In 2004, the Ministry of Health and Social Welfare (MOHSW), through the Zanzibar AIDS Control Program (ZACP), was awarded its first five-year Cooperative Agreement (CoAg), which came to an end in August 2009. The main focus of that CoAg was to enhance HIV/AIDS prevention, care and treatment services in Zanzibar, support multiple program areas, and interventions and services. These interventions and services included abstinence and faithfulness (AB), youth and faith-based organization prevention interventions, interventions for key populations (formerly called most-at-risk populations), prevention of mother-to-child transmission (PMTCT), HIV testing and counseling (HTC), antiretroviral treatment (ART) services, management of sexually transmitted infections (STIs), laboratory support and services, and strategic Information, which included surveillance, monitoring and evaluation (M&E), and human capacity development (HCD).

Recently, ZACP was awarded a new CoAg, which intends to scale up and synergize the invested efforts by the Zanzibar MOHSW and the government at large. This also builds upon a five-year experience of implementing PEPFAR supported HIV/AIDS program funded through the CDC. Through this support, HIV related services and interventions will target all HIV infected Zanzibaris living in the five regions and 10 districts of Zanzibar with a special focus on the key populations.

ZACP has developed a one-year costed M&E plan based on its M&E framework, which will be used to track the progress of the proposed activities. A car will be purchased to support outreach services for key populations. Explorations into this has shown that buying a car would be half the cost if the car was to be rented.

Global Fund / Programmatic Engagement Questions

1. Is the Prime Partner of this mechanism also a Global Fund principal or sub-recipient, and/or does this mechanism support Global Fund grant implementation? Yes2. Is this partner also a Global Fund principal or sub-recipient? Principal Recipient3. What activities does this partner undertake to support global fund implementation or governance?(No data provided.)

Home-based care (HBC) is recognized as one of the key interventions for persons infected with HIV. While HBC services on Zanzibar strive to be comprehensive in all ten districts, the care is not comprehensive, quality varies considerably, and does not include all of the components that are now standard-of-care for HBC. To-date, 123 health facilities provide home-based care services within 10 districts, while more than 204 health care providers and 270 HBC community volunteers have been trained and are involved in the provision of HBC services. ZACP intends to use these funds to ensure provision of comprehensive and quality care is at all levels by coordinating and harmonizing HBC implementation in Zanzibar.

The community HBC providers are working under the supervision of facility based providers. ZACP will develop and roll out a quality framework for HBC services to ensure that all of the components are now standard-of-care, including the offer of HIV counseling to family members and close linkages with prevention and care services are delivered consistently and with quality. Attention will be paid to strengthening of community-based activities in particular.

ZACP will hold coordination meetings for HBC stakeholders at all levels that will serve as a platform for sharing experiences and identifying and disseminating innovative approaches. ZACP will also provide guidance in the implementation of HBC services through development of different strategic documents, including an HBC strategic plan, SOPs and training materials for HBC, and conducting comprehensive supportive supervision to regions, facilities, and non-governmental implementing partners.

The Zanzibar Ministry of Health and Social Welfare (MOHSW) has adopted the WHO TB/HIV Collaborative Policy Guidelines, which address TB and HIV jointly. The Policy guidelines clearly demonstrate the need to fight the dual epidemics and provide the basis for action in collaborative TB/HIV activities by the Zanzibar TB and Leprosy Program (ZTLP), the Zanzibar AIDS Control Program (ZACP), and other stakeholders to work synergistically to reduce the burden of TB/HIV co-infection. ZACP will finalize, print, and distribute adopted WHO (and Mainland) guidelines and patient monitoring system (PMS) tools to support training of health care providers on the new PMS tools and strengthen collaboration between ZACP, NTLP, GFATM, and other stakeholders involved in TB/HIV interventions. Support will continue to be coordinated at the national level.

With these funds, ZACP, in collaboration with ZTLP, will scale up and improve collaboration and coordination of TB/HIV activities. The ZACP will continue to utilize the existing health workers by integrating collaborative TB/HIV activities in facility health care services plans. Health care workers from TB clinics and CTC will be trained on TB/HIV collaborative activities using national policy guidelines and training curricula. The program will conduct awareness of TB/HIV co-infection campaigns for patients, staff, and communities by developing, printing, and distributing TB/HIV IEC materials. This will encourage TB patients to get tested for HIV and empower HIV infected patients to demand TB screening routinely.

ZACP, in collaboration with ZTLP and other implementing partners, will continue to sensitize the community on TB/HIV by enhancing ex-TB/HIV patient clubs and promoting community leaders, including adding a TB/HIV component into primary and secondary school health subjects. ZACP will ensure printing and distribution of TB screening tools among care and treatment sites. ZACP will also ensure the incorporation of pediatric TB services into all the TB/HIV activities and observe gender mainstreaming.

Biannual meetings will be conducted between ZACP and ZTLP staff to enhance collaboration between the two programs and increase referrals and linkages between CTC and TB clinics. TB/HIV under one roof services will be improved and scaled up to other TB diagnostic centers. ZACP and ZTLP, in collaboration with other partners, will continue scaling up the 3Is at Mnazi Mmoja Hospital and Chake-Chake Hospital as pilot sites with the possible expansion into new two sites.

The funds will also be used to build capacity of ZHMTs and CHMTs in the implementation and monitoring of collaborative TB/HIV activities. ZACP will ensure ZHMT and CHMT include TB/HIV activities in their Comprehensive Council Health Plan (CCHP) to encourage sustainability and ownership. The program has already adopted the revised PF and PEPFAR II indicators. In addition, an M&E plan and tools have been updated to incorporate revised indicators. The indicators will be reported quarterly at district, zonal, and national levels.

The Strategic Information (SI) Unit of the ZACP is the custodian of health sector HIV data in Zanzibar. The unit is mandated to coordinate, collect, store, retrieve, and analyze various types of data for planning and policy formulation. Simultaneously, the unit has good capacity for data handling; hence, it will complement efforts of the HMIS unit within MOHSW within the production of health data required by stakeholders.

The SI Unit provides data collection tools on care and treatment, PMTCT, HIV counseling and testing, home-based care, laboratory, STI services, and HIV surveillance. Support under this application will help to continue and consolidate these efforts and increase capacity to monitor and evaluate HIV/AIDS interventions and services in Zanzibar.

The SI Unit is working in collaboration with other ZACP units to better link health sector HIV information to the national HIV data set. Data are collected from public, private, and CBO health facilities. ZACP also collaborates with other government ministries, local and international organizations, and technical experts to implement SI activities.

SI activities supported under this program include antenatal clinic (ANC) surveillance and M&E capacity strengthening among program staff and district healthcare workers, which are aligned with implementation of the HIV/AIDS M&E framework.

ANC HIV surveillance will be repeated at 20 sites using the PMTCT approach. Additionally, trend analyses will be performed on three data points (2008, 2010 and 2012) for those sites which participated in the three previous rounds of ANC. ANC surveillance data will be compared to PMTCT counseling and testing data in order to assess the feasibility of replacing ANC surveillance with PMTCT as the main source of data for monitoring the HIV epidemic in the general population in Zanzibar.

Human capacity development is being targeted through in-country trainings as well as external opportunities. The SI team conduct trainings for unit coordinators and health care workers from health care facilities on data management, basic epidemiology and specific research methods, monitoring tools and data management for ANC/PMTCT comparison study. A workshop on data auditing and verification will take place for district data managers. The program will encourage participation of SI staff in regional and international trainings and conferences; in addition, mid- to long-term SI capacity building opportunities will be explored, including linkages with Training Program in the Fields of Epidemiology Laboratory (FELTP) in Dar and Monitoring and Evaluation in Ethiopia.

As for implementation of the health sector HIV M&E framework, it has been translated into an operational plan in year one. Operationalization of the framework has commenced on sensitization of health care workers and stakeholders on the M&E plan, guidelines and standard indicators. As mentioned above, capacity building for health workers in data use, and adaptation of data collection tools on all ZACP projects will be done in this year.

Zanzibar National Blood Transfusion Services is responsible for the collection of blood by relying on voluntary, non-remunerated donors and the safe processing, storing, and distribution of safe blood and blood products to health facilities. It is also responsible for advocacy, training, and monitoring the appropriate utilization of blood and its products in the hospitals. The overall program goal is to establish, strengthen, and sustain a nationally coordinated blood transfusion system in order to ensure availability of an adequate supply of safe blood from voluntary, non-remunerated donors from low risk populations. By June 2014, the Zanzibar National Blood Transfusion Services objectives are to increase access and utilization of safe blood and products and strengthen the quality management system.

To increase accessibility and utilization of safe blood and products, the following activities will be implemented:(1) Mobilize and collect enough blood to increase coverage to 6,500 units per year;(2) Scale up blood components production to 40%;(3) Strengthen the blood collection and distribution satellite center;(4) Fractionate 10% of blood and components into pediatric units;(5) Roll out training to clinicians on rationale use of blood and components;(6) Train more staff on counseling so as to multi-task, such as increase post donation counseling to 65% and attracting more safe donors;(7) Train staff on customer care to improve donor and other clients care;(8) Create and support more in and out of school donors clubs to increase pool of safe donors; and(9) Develop and implement donor recognition guidelines.

Strengthening the quality management system will require the following activities:(1) Strengthen proper use of donor questionnaire and counseling in order to reduce HIV and other TTIs prevalence;(2) Review and implement testing algorithms in serology and TTIs test and implement proficiency testing (with NBTS);(3) Undertake EQUAS, IQAS, and NQAS each year;(4) Develop and implement SOP competency assessment and training packages;(5) Develop and implement NBTS national GMP guidelines;(6) Implement use of preventive maintenance and other guidelines;(7) Develop and implement safety and waste management guidelines;(8) Prepare and implement disaster management plans; and(9) Procure needed equipments for laboratory and BECS.

3. Financial management and sustainability strengthened by 2014. Its activities are: 3.1 Computerization of financial recording and reporting system3.2 Develop and implement revenue generation strategy3.3 Perform Blood unit cost estimate3.4 Develop Plan and Implement cost recovery mechanism3.5 Advocate for increased government and other source of funding

4. Strategic linkages expanded and strengthened by June 2014. Its activities: 4.1 To implement existing and establish 2 new technical linkages and partnerships internally and externally (e.g. exchange program, linkages with relevant programs)4.2 Regularly participate in stakeholders meetings4.3 Facilitate Quarterly meetings of National Transfusion Committee4.4 Revive the 2 and establish 3 new hospital transfusion committees4.5 Attend National and International Forums on Blood Transfusion Services

Taking into consideration that this Phase aims at strengthening the systems and sustainability, new strategic plan with above objectives was recently formulated to address this need.

Surveillance conducted with pregnant women in antenatal care (ANC) settings has documented an HIV prevalence of <1% on the islands. Higher HIV infection rates have been documented among women compared to men (5:1 respectively). At the same time, data has shown an annual increase in the number of clients diagnosed as HIV-infected. Studies conducted with key populations such as female sex workers (FSW), people who inject drugs (PWID), and men who have sex with men (MSM) revealed HIV prevalence up to 16% among these groups.

Based on this data, it is necessary to raise public awareness about behaviors that put individuals at the risk of contracting or transmitting HIV and other sexually transmitted diseases. The likelihood of transmitting HIV is greatly increased for those who have multiple, casual and/or high-risk sex partners, and engage in unprotected sex. All sectors at the various levels are involved in enhancing public awareness, particularly at the community level, to empower the community to develop culturally appropriate approaches in prevention of HIV transmission. These include being faithful to the same partner, practicing abstinence, and delaying engagement in sexual debut among youth. At the same time, use of and access to HIV services among key populations need to be promoted with faith-based organizations and communities playing an important role in both promoting service up-take as well as assisting with reduction of stigma and discrimination that are affecting these groups. Support to functional youth and faith-based initiatives that positively promote abstinence, faithfulness, partner reduction, and delayed sexual debut as well as assist with promotion of effective biomedical services and reduction of stigma and discrimination in a holistic manner are recognized as an important strategy for the prevention of HIV among Zanzibaris.

Activities will be implemented in collaboration with teachers and faith-based leaders currently working with ZACP. These leaders are interwoven with and supported by community members. As a result, their activities are propagated and sustained. At the same time ZACP has started a process, with the assistance of a PEPFAR/CDC funded technical assistance (TA) partner, to build capacity among ZACP technical staff across program areas and to improve the quality of information education and communication (IEC) materials developed by the program. An IEC Officer has recently been recruited to support these activities and improvements.

The activities and produced materials will play a particularly important role in increasing the demand, up-take, and adherence to effective HIV interventions and treatment. Monitoring and evaluation will continue to be conducted quarterly and performance be reported during quarterly progress reports as well as during annual/semi-annual PEPFAR progress reports.

The ZACP Counseling Unit (CU) coordinates the Zanzibar HIV testing and counseling (HTC) program through development of policies and guidelines, training protocols and manuals, and standard operating procedures and job aides. ZACP also provides supervision and technical guidance to HTC implementing partners, strengthens training of counselors to secure the required quantity and quality of services, and monitors the progress of implementation of HTC services through reports from district authorities, NGOs, and other stakeholders. While quality assurance (QA) efforts are lead by the laboratory unit, the HTC staff participates in HTC QA activities.

Through support provided under this agreement, past accomplishments include the development of the Zanzibar HTC guidelines and training manuals; the establishment of provider initiated testing and counseling (PITC) services at various hospitals, health centers, and primary health care units; training of health care workers in PITC; establishment of an HTC coordination forum; procurement and distribution of HIV kits for HTC service sites; and production and distribution of IEC materials to promote HTC. All these activities will continue into the next funding cycle with particular attention being paid to implementation of PITC in services, such as TB and STI clinics, where the proportion of HIV-infected and/or high risk clients is likely to be high.

In FY 2012, establishment and provision of HTC services that provide easier access to HTC services for key populations, such as sex workers (SW), people who inject drugs (PWID), and men who have sex with men (MSM) will be strengthened. This will include the increased use of mobile HTC strategies. For individuals testing HIV-positive, linkages will be made with various programs, including palliative care/home-based care and HIV treatment. Work will be completed in collaboration with various implementing partners including, ICAP, CHAI, Global Fund, and other ART and TB partners.

ZACP will continue to support integration of HTC in HMIS and training on M&E tools. ZACP will also provide support in the use of the tools in day-to-day operations. All supported sites will use MOHSW daily registers and monthly summary forms, which will harmonize recording and reporting of HTC services.

Surveillance conducted with pregnant women in antenatal care (ANC) settings has documented an HIV prevalence of <1% on the islands. Higher HIV infection rates have been documented among women compared to men (5:1 respectively). At the same time, data has shown an annual increase in the number of clients diagnosed as HIV-infected. Studies conducted with key populations such as female sex workers (FSW), people who inject drugs (PWID), and men who have sex with men (MSM) revealed HIV prevalence up to 16% among these groups.

Based on this data, it is necessary to raise public awareness about behaviors that put individuals at the risk of contracting or transmitting HIV and other sexually transmitted diseases. Combined with outreach efforts, condom promotion and distribution and the use of and access to HIV services among key populations need to be promoted with faith-based organizations and communities playing an important role in both promoting service up-take as well as assisting with reduction of stigma and discrimination that are affecting these groups.

ZACP will facilitate special clinical services for key populations at times of the day that are easily accessible to PWID and other key groups. The clinic will have a welcoming environment, offering services for STI, TB, and HIV care and treatment. In collaboration with the management of correctional facilities, ZACP will also establish similar services in correctional facilities. To complement static facilities offering the specialized services, ZACP will collaborate with NGO stakeholders to offer outreach HTC and relevant clinical services through a mobile facility.

In addition, ZACP has started a process, with the assistance of a PEPFAR/CDC funded technical assistance (TA) partner, to build capacity among ZACP technical staff across program areas and to improve the quality of information education and communication (IEC) materials developed by the program. An IEC Officer has recently been recruited to support these activities and improvements.

The activities and produced materials will play a particularly important role in increasing the demand, up-take, and adherence to effective HIV interventions and treatment. Monitoring and evaluation will continue to be conducted quarterly and performance be reported during quarterly progress reports as well as during annual/semi-annual PEPFAR progress reports.

Drug use plays a key role in the HIV epidemic in Zanzibar, whereby studies conducted in 2007-2008 have found HIV prevalence of 0.6% in the general population and 16% in people who inject drugs (PWID) on the main island of Unguja. ZACP is implementing a multi-year PEPFAR/CDC funded project aimed at creating an enabling environment and strengthening provision of effective HIV prevention, care, and treatment services on Zanzibar with specific interventions for PWID and other key populations. Specifically, the project fosters innovative approaches to offer the UN-recommended comprehensive package of services for HIV prevention and care for PWID, including outreach, condom promotion and distribution, HTC, STI screening and management, TB screening and treatment, overdose treatment, as well as linkages into ART for HIV+ PWID services.

The main focus is clinical services for PWID, which fall directly under ZACPs mandate under the Ministry of Health. The project will provide a forum in which ZACP, in collaboration with partners in HIV prevention and with PWID involvement, will continue to develop or improve tools, materials, standards, and guidelines for implementing and monitoring of HIV intervention and services for PWID.

Under this project, the ZACP, in collaboration with various stakeholders, is developing a plan for the provision of drug dependency services for PWID in Zanzibar that will contribute to reduction of HIV transmission and improve health outcomes for male and female PWID. This plan includes training of health care workers to provide comprehensive services for PWID, such as assessment of individual substance abuse and other risk factors, provision of HTC services, screening and treatment of STIs, condom promotion and distribution, injection use related risk reduction strategies, treatment for drug related emergencies, and the provision of medically assisted treatment services. This plan also includes initiation of a pilot site for provision of medication assisted treatment (MAT) to 100 clients with opioid addiction in Unguja, where initial studies identified the highest concentration of this population.

On-going surveillance will determine future MAT scale-up. Pangea will be contracted as the technical assistance (TA) provider for guidelines, protocol, and material development. ZACP will facilitate special clinical services for key populations at times of the day that are easily accessible to PWID and other key groups. The clinic will have a welcoming environment, offering services for STI, TB, and HIV care and treatment. In addition, screening services for viral hepatitis will be introduced and hepatitis B vaccination will be offered to individuals who are found to be uninfected. In collaboration with the management of correctional facilities, ZACP will also establish similar services in correctional facilities. To complement static facilities offering the specialized services, ZACP will collaborate with NGO stakeholders to offer outreach HTC and relevant clinical services through a mobile facility.

Currently, there are 50 sites at the RCH clinics providing PMTCT services (33%). In the coming years, ZACP aims to further expand PMTCT services in antenatal clinics (ANC) and maternity hospitals with the goal of achieving 80% of all pregnant women tested and 85% of those who are HIV positive to receive interventions. To achieve this goal, ZACP is planning to strengthen existing services as well as scale up availability and accessibility of PMTCT services in the islands.

PMTCT services will be established in 100 RCH clinics after a needs assessment is conducted. The qualified clinics will be supplied with HIV test kits, vacutainer tubes, protective gears, haemacue machines, and drugs, which include cotrimoxazole and ARVs for prophylaxis.

A minimum of one PMTC provider will be trained on PMTCT services in each new site, while 90 health care providers will be placed in Unguja and 60 in Pemba. Within the old sites, health care workers will receive refresher training to orient them with the revised PMTCT guidelines that have incorporated the new WHO recommendations. PMTCT providers will also receive other supportive trainings, including training on family planning and infant feeding. PMTCT guidelines and job aids will be printed and distributed to all sites. PMTCT sites will receive ARVs for prophylaxis from the nearby CTC sites and transport allowance will be provided to health care providers sending samples for CD4 testing.

Using a standard supervision tool, supportive supervisions will be conducted bi-annually followed by supportive meetings with PMTCT staff to discuss different issues related to PMTCT implementation with the main objective of increasing the quality of services. PMTCT coordinators will receive a short course of training on management to help strengthen the staff capacity at the central level.

HIV care and treatment services were initiated in Zanzibar in 2005. By 2010, eight ART clinics were operational in both Unguja and Pemba. All of the eight clinics carry out HIV testing with four of the clinics carrying out full-blood tests (FBT), including CD4 counts. Of these eight clinics, seven are public and one is a private health facility. The USG is one of the main supporters of treatment services in Zanzibar, through assistance to the ZACP at the national level as well as direct support at points of service through local and international implementing partners. Through this funding opportunity, ZACP will improve accessibility of care and treatment services by scaling-up treatment services, specifically the decentralization of services to the lower-level health centers, and empowering local health authorities to oversee the expansion of these services. $250,000 will specifically go toward the initiation of early treatment for the focus groups in Phase I of rolling out the new WHO treatment guidelines. To achieve this, ZACP will train more health care workers who work in potential health facilities for care and treatment services on comprehensive HIV/AIDS management, including adult and pediatric ART training, training on adherence counseling, and post exposure prophylaxis.

Through quarterly supportive supervision and mentorship program, ZACP will monitor the quality of services and clinical outcomes, such as percent of adults and children who are still alive and on treatment at 12 months after initiating ART, number of adults and children currently on ARVs, and number of adults and children newly and ever enrolled in care and treatment clinics. Special efforts will be placed to track lost to follow up patients using educators and by strengthening collaboration with home-based care providers through quarterly coordination meetings. Funds will also be used for implementation of the new WHO treatment guidelines. A pilot study will be conducted at Mnazi Mmoja CTC to evaluate feasibility of identification and optimal management of HIV/HBV co-infection.