THIS IS AN ONGOING ACTIVITY FROM FY 2008. ACTIVITIES LISTED HAVE BEEN INITIATED AND

WILL PROCEED DURING FY 2009 AS IN THE PREVIOUS YEAR. ACCOMPLISHMENTS WILL BE

REPORTED IN THE FY 2008 APR. PLEASE NOTE THAT THE ACTIVITY NARRATIVE REMAINS

UNCHANGED FROM FY 2008.

*END ACTIVITY MODIFICATION*

TITLE: SCALING UP COMPREHENSIVE PMTCT SERVICES IN A REGION (TBD)

NEED and COMPARATIVE ADVANTAGE: In Tanzania, PMTCT coverage remains insufficient with only

about 12% of all health facilities, mostly in urban areas, offering PMTCT services. Since 2004, African

Medical and Research Foundation (AMREF) has demonstrated a model of expansion of PMTCT services to

reach rural and underserved populations by integrating PMTCT into routine services with success in rolling

out to lower-level facilities. Additionally, AMREF has trained hospital-based PMTCT and infant-feeding (IF)

trainer of trainers (TOT) who conduct routine training of health care providers working at lower-level

facilities. AMREF has facilitated demand creation for PMTCT services through social marketing, local

community mobilization, sensitization, and enhancement of male involvement using community owned

resource persons (CORPs). Upon request from the USG to continue implementation of PMTCT programs

in collaboration with other partners and the GoT, AMREF will use its PMTCT model to scale up quality

comprehensive PMTCT services in a region to be determined by USG and MOHSW.

ACCOMPLISHMENTS: Working under the ANGAZA program, during the period October 2006 to June

2007, AMREF counseled, tested, and received results for 11,000 pregnant women. Of those individuals,

700 (6.3%) tested HIV positive and 400 received ARV prophylaxis according to national guidelines.

Roughly 1,500 male partners accessed care and treatment (C&T) at PMTCT service outlets. 75 health care

providers and 99 community workers were trained. AMREF has also worked with the Ministry of Health and

Social Welfare (MOHSW) to develop and pilot follow-up tools for HIV exposed children. AMREF, in

collaboration with various stakeholders, has developed standard operating procedures (SOP) and clinical

audit tools for PMTCT services.

ACTIVITIES: The USG has identified AMREF as the responsible partner for covering PMTCT in a region to

be determined that is not currently covered through the PMTCT regionalization Initiative. They will work

closely with USG and GoT treatment partners who are carrying out ART and PMTCT regionalization so that

activities are well coordinated and effective while avoiding duplication of services.

AMREF will increase the coverage of comprehensive PMTCT services by training health care providers on

provision of quality integrated PMTCT services using the curriculum formulated by the MOHSW. To

encourage men's participation in PMTCT services, AMREF will encourage training of at least one male

PMTCT counselor per health facility. The program will adopt and utilize national job aids to ensure

provision of quality service. The program will strengthen provider initiated ‘opt-out' C&T in antenatal clinics,

maternity waiting homes, labor wards, and during the postpartum period. HIV testing will be conducted per

the national guidelines (e.g., group counseling, individual HIV testing with same day results, and post-test

counseling). In addition, couples counseling and testing will be available.

AMREF will strengthen the integration of PMTCT into existing outreach reproductive health (RH) programs

and support minor renovations in debilitated health facilities to improve RH services. One mobile van and

at least two tents will be provided to hospitals to facilitate outreach. AMREF will support these programs

with essential supplies, equipment, and drugs including Cotrimoxazole. The program will strengthen

capacity of district-wide procurement systems in addition to providing training to districts on supply

management skills. AMREF will continue to access the PMTCT joint donation for Nevirapine and

Determine.

Other activities include; providing sustainable, comprehensive, and integrative quality PMTCT services with

quality antenatal and delivery services; encouraging deliveries in health facilities; orientation and

involvement of local government authorities on comprehensive provision of PMTCT services; TOTs in

community sensitization and mobilization in accessing integrated RH and PMTCT services. Additionally,

AMREF will promote male involvement as well as addressing cultural norms and behaviors hindering male

participation. The CORPs carry out household sensitization and mobilization on a routine basis and during

special events. Joint supportive supervision with council health management teams (CHMT) and refresher

training will be conducted biannually as part of on-job staff mentoring and quality assurance.

AMREF will adopt and implement National IEC/BCC materials and products produced for social marketing

of PMTCT in addition to utilizing media spots (e.g., local radio, television, and newspapers) to raise public

awareness of PMTCT services. AMREF originally developed these media spots to encourage male

participation in PMTCT programs. In an effort to have far-reaching implications, AMREF will collaborate

with MOHSW to explore the possibility of using local media to broadcast the spots.

Scale-up of services will be a major priority for AMREF in FY 2008. Activities in this area include facilitating

care and support for HIV-infected women and their infants, including early infant diagnosis and pediatric

care. Individuals testing HIV positive will be referred to care, treatment, and support services and the

AMREF Post-Test Club model will be used in all new sites. The PMTCT members will organize formal

selfgoverned

groups for support. Furthermore, AMREF will strengthen linkages to other RH services such as

Family Planning; low-cost cervical cancer screening services where available; STI, care and treatment clinic

(CTC), TB screening; and other care and support interventions. AMREF will facilitate early infant diagnosis

and follow-up for pediatric care and support, including safe IF practices.

Finally, in order to evaluate practices, a pilot will be conducted for a model of community support for

HIVinfected

women and their families including ensuring access to PMTCT services for home deliveries. This

will include supporting USG and GoT partners to establish a psychosocial support network of PMTCT

Activity Narrative: clients, their spouses, and families.

LINKAGES: AMREF will continue to work closely with MOHSW, all USG partners, and the local government

to scale-up PMTCT services. AMREF will encourage integration of PMTCT services and foster linkages

with other clinical services including home-based care for a comprehensive continuum of care.

Orientation will be facilitated for CHMT on PMTCT services management in addition to strengthening

supportive supervision of routine districts using the MoHSW guidelines. This will include linking PMTCT

services with Council Comprehensive Health Plans. Consistent collaboration with relevant stakeholders,

including academia and civil society organizations, will aid effective continuation of sustainable PMTCT

services implementation. AMREF will continue to strengthen public-private partnerships (PPP) down to the

district level by empowering and supporting sub-grantees, the local government, and other partners.

AMREF will continue to link with community structures with gender sensitive practices in order to utilize

services, as well as providing support to women and families.

CHECK BOXES: The interventions will target the general population, but with efforts to increase both men

and women's access to PMTCT services. Emphasis will be on linkages with other services and continuum

of care for PLWHA and training of health care providers for implementation of PMTCT services.

M&E: AMREF will build the capacity of partners by utilizing nationally approved monitoring and reporting

tools with PMTCT indicators for accurate and timely reporting. AMREF will train and support partners on

management skills and utilization of PMTCT information. Quarterly, semiannual, and annual reports will be

submitted to USAID per guidance of the USG. AMREF will use a clinical audit tool recently developed in

collaboration with a drafted facility-based SOP for enhancement of the quality of services for PMTCT

initiatives. AMREF is field-testing the draft SOP that were developed in collaboration with various

stakeholders and approved by the MOHSW. AMREF will empower partners in collection, reporting, and

utilization of community-based data in order to strengthen community-based health information systems.

Six percent of the budget will support M&E.

SUSTAINAIBLITY: AMREF will continue to work through partnerships and in collaboration with MOHSW

and district councils to ensure participatory planning, monitoring, and proper utilization of supervision tools,

as well as in skill development. AMREF will also support USG and GoT partners to ensure the inclusion of

PMTCT activities in comprehensive district health plans. In FY 2008, AMREF will encourage local partners

to participate in numerous activities including: planning, procurement, running of services, and other

community-based and mobilization activities. AMREF will coordinate with partners to address health

systems' challenges in relevant platforms, including human resources challenges. AMREF will also work on

a task-shift model through lay counselors and CORPs in Songea Rural district. This is a potential model for

replication.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13424

Continued Associated Activity Information

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

System ID System ID

13424 3432.08 U.S. Agency for African Medical 6489 1182.08 $300,000

International and Research

Development Foundation

7671 3432.07 U.S. Agency for African Medical 4512 1182.07 USAID $200,000

International and Research

Development Foundation

3432 3432.06 U.S. Agency for African Medical 2852 1182.06 USAID $200,000

International and Research

Development Foundation

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $75,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $15,000

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01:

THIS IS A NEW ACTIVITY.

Title: ANGAZA ZAIDI

The African Medical and Research Foundation (AMREF) Counseling and Testing (CT) program (called

ANGAZA ZAIDI meaning ‘shed more light') is a follow-on to AMREF's USAID-funded ANGAZA project

(2001-2008).

Need and comparative advantage:

According to the second THMIS -2007/8, Tanzania Mainland has a generalized HIV/AIDS epidemic with an

estimated HIV prevalence rate of 6% among people aged 15-49 years (7% women; 5% men). This gender

disparity has also been observed among clients accessing counselling and testing (CT) services in

AMREF's ANGAZA project. Among the 1,021,190 new clients who were tested and given results from

September 2001 to June 2008, approximately 90,901 tested HIV positive. Twice as many women 61,007

(12.5%) tested HIV positive as compared to men 29,894 (5.6%).

GOT has instituted several policies and programs to scale up a range of HIV prevention care, treatment and

support services. Provision of quality and broadly accessible counselling and testing services is pivotal to

the success of these initiatives. Evidence from the THMIS -2007/8 shows that the national uptake for CT

has almost doubled (37% female and 27% of men) as compared to the 15% of women and men reported to

have ever undertaken an HIV test in the 2003-04 THIS. Evidence suggests that the increase in testing was

boosted by the Presidential National Testing Campaign (July 2007-March 2008). Despite these impressive

gains, nearly 63% of adult women and 71% of adult men in Tanzania still do not know their HIV status.

Barriers to increasing uptake (as observed by both the Ministry of Health and Social Welfare and AMREF)

include: physical distance from facility-based CT sites; poor coverage of rural areas; inadequate number of

counselors to provide services; limited hours of service at public-health facilities; long counselling sessions

inherent in the traditional VCT model; and shortages of testing supplies management of the supply chain.

The project will play a key role in contributing to the Tanzania's Second National Multisectoral Plan and the

Ministry of Health and Social Welfare (MOHSW)'s new HIV/AIDS strategic plan efforts to expand VCT

services with a target of at least 50% of population receiving CT services by 2012. It will also contribute to

PEPFAR global targets for treatment, prevention and care.

Activities:

ANGAZA ZAIDI, in partnership with MSH will provide sub-grants to public health facilities, faith-based

organizations and NGOs to provide quality CT services with same-day results. ANGAZA ZAIDI will expand

access to CT services primarily through static VCT and mobile CT services and will target hard-to-reach

and high-risk communities. AMREF will work closely with other USG CT partners, and particularly with

JHPIEGO, to coordinate CT service expansion and CT Demand creation activities and to maximize

programmatic synergies. ANGAZA ZAIDI will, through partnership and sub-granting strategies, increase the

number of new individuals who have tested and know their results. ANGAZA ZAIDI, in collaboration with

the MOH, MSH, USG and other partners, will carry forward the "Know Your Status/Tanzania Bila UKIMWI

Inawezekana" campaign launched by President Jakaya Kiwete in July 2008.

ANGAZA ZAIDI will employ a two-pronged design covering all 21 regions of mainland Tanzania. It will (1)

focus intensively on rapid scale up in 10 of the 21 regions and (2) provide a basic set of support services in

CT in the remaining 11 regions. Intensive support to sub-partners in the 10 rapid scale up regions will focus

on capacity building and systems strengthening of sub-grantees enabling them to vastly expand the number

of static sites and mobile services providing high quality CT services. A different, less intensive basic

support package will be directed at existing ANGAZA sites in the remaining 11 regions with the aim of

sustaining on-going high quality CT work among these sub-partners. Intensive focus regions include Dar es

Salaam, Lindi, Kilimanjaro, Mara, Mbeya, Mwanza, Mtwara, Rukwa, Ruvuma and Arusha. These 10

regions are among the highest prevalence regions in Tanzania and are where AMREF's strongest sub-

partners are operational.

As part of project design, rapid assessments and baselines will be undertaken in all 10 intensive support

regions. Findings from the assessments will determine the scope and scale of expansion of CT service

provision. New sub-grantees will be identified through a competitive process. All ANGAZA ZAIDI sub-

partners will follow the national counseling and testing policy and guidelines and will ensure that finger-prick

rapid testing become the gold standard practice.

ANGAZA ZAIDI will deploy a variety of CT approaches in order to achieve accelerated access to HIV care,

treatment and support services including utilization of a high-quality CT standard package consisting of

group education, HIV testing, post-test counseling, and referrals. Activities will include:

- Outreach CT activities from the static sites as counselors move out to neighborhoods and villages in urban

and rural settings;

- Linkages with comprehensive prevention activities for high-risk populations, including peer education,

condom provision and referrals for STI services;

- Special campaigns during national events;

- Public and private sector initiatives to offer CT services in the workplace;

- Behavior change communication activities aimed at increasing demand for CT services;

- HIV prevention and risk reduction counseling delivered through a variety of CT service delivery channels.

Outreach services will reach populations in rural areas, schools, colleges, factories, border settlements as

well as other high risk populations (military, prisoners, mining centers, fishing communities, plantations,

IDUs, sex workers). Activities will also be undertaken during national festivals and events (e.g., World AIDS

Day, Worker's Day, International Women's Day, Sabasaba, Farmer's day, UHURU Torch).

Behavior change communication activities will be guided by the GOT National HIV/AIDS Communications

and Advocacy Strategy and implemented in collaboration with other USG partners. A variety of

Activity Narrative: "edutainment" methods, peer education programs, and interpersonal communication strategies will be used

to convey key messages that include the benefits of testing and raising individuals' risk perceptions, couples

testing and disclosure, and involving family members in CT. BCC activities will be designed to address

socio-cultural and gender norms that promote high risk behaviors such as MCP, trans-generational sex,

gender-based violence, and increased sexual risk related to alcohol and substance abuse.

ANGAZA ZAIDI will facilitate development of training tools (e.g., curricula, booklets, job aids, fact sheets,

posters) to facilitate dialogue with CT clients. The CT training package developed with MOHSW will be

designed in modules for lay counselors, post-test club facilitators and post-test club leaders. Master

trainers (who attend regional TOT workshops) will offer training in counseling, life skills, and advocacy at

district and ward levels. In collaboration with GOT, ANGAZA has already established standards in HIV

counseling and testing in Tanzania; ANGAZA ZAIDI will build on this experience and work with MOHSW to

finalize, institute and monitor an accreditation system.

This project will use the existing procurement and distribution systems of the Medical District Stores

Department (MSD) to avail high quality CT supplies to ANGAZA ZAIDI sub-grantees. To ensure that this

system runs smoothly, ANGAZA ZAIDI will hire an Administrative and Procurement Officer dedicated to

procurement and logistics issues. This officer will be responsible for maintaining close communication with

the sub-grantees and strengthening the capacity of sub-grantees in quantification and accurate and timely

re-supply orders. The project will purchase a minimal buffer stock to successfully navigate occasional

national stock-outs.

ANGAZA ZAIDI will play a key advocacy role to MOHSW to establish a permanent Counseling and Testing

Working Group. This group will advocate for the expanded use of lay counselors in Tanzania, using results

from a prior ANGAZA project. This group will also advocate for an accelerated roll-out of finger prick rapid

testing in Tanzania. ANGAZA ZAIDI will introduce Community-Owned Resource Persons (CORPS) who

will conduct community activities to raise awareness on CT benefits and post-test prevention, through peer

outreach and community mobilization. The CORPS, one female and one male, will be nominated by each

community/village.

Linkages:

ANGAZA ZAIDI will collaborate with MOHSW, the Global Fund, PEPFAR partners and local governments in

scaling up CT services. ANGAZA Zaidi and JHPIEGO will coordinate very closely to ensure maximum

synergy and complementarities. This project will build upon prior work engaging PLWHA by strengthening

referrals to enable HIV-positive clients to access a full spectrum of services offered through care and

treatment partners in the vicinity including: TB and STI services; post-test clubs; and income-generation

activities. At the community level, activities will include supporting community organizations to establish and

support Post-Test Clubs that will provide psychological and social support and linkages with health facilities

to strengthen care, treatment and support including condoms, safe water, and insecticide treated nets. The

capacity of sub-grantees will be strengthened through joint planning, mentoring and technical assistance to

integrate gender mainstreaming into their activities as appropriate.

Target Population:

The project will target the general population, with a focus on demand creation for hard-to-reach and higher-

risk groups and couples.

Monitoring and Evaluation:

Through its partnership with MSH, ANGAZA ZAIDI will build M&E capacity in every sub-grantee

organization. The project M&E team will establish standardized tools and information systems to track

targets and progress against results at three critical levels of impact: the National HIV/AIDS program; the

service delivery sites and the community/beneficiary. This information will inform program adjustments to

improve the reach and mix of services provided thus maximizing program quality over time.

Sustainability:

ANGAZA ZAIDI works through partnerships and collaborates with GOT and private sector institutions to

strengthen local capacities and facilitate policy change. Personnel are largely Tanzanian nationals who will

continue to work with HIV/AIDS and CT programs in the country. The decentralized approach of the project,

with a strong emphasis on capacity building and systems strengthening, will facilitate local institutions at

national and local government levels to sustain CT activities beyond project life.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.14: