Local Partners Excel in Comprehensive HIV&AIDS Service Deliver (LEAD) builds upon AIDSRelief program to ensure PLHAs in Manyara, Mara, Mwanza, and Tanga regions have access to ART and quality care. Through LEAD: PLHIV and their families have expanded access to care, treatment, and support services; local partners provide quality care and support; and government partners provide quality services beyond project period.

LEAD will continue to work with RHMTs and CHMTs to strengthen the capacity of health facilities. LEAD will provide technical support to local partner CSSC to transition to additional districts. Multi-disciplinary teams will provide on-site mentorship on clinical and programmatic aspects through didactic sessions and mentoring of health facility staff. The program will expand use of the district mentors approach, supporting providers to use a similar mentoring practice for lower health facilities. These approaches will ensure efficiency and initiation of new knowledge.

Districts will integrate financial resources into CCHPs in order to leverage additional resources from URT and other donors. LEAD will continue to advocate to URT to absorb eligible HCWs into government payrolls, hence increasing ownership and sustainability of care and treatment services.

The program will build on existing, innovative M&E systems that are in line with the national M&E system. Additionally, LEAD will focus on supporting health facilities to improve their capacity in data demand and information use.

The project intends to purchase five vehicles to replace part of its current fleet, some of which are old and in poor condition. It is also very challenging to cover visits to PMTCT sites, which grew 15 times in FY 11, with the current number of vehicles.

The LEAD project will utilize the Three Ones principle of adhering to one national coordinating AIDS authority, one national AIDS strategy, and one monitoring and evaluation framework to achieve the most effective and efficient use of resources, ensuring rapid action and results-based management. All strategies and activities to be implemented are within the Tanzania national health sector and multi-sectoral strategic plans and the national guidelines.

LEAD will support HIV care and support in four program areas, which include comprehensive adult care and treatment, TB/HIV, PMTCT of HIV, and pediatric care and treatment. Through family-centered activities, LEAD will serve PLHIV and their families from birth to end of life care. LEAD will also work on increasing access to the full continuum of care for PLHIV and their families and envisions a URT healthcare system linking care across community services, healthcare workers, local facilities, and government. Through improved case management of community and facility resources at different locations and a focus of supporting the entire family at one place, LEAD will purposefully engage women as access points to the family.

Activities at the treatment facilities, which focus on family centered approaches and community levels, will target couple and male involvement as well as ensure that the girl child receives needed care, treatment, and support. This will be achieved through on-site mentoring of providers in 36 hospitals and surrounding health centers. The on-site mentorship will be covered by all the components, including clinical adult and pediatric ART, TB/HIV, PMTCT, community-based treatment support, continuous quality improvements, nursing care, and laboratory services. LEAD will also utilize the identified and trained mentors to continue to provide supportive supervision in their respective districts.

The targeted mentoring will be guided through with data and chart reviews while all the facilities providers will receive mentoring focusing on adult and pediatric treatment, specifically on prevention, diagnosis, and treatment of opportunistic infections and other HIV related complications. Clinical and Laboratory management of patients on treatment will also be an important theme during the on-site mentorship. To enhance retention, LEAD will focus on utilizing the available volunteers to follow up and track patients who have missed appointments and find them before they are completely lost.

As part of working with existing structures in the regions and district, LEAD will work closely with district and other stakeholders to identify and collaborate with partners already providing support to PLHIV support groups. This will strengthen the linkages between programs and increase access to full continuum of care for PLHIV.

The project will provide in-service on-site training and technical assistance to strengthen the capacity of the district. M&E tools developed by MOHSW will be utilized to collect strategic information as to ensure quality and timely information is reported out to support clinical care, programmatic outcomes, and informed decision making.

To be in alignment with country policy, partner activities will maximize entry points for HIV diagnosis and treatment and screening for TB. To accomplish this, LEAD plans to strengthen the TB 3Is strategy in health facilities that will link to ART and TB services through its network of partners that provide quality HIV care and treatment. On-site didactics mentoring on TB diagnosis will be the focus activity, while mentoring will be done in 36 facilities and surrounding health centers. Proper TB diagnosis mentoring will range from clinical assessment to improved laboratory TB diagnosis.

LEAD will continue supporting and strengthening the ability of care and treatment clinics in Manyara, Tanga, Mara, and Mwanza regions to make ensure all HIV infected clients, including those from PMTCT and newly diagnosed clients from other sections, are screened for symptoms of active TB. Moreover, the TB suspects will be evaluated for TB diagnosis using the national TB diagnosis algorithm while non-TB suspects will be initiated on Isoniazid Preventive Therapy (IPT). Patients with TB/HIV co-infection with TB will be referred to TB clinics for treatment. The TB/HIV co-infected patients who are referred from TB clinics will be received at a care and treatment clinic (CTC) and provided with quality HIV services.

Intensified TB care finding (ICF), IPT and infection control (IC) will be scaled up, along with the increase of ART services to primary health facilities.LEAD supported regions will collaborate with other partners implementing collaborative TB/HIV activities, such as PATH in Mwanza, SHIRIKI project in Mara, and NTLP in Tanga, Mara, and Manyara, to ensure the efficient referral, linkages, and follow up of patients are provided and access to full continuum of care is increased.

LEAD has a direct intention of keeping the TB/HIV activities sustainable, ensuring there is integration of activities into the existing health system, involving regional and district health management teams in the activities, incorporating the activities in the district health plans, and building capacity of local authorities, coordinators, and health care providers on TB/HIV collaborative activities.

LEAD will collaborate with the NACP and NTLP to strengthen the existing national M&E systems for collaborative TB/HIV services in the four regions of Tanga, Manyara, Mwanza, and Mara. Also, LEAD intends to ensure the TB screening tool will be implemented at all 90 sites, including having the IPT eligibility assessment forms at all four selected sites to initiate on phased IPT implementation.

Improving pediatric enrollment is a key component for improvement of pediatric HIV care services. LEAD intends to scale up the pediatric enrollment using three approaches to target pediatric patients. The first is to offer counseling and testing to all children accessing all services at health facilities. LEAD will provide direct mentorship to facilities reaching pediatric patients and collaborate with partners providing PITC services to increase PITC services for pediatric patients.

The second approach is to identify and test exposed infants as part of PMTCT and EID initiatives. The program will provide one PMTCT training to cover facilities who have untrained staff, which will be followed up by on-site mentoring. This will take place simultaneously with the efforts to ensure the required commodities for the testing are also available. LEAD will also support the transportation of the DBS samples to and from the lab back to the facilities.

The third and last group is the group of children from other services outside the facilities, which will include OVC, or from support groups in the community. Reaching out to this group of children will be achieved by collaborating with stakeholders in the districts who are implementing services targeting OVC and other vulnerable children groups. The collaboration will be through meetings and sharing activity plans. The collaborations with stakeholders will not only increase enrollment in the facility but will also provide access to the services, such as support groups and PwP for the pediatric population within the facilities.

LEAD considers integration with routine pediatric care and maternal health service to be of the highest importance, therefore LEAD will facilitate and follow up the monthly facility coordinating meeting where all the departments meets with the CTC staff to present challenges and solutions to integration issues.

In continuing to provide quality care, improvement of laboratory services to support ART services is essential. LEAD will continue to provide on-site technical support to 56 laboratories and mentorship on Quality Assurance for HIV rapid testing, diagnosis of opportunistic infection (OI), HIV disease staging, drug safety monitoring tests, and commodity inventory management at facility level. Additionally, the LEAD laboratory team will provide on-site training on diagnostic techniques for cryptococcal, hepatitis, tuberculosis, as well as malaria testing and perform hands on training on the operations and maintenance of key equipment.

In order to ensure the quality of laboratory service and monitoring implementation of quality management system, LEAD will conduct trainings for 40 staff on laboratory quality management system. The training will be followed up with post training on-site visits to evaluate the impact of the training and to ensure a continuation of step-down training. LEADs regional laboratory specialists will continue to provide mentorship to district laboratory managers for efficient laboratory management of quality systems. In collaboration with MOHSW, the regional and district laboratory technologists will assist on participation in all available national EQA programs for HIV testing, CD4, hematology, chemistry, AFB microscopy, and malaria.

LEAD will support the on-going process of laboratory accreditation in four regions. Bugando Medical Centre Laboratory will continue to receive technical support towards accreditation using ISO 15189 standards. The laboratory quality specialist will continue to provide support on quality improvement and maintenance by working with BMC laboratory staff to accomplish planned activities and perform collective actions on gaps identified through assessments. LEAD will support post annual assessment learning sessions to 40 staff to improve quality management systems focusing on 12 quality elements and proper utilization of laboratory services. Production of documents and standard working tools will be supported to meet ISO 15189 standards. LEAD will also support annual performance assessment fees to be conducted by an accreditation board and their assessors.

Other laboratory accreditation activities will support five laboratories in their accreditation processes, based on a WHO-AFRO established stepwise approach, which uses a 0-5 star scale. This is regarded as an affordable, sustainable, effective, and scalable model. Through mentorship and supportive supervision, the team will help lab staff to develop culture quality and improve documentation related to quality management system. LEAD will support national assessors to perform annual interim assessments using the WHO-AFRO checklist to measure progress on the stepwise star system. Production of documents and standard working tools will be supported to meet the required standards. The target for stepwise star system is for all five laboratories to attain the minimum of two stars.

The LEAD program will support health facilities to provide comprehensive PMTCT services, HIV counseling and testing for pregnant women, ARV prophylaxis for HIV positive pregnant women, and EID and treatment of eligible infants. Expectations are to ensure 80% of women attending antenatal clinics are counseled and tested for HIV, while linking those identified as HIV positive into care where a more efficacious regimen will be administered according to the new PMTCT guidelines.Furthermore, the program will support facilities to ensure all HIV exposed infants are identified and tested, linking infants who are HIV positive into care and treatment services. To achieve this, the program will continue to provide TA, on-site mentorship, and supportive supervision to partner facilities through close collaborations with RHMTs and CHMTs. Health care providers from lower health facilities will participate in on-site trainings within 16 district facilities, thus helping to facilitate immediate initiation of the adopted PMTCT recommendations.Utilizing the district approach, the project will support, facilitate, and mentor districts on commodities management to ensure adequate availability of HIV test kits, ARVs, CTX, PMTCT M&E tools, and other commodities. Based on a best practice implemented during the AIDSRelief program to increase the quality of PMTCT practices, health care providers from poorly performing facilities will have the opportunity to visit stronger performing facilities to learn and identify ways of improving services in their respective facilities.Medical supplies will also be procured so that quality clinical evaluations of pregnant women are conducted within the RCH clinics and labor wards. In addition, renovation of 10 RCH clinics and labor wards will further improve conditions in which PMTCT services are delivered.LEAD will continue to work closely with district reproductive and child health coordinators (DRCHCOs) to collect and analyze data in order to make informed strategic programmatic decisions that will strengthen existing district M&E structures. The SI associates will also provide mentoring to complete MOHSWs PMTCT M&E tools. To increase efficiency in reporting, LEAD will expand IQSMS services, an innovative technology developed during the implementation of AIDSRelief, to an additional 150 PMTCT sites. This approach will also ensure improved timeliness of PMTCT data reporting.Linkages between CTC, RCH, TB/HIV, and VCT will be strengthened by facilitating monthly coordination meetings, allowing the various hospital departments to share challenges and identify solutions. Community linkages and male involvement is of paramount importance to increasing PMTCT uptake, reducing stigma, and retaining HIV infected women into care and treatment. By meeting with these stakeholders at the district level, the project will ensure proper utilization of the existing community structures to increase access to continuum of care.The project is expected to reach 700 PMTCT sites, requiring intensive supportive supervision to respective facilities. The project will utilize previously trained district mentors and identify additional district mentors who will provide technical assistance, supportive supervision, and other PMTCT related technical knowledge. To provide overall supervision, joint supportive supervision visits will be conducted with district mentors and DRCHCOs to ensure the process is sustainable.

In ensuring the provision of quality HIV services, LEAD project will continue to provide technical assistance to partner facilities. The technical assistance will consist of on-site mentorship to 36 hospitals and their surrounding health centers. The providers from the health centers will be invited to participate in didactic lectures and mentorship at the district facilities receiving the LEAD mentors.

To further build the capacity of the regional health teams, LEAD will build upon the district mentors approach to ensuring long lasting and sustainable quality HIV service provision at district levels. Conducting joint technical assistance visits and supportive supervision with the district mentors will be a fundamental activity to guarantee the transition of technical knowledge. LEAD will also strengthen monitoring and evaluation capacity of the districts by promoting routine data quality audit (DQA) and data utilization at facility level in collaboration with CQI teams, RHMTs, and CHMTs.

Utilizing already created hospital quality improvement (QI) teams, technical assistance from the QI team will focus on mentoring teams on conducting chart reviews and interpreting and analyzing data collected from chart reviews and produced reports. The QI teams will be supported to become a driving force towards ensuring data is used for planning and improving programmatic and treatment outcomes. The teams will continue to receive technical assistance and mentorship from the project.

Strengthening the adherence support in the facilities will be a vital role of LEAD to improve retention of patients starting ART. LEAD will support this process through on-site mentorship of adherence providers in 36 hospitals. Providers will receive guidance on establishing an active appointment system and immediately will follow up of patients with missed appointments. Two zonal clinical and treatment adherence trainings, reaching 72 providers, will be conducted and performance of trainees will be followed up during the on-site mentorship.LEAD is expected to reach 90 facilities where 73,010 individuals are expected to receive care and treatment services including the provision of ART, cotrimoxazole prophylaxis and TB screening. LEAD will also continue working with other stakeholders in the districts to access available resources in areas where LEAD is currently not supporting.

The focus of this budget will be utilized in the implementation of activities to increase the enrollment of children in care and on ART by increasing access to high quality HIV care and treatment. In scaling up pediatric treatment for HIV infected children, LEAD will focus on building capacity of the health care providers and the regions. A centralized training will be conducted for 30 health care providers. Additionally, the program will provide on-site training and mentoring to health care providers to promote improved clinical skills in clinical and laboratory monitoring of children on treatment and adherence support. On-site mentoring sessions will also provide the opportunity for the program to support sites in the implementation of the new WHO guidelines on pediatric ART guidelines. LEAD will also link with the Baylor Pediatric program by financially supporting clinical providers to attend a Baylor pediatric attachment program, which has been observed to provide clinical providers with skills that have resulted in significant improvement to children retention.

Identification and testing of exposed infants will be a key outcome activity in increasing enrollment of children in the facilities. During on-site mentoring sessions, LEAD staff will specifically target RCH staff to identify and test exposed infants and to link HIV+ children into care. Supporting the district in ensuring the availability of dried blood spot (DBS) collection kits will be an important step towards improving identification and diagnosis for infants and children. LEAD will support the transportation costs of the collected DBS samples and also facilitate the communication of results from the testing facility.

Providers in the RCH sections, outpatient sections, and pediatric wards will receive technical on-site trainings and mentoring in the provision of counseling and testing of children and in improving intra facility referral systems. To increase infants and children enrollment, LEAD will expand on the EPI/HIV integration pilot project implemented in two sites during the AIDSRelief program into six facilities.

Close collaboration with other implementing partners is key to improving pediatric enrollment into care. LEAD will work with partners currently implementing PITC activities in order to utilize the support and fulfill the provision of comprehensive care. Utilization of support from other partners will also include both URT and non-governmental partners who are supporting orphans and vulnerable children (OVC) and home-based care (HBC) services by collaborating with partners and other stakeholders in accomplishing the increase of access to the full continuum of care. Working with partners supporting home-based care will include supporting volunteers who will also be utilized in tracking and retaining children in care. LEAD will also facilitate the provision of MOHSW job aids and guidelines to healthcare providers. The providers will also receive on-site mentorship on pediatric related data management, which will include accessing and utilization of the data.