PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
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 2009
UNCHANGED FROM FY 2008.
The funding for this activity has not changed
All Early infant diagnosis activities will be moved and be funded out of pediatric HIV treatment.
*END ACTIVITY MODIFICATION*
TITLE: Expansion of PMTCT services in Dar es Salaam
NEED and COMPARATIVE ADVANTAGE: Mother-to-child transmission of HIV is a major problem among
pregnant women in Dar es Salaam (DSM), where 10.9% of the population is estimated to be HIV positive.
Service delivery gaps, including lack of trained personnel, insufficient space for counseling and testing, and
erratic supply of HIV rapid test kits, ARVs, and other essential commodities are being addressed but remain
challenges.
MDH, a collaboration between Muhimbili University of Health and Allied Sciences, Dar es Salaam City
Council, and Harvard School of Public Health, has been providing PMTCT services at eight large antenatal
clinics and seven labor wards in DSM. MDH has helped to ensure that laboratory facilities are functioning
well, a strong training base exists, patient monitoring and tracking loss to follow-up is in place, and that
health infrastructure is well developed. There is strong commitment from the city council authority for the
advancement of HIV prevention, care, and treatment services in DSM. By September 30, 2008, MDH will
expand PMTCT services to twenty antenatal clinics and fifteen labor wards within DSM. The population
served will include 47,000 new antenatal clients and 65,000 deliveries.
ACCOMPLISHMENTS: MDH has been supporting the provision of PMTCT services in eight sites within
DSM. By the end of FY 2007, approximately 41,000 pregnant women will be enrolled in comprehensive
PMTCT services. MDH has implemented best practices such as opt-out testing, testing at labor and
delivery, and male involvement in PMTCT. These practices resulted in fewer missed opportunities for
counseling and testing and increased uptake of PMTCT services. Activities to strengthen existing referral
networks and improve access to care and treatment services for HIV positive mothers, partners, and HIV
exposed
and infected infants are ongoing.
From October 2006 through June 2007, 23,219 women received HIV counseling and testing with test
results at the antenatal and labor ward; and 2,456 HIV positive pregnant women received nevirapine (NVP)
prophylaxis. Between January 2006 and May 2007, 209 health care workers (HCWs) were trained in the
provision of PMTCT services.
ACTIVITIES: MDH will scale-up PMTCT services from the current 14 sites to an additional six sites by
September 30, 2008. The new sites that MDH will include: Muhimbili National Hospital, Kimara, Tandale,
Kiwalani, Vijibweni and Kawe dispensaries. PMTCT services at these sites will be strengthened and
expanded.
In all existing and new sites, comprehensive and quality services will be provided. The following areas will
be our priority: 1) Train 250 HCWs using the revised national PMTCT training curriculum. A two-day
refresher course will be periodically provided to HCWs to further build capacity. PLWHAs will service as
facilitators in a panel discussion during the training;
2) Implement provider initiated opt-out counseling and testing at all MDH supported sites to decrease
missed opportunities for PMTCT service provision;
3) Train HCWs on the use of more efficacious ARV prophylaxis regimens and provide site assistance in the
procurement and distribution of ARVs. Provide single dose NVP to HIV-positive pregnant women at time of
HIV diagnosis to ensure mothers who deliver at home or do not return to ANC receive the minimum ARV
prophylaxis regimen. Initiate ART, or provide the most efficacious regimen available, in accordance with the
national guidelines;
4) Strengthen referral systems and integrate care and treatment clinic (CTC) activities with ante-natal clinic
(ANC) services. A nurse counselor and a clinical officer will be assigned to the ANC to initiate care and
treatment services and minimize missed opportunities. Nurse counselors will be responsible for CTC
enrollment and taking map-cues for home visits when required. A map-cue is a form used to capture
directions to a mother's home using landmarks and street addresses. HIV positive pregnant women will be
given a referral form, or will be physically escorted to the CTC, on the day they are given their results;
5) Transfer mother's PMTCT information from the ANC card to the infant's road-to-health (RHC) card after
delivery to ensure that HIV-exposed infants receive optimal care including cotrimoxazole prophylaxis and
immunization;
6) Provide infant feeding counseling at ANC, labor and delivery (L&D), CTC, and immunization clinics;
7) Offer PCR early infant diagnosis HIV-testing to all HIV -exposed infants at six weeks of age and six
weeks after the cessation of breastfeeding;
8) Address prevention messages for HIV-negative and HIV-positive pregnant women and their partners
during counseling sessions conducted at ANC, L&D and CTC;
Activity Narrative: 9) Increase male involvement in PMTCT by providing invitation letters to partners of ANC clients; making
PMTCT services more male-friendly by fast-tracking PMTCT services for couples; and working with
community organizations to include male involvement messages into ongoing activities.
10) Conduct home visits using a map-cue to track those lost to follow-up and ensure they receive PMTCT
services and HIV care and treatment;
11) Recruit a PMTCT coordinator in each district to enhance supervision, coordination, and exchange of
information across districts and sites. During supervisory visits and monthly review meetings, data and other
new information will be shared with HCWs at the sites;
12) Engage the labor ward in-charge, the RCH coordinator, and the PMTCT coordinator at each site to
improve provision of PMTCT services by organizing monthly review meetings to discuss accomplishments,
challenges, and opportunities; and
13) Increase PMTCT uptake through community awareness-building activities such as training community
leaders and PLWHA in PMTCT.
LINKAGES: MDH works under the National AIDS Control Program (NACP) by following the national
PMTCT and treatment guidelines. PMTCT services will be strongly linked with other HIV prevention, care,
and treatment activities, including links to CTC and family planning (FP) programs. The MDH CTC intake
form has been revised to allow for tracking of referrals and home-based care providers will track women
who have been lost to follow-up.
MDH will work with heath facility and district level management to support and link PMTCT and other
related services. There will be a PMTCT task force at each site comprised of people from CTC, expanded
program on immunization (EPI), and FP. MDH will work with District Councils to include PMTCT activities in
their Comprehensive Council Health Plans. MDH will also work with local NGOs and community leaders to
support and link PMTCT and other related services for PLWHA, including linkages with OVC programs. In
addition, MDH will work with other partners providing PMTCT services in DSM.
CHECK BOXES: Training will be provided to HCW to build human capacity. The effort to increase male
involvement in PMTCT is a gender related activity. The general population, and specifically pregnant
women, will be targeted in our testing activities; PLWHA will be used to strengthen linkages and prevent
loss to follow-up; and counseling services will focus on discordant couples. Local organization capacity
building will be addressed to strengthen the capacity of health facility and district level management, local
NGOs, and community leaders to be able to provide quality services on their own in the longer term.
M&E: MDH has established a strong data capturing, processing, reporting and utilization system. National
monitoring and evaluation tools (registers and monthly report forms) are used at all sites. Training on
monitoring and evaluation is included in the PMTCT curriculum. Monthly reports are used to provide
supportive supervision. Quarterly reports are generated for PEPFAR and NACP from the PMTCT
database. MDH also uses the database to analyze quality indicators as part of the larger MDH Quality
Management Program. This allows us to develop quality improvement activities, including training and
change in procedures. Feedback to the site coordinators is provided during monthly review meetings which
serve as a forum for monitoring process of program implementation. Strategies to improve data collection
and PMTCT services will be implemented. The monthly review meeting is approximately 13% of the total
PMTCT budget. We will also leverage resources from Care and Treatment where we have built capacity for
data entry, processing, analysis and reporting.
SUSTAINAIBLITY: The MDH PMTCT program is run by managers and staff who are fully integrated within
the government system. The capacity of health workers is being built on an ongoing basis by updating their
clinical skills through in-service and on-the-job trainings. The City Council is a partner of the MDH program
which ensures that all activities are carried out as per the needs and directions of the government system.
National guidelines will be used to ensure continuity of the implemented activities. MDH will work with
District Councils to include PMTCT activities in their Comprehensive Council Health Plans to further ensure
New/Continuing Activity: Continuing Activity
Continuing Activity: 13488
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13488 3414.08 HHS/Health Harvard University 6520 3621.08 $900,600
Resources School of Public
Services Health
Administration
7720 3414.07 HHS/Health Harvard University 4540 3621.07 Tz Budget $1,065,000
3414 3414.06 HHS/Health Harvard University 3621 3621.06 $500,000
Emphasis Areas
Gender
* Addressing male norms and behaviors
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Malaria (PMI)
* Safe Motherhood
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $220,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY 2008 COP
TITLE: Support to the Provision of HIV Care and Support to Adult Population in Dar es Salaam
NEED and COMPARATIVE ADVANTAGE: Out of the approximately three million people living in the Dar es
Salaam region, nearly 300,000 (8.9%) are estimated to be people living with HIV/AIDS (PLWHA). Of these,
an estimated 213,600 (80%) require care and support, while 53,400 (20%) are in need of antiretroviral
therapy (ART). Collaboration between the Harvard School of Public Health, Dar es Salaam City Council,
and Muhimbili University of Health and Allied Sciences, collectively known as MDH, has been conducting
training and research for more than 15 years. This collaboration has improved the health system including
space, laboratory facilities, training base, patient monitoring, and tracking loss to follow up. There is strong
commitment from the local authorities to advance HIV care and treatment services.
ACCOMPLISHMENTS: By September 2008, 36 sites will be providing comprehensive HIV care services,
including ART and care and support. These include 20 public and 16 private health care facilities in Dar es
Salaam. A total of 36,000 PLWHA will have been enrolled in HIV care, 69% of whom will be receiving
Cotrimoxazole prophylaxis. For all HIV patients enrolled in the care and support program, MDH provides
routine pain assessment and management.
ACTIVITIES: In FY 2009, MDH shall:
1. Expand comprehensive care and support services from 36 to 42 sites. HIV care and support services will
be expanded to six additional public dispensaries; two in each of the three districts (to be identified with the
district and regional medical offices). By the end of FY 2009, 54,000 PLWHA (20% of eligible patients in
Dar) will be enrolled into HIV care and support services in Dar es Salaam.
2. Provide basic care and support for all HIV patients
All PLWHA who are enrolled in HIV care and treatment will be provided with follow-up counseling, clinical
and laboratory assessments, treatment of opportunistic infections, and assessment and management of
pain and other illnesses, as per the national guidelines. Inpatients will receive palliative care including pain
management as well as end-of-life care, as necessary. For those patients receiving care in their homes, the
program will provide a continuum of care through the community-based health care (CBHC) system in the
three municipalities. The CBHC volunteers have care kits for providing appropriate care in the homes.
MDH will provide necessary technical support, train, mentor, and build capacity at the community level for
palliative care.
3. Staffing support
MDH will recruit and hire staff within the city and district municipal systems. The initiative will create a
positive work environment, and provide training and career planning to ensure job satisfaction and retention.
4. Procure and provide various non-ARV medications
MDH will support sites in procuring and managing stock of non-ARV drugs for treatment of opportunistic
infections, including pediatric preparations, when they are not otherwise available through the Medical
Stores Department.
5. HIV counseling and testing
For all patients under care and support, including those receiving treatment, follow-up counseling focusing
on adherence is offered at all MDH-supported care and treatment centers (CTCs). MDH will strengthen this
support at the current sites and expanded to the new sites.
6. Intensify efforts in nutritional support for PLWHA
Currently, MDH is providing nutritional information and counseling to all patients. In FY 2009, clients will
also receive multivitamin supplements, and those with severe malnutrition will be referred for nutritional
therapy at the Muhimbili National Hospital. MDH will recruit and train a nutrition coordinator and assistant,
and ensure one available nutritionist at each site. New activities for nutritional support for OVC are currently
being developed (e.g., food by prescription and weaning support). MDH will support CTCs to conduct
anthropometric measurements and determine nutritional status using Body Mass Index (BMI) calculations
and other appropriate measurements such as mid-upper arm circumference (MUAC) and weight for age.
MDH will procure the necessary equipment required to carry out effective nutritional assessment such as
weighing scales, MUAC tapes, and stadiometers. The program will conduct training in the use of these
tools, as well as in dietary assessments of patients and the provision of nutrition counseling and education.
Finally, MDH will link with other organizations addressing household food security and economic
strengthening to ensure PLWHA have access to these services.
7. Increase emphasis on provision of prevention with positive services for PLWHA
PLWHA will be provided with counseling, and linked to support groups or peer-led interventions through the
CHBC system. There will be increased involvement of PLWHA in the communities in service provision as
HBC providers. PLWHA will be provided with information about ways they can protect their own health,
prevent common illnesses, and improve access to safe water and hygiene practices. MDH will ensure that
interventions address the comprehensive needs in an environment free from stigma and discrimination.
Sexually active PLWHA will be provided with condoms, which is an essential component of prevention of
further HIV transmission. Coupled with condom provision, PLWHA will be linked with sexually transmitted
infection treatment services and counseling to reduce high-risk behaviors. MDH counselors will discuss
with PLWHA specific strategies for disclosing one's HIV status to sexual partners, and offer confidential HIV
testing to the partners of and children born to all PLWHA in their coverage areas. MDH will link patients
with programs for the distribution of insecticide-treated nets to PLWHA, and promote their correct usage.
MDH will train CHBC providers on screening for TB and linking the clients to services. CHBC volunteers
will also be addressing and monitoring adherence to TB treatment
8. Support the national program through the Ministry of Health and Social Welfare and the national referral
Activity Narrative: lab
MDH will support procurement of essential lab equipment, test kits, reagents and consumables for the 42
sites when it is not otherwise available through Government of Tanzania systems. MDH will reinforce
laboratory testing activities, reporting at central and district health center laboratories in order to increase
yield and efficiency. The program will establish new site laboratories to decentralize testing. MDH will
support and provide Dried Blood Spot DNA polymerase chain reaction testing for early infant diagnosis in
Dar es Salaam and Eastern zone sites. MDH will support human resource capacity building through hiring
and laboratory trainings, and will provide supportive supervision for testing and implementation of the lab
quality assurance and control program. MDH will provide regular maintenance services and repairs for lab
equipments and instruments.
9. Implement a Quality management program (QMP)
MDH has developed a comprehensive quality of care assessment and improvement program which has
indicators on all aspects of HIV prevention, treatment, care, and support, including prevention of mother-to-
child transmission and TB/HIV. Data is regularly collected and used to monitor and improve the quality of
patient care. QMP will cover all existing as well as new sites. All the national M&E indicators are included
in the QMP.
10. Strengthen community links
MDH is working very closely with the CHBC system through the three municipalities to track all patients who
missed regular clinic visits, as well to provide home-based care. The program will continue to develop and
expand related referral and communication channels.
11. Build capacity of MDH health care providers and District Health Management Teams (DHMTs), in
provision of care and support to HIV-positive patients
MDH will provide year-round training sessions (introductory and refresher) on the full spectrum of HIV
treatment, care and support, based on the national curricula. Priorities include: onsite training and follow-
up, monthly supportive supervision with DHMTs, preceptorship opportunities, systems strengthening, and
logistical improvements. In consultation with the DHMTs, the program will offer further training opportunities
for selected MDH staff.
LINKAGES: Within all MDH-supported health facilities, mechanisms are in place to identify pregnant women
to be tested for HIV, and then assessed for eligibility for either prophylaxis, highly active antiretroviral
therapy or other HIV care. Women found to be HIV-positive are referred or escorted to the CTCs, and are
provided treatment and follow-up on clinic days reserved for HIV-positive pregnant women. MDH is putting
all systems in place to be able to screen, diagnose, and initiate anti-TB treatment for HIV-positive patients
as per the national guidance. The program will continue to work with partners such as PATH in HIV
counseling and testing for TB patients, and initiate ART for all eligible patients. MDH will continue referring
to and working with other organizations providing services at community and household levels to ensure
continuity of care, including clinical, psychological, spiritual, social, preventive and palliative care. Patients
will be linked with various wraparound programs to provide additional counseling and support, reproductive
health, family planning, malaria control, safe water and sanitation.
M&E: MDH will continue collaborating with the National AIDS Control Programme (NACP) to implement the
national M&E system for care and treatment. Patient records at all sites will be managed electronically
using the national CTC2 database for generation of NACP and USG reports, as well as for local-level use
for program planning, monitoring, and improvement. MDH will provide ongoing and regular support
through training and supportive supervision to all HIV care sites to build capacity for optimal data use. The
program will support training for at least 75 health care workers and data personnel in SI, and provide
technical assistance to all 42 CTCs, three district offices and one regional office. MDH will regularly perform
data analyses to evaluate treatment outcomes and to document the lessons learned, which will be shared
through various forums including conferences and publications.
SUSTAINAIBLITY: MDH is working with regional and district authorities in the day-to-day activities of the
program within the existing system. Planning, implementation, and monitoring of the activities are done in
collaboration with the district staff. All MDH activities will be aligned with the Council Health Plans. MDH
will continue to build district capacity in infrastructure and human resource. Financial and program
management system capacities will be strengthened through training and technical assistance.
Continuing Activity: 17324
17324 17324.08 HHS/Health Harvard University 6520 3621.08 $200,000
Estimated amount of funding that is planned for Human Capacity Development $650,300
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $20,000
and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Commodities $50,000
Table 3.3.08:
ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY2008COP
TITLE: HIV Anti-retroviral Therapy for Adults in Dar es Salaam
NEED and COMPARATIVE ADVANTAGE: Of the 3 million person population of Dar es Salaam region,
267,000 (8.9%) are estimated to be living with HIV/AIDS (PLWHA). Of these, it is estimated that 53,400
(20%) will need ART.
The Muhimbili University of Health and Allied Sciences (MUHAS) is part of the MUHAS, Harvard School of
Public Health (HPH) and Dar es Salaam City Council collaboration, the so-called MDH. MDH has involved
in training and research for more than 15 years. This collaboration has improved the health system through
increasing space, improving laboratory facilities, training bases, patient monitoring and tracking loss to
follow up. There is strong commitment from the local authorities to advance HIV care and treatment
services.
ACCOMPLISHMENTS: By September 2008: 1) 36 sites provide comprehensive HIV care services,
including ART. 20 of these sites are public and 16 are private facilities (to boost public-private partnership).
2) A total of 25,435 and 17,200 adult HIV patients will have been initiated and actively on ART, respectively.
Previously, among the MDH-supported sites, it was possible increase the median CD4 count from 143/mm3
to 277/mm3, and from 131/mm3 to 317/mm3 among the six and 12 months cohorts of patients on ART,
respectively.
ACTIVITIES:
Expansion of ART services to public and private health facilities.
ART services will be expanded to public dispensaries in each of the three districts. These dispensaries will
be identified together with the district and regional medical offices; discussion is underway.
Staffing support -MDH will support the human resource requirements for delivery of ART in the city through:
recruitment and hiring of necessary staff within the government system with acceptable compensation,
creation of a conducive work environment and training and career planning to ensure job satisfaction and
retention.
Laboratory services - Expand the Ministry of Health and Social Welfare's (MOHSW) zonal quality
assurance\quality control activities. MDH will work with regional and facility level Quality Assurance Officers
to support zonal Quality Assurance Officers in conducting supportive supervision at all regional and district
CTCs in the zone.
Support implementation of the zonal external laboratories' quality assurance activities by: 1) supporting the
quarterly meetings and 2) ensuring enrollment and participation of 22 regional labs in the national and
international external quality assurance (EQA) programs. Support equipment services and maintenance by
training 66 lab staff and 12 zonal equipment engineers on planned preventive maintenance. Support zonal
equipment engineers to perform quarterly supervisions, produce quarterly updates on equipment status and
report to the zonal director, ART partner and equipment engineer at MOHSW diagnostic. Work with Supply
Chain Management Systems (SCMS) and the USG lab team to build the capacity of 50 CTC laboratories'
staff in laboratory supplies and reagent forecasting logistics to ensure uninterrupted quality laboratory
services. Procure reagents for hematology, chemistry, CD4 count and DNA polymerase chain reaction
(PCR) for early infant diagnosis (EID).
Procure 30 additional CD4 machines and chemistry and hematology analyzers for hard-to-reach care and
treatment centers.
ARV provision support - MDH will continue supporting the district medical offices and all the supported
sites in forecasting, acquisition, transport, distribution, storage and stocking of ARVs from the Medical
Quality management program (QMP) - MDH has developed a comprehensive quality of care assessment
and improvement program. The program has indicators for all aspects of HIV prevention, treatment, care
and support, including PMTCT and TB/HIV. On a regular basis, data is collected, and used to monitor and
improve the quality of patient care. QMP will cover all the existing, as well as new, sites. All the national
M&E indicators are included in our QMP.
Tracking patients on ART lost to follow up: MDH has a patient tracking system to trace those who missed
their scheduled visit, those lost to follow up and those with abnormal laboratory results. Currently, the team
has 37 nurses; an additional 34 will be recruited. We will also involve PLWHA and volunteers with the care
and treatment tracking system. MDH will continue strengthening linkages with other organizations to
ensure continuity of treatment and care to their homes.
Training: In order to continuously build the capacity of all the MDH health care providers, and the district
health management team, a cascade of year round training sessions (introduction and refresher courses)
on the full spectrum of HIV treatment will be conducted using the national curricula. MDH will provide on site
training and follow up, monthly supportive supervision and preceprtorship together with Council Health
Management Teams (CHMT) teams. System strengthening and logistical improvement will be prioritized. In
consultation with the DHM, further training opportunities for selected MDH staff will be offered.
LINKAGES: Within all supported health facilities, mechanisms are in place to: 1) identify pregnant women to
be tested for HIV, 2) assess their eligibility for either prophylaxis (PMTCT) or HARRT, and 3) refer or escort
them to CTC services. Special days for pregnant women's ART management are now in place, and will be
strengthened. MDH is putting all systems in place to be able to screen, diagnose and initiate anti-TB
treatment for HIV patients as per the current national guidance and algorithms. MDH is also working with
partners such as PATH to counsel and test TB patients for HIV; initiating ART for all those who are eligible.
MDH will continue referring to, and working with, other organizations providing services at the community
and home level to ensure continuity of care.
CHECK BOXES: Emphasis will be given on the vulnerable groups including adolescents and youth.
Friendly services will be established to attract more youth to the clinics by addressing their needs. MDH will
Activity Narrative: 1) train of service providers in adolescent and youth-focused care, 2) set separate operating hours for them
and 3 ) provide a package of services under one roof.
MONITORING AND EVALUATION: MDH will continue collaborating with the National AIDS Control
Program (NACP) to implement the national M&E system for care & treatment. Patient records at all sites
will be managed electronically using the CTC2 database to generate NACP and USG reports, as well as
local site-level data for use in program planning, monitoring and improvement purposes. MDH will provide
ongoing and regular support, through training and supportive supervision, to all ART-providing sites in order
to build their capacity for optimal data use. MDH will support training for health care workers (HCWs) and
data personnel in SI and provide technical assistance to all CTCs, three district offices and one regional
office. MDH will regularly perform data analyses to evaluate treatment outcomes, and document the lessons
learned which will be shared through various forums, including conferences and publications.
SUSTAINAIBLITY: MDH is working with regional and district authorities in the day to day activities of the
existing system's program. Planning, implementation and monitoring of the activities are done jointly with
the district staff. All MDH activities will be in line with the Comprehensive Council Health Plans. MDH will
continue with district capacity building in infrastructure and human resources. Financial and program
Continuing Activity: 13490
13490 5384.08 HHS/Health Harvard University 6520 3621.08 $8,010,000
7722 5384.07 HHS/Health Harvard University 4540 3621.07 Tz Budget $2,720,000
5384 5384.06 HHS/Health Harvard University 3621 3621.06 $955,000
Estimated amount of funding that is planned for Human Capacity Development $419,813
Table 3.3.09:
TITLE: Pediatric HIV Care and Support in Dar es Salaam
NEED and COMPARATIVE ADVANTAGE: Out of the approximately three million people living in Dar es
an estimated 20%, or 60,000, are thought to be HIV-positive children requiring care and support.
Collaboration between the Harvard School of Public Health, Dar es Salaam City Council, and Muhimbili
University of Health and Allied Sciences, collectively known as MDH, has been conducting training and
research for more than 15 years. This collaboration has improved the health system including space,
laboratory facilities, training base, patient monitoring and tracking loss to follow-up. There is strong
commitment from the local authorities to advance HIV care and treatment services, particularly for children.
including antiretroviral therapy (ART) and care and support. These include 20 public and 16 private
facilities. A total of 5,000 pediatric HIV patients will be receiving HIV care and support, 91% of whom have
been provided with Cotrimoxazole prophylaxis. Various efforts have been exerted to increase the early
identification and diagnosis of HIV/AIDS in pediatric patients. Early infant diagnosis (EID) has now been
made possible through instituting DNA polymerase chain reaction (PCR) testing at all sites and recently
using the dried blood spot (DBS) method. Possible entry points into pediatric HIV care and treatment
include following patients from Prevention of Mother-to-Child transmission (PMTCT) programs, regular
immunization visits, care and treatment center (CTC) visits of mothers, as well as children attending
outpatient departments for other services. Staff at these points have been trained on addressing HIV
exposure, testing, and referral, and designated staff will ensure follow up. Pediatric testing has been
introduced at all entry points of the facilities. A child-friendly atmosphere has been created through special
pediatric care and treatment days to attract more eligible children into HIV care.
ACTIVITIES: With FY 2009 funding, MDH shall:
1. Expand comprehensive pediatric HIV care and support from 36 to 42 sites
HIV care and support services will be expanded to six additional public dispensaries; two in each of the
three districts (to be identified with the district and regional medical offices). By end of FY 2009, 10,000 HIV
-positive children (16.1% of eligible patients in Dar) will be enrolled into HIV care and support services in
Dar es Salaam.
2. Strengthen pediatric AIDS care and support
Increase pediatric enrollment from 10% to 16% by strengthening CTC linkages with PMTCT programs,
using antenatal and immunization care to identify HIV-exposed infants; strengthening Provider Initiated
Testing and Counseling in maternal and child health clinics and inpatient wards. Sick children attending
immunization clinics will be evaluated and referred for HIV testing. EID through DNA-PCR will be made
available at all entry points and in all supported sites. All HIV-infected children will be encouraged to enroll
into the care program. MDH will promote innovative strategies to increase pediatric care enrollment such as
"pediatric only days." All health care workers (including non-pediatricians) will receive training on strategies
of identifying and enrolling eligible children, as well as providing treatment, care, and support for pediatric
AIDS patients. All HIV-positive children enrolled into HIV care will be followed-up regularly and continuously
assessed for their ART eligibility, both clinically and via laboratory parameters. The children under care and
support will receive follow-up counseling and Cotrimoxazole prophylaxis, and other clinical concerns will be
assessed and managed accordingly.
3. Provide the necessary technical and financial support to meet the human resource requirements for
strengthened pediatric care and support programs
MDH will recruit and hire staff within the city and district municipal systems. The initiative will ensure
acceptable compensation, create a positive work environment, and provide training and career planning to
ensure job satisfaction and retention.
4. Procure and provide various pediatric non-ARV medications
MDH will support sites in procuring and managing stocks of pediatric non-ARV drugs for treatment of
opportunistic infections when they are not otherwise available through the Medical Stores Department.
MDH will link with malaria programs to ensure that children have access to insecticide-treated bed nets.
Emphasis will also be on strengthening Integrated Management of Childhood Illnesses through training of
staff and improved management of general pediatric diseases.
5. Support the national program through the Ministry of Health and Social Welfare (MOHSW) and the
national referral lab
support and provide DBS DNA PCR testing for EID in Dar es Salaam and Eastern zone sites. MDH will
support human resource capacity building through hiring and laboratory trainings, and will provide
supportive supervision for testing and implementation of the lab quality assurance and control program.
MDH will provide regular maintenance services and repairs for lab equipment and instruments.
6. Implement a Quality Management Program (QMP)
indicators on all aspects of HIV prevention, treatment, care, and support, including those for pediatric HIV
care. Data is regularly collected and used to monitor and improve the quality of patient care. QMP covers
all existing as well as new sites. All national M&E indicators are included in the QMP.
7. Strengthen community links
Activity Narrative: MDH is working very closely with the community-based health care (CBHC) system through the three
municipalities to track all pediatric patients who missed regular clinic visits, as well to provide home-based
care. The program will continue to develop and expand related referral and communication channels. In
addition, MDH will intensify efforts to strengthen the working relationships with the CBHC system to ensure
continuity of pediatric HIV care at the community and household levels. MDH will give special attention to
orphans and vulnerable children (OVC), and seek out linkages to existing networks and organizations
providing specialized care for OVC.
8. Build capacity of MDH health care providers and District Health Management Teams (DHMTs) in
provision of care and support to pediatric HIV-positive patients
MDH will provide year-round training sessions (introductory and refresher) on the full spectrum of pediatric
HIV care, based on the national curricula. Priorities include: onsite training and follow-up, monthly
supportive supervision with DHMTs, preceptorship opportunities, systems strengthening, and logistical
improvements. In consultation with the DHMTs, the program will offer further training opportunities for
selected MDH staff.
9. Intensify efforts in nutritional support for PLWHA
weighing scales, MUAC tapes and stadiometers. The program will conduct training in the use of these
LINKAGES: MDH is putting all systems in place to be able to screen, diagnose, and initiate anti-TB
treatment for pediatric HIV patients as per the national guidance. The program will continue to work with
partners such as PATH in HIV counseling and testing for pediatric TB patients, and initiate ART for all
eligible patients. MDH will continue referring to and working with other organizations providing services at
community and household levels (e.g., Pathfinder) to ensure continuity of care, including clinical,
psychological, spiritual, social, preventive, and palliative care for pediatric patients. Pediatric patients will be
linked with various wraparound programs to provide additional nutritional counseling and support,
reproductive health, family planning, malaria control, safe water, and sanitation.
M&E: MDH will continue to collaborate with the National AIDS Control Programme (NACP) to implement the
national M&E system for pediatric care and treatment. Patient records at all sites will be managed
electronically using the national CTC2 database for generation of NACP and USG reports, as well as for
local-level use for program planning, monitoring and improvement. MDH will provide ongoing and regular
support through training and supportive supervision to all HIV care sites to build capacity for optimal data
use. The program will support training for at least 75 health care workers and data personnel in SI, and
provide technical assistance to all 42 CTCs, three district offices, and one regional office. MDH will
regularly perform data analyses to evaluate treatment outcomes and to document the lessons learned,
which will be shared through various forums including conferences and publications.
Estimated amount of funding that is planned for Human Capacity Development $15,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $5,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $15,000
Table 3.3.10:
THIS IS A NEW ACTIVITY.
TITLE: Scaling up Pediatric ARV Treatment services in Dar es Salaam
NEED and COMPARATIVE ADVANTAGE: Of the 3.5 million person population of the Dar es Salaam
region, 311,500 (8.9%) are estimated to be living with HIV/AIDS (PLWHA). Of these, it is estimated that
62,300 (20%) will need ART.
MDH (Muhimbili, Dar City and Harvard ) is collaboration of Muhimbili University of Health and Allied
Sciences (MUHAS) , Harvard School of Public Health (HPH) and Dar es Salaam City Council collaboration,
MDH has been involved in training and research for more than 15 years. This collaboration has improved
the region's health care system including increasing space, improving laboratory facilities and training
bases, improving patient monitoring and tracking loss to follow up. There is strong commitment from the
local Dar es Salaam (Dar) authorities to advance HIV care and treatment services.
ACCOMPLISHMENTS: By September 2008, 1) 36 sites will be providing comprehensive pediatric HIV care
services, including ART. 20 of these are public facilities, and 16 are private (to boost public-private
partnership). 2) A total of 3,425 and 2,620 pediatric HIV patients will have been initiated and actively on
ART, respectively. 3) A total of 298 pediatric HIV patients under two years of age have ever started ART, of
those, 266 are currently receiving ART.
Various efforts have been exerted to increase the early identification, diagnosis and initiation of ART for
pediatric AIDS patients. Various entry points, including in-patient wards, immunization clinics, and PMTCT
follow-up, have been identified, and the staff of these points have been trained. Pediatric Focal persons
have been placed to draw attention and for closer follow up. HIV testing has been introduced at all entry
points of the facilities. A child-friendly atmosphere has been created through special pediatric treatment
days, meant to attract more eligible children into HIV treatment.
Expansion of pediatric ART services ( in both public and private)
Pediatric ART services will be expanded to additional public dispensaries , in the districts (to be identified
with the district and regional medical offices; discussion is underway). By the end of FY 2009, MDH
estimates that 80% of eligible children in Dar will be actively on ART.
Strengthening the existing pediatric AIDS treatment - All efforts to increase pediatric enrollment will be
intensified. We will increase the proportion of patients initiated on ART that are children to 15%. MDH will
continue strengthening linkages between PMTCT (using antenatal clinics (ANC) and immunization clinics to
identify HIV-exposed infants), MCH, in-patient and care and treatment centers (CTC). Provider-initiated
counseling and testing (PITC) will be conducted at immunization clinics. HIV-positive children will be
evaluated, initiated on Cotrimoxazole and referred for ongoing HIV care and treatment as necessary. See
Pediatric Care narrative for the complete package of services for pediatric patients on ART. HIV testing
using DNA-polymerase chain reaction (PCR) will be made universally available across all sites. Innovative
strategies such as the ‘pediatric only days' will be further promoted and utilized. The family-centered HIV
management approach currently practiced at one of the MDH-supported sites will be scaled up to other
sites as well. All health care workers (including non-pediatricians) at all entry points will continue to be
trained to screen, assess and treat pediatric AIDS patients (including the use of co-trimoxazole prophylaxis).
Staffing support -MDH will support the necessary human resources for pediatric HIV management through
recruitment and hiring of necessary staff within the city and district municipality systems, with agreed upon
compensation. This will create a conducive working environment along with training and career planning to
Facilitate availability of pediatric ARVs - MDH will continue supporting the district medical offices and all
supported sites in forecasting, acquisition, transport, distribution, storage and stocking of pediatric
formulations of ARVs from the Medical Stores Department.
Laboratory services - MDH lab support will be coordinated and synchronized with the national program of
the Ministry of Health and Social Welfare (MOHSW) and the national referral lab. MDH will support
procurement of essential lab equipments/instruments test kits, reagents and consumables for the sites.
MDH will reinforce laboratory testing activities and results reporting at central and district/health centre
laboratories in order to increase yield and efficiency. MDH will also establish new site laboratories to
decentralize testing. MDH will support and provide dried blood spot (DBS) DNA PCR testing for early infant
diagnosis (EID) of HIV for Dar and Eastern zone sites. MDH will support human resource capacity building
through hiring and laboratory training, and will provide supportive supervision for testing and implementation
of the lab quality assurance/quality control program. MDH will support provision of regular preventive
maintenance services/repair for lab equipment/instruments. The following numbers of lab tests are targeted
to be performed: 10,000 rapid HIV tests, 3,000 HIV DNA PCR and 25,000 CD4 count/percent.
Quality management program (QMP) - MDH has developed a comprehensive quality of ART and care
assessment and improvement program; it has pediatric indicators on HIV treatment and care. On a regular
basis, data is collected and used to monitor and improve the quality of pediatric patients' care. QMP will
cover all the existing, as well as the new, sites. All the national M&E indicators are included in our QMP.
Tracking pediatric patients lost to follow up: MDH has a patient tracking system to trace those children on
treatment who missed their scheduled visit, were lost to follow up, or had abnormal laboratory results.
Currently, the team has 37 nurses; an additional 34 will be recruited. We will also involve PLWHA and
volunteers with the ART patient-tracking system. MDH will continue strengthening linkages with other
organizations to ensure continuity of treatment and care to their homes.
Training: All health care workers from all entry points for pediatric HIV patients will continue to be trained on
Activity Narrative: screening, diagnosis, management and follow-up of pediatric AIDS patients. To do so, a cascade of year
round training sessions (introduction and refresher courses) on the full spectrum of pediatric HIV treatment
will be conducted using the national curricula. Monthly on site training and follow up, supportive supervision
and preceptorship, together with Council Health Management Teams (CHMT),system strengthening and
logistical improvement will be prioritized. In consultation with the CHMT, further training opportunities for
selected MDH staff will be offered.
LINKAGES: Referral systems and lines of communications will be strengthened. This will enable pediatric
patients' access to various levels of services provided by health facilities and other organizations,
particularly those of PLWHA and OVC that provide clinical, psychological, spiritual, social, preventive and
palliative care in the communities. Linkages within health facilities, particularly between RCHs, CTCs, TB,
PMTCT, out-patient and in-patient departments will continue to be strengthened. Provider initiated
counseling and testing (PICT) will be strengthened to minimize missed opportunities. Tracking patients, as
well as ensuring continuum of care, will be accomplished through the linkages that are currently established
with the Community Home Based Care (CBHCs) provides in the three municipalities.
CHECK BOXES: Emphasis will be given to vulnerable groups: children and early adolescents. A child
friendly clinic atmosphere will be further promoted to attract more eligible children.
Program (NACP) to implement the national M&E system for pediatric care & treatment. Patient records at all
sites will be managed electronically using the CTC2 database for generation of NACP and USG reports, as
well as for the local site-level data use for program planning, monitoring and improvement purposes. MDH
will provide ongoing and regular support, through training and supportive supervision, to all ART-providing
sites to build their capacity for optimal data use. We will support training for no less than 75 health care
workers (HCWs) and data personnel in SI, and provide technical assistance (TA) to all 42 CTCs, three
district offices and one regional office. MDH will regularly perform data analyses to evaluate treatment
outcomes, and to document the lessons learned which will be shared through various forums, including
conferences and publications.
SUSTAINAIBLITY: MDH is working in the day to day activities of the existing program with regional and
district authorities. Planning, implementation and monitoring of the activities are done jointly with the district
staff. All MDH activities will be in line with the Comprehensive Council Health Plans. MDH will continue with
district capacity building in infrastructure and human resource. Financial and program management system
capacities will be strengthened through training and technical assistance.
Estimated amount of funding that is planned for Human Capacity Development $210,289
Table 3.3.11:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
TITLE: Expansion and Integration of TB/HIV Services in Dar Es Salaam
Harvard University will expand integrated collaborative TB/HIV services from the current three sites to 11
sites. The focus for FY2009 is to strengthen activities of reducing burden of TB among people living with
HIV/AIDS (PLWHA) with emphasis on implementation of the intensified TB case finding (ICF), infection
control (IC) and provision of Isoniazid in the pilot sites. Harvard will make sure that guidelines for TB/HIV
collaborative activities are available at the sites and that health care providers at care and treatment clinics
(CTC) are trained on TB/HIV co-management. Supportive supervision and mentoring will be provided to
ensure quality of services. Intensified TB case finding (ICF) among HIV will be strengthened to ensure that
all PLWHA attending CTC are screened for TB and those with active TB are referred to TB clinic for
management. The plan is to ensure that all HIV infected individuals are screened for TB at enrollment and
at all follow up visits. TB screening activities will be linked with PMTCT program, HBC and Pediatric units.
TB infection control will be implemented to all Harvard supported sites according to national guidelines.
Harvard University will work with Ministry of Health and Social Welfare (MOHSW) to pilot provision of
Isoniazid preventive therapy for PLWHA whom active TB has been excluded and who will be eligible for
IPT. Harvard University will work with MOHSW and other partners to finalize guidelines for implementation
of IPT, TB infection control in Care and Treatment settings. In collaboration with NACP and NTLP, Harvard
plans to pilot provision of IPT in one care and treatment clinic that have demonstrated quality of intensified
TB screening in Dar Es Salaam.
NEED and COMPARATIVE ADVANTAGE: TB and HIV co-infection is a major public health problem in
Tanzania, with Dar es Salaam among the most severely affected regions in the country. Our group has long
-standing collaboration in the provision of services to patients at TB clinics and in HIV/AIDS care and
treatment. We will extend our current integrated TB/HIV services from three clinics (based at the three
district hospitals) to an additional 2 health centers and 2 dispensaries where we currently have a functional
CTC.
Muhimbili Dar es Salaam and Harvard (MDH) is well placed to continue doing these activities for various
reasons. MDH has established a unique relationship between the Harvard School of Public Health (HSPH),
Muhimbili University of Health And Allied Sciences (MUHAS) and the Dar es Salaam City Council (DCC),
and which has been ongoing for past 15 years - especially in training and research. The health
infrastructure is well developed - the lab facilities are functioning well, there is a strong training base and
patient monitoring and tracking loss to follow-up is well placed. There is strong commitment from the Dar
City Council as well as the three municipalities for the advancement of the HIV care and treatment services
in the Dar.
ACCOMPLISHMENTS: TB/HIV services were initiated recently, and currently three sites (Temeke, Amana
and Mwananyamala hospitals) are involved. As of June 30, 2007, a total of 1,961 TB/HIV patients were
enrolled, of which 1,083 have been initiated on ARV and 878 are on care. On average, 324 patients are
enrolled per month from the three sites.
ACTIVITIES: In order to rapidly expand an integrated TB/HIV services in Dar the MDH program has been
involved in strengthening TB/HIV activities at three sites. Considering the large burden of TB/HIV in the
region, MDH will further expand the services to four more sites within the proposed funding period - Sinza
and Buguruni health centers, Mbagala Rangi Tatu dispensary and at the Infectious Diseases Center (IDC).
By improving the uptake at the current three sites, and with the addition of four more sites, we expect to
expand enrollment to a total of 5,000 TB/HIV patients from the current 1,961 by the end of September 2008.
All the TB/HIV activities will be conducted in close collaboration with the National Tuberculosis and Leprosy
Program (NTLP) and the National AIDS Control Program (NACP). The innovative initiatives proposed will
enhance the ability of TB clinics to identify HIV patients, and for the CTCs to detect more TB cases among
HIV patients, provide seamless referral to TB clinics, and deliver excellent care to TB/HIV co-infected
patients with documented monitoring and evaluation (M&E) of all these activities.
We will continue the efforts to improve communication between TB and CTC units, hold regular monthly
meetings to build team moral, have a holistic approach to patient management, and identify challenges and
plan for common solutions. Efforts will continue to bring improvements in provision of HIV counseling and
testing to all TB patients, on-going TB screening for all HIV-infected patients, provide all HIV-infected TB
patients with HIV care and treatment, and enhance TB diagnosis and therapy for all HIV-infected TB
suspects.
The program will implement an infection control plan through work practice, administrative and
environmental control measures by training of health care workers.
In order to carry out these activities, optimal number of staff will be recruited, trained and placed at the
TB/HIV sites.
We will continue using national guidelines and curricula to train health workers on the various aspects of TB
and HIV co-infection including TB/HIV indicators and strategic information systems, data documentation and
analysis and reporting in collaboration with the NTLP and NACP. All patients attending care and treatment
clinics will be screened for TB. Those diagnosed with active TB will be referred to TB Clinic for
management. MDH will continue training TB clinic staff, strengthen lab diagnostics related to TB and
ensure that regular quality assurance/quality control of lab activities at the sites will be done by the central
lab at MUHAS.
Funds from the COP will used to pay for the MDH staff. Moreover, we intend to provide essential equipment
Activity Narrative: such as mobile chest x-rays machines and the necessary supplies to the TB/HIV clinics.
LINKAGES: MDH works very closely with the MOH NACP and NTLP. Maximal linkages are being
established between the HIV care and treatment programs and the TB diagnosis, treatment and follow-up
clinics at each site. Additionally, tracking patients lost to follow-up will be conducted through the HBC
patient tracking teams.
A referral system has been established between TB and CTC clinics for patients who are referred to TB/HIV
clinics and those who are referred to CTC upon completion of anti-TB courses. The referral system will use
registers and intake forms.
CHECK BOXES: Emphasis will be on strengthening the linkages and referral systems between the TB
clinics and CTC, so that HIV care and treatment services are made maximally accessible and available to
TB patients.
M&E: The MDH TB/HIV program utilizes TB/HIV forms on all TB patients enrolled at the TB/HIV clinic.
Nurses at TB/HIV clinics document HIV diagnostic counseling and testing (DCT) data in the TBLP registers
and the TB/HIV form. TB/HIV co-infected patients are enrolled at the CTC during their second visit to the
TB/HIV clinic. Data from TB/HIV co-infected patients will be collected and monitored at each subsequent
visit using a MDH TB/HIV form and the MDH CTC data collection forms. The TB/HIV form collects
information on TB treatment outcomes, while the MDH CTC forms collects information on TB screening,
diagnosis and management Data will be entered daily by data clerks into Access databases developed
onsite.
Monthly evaluations of the data will be performed. Examples of parameters to be measured include a)
the proportion of TB patients enrolled in TB centers receiving DCT b) the proportion of patients in CTC who
are screened and subsequently diagnosed with TB, Quarterly reports will be forwarded to the NTLP,
NACP and CDC. At least one data clerk will be trained from each of the seven TB/HIV sites in electronic
data processing.
SUSTAINAIBLITY: In order to sustain our efforts in integrating and expanding the TB/HIV services, MDH
will continue working very closely with the National TB and Leprosy Control Program and NACP. All the
plans and implementation of the program will be according to the National Strategic Plans. Sustainability is
the core of our program. We will continue to build local capacity through on-going training and by
Continuing Activity: 13489
13489 5120.08 HHS/Health Harvard University 6520 3621.08 $300,000
7721 5120.07 HHS/Health Harvard University 4540 3621.07 Tz Budget $200,000
5120 5120.06 HHS/Health Harvard University 3621 3621.06 $200,000
Table 3.3.12:
