ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY 2008 COP.

TITLE: Community-Based Palliative Care for People Living with HIV/AIDS (PLWHA) in Lindi and Mbeya

Regions

NEED and COMPARATIVE ADVANTAGE: Many PLWHA in Tanzania have limited access to quality

palliative care services in their communities. This is due to a limited numbers of skilled health workers, poor

linkages to treatment and other services, stigma, and lack of knowledge for prevention of opportunistic

infections. Innovative community-based care programs that increase access to drugs, prevention and

counseling services are required to improve the quality of care for PLWHA.

Axios' extensive work in the past seven years has been in the area of community-based prevention and

care for HIV/AIDS and strengthening the capacity of health facilities and management teams to manage

and maintain services. Lessons learned in these areas are strengths that are essential to improve access

to care and resources in poor settings, and would be applicable and useful in future programs.

ACCOMPLISHMENTS: Axios has been working on HIV/AIDS programs in Tanzania for the past seven

years. This work initiated in two districts of the Mbeya region (Rungwe and Mbeya City), and has since

scaled-up to 16 regions. The past work included an innovative community-based program for orphans and

vulnerable children (OVC), with a human rights component through establishment of paralegal centers for

orphans and widows; an outreach community-based prevention of mother-to-child transmission (PMTCT)

program in all health facilities in two districts; and integrated voluntary counseling and testing (VCT)

services established in 92 health facilities. Clients found to be HIV-positive were linked to care and support

services through home-based care (HBC) and referral networks. A strong community care component

impacted stigma, resulting in a high uptake of testing services. Strengthening and capacity building of

Regional and Council Health Management Teams (RHMT and CHMT), ward-level structures, and health

facility management boards was part of the program from design to implementation, in order to ensure

smooth transition of responsibilities to the local authorities at the end of implementation.

Axios received PEPFAR funds in FY 2008 to establish palliative care services in the Lindi region in southern

Tanzania. Lindi is a region in which the Clinton HIV/AIDS Initiative is the provider for facility-based care and

treatment services, and there was a gap in community care services for PLWHA. In July 2008, Axios

conducted a situation analysis in ten wards of three districts in Lindi to establish a baseline for palliative

care program needs.

A total of seven wards have been selected for the project implementation. Axios has already conducted

community meetings with local government leadership in the selected sites. In addition, about 16 health

facilities in the catchment area were involved in the discussion to ensure linkages in services. Palliative

care management teams have been established in seven wards to ensure continuity and improved

management of services.

ACTIVITIES: In FY 2009, Axios will continue the activities planned for the seven wards in Lindi. However,

instead of continued expansion in Lindi and neighboring Mtwara (both of which have relatively low

prevalence), the USG has directed Axios to change its plans for expansion to ensure a more strategic

approach. The decision to move Axios' focus to higher prevalence areas in Mbeya was based on HIV

prevalence information and an estimation of potential clients using population data.

In FY 2009, there will be more focus on increasing comprehensiveness of services and improving the

coverage of programs in the selected districts and wards. Axios will promote the establishment of PLWHA

support groups to facilitate increased access to services, and to facilitate linkages to other wraparound

programs addressing livelihood and household food security.

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

for 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, Axios will strengthen the 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

access to safe water and hygiene practices. Axios will ensure that interventions address the

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

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

usage. Axios 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. Axios will also 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.

In Lindi (Kilwa and Lindi town council), the program will be strengthened, focusing on providing quality

palliative care as stipulated in the National AIDS Control Programme (NACP) guidelines. Axios will also

ensure that the selected wards are fully permeated so as to improve access to services. Axios will work

with health facilities to strengthen referrals, access to services, and supportive supervision. Axios will

engage the community leaders and other community groups (women, youths, PLWHA support groups) in

addressing stigma, uptake of services, and to support community HBC volunteers. Axios will work with and

strengthen the ward AIDS committees and Community Development staff to be part of management teams,

and assist mobilization for identification of clients in the communities, especially HIV-exposed children

under five years. There will be quarterly coordination meetings of community-based volunteers and health

Activity Narrative: facility staff at the district level to share best practices and challenges. District coordination meetings will be

a part of strengthening the roles of district HBC coordinators (or their designated equivalent).

Following PEPFAR/Tanzania's review of need based census and prevalence data, Axios will be redeployed

to assist in Mbeya Region (Rungwe and Mbozi district). Mbeya is the region with the second highest

prevalence of HIV/AIDS in Tanzania. Presently the US Department of Defense (DOD) is the major agency

implementing a range of services from prevention to care and treatment. To accelerate the scale up of

services, Axios will collaborate with DOD. Axios has a history of implementing HIV/AIDS programs in

Mbeya through Abbott funding, working with VCT and PMTCT in Rungwe and Mbeya Urban districts.

Established relationships in Rungwe will facilitate faster onset of activities and achievements in this district.

The provision of quality HBC services depends on well-trained volunteers, so emphasis will be on

identifying and training healthcare workers and HBC volunteers, providing refresher trainings when

necessary. Axios will also strengthen referrals, M&E systems, and identification of HIV-exposed children.

Axios will encourage the use of PLWHA as HBC volunteers as a measure to reduce stigma and to ensure

that their needs are well-addressed through meaningful involvement of PLWHA.

The other proposed district in Mbeya is Mbozi. In FY 2009, Axios will conduct a situation analysis and

obtain baseline information on the scope of the program and available support. This will be followed by

intensive community mobilization for involvement and revising the activity plan. Axios will strengthen

district, ward, and village leader capacity for improved planning and program support during the planning

phase of the program.

If SCMS is unable to supply commodities through the Tanzanian Medical Stores Department for HBC, Axios

will purchase HBC kits, including essential OI drugs, and supply project sites. Through the linkages formed

with CHMTs, Axios will participate in planning meetings to leverage community support and ensure

activities are absorbed in Comprehensive Council (district) Health Plans. Axios will strengthen local

organizations and health facility boards to ensure HBC programs access commodities available through

health facilities, and also to strengthen fiscal and programmatic accountability.

LINKAGES: To improve the quality of services, linkages will be established at district levels with NGOs that

provide services for condom promotion, malaria prevention through ITNs, safe drinking water, nutritional

support, income generating activities, and other prevention and care activities such as PMTCT and OVC

support. At the local level, Axios will work together with other PEPFAR partners and stakeholders,

specifically DOD, with a close collaboration with RHMT and CHMT to ensure sustainability. Ward and

village executive teams and multi-sectoral AIDS committees will be strengthened and involved in planning.

At the national level, linkages with USG and NACP will ensure implementing guidelines are adequately

applied, monitoring tools are used, and core indicators captured.

M&E: Axios' M&E Senior Program Manager will be responsible for retrieving and disseminating revised

HBC guidelines, monitoring indicators and tools to ensure clear understanding of national and PEPFAR

monitoring indicators. Orientation meetings with RHMTs and CHMTs will be organized, as well as meetings

with all health facility staff and HBC volunteers in project wards. HBC trainers will be targeted to ensure

dissemination of M&E tools during training sessions. Copies of guidelines and monitoring tools will be

made available at all levels, from regional to district and in health facilities at village and ward levels. Follow

-up will ensure accurate reporting from ward to district level.

Axios will adopt and support the rollout of the national monitoring system for palliative care, through

provision of appropriate support to the local government and health system management teams. Activity

supervision will be organized monthly for HBC volunteers by health facility staff within the ward, and

quarterly by district teams in collaboration with the Axios Program Manager. The districts will manage

reporting to NACP and Axios with a follow-up by the Axios Program Manager. Data management and

analysis will be conducted by Axios and shared with Ministry of Health and Social Welfare, donors, and

other stakeholders.

SUSTAINAIBLITY: Community involvement, from the planning stage through implementation of activities,

creates program ownership and sustainability. Initial planning of project activities will include consultation

with the CHMT to ensure some activities are absorbed within the Comprehensive Council Health Plan. A

completed plan will be shared with the District Executive Director and members of the Council Social

Services Committee to solicit some funds and program support. Past work experience shows health facility

boards to be an important structure that can be strengthened for sustainability. These boards will be

strengthened and involved in planning at ward levels to leverage community support for affected families

and Community HBC volunteers. For continuous support, Axios will establish and strengthen ward

palliative care management teams (three members in each ward) comprised of the Ward Community

Development Officer, health center staff in charge, and ward HBC supervisor.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17013

Continued Associated Activity Information

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

System ID System ID

17013 17013.08 U.S. Agency for Axios Partnerships 7576 7576.08 $300,000

International in Tanzania

Development

Emphasis Areas

Health-related Wraparound Programs

* Malaria (PMI)

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Estimated amount of funding that is planned for Water $40,000

Table 3.3.08: