THIS IS A NEW ACTIVITY.

This narrative is being submitted by each agency to allow for flexibility in working with the MCC in relevant

high-prevalence regions. Since each agency has existing partner networks in different areas, the final

decision on partnerships will be made based on an analysis of MCC's final selection of project sites.

In February 2008 President Bush signed a $698.1 million Millennium Challenge Compact with the

Government of Tanzania (GOT) to rehabilitate and improve infrastructure in the Transport, Energy and

Water sectors. Nearly half the Compact is dedicated to road construction projects.

MCC recognizes that its road construction projects have the potential to negatively impact communities by

increasing exposure to and interaction with higher risk mobile populations. These risks have been well

documented throughout Africa in areas where roads are being constructed and where contractors establish

camps to house their typically unaccompanied male staff. Often these workers are isolated from their

families for long periods of time and have disposable income which facilitates risk-taking behaviors that

result in the spread of HIV/AIDS. MCC and PEPFAR/Tanzania are committed to working together on HIV

prevention programs that will reduce the risk of HIV transmission among MCC project beneficiaries, and will

also diminish other unintended consequences that could put the MCC goals of economic development and

poverty reduction at risk.

In addition to project-specific assessments, MCC recommends a tiered approach to identify the level of

attention needed for HIV/AIDS risk reduction activities. For high-risk countries, such as Tanzania, draft

MCC guidance recommends an HIV/AIDS risk mitigation assessment and strategy as part of any relevant

sector project design. While specific activities between PEPFAR and MCC are in the development phase, a

robust MCC-PEPFAR partnership is envisioned.

Activities will build upon the following MCC principles:

- HIV/ AIDS Expertise among MCC contractors: Persons with demonstrated and contextually relevant

HIV/AIDS expertise will be involved in the design and implementation of program activities. To ensure that

appropriate expertise and sound planning are integrated, language on required HIV/AIDS expertise will be

woven throughout all Terms of Reference and bidding documents.

- Public Consultation: Stakeholders will be involved in project workshops to discuss lessons learned and

recommendations for improvement strategies for future HIV prevention activities. Consultations will ensure

that relevant stakeholders are included in discussions surrounding vulnerable groups such as women,

elderly, disabled, migrant workers, and ethnic or religious minorities.

- Gender Integration and Targeting Vulnerable Populations: Efforts will ensure that women are adequately

represented in public consultation and stakeholder meetings. Assessments will address gender inequalities

and biases against people perceived to be at high risk for HIV, including sex workers and men who have

sex with men. Behavior change communication materials will be culturally and linguistically appropriate,

participatory, and take into account the possibility of low literacy and education levels.

Examples of MCC-PEPFAR collaboration for HIV/AIDS awareness and prevention activities include:

- Public education and sensitization campaigns to increase HIV/AIDS awareness and understanding of

prevention methods in communities along the construction routes and transport corridors;

- Support for prevention programs that include condom distribution for local communities;

- Targeted interventions with construction workers that include individual risk assessments and risk

reduction planning;

- Counseling and testing for construction workers and communities;

- Public-private partnerships with local businesses and construction companies for HIV prevention

workplace programs;

- Targeted HIV prevention programs in bars and other high-risk settings in construction areas and along

roads;

- Integration of alcohol abuse and gender-based violence prevention messages into HIV prevention and

awareness programs;

- Collaboration with local leaders and faith-based organizations in HIV prevention advocacy efforts.

Linking PEPFAR programs with MCC activities will allow for a comprehensive approach to HIV/AIDS in

affected communities. PEPFAR will expand its reach to populations newly exposed to elevated HIV/AIDS

transmission risks, while MCC will be able to leverage PEPFAR's expertise and experience in implementing

effective, state-of-the-are prevention programs. The funding level is currently at $0, as MCC has dedicated

funding for HIV/AIDS prevention activities linked to its projects. MCC and PEPFAR will collaborate closely

and joint prevention activities may involve a variety of partnerships, including PEPFAR- technical assistance

to MCC projects, joint funding of PEPFAR HIV prevention implementing partners, or direct MCC funding of

specific PEPFAR HIV prevention activities.

Linkages:

It is envisioned that MCC and PEPFAR Tanzania will work closely together to implement the above

activities and to link MCC contract workers and community members from MCC road construction areas to

HIV prevention, counseling and testing and care and support services in the neighboring areas. Since each

USG PEPFAR agency has existing partner networks in different areas, each agency has submitted a similar

narrative to allow for flexibility in working with the MCC. Actual MCC/PEPFAR partnerships will be

established based on an analysis of MCC's final selection of project sites. Partnerships with local

government and other stakeholders are equally critical to maximizing the benefits received by targeted

communities.

M&E:

As part of its overall M&E plan, MCC will collect baseline and follow-up data on a sample of communities

near roads. The data will include:

1) Major public services (will collect GPS readings of nearest public medical facility, secondary school, post

office, etc.)

Activity Narrative: 2) Perception of well-being (asking people about acceptable levels of certain services, including health)

3) Education level and health status of the population (from focus groups)

Data collected will include communities near the rehabilitated roads and elsewhere for comparison

purposes, while also controlling for other factors (i.e. economic growth or recession, drought, etc.).

Sustainability:

MCC recognizes that the reduction of HIV/AIDS risks must be viewed on two levels: first are the risks

associated with construction; these risks are addressed though the responsibilities of contractors as

described in standard bidding documents and project-specific requirements. The second level includes the

risks associated with increased mobility and activities that are the results of the project. MCC believes that

both risks should be assessed and addressed in different ways in the Compact, and that it should support

capacity building in local entities to assure the sustainability of HIV/AIDS awareness, prevention and

support after the completion of the construction project

It is vital to the sustainability of HIV/AIDS activities that local NGOs working in the sector and local

communities and government authorities be included in planning and implementing activities to ensure that

upon project completion there is not a vacuum where there had previously been support. Work towards

capacity-building and training to transfer skills and knowledge to affected local communities should be

explored to maximize collaborative benefits for partnership, information sharing, and co-financing

opportunities with the goal of long-term sustainability.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety

Total Planned Funding for Program Budget Code: $5,622,182

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Program Area Context

Biomedical Transmission

COP FY 2009

The FY 2009 PEPFAR Tanzania biomedical prevention portfolio reflects a strengthening in strategic focus to align with new data

and programmatic priorities. The biomedical prevention portfolio will work closely with the sexual prevention portfolio to

coordinate work with key target groups and expand reach. Male Circumcision:Male circumcision (MC) has been found to reduce

the risk of transmission of HIV from women to men by approximately 60%. This compelling evidence has led the Government of

Tanzania (GoT) to support the inclusion of MC as a core prevention strategy in the National HIV & AIDS Multisectoral Strategic

Framework 2008-2012. In Tanzania, 70% of males between the ages of 15-49 are circumcised. However, rates of MC vary

considerably between regions; from 26% to 97%.As part of its commitment to introduce MC, the GoT endorsed a PEPFAR-

supported situational analysis in FY 2007 and FY 2008 to assess the feasibility and acceptability of MC in three regions (Kagera,

Mara and Mbeya). These sites were selected by the GoT to examine MC in a range of cultural, demographic, and cultural

contexts. The prevalence of HIV among males aged 15-49 years in these regions is 3%, 3.5% and 8.3% (THIMS 2008)

respectively, while the prevalence of MC in the same age group for these regions is 26%, 89%, and 34% (THIS 2003, most recent

data). In FY 2009, the USG will implement a coordinated demonstration project in two of these three regions (Kagera and

Mbeya). The project will also incorporate Iringa, the region with the highest HIV prevalence (15%) and a low rate of MC (38%),

and enlisted men in the Tanzania People's Defense Force presenting at their Dar es Salaam facility. USG technical assistance to

MC efforts will be led by a partner with global expertise, which will collaborate with WHO and UNAIDS on operational guidelines,

training materials, and quality standards. This partner will work with the GOT, WHO, MOHSW, and USG partners to adapt these

materials and ensure incorporation of the determinants of feasibility and acceptability identified through the situational analysis. In

addition, they will undertake capacity development through site assessments, guiding facility improvements, and developing

standardized training materials and patient education materials. Four additional partners will initiate a comprehensive MC service

package including the provision of HIV testing and counseling services to identify HIV-negative males eligible for circumcision, as

recommended by WHO and UNAIDS. This package will also include treatment for STIs, ensuring infection control, promotion of

safer sex practices, provision of male and female condoms and promotion of their correct and consistent use, and linkages to

prevention interventions and other social support services. An additional emphasis will focus on counseling men and their sexual

partners to prevent a false sense of security resulting in high-risk behaviors that could undermine the partial protection provided

by male circumcision. Patient follow-up will include assessment of counseling effectiveness, monitoring adverse unintentional

gender outcomes (e.g. violence), tracking adverse clinical events and complications, and possibly collecting sero-conversion

rates.Service provision will complement the development of demand creation, partner education, and "service literacy" messages

and materials by a social marketing partner. Finally, the TA partner will use the access achieved to a traditionally circumcising

community (Mara) via the situational analysis to explore the potential of engaging traditional circumcisors.Ultimately, the

demonstration project will provide lessons learned and identify best practices to support the scale up of MC services that balance

general access to high quality comprehensive services with the need to reach high-risk males. Findings will build confidence

among national policymakers that MC can be done in an efficient, safe and effective manner. The findings from this project will

also inform policies and standardize protocols and practices for a regulatory environment. Injection Drug Use: Tanzania is

witnessing an increase in the trafficking and transit of drugs. The number of injecting drug users (IDUs) is growing Data indicates

that injection drug use, specifically heroin, is rapidly increasing in urban Tanzania and on the island of Zanzibar. A recent study in

Dar es Salaam indicates that the HIV prevalence among IDU is 42% while the prevalence among a recent cohort of approximately

500 IDU in Zanzibar was 15%. This is largely attributable to unsafe IDU injection practices such as needle sharing and the

efficiency of transmitting HIV intravenously. Additionally, high risk sexual activities are often abundant in settings in which

substance use occurs. For instance, risk for female IDU is heightened in many instances by reliance on commercial sex, both

formal and informal, to fund the purchase of drugs. Men who have sex with men (MSM) who overlap with the IDU community are

also at heightened risk particularly in Zanzibar where MSM are more often involved in the sex trade. Sexual risk among IDU

facilitates the spread of HIV beyond drug user networks where it can heighten generalized epidemics.Given the current HIV

prevalence among IDU and the potential for bridging to the larger community through sexual intercourse, GoT supports expanded

access to HIV prevention services among IDU and other drug users in Tanzania. Increasing concern over rising HIV prevalence

rates among IDU is reflected in the NMSF 2008-2012, which proposes comprehensive programming to address HIV risk reduction

for IDU and their partners. The GoT's willingness to address the needs of IDU is a positive shift toward provision of services, and

is due in part to the assistance and advocacy by the USG. In FY 2008, the USG coordinated a stakeholders' workshop on HIV

prevention among IDU and sub-groups (e.g. CSW and MSM). The workshop reviewed evidence and best practices, and

identified opportunities to strengthen interventions and reinforce existing efforts. In FY 2009, building upon the collaborations

fostered during the FY 2008 workshop, three partners will address the risk behaviors and prevention needs of IDU and

overlapping populations and promote appropriate policy development. Two partners (in Dar es Salaam and Zanzibar) will

implement interventions that target most at risk populations through a core intervention of community outreach, which includes

voluntary HIV counseling and testing, condom distribution, and harm reduction strategies to discourage needle sharing and

unsafe injection practices. Partners will also provide linkages to STI services and referrals to care and treatment for those found

to be HIV positive. At risk individuals will also be directed to public and private pharmacies where clean needles can be

purchased. Treatment options for IDU (including medication assisted treatment) are not currently available in Tanzania.

However, a governmental agency, will take the lead in advocating for the treatment of drug dependence. This partner will initiate

efforts to foster greater understanding and awareness of injection drug use in Tanzania and provide forums for discussing

opportunities, gaps, challenges, and strategies for HIV prevention efforts with IDU populations. Injection Safety: The WHO

estimates at least 5% of new HIV infections, globally, are attributable to unsafe injection practices. In Tanzania, research

suggests unsafe injection practices occur in 47% of instances, there are high rates of inadequate disposal procedures (89%), and

50-90% of curative injections could be avoided. Post-exposure prophylaxis (PEP) is neither widely used nor consistently

available. Factors contributing to unsafe practices include a lack of safe disposal containers, improper disposal procedures, and

disposal of hazardous waste in open, unguarded rubbish areas. USG Tanzania collaborates with GOT and other partners to

support the WHO and safe injection global network (SIGN)-recommended three-step strategy. Accomplishments to date include

the development of policy guidelines, decentralizing training through zonal training centers, development of BCC materials to

reduce provider and patient demand for unnecessary injections, and incorporating IS into the IPC training. Reuse prevention

syringes and safety boxes are included in the national essential drug list and injection devices are registered with the Tanzania

Food and Drug Administration (TFDA). The MOHSW coordinates IPC-IS implementation through Infection Prevention Control

Committees and Health Care Waste Management Committees at both the Ministry and facility levels. Key challenges include the

slow implementation of PEP policy and guidelines; ensuring continued quality training for healthcare workers; and procurement of

injection equipment with safety features, safety boxes for health facilities, and protective gear for waste handlers. In FY 2009,

