ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY 2008 COP.

NEED and COMPARATIVE ADVANTAGE: Mildmay is working with the Ministry of Health and Social

Welfare (MOHSW), faith-based organizations, community and local authorities, as well as organized groups

of people living with HIV/AIDS (PLWHA) to roll out home-based care (HBC) in two districts in Kilimanjaro

and two in Tabora Region. The model of care and support employed aims at improving the quality of life of

PLWHA by strengthening the capacity of the health care system to support HIV/AIDS initiatives and

empower those infected to live their lives purposefully and productively.

ACCOMPLISHMENTS: Mildmay has supported Tanzania's national strategy against HIV/AIDS by

implementing a model of HBC that aims to improve access to quality holistic care for adults and children

living with HIV/AIDS by strengthening the capacity of the healthcare system to support HIV/AIDS initiatives.

Key accomplishments include:

- About 300 Mildmay-trained healthcare workers within the national healthcare system are providing care

and support to PLWHA.

- Approximately 3,000 PLWHA are receiving holistic care and support.

- The quality of life of about 3,000 PLWHA, including 100 children, on antiretroviral therapy (ART) continues

to improve with access to HBC kits, nutritional supplements, income generating activities (IGAs) and an

improved referral system.

- Close to 50,000 people affected by HIV/AIDS have been served through improved continuum of care and

support, advocacy against stigma and discrimination, improved livelihoods through IGAs and food

production activities, and an environment that provides safe spaces for self-actualization.

ACTIVITIES: Four key strategies are used in programming: 1) skills development through training, including

for senior healthcare managers, health workers in facilities, and caregivers and volunteers offering palliative

care in the communities; 2) establishment of patient support centers that act as referral hubs between

facility- and community-based care; 3) technical support to health workers and volunteers to scale-up and

improve quality of care offered in the communities; and 4) empowerment of PLWHA and their families

through greater involvement in household food production and income generation.

In FY 2009, the program will be focusing on consolidating the services initiated, ensuring quality is

maintained, and increasing the range of services offered without expanding geographically.

Specifically, in FY 2009, Mildmay will:

1. Train health workers in the care and management of PLWHA.

- Train 15 health workers from different wards, nominated by Council Health Management Teams (CHMTs),

on design, setup, and management of HBC programs using the 34-day National AIDS Control Programme

(NACP) curriculum. This training will be carried out by NACP-accredited trainers supported by Mildmay

staff in one cohort of participants from both regions.

- Train 300 community health workers as HBC providers. This includes ten HBC volunteers in each of the

15 service outlets in Kilimanjaro, and an additional ten volunteers from 15 wards in Tabora, to be selected

by the community to complete the 21-day training using the NACP curriculum.

- Train 12 continuing senior health workers on the 18-month Mildmay Diploma to provide much-needed

management and leadership of HBC services at the district level.

2. Support the continuum of care by strengthening the link between treatment sites and communities to

address gaps that exist between care provided in the community and care provided in formal treatment

centers such as those offering ART and prevention of mother-to-child transmission (PMTCT).

3. Promote the continuum of care by strengthening Patient Support Centers to act as referral hubs between

care in the community and ART offered at select health facilities. Provide services, including treatment of

opportunistic infections (OIs), and use centers as supply points for HBC kits. Mobilize active involvement of

PLWHA in the design and delivery of HBC services by providing training on public speaking skills, positive

living, countering stigma and discrimination, and the formation of support groups that meet monthly.

- Set up four new patient support centers to act as HBC kit distribution sites, facilitate refresher training and

reference points for community health workers and for mobilizing PLWHA into support groups for

psychosocial support.

- Work with other agencies providing treatment to improve referrals and tracking of patients.

4. Strengthen district-level HIV/AIDS coordination mechanisms to help create a conducive environment at

management level, ensuring that the trained health workers are supported in their development of the HBC

programs and that HBC is integrated into existing local healthcare activities.

- Convene district-specific semiannual updates and consultative workshops for senior managers of partner

organizations to promote collaboration.

- Work with District AIDS Coordinators and Council HIV/AIDS Coordinators in the target districts to develop

work plans for supportive supervision of HBC activities in their districts.

- Provide basic resources to enable CHMT to coordinate and report on care and support in their respective

districts.

5. In FY 2009, there will be an increased emphasis on provision of prevention with positives (PWP) services

for People Living with HIV/AIDS (PLWHA). All sexually active PLWHA will be provided with condoms and

linked with sexually transmitted infection treatment services and counseling to reduce high-risk behaviors.

Referrals will be made for family planning, if appropriate. Implementing partners 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.

In addition, Mildmay will strengthen its basic prevention package. PLWHA will be provided with counseling,

and linked to support groups or peer-led interventions through the HBC 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

Activity Narrative: access to safe water and hygiene practices. Mildmay will ensure that interventions address the

comprehensive needs in an environment free from stigma and discrimination. Mildmay will support

procurement and/or distribution of insecticide-treated bed nets to PLWHA, and promotion on their correct

usage. Mildmay will ensure that all PLWHA are receiving Cotrimoxazole for prevention of opportunistic

infections. PLWHA will also be provided with water treating tablets and water vessels in provision of safe

drinking water. Mildmay will train HBC providers on screening for TB and linking the clients to services.

HBC volunteers will also be addressing and monitoring adherence to TB treatment.

6. The importance of nutrition in determining clinical outcomes for people on ART is becoming increasingly

more apparent. In FY 2009, USG/Tanzania programs will put more emphasis on addressing food and

nutrition needs of clients receiving care and support. In home visits, Mildmay volunteers will conduct

nutritional counseling and refer patients to the facility for nutritional assessments, which will help to inform

the clinical management of PLWHA, pregnant women under PMTCT programs, as well as HIV-exposed

infants and children receiving care and support.

7. Scale up Greater Involvement of People Living with HIV/AIDS (GIPA). Mildmay recognizes the important

contribution that PLWHA can make in the response to the epidemic.

- Mobilize PLWHA to form support groups to boost PLWHA numerical strength to stimulate the creation of

supportive political, legal, psychological and social environments and reducing stigma and discrimination.

Men will particularly be encouraged to join a support groups.

- Train PLWHA to be advocates against stigma and create awareness of vulnerable groups' rights and

entitlements. The training will be provided through quarterly meetings that will also act as a forum for

monitoring the performance of other project inputs. Using a seven-module training curricula, PLWHA will be

trained on important skills/issues including communication, disclosure, gender, GIPA, stigma and

discrimination, advocacy, inheritance and writing a will.

8. Provide trainings to reduce stigma, encourage families to develop memory books, and write wills to

protect their families' inheritance and ownership rights from extended family members.

- Promote community sensitization and advocacy against stigma and discrimination. Through engagement

with community members and targeted sensitization in schools, colleges, churches and social gatherings,

as well as participation in events such as World AIDS Day and "Mbio za Mwenge" (National Torch Relay),

this project intends to increase understanding of HIV/AIDS, correct myths and misconceptions and reduce

stigma attached to the disease.

- Empower PLWHA through skills development, and training on food production and IGAs in order to

address food security issues and lack of funds for transport to treatment sites.

9. Provide training in basic animal husbandry, poultry and fish faming, and crop farming to 200 PLWHA who

are members of support groups. Local experts living within the target communities and who are already

using these vital skills will perform the trainings, as well as local authorities' extension services. In addition,

Mildmay will provide small business management skills such as bookkeeping and accounting for small

businesses, with an emphasis on agricultural production for household food production and sale. Trainings

will be followed with provision of small seed funding as startup capital.

10. Consolidate care and support services in Kilimanjaro and Tabora. Through routine home visits,

community health workers identify patients who need referrals for care and treatment of OIs and/or ART

and PMTCT; track patients who miss their appointments; train on adherence, nutrition and general health

care; and provide hope and comfort through good quality and appropriate care. In conjunction with CHMTs,

provide continuous supportive supervision to all health workers supervising HBC activities. Mildmay will

also provide financial and technical support, including but not limited to: quality control tools, work-based

training and technical updates to health workers to improve services. In addition, Mildmay will provide

community health workers with tools for their work including transport and HBC kits.

LINKAGES: Mildmay has established strong partnerships in Kilimanjaro, starting with a Memorandum of

Understanding with the Kilimanjaro Regional Medical Office. Partnership has also been established with

KIWAKKUKI, the principle non-governmental organization in Kilimanjaro providing HBC and support for

PLWHA in training and resource mobilization. Mildmay also collaborates with the Lutheran and Catholic

churches and their charitable arms. Their health workers benefit from Mildmay training and technical

expertise in designing and delivering HBC.

The Elizabeth Glaser Pediatrics AIDS Foundation (EGPAF) continues to be a key collaborator in facilitating

continuum of care. EGPAF supports treatment through care and treatment and PMTCT clinics, and

Mildmay provides the community linkage through the patient support centers and HBC. Mildmay will

strengthen referrals between the two agencies to ensure that clients do not fall through the system cracks.

Mildmay is seeking a collaborative agreement at the national level with the MOHSW, while forging

partnerships with agencies identified in the situation analysis in Tabora.

M&E: Mildmay has developed monitoring tools for use by the community health workers and facility-based

health workers who supervise HBC services in their catchment areas. Mildmay uses the aggregated

information for organization, decision-making, donor reporting and feeding into the national reporting

system. The data, generated monthly, is plotted against targets to monitor performance and inform

program policy. Targets for program delivery have been set in agreement with the USG and will be

monitored on a monthly basis and reported to the USG and Regional AIDS Control Coordinators quarterly.

Once the NACP HBC monitoring system is available, it will be fully integrated in the existing M&E system.

Quantitative information is generated from training reports, meetings attendance sheets, records of services

delivered at the Patient Support Centers and project records. Qualitative information is generated during

PLWHA meetings and interaction with project staff, HBC providers and health workers at Patient Support

Centers, as well as visits to PLWHA project sites.

Mildmay has developed a quality control tool to assess the quality of home HBC services provided by those

Activity Narrative: trained and supported by the program. This is been applied by the program technical staff on supportive

supervision on a pilot basis and will be rolled out to health workers during this project period. To measure

program outcomes, especially the improvement in the quality of life of PLWHA, the Palliative Outcome

Scale will be used. Five percent of the budget is dedicated to M&E.

SUSTAINABILITY: Mildmay activities aim at strengthening the health care system through capacity

development and establishing care and support models that are replicable and self-sustaining. Patient

Support Centers are established within existing health care systems and activities initiated by Mildmay-

trained health workers become part of their institutional activities. By involving community-based

organizations, support groups of PLWHA and volunteers, HBC services are integrated within communities

that require minimal input after the initial training and resource allocation. PLWHA support groups often

grow to be community-based organizations with legal status, and can access funding and other support

independent of Mildmay.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13521

Continued Associated Activity Information

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

System ID System ID

13521 6516.08 U.S. Agency for Mildmay 6538 4083.08 $750,000

International International

Development

7753 6516.07 U.S. Agency for Mildmay 4559 4083.07 $350,000

International International

Development

6516 6516.06 U.S. Agency for Mildmay 4083 4083.06 $450,000

International International

Development

Emphasis Areas

Gender

* Increasing women's access to income and productive resources

* Increasing women's legal rights

Health-related Wraparound Programs

* Family Planning

* Malaria (PMI)

Human Capacity Development

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

Estimated amount of funding that is planned for Food and Nutrition: Commodities $25,000

Economic Strengthening

Estimated amount of funding that is planned for Economic Strengthening $60,000

Education

Water

Table 3.3.08: