THIS IS A NEW ACTIVITY.

At the request of the GOT, the USG will implement a pilot male circumcision program through 5 partners

including: Jhpiego, Columbia University, AED/TMARC, Pharm Access and Mbeya Referral Hospital.

Jhpiego will provide technical oversight, training and support with systems development (i.e., supervision,

quality improvement, etc.) to the other implementing partners as well as implement the MC demonstration

program at Iringa Regional Hospital. Jhpiego will also conduct formative research on traditional

circumcisers in Mara. Columbia University will implement the MC demonstration program in Kagera, Mbeya

Referral Hospital will implement in Mbeya, and Pharm Access in Dar es Salaam (with the TPDF).

AED/TMARC will work closely with Jhpiego in the development of appropriate communications initiatives

targeting health care providers as well as surrounding demonstration site communities.

Need and comparative advantage:

Male circumcision (MC) has been shown to sharply reduce men's risk of becoming infected by HIV through

heterosexual intercourse. Three randomized clinical trials have shown that men who were circumcised

were 60% less likely to become infected with HIV within the trial periods. Based on data from the trials,

models have estimated that routine MC across sub-Saharan Africa could prevent up to six million new HIV

infections and three million deaths in the next two decades. In March 2007, WHO and UNAIDS issued

guidance encouraging countries with high HIV prevalence and predominantly heterosexual epidemics to

adopt MC as one component of a comprehensive HIV prevention strategy.

While MC has been shown to significantly reduce the risk of female to male HIV transmission, MC does not

provide men with complete protection from HIV infection. Although data from the three trials shows that the

circumcised men were not significantly more likely to engage in high risk sexual practices after the

procedure than the uncircumcised men, there is still a need to minimize disinhibition or risk compensation

and to ensure that men abstain from sex during the wound healing period.

The Tanzania MoHSW organized a stakeholder consultation meeting in September 2006 to review

evidence on MC and discuss programming interventions. A Tanzanian team subsequently participated in

the regional September 2007 WHO workshop in Zimbabwe to orient countries to the WHO situational

analysis (SA) tool kit for assessing the current status and need for MC programs. A second meeting was

held in November 2007 to establish both a National MC Task Force and MC Technical Working Group

(MCTWG) (of which JHPEIGO is a member) to follow up operationalization of proposed programming

efforts, and to plan for implementing the SA. With support from WHO and CDC, NIMR carried out a pilot

test of the SA tools in Mwanza Region in March 2008 to determine the suitability of the tools for more

widespread use in Tanzania. Results were shared with stakeholders in May 2008 and it was determined

that the tools would be revised and implemented in Mbeya, Mara and Kagera Regions, with results

available by September 2008.

In Iringa, where there are limited rates of traditional circumcision, MC prevalence is low (estimated 37.7%)

while HIV prevalence, at 14.7% is the highest in the country. In Mara, there is a strong history and practice

of traditional circumcision (estimated 89%) and relatively low HIV prevalence (3.5%) compared to other

regions in the country, which provides an interesting opportunity to explore the role of traditional

circumcisers within a national health facility-based MC program.

Accomplishments:

Jhpiego has provided leadership on MC programs since 2002, when the organization co-sponsored an

international meeting on MC and HIV prevention with USG and PSI. Jhpiego's most extensive and

demonstrative program is in Zambia, which has focused on making high-quality, comprehensive MC

services safe and accessible, and integrating MC into the compendium of HIV prevention activities. Jhpiego

has supported this program since 2004, and through this process, established the groundwork for

expanding quality MC services in Zambia. The initial pilot, funded by USG and implemented with Jhpiego's

technical assistance (TA), resulted in agreement on a standard procedure for MC as well as experience with

training clinicians and supporting services. Jhpiego has subsequently worked with the Zambia MoH to

scale up MC service delivery in the country and is active in MC in Botswana, Ethiopia, Lesotho,

Mozambique and South Africa.

Jhpiego also plays a leadership role in MC at the global level, assisting WHO and UNAIDS in December

2005 to develop the MC reference manual, Male Circumcision under Local Anesthesia, and associated

training materials. Jhpiego also collaborated with WHO and UNAIDS to develop the MC SA Toolkit and is a

key partner of WHO in the development of performance standards to guide quality assurance of MC

services. In collaboration with WHO, Jhpiego has conducted three regional MC courses in Zambia. Three

Tanzanian health providers from Iringa Regional Hospital participated in the first course in June 2007and

have since begun providing MC services at their hospital.

Activities:

Jhpiego will work with the MOHSW, WHO, the MCTWG and other key partners to develop the necessary

resources to support the national MC program and to implement an MC demonstration project in Mbeya,

Iringa, Kagera and Dar es Salaam Regions over a 1-year period, including formative research to be carried

out in Mara to explore the role of traditional circumcisers. Jhpiego will implement activities in Iringa and

provide TA to key partners in each of the other regions to implement regionally relevant approaches to

improve capacity to deliver quality services, while creating demand through advocacy and communication

(in partnership with T-MARC, who will receive funding from USAID to develop client education materials and

communication strategies). Jhpiego will partner with each of the relevant regional partners for service

delivery. The demonstration project will also lay the foundation in terms of training and supervisory

resources for program expansion in a follow-on phase.

Jhpiego will implement or provide TA for the following activities:

- Meeting to review results of MC situational assessment (in collaboration with Columbia University) and

design strategy for implementation of MC services;

Activity Narrative: - Workshop to develop MC service delivery guidelines, review/adapt MC training package and develop

reporting/recording forms;

- Workshop to develop and pilot test performance standards for quality MC service delivery;

- Development of strategies to involve community leaders and village health team leaders in the catchment

areas served by the facilities;

- TA in the development of MC IEC materials for clients and community (in partnership with T-MARC);

- Implementation of communication strategy, linking with existing IEC and community mobilization programs

to deliver correct and informative MC messages to target populations, and focused effort on working with

traditional circumcisers (in partnership with T-MARC);

- Development and commencement of formative research strategy to assess sexual behavior post-MC

service delivery and (to continue in a follow-on year);

- Printing of service delivery guidelines, training package, performance standards and IEC materials;

- Participate in quarterly MC Task Force meetings;

- Program introduction meeting and onsite orientation workshops (2-3 days per site): Regional hospital in

Mbeya; Lugalo Hospital (TPDF) in Dar es Salaam - in partnership with DOD; Regional Hospital in Iringa;

Regional Hospital in Kagera with Columbia;

- Support for developing MC service delivery at Iringa Regional Hospital through a sub-grant and TA to the

Iringa RHMT;

- Site strengthening at the 4 above-referenced sites;

- Provider training at Iringa Regional Hospital: course for provider teams from each of the 4 sites, with follow

-on counseling-specific training as necessary;

- Onsite supportive supervision to all 4 sites;

- Assessment of program progress, quality of services and client satisfaction; and

- National meeting to share assessment results and initial formative research findings and determine next

steps.

Linkages:

Activities will be linked to other policy initiatives on male reproductive health that are taking place in

Tanzania (such as CHAMPION) as well as with experiences on MC from neighboring PEPFAR countries.

Jhpiego will partner closely with the Tanzania regional prevention and care and treatment partners to

ensure that MC services are effectively implemented, supported and supervised. Jhpiego will provide TA to

these partners - DOD in Mbeya and Dar es Salaam and Columbia University in Kagera, with a direct sub-

grant (with assistance from Deloitte) to the Iringa RHMT (or other relevant institution) - in site preparation,

training and supervision of providers and monitoring of the quality of MC service delivery. Jhpiego will also

collaborate closely with T-MARC in the development of appropriate MC messages for client education

materials.

Target Population"

Men in Iringa, Mbeya, Kagera and Dar es Salaam regions

M&E:

A mid-term evaluation will be completed in regard to the demonstration project. Specifically, the knowledge

and competencies of providers regarding MC will be assessed and evaluated, and programmatic successes

and issues will be documented. In addition, Jhpiego will conduct an assessment in Mara Region to look at

the potential role of traditional circumcisers in a national health-facility based male circumcision program.

Jhpiego will also conduct formative research to look at risk compensation post-MC procedure.

Sustainability:

Jhpiego will collaborate with the NACP's relevant units to develop their capacity to provide leadership,

oversight, and support to the national MC program. NACP staff will be involved in advocacy, strategic

design, planning, implementation, and monitoring of all program activities, with programmatic and technical

expertise transferred to the greatest extent possible. While supporting capacity development at the national

level, Jhpiego will work in partnership with local government authorities in the target regions, including

relevant coordinators working within district/regional CHMTs, to build their skills in program implementation

and coordination. Jhpiego will work in close collaboration and coordination with USG to build GoT

counterparts' capacity to: use data for decision making; access information on best practices, international

recommendations, and programming guidance; establish effective, evidence-based policies and guidelines;

strengthen performance/standards-based supervision and monitoring systems; develop trainers, necessary

training materials, and job aids; and identify available technical resources within Tanzania and the region to

provide support to the national program.

Jhpiego will also work with trainers at the national and regional levels to develop their ability to implement

MC training, develop relevant MC training materials, and conduct MC supportive supervision visits, with an

aim toward creating a pool of technical resources that can be subsequently tapped by national counterparts

for assistance in supporting and further developing the national MC program.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Addressing male norms and behaviors

Military Populations

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $32,557,173

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Program Area Context: Adult Care and Treatment

Planned Funding for Adult Treatment: $106,182,096

Planned Funding for Adult Care and Support: $21,969,390

Total budget for Adult Care and Treatment Program Area: $128,151,486

Word count: 14,408 (With spaces)Tanzania has an estimated 1.3 million adults living with HIV/AIDS. USG remains a key donor

in Tanzania and currently provides direct support to the majority of patients in both care and treatment. Other key sources of

program support come from multilaterals mechanisms; for example Global fund (GFATM) support for Antiretroviral drugs (ARV)

and bilateral donors, especially: the German government (GTZ), DfID, Canadian CIDA, DANIDA, Norwegian and Japanese

governments through JICA for test kits, ARV, laboratory reagents and training of health workers. The Clinton Foundation (CHAI)

supports the Antiretroviral Therapy (ART) program in southern regions of Tanzania. USG programs are designed supporting

compliance with the National Multi-sectoral Strategic Framework (NMSF), the Health Sector Strategy and the Emergency Plan

Five-year strategy. At the time of the initiation of the Emergency Plan in September 2004, only about 1,500 - 2,000 of the

estimated 440,000 people in need were receiving ART.

By September 2008, USG directly supported an estimated 246,000 people living with HIV/AIDS (PLWHA) with care and treatment

services and a total of 205,000 PLWHA with facility-based care. In addition, USG supported nearly 150,000 people currently

receiving ART in Tanzania. Concurrently, the community-based care programs have reached over 91,000 PLWHA through home

-based care (HBC) programs with a growing proportion of overlap with facility-based care and support. According to a 2008 USG

evaluation of HBC services, the proportion of patients receiving HBC who are also receiving facility based services was estimated

at 65%. The USG ART program is on track to provide direct treatment support to almost 180,000 adults. This will be a

substantial contribution to the Tanzania government target of 440,000 PLWHA treatment by December 2010. USG anticipates to

indirectly support about 20,000 adults accessing ART. One of the successes of the Tanzanian Care and Treatment Program

resulted from a regionalization approach initiated by the Ministry of Health and Social Welfare (MOHSW) through the National

AIDS Control Programme (NACP) in FY 2005. Although some temporary inefficiency resulted from reassignment of partners and

the necessary strengthening of local government capacity, this approach has yielded broad geographic coverage, many operating

efficiencies, and an excellent platform for provision of support to Government of Tanzania (GoT) structures responsible for

implementation and supervision of HIV care and treatment services. It is also an excellent forum for linkage of services. In FY

2007, USG took the leadership of supporting NACP in aligning the community-based care and support partners into regions to

minimize duplication of efforts and reduce the number of partners with which treatment partners would need to coordinate. USG

will continue to provide the necessary support and collaboration to facilitate this process. USG treatment partners have taken on

responsibilities for supporting the implementation of Pediatric, TB/HIV, and PMTCT services, which will help significantly with

referrals. They provide or have been strategically linked to partners supporting implementation of testing and counseling,

community-based HBC and other community services, as well as programs for orphans and vulnerable children (OVC). Two of

the treatment partners (Selian and PASADA) are indigenous faith-based organizations (FBO) graduated from sub-partner status

to become prime recipients for Emergency Plan funds. One partner (PharmAccess) is working with the Tanzanian People's

Defense Forces and the Tanzanian Uniformed Services (police, immigration, and prisons). USG care and treatment programs

initiated broad scale-up of services in FY 2008, focusing on expanding the geographic coverage, quality, and comprehensiveness

of services. In FY 2008, there was greater emphasis on improving linkages and referrals between the facility-based and the

community-based programs to ensure improved tracking of clients, adherence to treatment, and provision of the continuum of

care. During the past year, additional efforts have focused on improved matching of services to the potential need based on

available HIV prevalence data. The proportion of those in need accessing ART services now range from 4,162 to 55,891 with a

median of 22,453. With the planned level funding in FY 2009, the focus will be on improved quality and comprehensiveness of

services and supporting the GoT expansion of care and treatment services to 500 lower level facilities (health centres), which will

serve as either treatment sites or refill stations for ARVs. USG will gradually decrease the intensity of direct support provided at

long-established sites (i.e., regional and district hospitals), and will expand support for the MOHSW plan to roll out services to

health centers. Main counterpart for program implementation, coordination and evaluation are the district health management

teams. Other areas of focus in FY 2009 are to continue improving linkages between facility and home-based care (HBC) services

and improving services focused on specific sub-populations including: pregnant women, patients with tuberculosis, and children

(see pediatrics narratives). In FY 2009, efforts will increase engagement with the private sector through public private

partnerships (PPP). In addition, USG will encourage collaboration between treatment partners supporting MOHSW and FBO

facilities, as well as supporting the training of private health care workers through existing treatment partners plans and funds.

Substantial local capacity exists at GoT and FBO Care and Treatment Clinics (CTCs) in Tanzania. A key strategy for

sustainability is to gradually reduce the intensity of direct partner support to well-established CTCs, while USG partners expand

their support in the extension of ART services to 500 health centers. Lessons learned during the transition of two sub-parters to

prime partners (Selian and PASADA) will be applied to these efforts, complemented by ongoing strengthening of local government

authorities (LGAs), will ease the anticipated transition. National ART guidelines are in the process of being rolled out and now

include the use of tenofovir as an alternate first line therapy, but limited to patients with peripheral neuropathy and anemia. USG

will continue support to GoT in operationalizing the new guidance, by assisting the GoT with the development of job aids and

training of health care workers. In support of the national guidelines, all USG treatment partners provide Cotrimoxazole to all

patients with WHO stage II, III, or IV disease or CD4 cell counts below 350. Most patients enrolled in care and treatment clinics

meet criteria, and coverage for adults and adolescents is estimated to be greater than 75%. A consortium comprised of NACP,

USG staff, major treatment partners, PharmAccess, and University Research Council (URC) support harmonized approaches to

quality improvement (including development of standards for support supervision and QA/QI coordination as well as harmonized

CQI efforts in all regions). Substantial progress has also been made in the broad area of care and support for people with HIV.

The active treatment subcommittee of the National Care and Treatment Task Force and the Care and Support Subcommittee

oversee national care activities. A current review of HBC guidelines will refine the basic care package and address provision of

palliative care and pain management to PLWHA through the care and support program. USG supports the African Palliative Care

Association (APCA) to take a lead in developing national pain management guidelines. A national monitoring system for the

community care and support program has been developed, with the paper-based tools ready for field testing in two districts.

Lessons learned from pilot testing will inform the national roll out of the system. A computerized national data system based on

the experience with the paper-based system is also underway with USG support, with development completion and rollout to all

regions projected to begin in FY 2009. USG will also support NACP and the district management teams to conduct supportive

supervision to ensure the quality of services. The expansion of home-based counseling and testing is also challenged by the

absence of policy allowing for non-medical HBC providers to perform HIV tests. USG will continue dialogue and collaboration with

MOHSW to affect a change in policy. FY 2009 funds will support a rollout of facility-based nutritional assessments of PLWHA in

care and treatment programs to determine nutritional status and identify those eligible for therapeutic supplementary feeding

support. Using FY 2008 funds, a Food by Prescription (FBP) program will be initiated in at least six treatment facilities, with the

lessons from this pilot test helping to inform a scale up of the program using FY 2009 resources (see Nutrition Partner narrative).

Community-based care and support partners provide, at a minimum, nutritional education and counseling. Some programs link

with the World Food Programme (WFP) to provide food supplementation. Peace Corps Volunteers will continue to provide

nutrition education and support permaculture gardening, an easy and effective method for families to provide for basic nutritional

needs. In FY 2009, USG will continue to link with GoT through relevant ministries and other developmental partners, as well as

the implementing partners, in addressing household food security. In addition, USG will expand the work that Peace Corps is

doing in promoting permaculture gardens through community-based partners, including distributing a permaculture gardening

instructive video to CTCs. Program goals will be accomplished through ongoing support to established care and treatment

partners and support for a number of efforts to build capacity, strengthen systems, and address barriers faced by the program.

The AIDS control programs of both mainland Tanzania (NACP) and Zanzibar (ZACP) will receive funding to support key activities

including policy development, guideline development, adaptation of training materials, program planning and implementation,

supportive supervision, and monitoring and evaluation. USG staff and partners will continue to provide technical assistance to the

MOHSW and NACP.

A new activity will be implemented in FY 2009 to strengthen LGAs' (particularly district councils) leadership and management

approaches to assure greater accountability and sustainability. This will build on the existing collaboration in planning,

coordinating, supervising, and monitoring care and support programs established under regionalization. This activity will be

initiated in four districts where support services activities will be integrated into the comprehensive council plans, and the lessons

from the activity will help to inform a broader scale up of this strengthening to support the sustainability plans of implementing

partners.

Another new activity in FY 2009 will address screening for cervical cancer among HIV-infected women. This is a new emphasis

area, and there is very little known about the extent of the problem, and the capacity to address it in Tanzania. JHPEIGO has

been tasked with doing necessary ground work in collaboration with the MOHSW, Ocean Road Cancer Institute (ORCI) and other

partners in determining current capacity and policy, coordinating an interest group, providing up to date technical information to

help inform a response plan, and developing plan for future engagement in this technical area.

PEPFAR collaborates with the President's Malaria Initiative (PMI), National Malaria Control Program (NMCP), and GFATM

regarding control of malaria for PLWHA and other vulnerable groups. USG and partners work to ensure that policies and

guidelines are consistent, and that malaria prevention and treatment guidelines are implemented in HIV care settings. UGS and

partners will also work to disseminate health promotion messages, and ensure that they are followed up by community-based

care providers promoting the use of insecticide treated bed nets (ITNs). USG will continue to collaborate with PMI and GF to

support the under five catch up campaign (aimed at reaching all under five children with ITNs) to ensure that vulnerable children

are included. In addition, USG will leverage the large program for universal coverage for ITNs expected to be funded through

GFATM to ensure that PLWHA receive support.

Provision of safe drinking water for PLWHA households is another area of emphasis for FY 2009. USG will procure water

purification tablets and water storage containers for distribution through a social marketing program. In FY 2008, USG conducted

an assessment on various practices in provision of safe water in rural settings, and in FY 2009, USG will pilot some of the

recommended practices of water purification at the "point of use," which do not need continual supplying of commodities. USG

will link with other organizations and initiatives that address water safety in targeted communities.

More than 90% of programs provide condoms. Other commonly supported services include general supportive counseling and

education about HIV care, treatment, and prevention, family counseling and testing or testing referral, and education about

nutrition, safe water, and hygiene. Efforts were initiated in FY 2008 to develop a comprehensive Prevention with Positives

program, both in facilities and through the community, and these programs will be broadened through implementing partners in FY

2009.

In FY 2009 USG will continue to improve linkages in care and support services, particularly enhancing the roles of community

care providers in TB screening and referrals, pain management, screening for opportunistic infections and assisting stable

patients by collecting refills of Cotrimoxazole and other drugs. An activity to develop and supply informational brochures, and

other job aid (laminated flip cards) to assist HBC providers will be expanded in FY 2009.

To support care and treatment approaches, an assessment of longitudinal treatment outcomes is underway to provide information

about retention on ART and clinical outcomes, including weight gain and increase in CD4. The USG team and the MOHSW are

also discussing plans for ongoing program assessment, including possible repeats of the clinical outcomes assessment and/or

implementation of the WHO protocol for monitoring of resistance and treatment outcomes among patients on ART.

Table 3.3.08: