The goal of Tanzania AIDS Prevention Program (TAPP) is to reduce HIV transmission and provide care and treatment for people who inject drugs (PWID) and other MARPS in Tanzania. This aligns itself with the second goal of the PF, which prioritizes accessible and efficacious prevention programming targeting drivers of the epidemic. The project targets MARPS and their sexual or injecting partners through community outreach by facilitating access to services, including methadone treatment, ARV, STI, and TB treatment. Secondarily, outreach services promote harm reduction by distributing condoms for sexual risk reduction and bleach kits for injection risk reduction.

Coverage of services will be in Dar es Salaam, although an integrated bio-behavioral survey will be conducted in Tanga and Arusha urban centers with the expectations of expanding interventions for MARPs in these locations.

TAPP works within the government structure, mainly Muhimbili University, for administrative activities and through Muhimbili Hospital to access the health care delivery system for medically assisted therapy (MAT), ART, and TB treatment, as well as HTC (with the except of mobile services).

The MAT services at Muhimbili Hospital serve as a pilot for MOHSW to incorporate activities into its annual budget and scale out similar services to accredited health facilities for managing opium addiction. TAPP works with local NGOs sub partners in this capacity.

Monitoring and evaluation involves actual number counts of individuals reached and services provided. An electronic real-time data collection method will enable real-time data capture and processing.

Even though no new vehicles will be purchased, there are still running costs of two mobile caravans that conduct mobile outreach serv

Muhimbili University of Health and Allied Sciences (MUHAS) TAPP HIV counseling and testing (HTC) targets the general population, couples, and MARPs through mobile and static facility-based services. HTC services are also offered in 101 health care facilities with providers trained in provider-initiated testing and counseling (PITC). In Dar es Salaam, HIV seroprevalence is estimated at 9%. HTC results in PITC portray prevalence of 11% while that in the facility and mobile services is 8.9%. PITC is offered in health care settings while client initiated services are offered at the static Muhimbili Health Information Center and the mobile caravan services. PITC is also offered for those persons accessing medically assisted therapy (MAT) services.

The HIV testing algorithm is a vertical algorithm starting with SD Bioline as a first test. For those who test positive a second test, Determine, is used and if the tests are discordant, Unigold, is used as a tie-breaker. This is the national testing algorithm approved by the MOHSW. During FY 2012, gains in integrating alcohol screening and brief motivational intervention will be solidified and MUHAS TAPP will ensure that all of its staff and the PITC trainees receive training and supportive supervision to address the issue of alcohol use among their clients.

Currently, escorted referrals to other services are only offered to MARPs populations, therefore tracking of service outcome is clearly linked to the program. General population clients are assumed to have concluded their referrals. Following training in quality HTC services, the newer quality assurance model of HTC services, which is supported by CDC Headquarters, is introduced. Quality control is achieved through testing of proficiency panels from the National Public Health Laboratory. Utilization data is stored in an electronic format and entry is done within real time or as close as possible.

The TAPP PITC trainees reached 16,459 (secondary HTC data) patients who were additionally referred to CTC services (1,637). A nationwide shortage of HIV test kits limited PITC activity in the current year. With reference to couples, MUHAS TAPP now has 20% of its clinic population come as couples for client-initiated services both at facility and mobile services. Training and service provision targeting couples will continue to be offered to previously trained PITC trainees. Promotional activities around HTC for demand creation and target markets will be offered to the general population, MARPs, and couples.

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CSWs and MSMs are the target population; MSMs approximate cost is $100,000 reaching a target of 1,500 with networking and community outreach work; CSWs approximate cost is zero, reaching a target of 3,000 with community outreach work.

In FY 2011, two organizations serving Men who have Sex with Men (MSM) will consolidate and strengthen their activities of national MSM networking and MSM outreach in Dar es Salaam. The initial target audience is MSM aged 15 years and above. Population estimates and HIV prevalence among MSM are yet to be established, though various stakeholders have activities underway to establish this information.

In the current year, partners are defining the package of services for MSM based on existing guidelines and best practices in similar low-resource settings in line with identified needs of MSM in Tanzania, as identified from ongoing surveillance activities. Services will include, but are not limited to, HIV testing and counseling (HTC) diagnosis and treatment for sexually transmitted infections (STI), condom and lubricant promotion and distribution, and health promotion communication and referrals for relevant additional health services, including ART. To facilitate sustained quality care for MSM and other MARPs, health care providers in selected facilities will receive sensitization training to MARPs-friendly service provision.

The national network NGO will host an annual bonanza (networking en masse) and three quarterly meetings that will consolidate the gains of the previous year. The second NGO/CBO staff will receive training and supportive supervision for community outreach aimed at prevention of HIV transmission, including procuring and promoting condoms and lubricants for safer sex and facilitating referrals to health facilities for management of STI, which at the same time will sensitize health care providers to become less judgmental when offering services to MSM. HTC will be offered through mobile caravan services as well as existing health and non health facilities.

The community outreach strategy will be used as the intervention. Master training for NGO leads (CEO, Program Coordinator, Community Outreach Coordinator, and Community Outreach Trainer) will form a basis for offering cascade training. Master trainers will then offer training to the outreach workers who will become the implementers of the program. Screening and brief motivational intervention for alcohol use will be integrated to MSM services.

The training packages to be provided will include a cue card for offering such services and TAPP supervisors will offer supportive supervision to ensure fidelity to the program. Service data will be entered in real time benefiting from M&E mechanisms established from the program targeting PWID.

The project primarily targets people who inject drugs (PWID) and MSM with outreach activities and services, but also attracts a significant number of sex workers who also benefit from these services.

People who inject drugs (PWID) in Dar es Salaam have been found to have HIV prevalence of 42%, whereas the general population prevalence is 8%. PWID also exhibit higher sexual behavior risks, including multiple sexual partners, low condom use, and selling sex, particularly female PWID. The project contributes to providing a comprehensive package of HIV prevention and care and treatment services to PWID by offering medically assisted treatment (MAT) for addiction, HIV testing and counseling (HTC), diagnosis and treatment for sexually transmitted infections (STI), condom promotion and distribution, health promotion communication, viral hepatitis counseling and testing, bleach needle cleaning kits, screening for TB, and referral for relevant treatment, including ART.

Among clients currently receiving MAT from the project, the prevalence of Hepatitis C is 70% while that of HIV is 50%, concurring with recent studies, including one dissertation that shows similar trends among PWID. In addition to the injection risk, use of drugs has been financed through formal and informal sex work. For this reason, assessing and treating STIs is a critical component that is necessary to reducing STIs and HIV risk.

The project aims to provide MAT to 400 clients this year, for which medication and supplies procurement is included under this program area budget code. Supplies for syringe cleaning kits, condoms, and communication materials are also included in this category. During the fiscal year, 150 community outreach workers will be trained, while complimentary activities of developing targeted messages and facilitating community mobilization will be conducted. Clean needle syringe access is critical to turning the tide of the HIV and hepatitis epidemics; as such support for partner-led activities to initiate needle-syringe programs (NSP) will be initiated.

While referrals for other clinical care (e.g. HIV, TB) are to be made to existing partner health care facilities, challenges are expected, particularly during the initial months of stabilization on MAT. To alleviate this, integrated services at the MAT clinic for HIV care and treatment, as well as TB treatment, will be offered. Upon stabilization, clients can be linked to other care and treatment facilities where referrals can be tracked to maintain linkages with IDU services.

The project targets male and female PWID in all three municipalities of Dar es Salaam, expanding from Kinondoni Municipality where current activities have begun. With the availability of additional funding, expansion of services may include the cities of Tanga and Arusha, which will be guided by ongoing surveillance in these locations.

Supervisory mechanisms are in place with regular monitoring and evaluation of daily activities through sub partner organizations mechanisms, which will be backed up by scheduled and ad hoc supervisory interactions with TAPP supervisors. A database is in place to manage MAT clients data and quality of services will be ensured through current close supportive supervision at this initial treatment site, which is the first in the country.

TAPP works in close partnership with MOHSW and the Drug Control Commission, which are mandated to oversee all prevention, care and treatment services related to drug use. Existing stakeholder platforms facilitate joint planning for complementary service provision to the population in need.