USG Tanzania will continue to improve IPC-IS quality and coverage, scaling-up to 20 hospitals, 50 health centers and over 250

dispensaries. USG Tanzania will support multiple training initiatives including in-service training of health workers; strengthening

pre-service medical training institutions; promoting supervisors' capacity to provide supportive feedback; and incorporation of IS

indicators into the national integrated supervision checklist. In addition, USG will share health facility assessment findings with

stakeholders to improve health facilities' performance; encourage local government authorities to establish a health care waste

management budget line item; and support USG Tanzania care and treatment partners to identify sustainable methods for final

disposal of used needles and syringes. USG Tanzania will promote universal precautions to reduce risk of medical transmission

of HIV by supporting needlestick surveillance, advocating for post-exposure prophylaxis (PEP) and hepatitis B vaccination for

health care workers, and improving the safety of phlebotomy practices. The ministry will work with other programs like CT, Care

and Treatment to roll out the PEP interventions, to ensure that staff reporting work accidents are accessing HIV counseling and

testing, as well as prophylactic treatment where appropriate. Training has been provided to 4 for-profit hospitals as well as 37 faith

-based facilities. The NACP will strive to have PEP will be included in council health plans.As MMIS/JSI comes to an end in

FY09, it will reinforce country ownership and strengthen the capacity of partners to manage injection safety programs;

transitioning project activities to local partners and other projects, ensuring injection safety interventions' sustainability. Finally,

USG Tanzania and the MOH will jointly develop a performance evaluation tool, to enable national, district and health facility

authorities to master IS and health care waste management indicators.Blood Safety:Reducing HIV transmission through the

transfusion of contaminated blood is a key component in the GOT's HIV/AIDS policy, the NMSF and the Health Sector Strategy

on HIV/AIDS. Tanzania's annual blood transfusion need is estimated at 500,000 units. NBTS's FY 09 target is 180,000 units,

scaling-up to 200,000 units for FY 10. Through USG-supported efforts, there has been an increase in the proportion of voluntary

non-remunerated blood donors (VNRBD), versus donations from the family and friends of needy patients, from 20% to above

80%. More than 20% of all donors are recurrent. Collecting blood from VNRBD has reduced HIV prevalence amongst blood

donors from 7% in 2005 to less than 2.8% in 2008. The National Blood Transfusion Service (NBTS) is the MOHSW unit

responsible for the provision of safe and adequate blood and blood products in Tanzania.More than 80% of blood is collected by

mobile teams. Donor testing for HIV at the Zonal centre using whole blood is performed after donor counseling with over 25,000

donors receiving their test results in FY 08, a figure projected to over 50,000 in FY 09. All blood is also screened for HBV, HCV,

and syphilis prior to distribution, requiring whole blood and ELISA testing as recommended by WHO. In FY 08 at least 50% of

collected blood was processed into components following the procurement of separation equipment for the four zonal centers. An

important element to achieve the GOT unit goal is the identification and sustenance of HIV-, recurrent donors. In FY 08 donor

clubs were expanded to 18 regions; in FY 09 seven regions will be added thus covering the country. These donor clubs consist of

individuals counseled, tested and committed to remaining HIV free. To recruit more donors both public and private mass media

have provided the NBTS with free and subsidized announcements which NBTS will expand in 09 to complement community

mobilization and education efforts. Another initiative will facilitate maintenance of a safe donor pool by direct communication with

existing and eligible new donors via cell phones. Collaboration will expand with voluntary counseling and testing partners, with

HIV-negative clients encouraged to become VNRBD. Finally, private businesses will be requested to sponsor non-remunerative

donor recognition systems while the NBTS will link with PMI to promote malaria prevention among repeat donors. To enhance

availability of safe blood to the districts, in FY 08 USG equipped 13 regional hospital blood banks with cold chain equipment and

procured buffer supplies to avoid test kit stock outs. In FY09, NBTS training for hospital physicians and blood transfusion

committees will continue, building upon prior training for phlebotomists, laboratory staff and donor counselors and will include post

-exposure prophylaxis and proper waste disposal. In addition, NBTS and USG partners will continue to expand their quality

monitoring program, including supervisory visits, discard rates due to HIV, % coverage and proportion of blood needs met.

Additional PDAs will be procured to facilitate efficient data collection from the field. To build sustainability, GOT is incorporating

the NBTS into its national planning strategies and the MOHSW is establishing the NBTS as an executive agency to give it

independent financial status and greater autonomy. Other efforts have focused on expanding collaboration with partners such as

the Norwegian Agency for Development Cooperation who are constructing a Zonal Blood Transfusion and Training Centre in

Dodoma and the Abbot Fund which is renovating the regional hospital laboratories.Monitoring and evaluation of the program will

be based on reduction in TTI rates, retention of donors, reduction in discard and percentage of unmet needs through data

collected from facilities and NBTS data collection systems

Table 3.3.04: