidemic, while balancing the need to ensure broad geographic coverage of prevention programming. During compact

negotiations, the GoT requested PEPFAR to pay particular attention to high-risk groups and communities and the eight regions

with the highest prevalence. THMIS data is still being analyzed, but initial results indicate that prevalence rates range widely, with

highest prevalence regions including Iringa (14.7%), Dar (8.9%), Mbeya (7.9%), Shinyanga (7.6%), Tabora (6.1%), Ruvuma

(5.4%), Pwani and Mara (5.3%), and Mwanza (5%). Urban prevalence appears to be almost double that of rural areas.

Prevalence is highest among adults, peaking in women 30-34 and men 35-39 years old. Sexual debut occurs relatively early (by

age 15, 11% of young women and 10% of young men have had sexual intercourse) and many young adults are sexually active by

18 years old (58% female, 43% male). While preliminary THMIS analysis suggests slight decreases in HIV risk behaviors, high

rates of MCP, commercial, transactional, and trans-generational sex continue and condom use during high-risk sex remains low.

For 15-49 year olds who report having sex in the past 12 months, 3% of women and 25% of men had sex with two or more

partners in the past 12 months. Among adults who reported sexual intercourse in the past 12 months, 21% of women and 41% of

men reported higher-risk sex (defined as with a non-marital, non-cohabitating partner) and of those, 43% of women and 53% of

men used a condom the last time they had sex with such a partner. Increased rates of high risk sex appear to continue with

divorced, separated, and widowed women and men who had sex in the previous 12 months: 8.6% of women and 37% of men had

two or more partners and 43.3% and 40% respectively reported condom use during last sexual intercourse. Paying for sex is

most frequent among men age 20-24 (13%) and men who are divorced, separated, or widowed (23%). To address the evolving

Tanzanian context, the portfolio will build on gains achieved in FY 2008 through implementation of programming efforts outlined

below.The USG will increase its focus on adults, sexually active youth, and couples through targeted programs and complex

behavior change messaging to continue translating HIV awareness into safer practices. Efforts will include: programming to

reduce MCP; intense behavior change campaigns via mass media (radio, TV, print) and inter-personal communication

(community mobilization, individual risk reduction counseling); messaging around transmission dynamics, window period, and

early/acute infection; emphasis on prevention of alcohol and drug abuse; and expansion of MC and GBV programming. PWP

programs will target HIV-positive individuals and sero-discordant couples with risk reduction messages; activities will stress the

importance of CT, especially couples CT and disclosure.The USG will redouble efforts to effect normative social and cultural

change, addressing gender and social norms that underlie key behavioral drivers (MCP, cross-generational sex, transactional

sex) and/or hinder protective behavior change; and safe environments for vulnerable girls and women including GBV prevention.

A critical focus will involve collaboration with community leaders, men, and the education sector to transform norms that promote

predatory sexual behavior, including sexual violence as well as work with women and girls around skills development (e.g.,

condom negotiation, avoidance of trans-generational sex). Wrap-around programs will ensure that particularly vulnerable groups

have access to livelihoods and training. For most at-risk populations, the USG will provide a comprehensive package of risk

reduction services which includes peer outreach and education (e.g., correct and consistent condom use, sexual health, and

empowerment), mass media, condom distribution, CT, STI referrals and treatment (as appropriate), and linkages with care and

treatment. These services will be targeted for the needs of high-risk groups, including sex workers, fishermen, truckers, and

uniformed service personnel. Efforts will also focus on addressing sexual risk-taking among IDUs and their partners, including

those in Zanzibar, to address the high rates of transmission among IDU populations and to prevent bridging into the general

population. Condom promotion efforts will be targeted to high-risk venues and populations, including discordant couples and HIV-

positive individuals through expanded PWP programming (see Care section). The overall condom market has grown by about

25% over the last two years, reflecting increased awareness and risk perception. Through USG-funded programs, female

condom programming and demand has been very successful with high-risk women. Key challenges include the weak public

distribution system and access to public sector condoms outside of health facilities. The USG will continue its support of male and

female condom social marketing and build on gains achieved. The USG will focus on addressing the low age of sexual debut,

preparing youth to transition to healthier sexual behaviors, and reinforce the portfolio's emphasis on key risk behaviors and

translating awareness into safer practices. Building on gains achieved, youth program components will focus on prevention

outreach with peer educators; life skills curricula-based programming; FBO/CBO involvement; linkages with CT; school-based

programs; and youth-directed mass media such as radio programs and youth magazines. Programs targeting decision-makers,

power-holders, and gatekeepers will complement efforts with youth. The lack of comfort and capacity among many FBO/CBO

partners to address the needs of high-risk youth remains a key challenge. The USG will continue to work closely with

implementing partners on this area. Tanzania's five Track 1 ABY partners will develop transition and sustainability plans in

preparation of their program end-dates of about June 30, 2010. Due to the prevention strategy's focus on adults and high-risk

youth, the flat prevention budget, and the broad reach of youth prevention partners FHI/UJANA and TAYOA, as well as new

education wrap-around programs, the USG is not proposing additional COP 2009 youth activities. The USG will continue to

analyze its prevention portfolio and the THMIS data to determine the appropriate scale and scope for youth prevention

programming. Analysis results will be reflected in COP 2010 development. The portfolio will continue to harmonize activities,

including coordination of youth prevention programs; collaboration among main implementing partners on alcohol and drug abuse;

sharing of lessons learned; and linkages among gender norms activities. Comprehensive prevention activities receive AB and OP

funding to target sexually active and high-risk populations. Efforts will continue to increase capacity of local implementers and

enhance program quality through an expanded emphasis on capacity building among sub-partners, between more experienced

and less-established prime partners, and through a proposed new technical assistance mechanism. Based on successful

recruiting through its Staffing for Results exercise, the USG's Prevention SRU will be fully staffed in FY 2009 with senior-level

prevention experts, allowing the USG to take a more proactive and in-depth approach to capacity-building with its prevention

partners. Key achievements include a comprehensive portfolio, which addresses a wide range of risk behaviors and target groups;

strong partner coordination; and the creation of the Prevention SRU, for a more coordinated USG approach. Individual partners

have enhanced program quality and scope. The core challenge for FY 2009 is to reallocate efforts and resources among existing

partners to address the portfolio's strategic vision. Challenges include the straight-lined prevention budget, the addition of new

initiatives such as male circumcision, and the current lack of a GoT-led costed national strategy, although efforts are underway

and the USG is a key supporter of this process. An additional constraint is the need to continue strengthening partners' ability to

implement the USG prevention portfolio's new strategic focus. This challenge will be addressed through the capacity building

efforts described above. TACAIDS, through its National Multisectoral Strategic Framework (NMSF) 2008 - 2012, has identified

the prevention of new HIV infections as its top priority. The USG will collaborate with the GoT to address national level policy

barriers, training, M&E, and other systems strengthening issues. While the USG places high priority on donor coordination, it is

the predominant donor in the area of sexual prevention. The GFATM focuses on service delivery in care and treatment, providing

limited funding for sexual prevention efforts. FBOs/NGOs in Tanzania have limited donor funding for prevention programming.

Linkages have been created and will be strengthened with CT, OVC, care, and support partners. The USG will continue to

expand, through innovative wrap-around programming with the RH/FP, Education and NRM sectors, increased public-private

partnerships, and collaboration with the MCC to ensure effective prevention programming is incorporated into their infrastructure

development programs (e.g., ensuring construction camp workers have access to prevention activities).The USG ensures

sustainability through a broad portfolio of implementing partners and local sub-partners, spanning public and private sectors, and

close coordination with national, regional and local governments. The USG will continue to proactively engage GoT counterparts

to ensure that PEPFAR efforts are fully aligned with and supportive of GoT priorities. The USG is strengthening its M&E

processes to increase the frequency of quality assurance visits with partners. The USG will continue to work closely with partners

to enhance data quality and monitoring efforts, and ensure that data is used to support continuous program improvements. The

USG will implement a PHE to compare cost-effectiveness of condom distribution methods; study outcomes will inform future

program implementation and design.

Table 3.3.02:

The reprogrammed funds will focus on Wide Area Network (WAN) activities and Geographic information

systems (GIS) support. The WAN sub-program goals include strengthening national and facility-based

strategic information infrastructure by improving information sharing. The GIS program strengthens and

complements monitoring and evaluation efforts of PEPFAR and MoHSW programs on HIV/AIDS

interventions through providing technical support on various aspects of GIS.

Funds will be used for identification of new Area Wide Network sites and handover of several existing sites.

Selection of sites will be identified with discussions between NIMR and MoHSW. Implementation,

installations, configurations and testing and commissioning will be done by a contractor by close supervision

of WAN staff.

The GIS sub-program in collaboration with MoHSW will create and update a GIS health facilities database.

Health facilities will be coded by using Health Management Information System (HMIS) codes. Information

on services provided by each facility (PMTCT, VCT, and ART) will be included in the database. The sub-

program will link this database to a web-based (Internet) GIS in collaboration with local technical partners

for data sharing which will allow stakeholders to access spatial information from the central database

through the web.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 18 - OHSS Health Systems Strengthening

Total Planned Funding for Program Budget Code: $24,557,861

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

PROGRAM AREA CONTEXT: HEALTH SYSTEM STRENGTHENING

$23,236,734

14, 947 CHARACTERS

Sustainable systems to support the delivery of effective HIV/AIDS services are critical to the United States Government's (USG)

efforts to support Tanzania in the fight against HIV/AIDS, and were highlighted as essential in the Partnership Compact

discussions as a fundamental set of investments to ensure that mutual goals be met. In FY 2009, the USG will work to strengthen

the capacity of the Government of Tanzania (GOT) and civil society organizations (CSOs) to effectively lead and manage the

HIV/AIDS response. The USG will also focus on policy development, advocacy for policy change, and policy implementation. In

addition, the USG will redouble efforts to address the issue of HIV/AIDS stigma and discrimination. The USG will work to

strengthen the ability of local government authorities to better plan for and manage the delivery of health and social services,

increase the number of trained health care and social workers, upgrade health facilities, and strengthen the systems that will

ensure sufficient quantities of drugs and other commodities for HIV/AIDS services throughout the country. The GOT has made

significant strides in strengthening the health system through the development of policies and strategies that establish a clear

framework for addressing HIV/AIDS. The GOT demonstrated strong leadership in the development of the new National Multi-

Sectoral Strategic Framework (NMSF) on HIV/AIDS and the Ministry of Health and Social Welfare's (MOHSW) Health Sector

Strategic Plan (HSSP). In the USG/Tanzania's Partnership Compact discussions with the GOT, there was general consensus on

priorities and critical systems strengthening needs and approaches. The parties agreed to pursue public expenditure tracking

systems at all administrative levels in order to promote accountability and transparency in the use of funds in the sector. Overall,

leaders in Tanzania have become more open to change and innovation in the management of the HIV/AIDS crisis. These

encouraging trends will provide an enabling environment in FY 2009 for the implementation of critical interventions and increased

sustainability. While the policy environment is improving, capacity for implementation requires considerable focus. Capacity must

be built among government authorities at all levels to ensure accountability, with particular focus on the district level is needed.

Also, while the work of CSOs in the area of HIV/AIDS has been impressive, many still face challenges in terms of management

and leadership, which hampers the scale-up of their activities. Stigma and discrimination remain a widespread problem preventing

many Tanzanians from accessing care and treatment, especially in the rural areas. A 2005 study reported that 63 percent of HIV

positive women and 50 percent of HIV positive men had recently experienced stigmatization. Even when people do access

HIV/AIDS services, the existing health infrastructure and the number of available health care workers are still inadequate to meet

the need. Furthermore, the capacity for timely procurement, storage, and delivery of HIV/AIDS drugs and commodities is weak. In

FY 2009, the USG will continue to offer assistance to coordinate and collaborate with other donors to improve the policy

environment. The USG chairs the donor partner group for HIV/AIDS, and worked closely with other donors to support the

development of the NMSF and the HSSP. The USG has recently joined the donor working group on basket funding under the

sector wide approach, which allows the USG to advocate for funding to achieve the GOT goals and to complement USG efforts.

The USG has a seat on the Global Fund for HIV/AIDS, Tuberculosis and Malaria's (GFATM) Tanzania National Coordinating

Mechanism (TNCM) and has used this position to advocate for more coordinated programs, strengthened management, and

greater accountability. The USG will use this position to strengthen the technical committees so the review of priorities and

proposals is more rigorous, as well as to improve general oversight, use of resources, and disbursement of funds. USG-

supported partners will also continue to work with the TNCM to ensure they embrace their roles and responsibilities, and to ensure

systems are in place for them to manage GFATM programs through effective monitoring and management systems (e.g.

executive dash boards), and to hold open elections for constituents. These steps are essential for a strengthened TNCM and

members who empowered, particularly those who are people living with HIV/AIDS (PLWHAs). Given these strategic levers, the

USG is well placed to assist in ensuring the critical interventions laid out in the NMSF and HSSP are appropriately implemented.

Also in the policy arena, the USG will work in FY 2009 with influential bodies to build public knowledge, enhance accountability,

and build leadership related to HIV/AIDS. A new program will provide support to strengthen the HIV/AIDS Committee of the

Tanzanian Parliament so that the committee can better engage with the MOHSW, the Tanzania Commission for AIDS

(TACAIDS), and other executive branch agencies. Funds will be provided so that members can conduct small-scale field studies

related to the delivery of HIV-related health services in their constituencies, the integrity of GFATM sub-grants, and discrimination

against PLWHAs. The USG will also help the members to administer a small grant mechanism (less than $15,000 per grant) so

that members of the Committee may receive, competitively review, and fund selected proposals to strengthen HIV/AIDS

interventions. The grant mechanism will link the Committee members more closely to their constituencies and allow them to

become champions of PLWHAs and their caregivers. In FY 2009 the USG will continue to build capacity of the GOT to lead and

manage. Efforts will be focused on achievements that support the new strategic plans that have been completed in the mainland

and Zanzibar. Focus will be on the development and implementation of a human resource management information system

(HRMIS) on the mainland that is similar to the HRMIS that has proven useful in Zanzibar. The Department of Social Welfare

(DSW) will receive targeted assistance to increase its ability to manage the programs under their auspices which benefit orphans

and vulnerable children (OVCs). Training will be provided to the National Institute for Medical Research (NIMR) to improve the

oversight of research involving human subjects and to build their capacity to carry out operational research. At least three other

key national GOT organizations will also receive institutional capacity building support, and key training institutions will receive

support to increase their training throughput.At the district level, the USG will continue to support a wide range of interventions to

enhance the management and leadership capabilities of policy makers, planners and implementers. The focus on the district level

ensures greater sustainability and accountability for programs. A toolkit for improved recruitment and retention, and a facility

management orientation package were developed and applied in 19 districts chosen for the GFATM emergency hiring plan so that

they are organized to retain those specially recruited and existing health workers. The expectation is that these districts will

budget for plans related to manpower that will enable expansion of HIV/AIDS services into the comprehensive council plans and

budgets. In FY 2009, support for this program will be expanded dramatically. Other district strengthening will complement this

work to improve to ensure that districts are better able to plan, budget, and implement successful programs. "Model districts" will

be created whereby best practices such as pay for performance and other innovations will be piloted. These districts will serve as

learning labs for other districts. In addition, a program to have local CSOs undertake public expenditure tracking will be piloted in

partnership with district health management teams. The goal of the pilot is to create a mechanism through which leaders will be

accountable for income and expenditure on HIV-related services in their districts by interfacing with grassroots-level committees

trained in the analysis of budgets.

It is clear that efforts by the GOT alone cannot address the HIV/AIDS crisis in Tanzania; partnerships with CSOs and the private

sector will be nurtured and strengthened. Through USG partners, "just in time" technical assistance is provided to CSOs to

increase their ability to manage grants and to achieve their work objectives. This work with CSOs will continue in FY 2009. Based

on assessments done with each CSO, a plan will be designed to address key organizational weaknesses that impede the

organization's delivery of HIV/AIDS services and limit results. In the coming year at least 80 CSOs will be provided with technical

assistance. The USG will also support two public private partnerships to strengthen systems, for human capacity development in

general and specifically to strengthen pediatric AIDS training. Support will also be continued for the Tanzanian and Zanzibar

HIV/AIDS Business Coalitions to support private sector involvement in the response to HIV/AIDS. In the effort to address stigma

and discrimination, there will be considerable focus on the national HIV/AIDS law, which was passed earlier in 2008. The law

commits the MOHSW to formulate public education programs to reduce stigma and discrimination against PLWHAs and

caregivers. The law also mandates that every employer establish a workplace program on HIV/AIDS, and mandates that all

health care workers and other custodians of medical records observe confidentiality. Criminal penalties are imposed for breach of

confidentiality. Additionally, the law prohibits discrimination against PLWHAs, orphans, or their families. Building upon the rights

established under the law, the USG has worked closely with the MOHSW's HIV Workplace Intervention Programme (WIP) to

develop programs on HIV/AIDS. The WIP has incorporated training materials that reduce stigma related to HIV-positive health

workers, encourage health workers to get tested, and facilitates the formation of support groups for HIV-positive health workers.

A film on HIV-positive health workers, which was developed with USG funding in FY 2007, will continue to be incorporated into the

WIP training in order to help sensitize health workers. Building on the achievements in FY 2008, the USG will focus on expanding

the understanding and reach of the HIV/AIDS law at all levels of government and amongst constituents, and doing a review of

other legislation that may conflict with the new law. This is essential to maximize the law's effectiveness. Additionally, regulations

under the law must be developed. The USG will support the aforementioned HIV/AIDS Committee to engage with the MOHSW to

address problems in the HIV/AIDS law and to develop proposed amendments. USG activities will also help enable the GOT to

enforce the rights set forth in the new law. A partnership with the Commission on Human Rights and Good Governance to focus

on how to better address human rights and stigma will be developed. The USG will engage with the media to reduce stigma and

discrimination by offering intensive, university-based training to a small, competitively-selected group of Tanzanian journalists.

The training will focus on HIV, human rights, and investigative reporting and will help build a small but highly influential national

cadre of reporters who regularly investigate and expose stigma and discrimination. In addition, the USG will begin a new initiative

to provide legal counseling related to the HIV/AIDS law at HIV/AIDS testing centers to reduce stigma and discrimination. Lastly,

the work with the WIP will continue as training is rolled out.To improve access to HIV/AIDS services, the USG has worked to

increase the number of quality health care facilities and the number of well-trained health care workers. In the last two years

PEPFAR has funded the construction and renovation of 84 buildings, including 21 TB/HIV clinics, two laboratories and 51 care

and treatment centers. Due to a change in policy whereby the Regional Procurement Supply Office will only be undertaking larger

construction and renovation projects, in FY 2009 the USG- funded partners will directly implement smaller projects. This will allow

for more flexibility in the type of infrastructure supported, such as housing for health staff, which can improve worker retention, and

renovation of pre-service training institutions so they can admit more students. Seventy construction and renovation projects will

be completed in FY 2009.

Tanzania faces an acute shortage of health professionals. To address this HRH crisis, the USG will provide scholarships to

increase the number of students in pre-service training; revise in- and pre-service curricula so it includes the latest information on

HIV/AIDS; improve the skills of training faculty; and provide equipment and other materials to training institutions. In addition, the

USG, in collaboration with the GOT, will strengthen the Tanzanian-based Field Epidemiology Laboratory Training Program

(FELTP) to increase the numbers of health care workers with expertise in epidemiology and HIV/AIDS disease response. In FY

2009, the USG will continue to work closely with the National AIDS Control Programme and the Medical Stores Department MSD

to monitor drug and commodity needs, as well as stock levels. The USG will place specialized logistics teams to work at zonal

level stores to strengthen logistics at the regional level. A major focus in FY 2009 will be to decrease the proportion of emergency

versus standard procurements used by government to maintain its commodity supply. This will involve increased supportive

supervision at all levels of the procurement process from forecasting through delivery. In addition, work with MSD to improve the

storage and delivery capacity of their nine national and regional facilities will continue. Innovative technologies and training

approaches will be employed, including the possibility of using a bar coding system to track drugs and commodities. Coupled with

better trained staff at facilities this work will have an important impact in improving the delivery of HIV/AIDS services. Investing in

health system strengthening lays the foundation upon which HIV/AIDS interventions are delivered and ultimately ensures the

achievement of PEPFAR goals. In FY 2009 a total of 202 organizations will be provided with TA in policy development and 323 in

capacity building. A total of 1,085 individuals will be trained in policy development, 6,575 in capacity building, 2,100 in stigma

reduction, and 1,031 in community mobilization.

Table 3.3.18: