ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY2008COP

Need and comparative advantage:

AIDSRelief (AR) provides HIV care and treatment in four regions: Mwanza, Mara, Manyara, and Tanga,

where prevalence ranges from 2-7%. To effectively scale up and provide quality services in these regions,

care and treatment centers continue to require improved infrastructure, staff capacity building, strengthened

supply chains and enhanced management systems. With four regionally-based teams working closely with

Regional and Council Health Management Teams (RHMT and CHMT), faith and community-based groups,

CRS' AIDSRelief clinical consortium has the capacity to provide the technical support and material inputs

necessary to increase ART enrollment and support ongoing quality improvement.

Accomplishments:

AIDSRelief supports the delivery of a comprehensive continuum of care for HIV-infected adults and children

extending from health facilities to the community. By June 30, 2008, AIDSRelief was supporting 51 sites in

four regions; 58,742 patients (77% of September 30, 2008 target) had been enrolled into care (male 20,635

and female 38,107) and 21,171 cumulative patients had been enrolled into ART (9,747 males and 17,424

female). 69%, or 18,685 patients (6507 male and 12,178 female), were actively enrolled as of June 30th

2008. That number represents 74% of the September 30th 2008 target. In the past year, notable

achievements in addressing improved quality of care have included: increased health workers' clinical skills,

strengthened systems in supply chain and laboratory support, improved strategic information skills and

implementation at sites (with increased understanding, through computerization of medical records) and

improved program management. Campaigns such as the "CD4 campaign" yielded a 100% increase in the

number of CD4 measurements in a targeted number of sites. The median CD4 level in a 6 month cohort

increased from a baseline of 128/mm3 to 234/mm3; in a 12 month cohort, the baseline was 164/mm3 and

after 12 months was 311/mm3.

Activities:

By February 2009, AR will continue to initiate ART treatment to adult patients. AR's strategies will

comprise of : 1) increased HIV testing to bring more patients into the health system; 2) improved quality of

HIV care and treatment; 3) decongestion and decentralization to lower level health facilities; and 4) reliable

data that informs clinical providers and increases the quality of care, as well as feeding into donor and

national government reporting.

Clinical Management

Through clinical leadership, AIDSRelief, in conjunction with RHMTs and CHMTs, will focus on the following

key activities: mentoring/preceptorship visits to assist clinical providers in the provision of quality HIV care

and treatment; strengthening linkages and referrals between different clinical units within the health

institution; promoting partner-initiated counseling and testing (PICT); promoting the three "I's" for TB:

intensified case finding, INH prophylaxis and infection control; promotion of a family-centered approach to

care in order to identify more HIV-exposed and infected infants and children; ensuring that CTC staff have

basic ARV training as per The National AIDS Control Program (NACP) guidelines; training and mentoring

clinical staff in the identification of first line regimen failure and rational switch to second line regimens;

participation in NACP ART technical working groups (TWG) and advocating for increased opportunities for

HIV testing and treatment in line with international guidelines and best practices; providing input into clinic

organization, including appointment systems, triage and patient flows (critical levels of trained health

professionals require attention be paid to maximizing these resources and appropriate task shifting). The

nursing team will also focus on: training of CTC nurse coordinators and CTC-in-charge on roles,

responsibilities, and management of CTC; training and mentoring nurses at health facilities on triaging, ART

care, and community nursing; improving linkages with other services in the health facility, especially TB

units and antenatal clinics (ANC) for PMTCT; training and mentoring nurses in CTC, RCH, and health

centers to become proficient in WHO staging, ARV side effects and basics of OI diagnosis and

management; collaborating with Nurses Council of Tanzania to develop guidelines and curricula for nurses

to increase their role in ART provision.

Support for adherence is crucial for durable viral suppression. A critical component of the AR model of care

has been adherence preparation and strong links from health facility to community through a variety of

mechanisms, which include support groups and working through CBOs. Key activities for the Community-

Based Treatment Support Services (CBTSS) will focus on both facility and community outreach, and will

comprise of: training all providers at health facilities to perform adherence assessments, adherence

preparation and provide counseling using an adherence tool developed by the CBTSS team; integrating

facility community nurses into the CBTSS team, including traveling with the CBTSS team; training HBC and

community health workers (CHW) on the TB screening tool and on recognition of symptoms and signs of TB

and other major opportunistic infections; training HBC and CHWs on common ARV side effects, and how to

provide basic nursing services to patients during community visits; rolling out enrollment campaigns (ARV,

CD4, pediatric testing days and HIV testing for families including pregnant women); participating in the

NACP TWG on community health and treatment support to: (1) advocate for community-based testing of

HIV for all family members (2) promote the AR adherence and treatment support model

A cornerstone of the AR model of care has been continuous quality improvement (CQI) by instilling a culture

of data usage to influence clinical and management decisions (utilizing a process of small steps of change).

In addition, AR plans to carry out on an annual basis chart abstraction and viral load and adherence

questionnaires on a selected number of sites. The CQI team will also focus on: identifying reports health

facilities generate on a monthly and quarterly basis for use at their own sites to ensure on-going

improvement of service delivery, including increasing number of patients on ART per month; training health

facility staff to implement Life Table analysis as part of routine data use, how to use local report generation

to monitor their own activities and achievements. The CQI team will review findings from chart reviews with

CTCs, introduce small tests of change upon discussion with CTC and hospital management as a follow-up

to chart reviews at five health facilities. The CQI team will perform chart abstractions at five hospitals,

administer adherence surveys at five hospitals, collect viral load samples and send them for analysis,

perform statistical analysis of the data generated, disseminate results to health facilities, MOHSW, and

Activity Narrative: donors, collaborate with national partners of NACP to work on quality issues, document best practices at

health facilities, disseminate best practices amongst partner health facilities, and replicate model practices

at other partners' health facilities.

Pharmaceutical and supply chain management

There has been an established and documented gap in ARV management, particularly in forecasting,

dosage monitoring, products selection (switching and initiation) and medicine information given to

caregivers. To address this gap, AIDSRelief pharmaceutical management and supply chain team

(ARPMSCT) will provide continuous monitoring of ARVs in the national pipeline by liaising with Medical

Stores Department (MSD) and NACP to get regular updates. They will relay that information to LPTFs.

Likewise, feedback from LPTFs on inventory status will be communicated to relevant actors. ARPMSCT

will improve the ability of LPTF staff to use available ARV logistics management information systems (MIS)

tools to forecast, order and dispense ARVs by providing centralized training and on-site mentorship.

ARPMSCT will improve the rational use of ARVs by: documenting ARV rational drug use issues (such as

dispensers' knowledge through review of prescriptions) and dispensing records and feedback from patients.

ARPMSCT will advise on dosing, and dosing schedules, by providing easy to use information packages,

national dosing charts and treatment updates. ARPMSCT will establish therapeutic drug committees at the

health facility level. AIDSRelief will develop a user friendly drug information leaflet (in Swahili) to be handed

over during dispensing. The content will be basic ARV information on the specific drug, dosing and

dosages, usage, drug interaction and side effects.

Laboratory

AR will expand MOHSW zonal quality assurance (QA) and quality control (QC) activities by working with

regional and facility-level QA officers to support the zonal QA officersin conducting supportive supervision

of all regional district and CTCs in the zone. AR will support implementation of the zonal external laboratory

quality assurance activities by supporting the quarterly meetings, and ensuring enrollment and participation

of four regional labs in national and international external quality assurance (EQA) programs. AR will

support equipment services and maintenance by training 41 lab staff and four zonal equipment engineers

on planned preventive maintenance. AR will support zonal equipment engineers to perform quarterly

supervisions, and produce quarterly updates on equipment status, then report to the zonal director, ART

partner and equipment engineer at MOHSW diagnostic.

AR will work with Supply Chain Management Systems (SCMS) and the USG lab team to build the capacity

of 41 CTC laboratory staff in logistics and planning and doing laboratory supplies and reagent forecasting to

ensure uninterrupted quality laboratory services. AR will procure reagents for hematology, chemistry, CD4

count and DNA polymerase chain reaction (PCR) for early infant diagnosis.

AR will procure for two hard-to-reach care and treatment center laboratories: equipment for CD4, six

chemistry and six hematology analyzers.

Program and Finance Support

This will be accomplished through:

sub agreements with all partners accompanied by agreed-upon workplans and budgets; provision of

resources; supportive supervision and no fewer than quarterly meetings with all partners (including liaising

with RHMTs and CHMTs); capacity building through finance and compliance training.

Linkages

AIDSRelief will reinforce established relationships with regional and district authorities, including RHMTs

and CHMTs, faith-based networks and community based groups. Many of our 71 (65 LPTFs plus Christian

Social Science Commision (CSSC), Archdiocese of Mwanza, African Inland Church, Evangelical Lutheran

Church of Tanzania (ELCT), Anglican Health Secretariat and Mennonite Church) current partners link to

programs in Tanzania's portfolio including OVC and nutritional support, HBC, water resource development,

micro enterprise and other international and private donors.

During year six, formal linkages will be strengthened between CTCs and groups providing home based

palliative care in these areas, such as Tunajali. Outreach and adherence staff, using patient attendance

data, will utilize these networks to follow up on missed appointments or patients lost to follow up. PLWHA

groups will assist with scale up by performing as lay counselors and adherence support partners.

Specific efforts will be made, by engaging the facility management, to strengthen linkages between the CTC

and TB units, RCH, out-patient and in-patient services within health facilities. In addition, referral linkages of

local-level facilities to hospitals will be strengthened in order to maximize the provision within the continuum

of care (prevention, PMTCT, care and treatment).

Areas of Emphasis and Populations

Capacity building of health care workers to offer quality care to PLWHA on ART; Supply chain

management; Human resource development ; Laboratory services strengthening;; Proper use and

documentation of pediatrics information.

Monitoring and Evaluation

AIDSRelief will continue providing M&E technical assistance to 65 existing health facilities plus three

community based groups. The technical assistance will be accompanied by regional and district-level

MOHSW personnel. This approach will build the capacity of facility-based staff to use existing MOHSW

tools for patient monitoring and tracking. This approach will also enhance the ability of MOHSW staff to

provide quality supportive supervision. Initial and refresher trainings in the use of revised MOHSW data

collection tools will be provided to 498 HCW's, including members of RHMT and CHMT. AR will provide

physical improvements, including computerization of paper-based information systems at 35 hospital

facilities, further enhancing their ability to generate and use data for quality improvement, patient

management and reporting to MOHSW. Approximately 7% of project support is designated for M&E.

Sustainability

Activity Narrative: AIDSRelief will a) support RHMTs and CHMTs in planning, implementation, and supportive supervision, and

to ensure ART support activities are included in the Council Comprehensive Health Plans (CCHPs), b)

conduct joint supportive supervision with CHMT and RHMT members, c) support local partners (FBOs e.g.

Christian Social Science Commision (CSSC), Archdiocese of Mwanza, African Inland Church, Evangelical

Lutheran Church of Tanzania (ELCT), Anglican Health Secretariat and Mennonite Church; CBOs), (c)

support PLWHA groups to conduct adherence support activities; d) address policy issues around the use of

lay counselors and task shifting amongst HCWs at the national level.

Specifically, AIDSRelief will work with stakeholders to develop a transition plan that transfers components of

the care and treatment program over to local partners. The plan will be designed to ensure the continuous

delivery of quality HIV care and treatment All activities will continue to be implemented in close

collaboration with the Government of Tanzania to ensure coordination, information sharing and long term

sustainability. For the transition to be successful, sustainable institutional capacity must be present within

the indigenous organizations and LPTFs they support. Therefore, AR will strengthen the selected

indigenous organizations according to their assessed needs, while continuing to strengthen the health

systems of the LPTFs. This capacity strengthening will include human resource support and management,

financial management, infrastructure improvement, and strengthening of health management information

systems.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13449

Continued Associated Activity Information

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

System ID System ID

13449 3476.08 HHS/Health Catholic Relief 6503 1514.08 Track 1.0 $1,063,792

Resources Services

Services

Administration

7692 3476.07 HHS/Health Catholic Relief 4524 1514.07 AIDSRelief $1,063,792

Resources Services Consortium -

Services Central

Administration

3476 3476.06 HHS/Health Catholic Relief 2878 1514.06 $1,063,792

Resources Services

Services

Administration

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $295,741

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09: