Rukwa Region is located in the remote southwestern part of Tanzania between Lakes Tanganyika and Rukwa. The transport infrastructure is poorly developed with gravel roads that are usually impassable during rainy season.

Health services to the catchment population of approximately 1 million people are provided by URT, FBOs, and the private sector. There are 234 health facilities in the region, including four hospitals, 31 health centers, 199 dispensaries, and two training institutions. These facilities are relatively unevenly distributed, although approximately 70-85% of people live within five kilometers of a primary health facility.

Rukwa Regional Medical Office (RMO) supports the implementation of prevention, care, and treatment programs throughout its region, providing funding and supervision to the regional hospital and district level facilities. The region has created a monitoring and evaluation plan that ensures planned interventions are implemented in a timely and cost-effective manner. Regional Health Management Team (RHMT) and Council Health Management Teams (CHMTs) are responsible for implementation and the monitoring and evaluation of the HIV/ AIDS activities, thus strengthening the local capacity. The region has been working with CHMTs and all stakeholders to help the councils incorporate health interventions into their routine plans.

Rukwa Regional Medical Office (RMO) supports the implementation of facility-based activities aimed at extending and optimizing the quality of life for HIV infected adults and their families through clinical, psychological, spiritual, social, and prevention services throughout the continuum of illness.

For COP 2012, the following adult care and support services make up a standard DOD package of care:

1) Strengthen facility-based adult care and support services through strategic in-service training, supportive supervision and on-the-job mentorship of HCWs offering adult care and support services at the regional and district hospitals n Rukwa region. Rukwa RMO will also support CHMTs/DHMTs to provide similar services in lower-level facilities.2) Strengthen facility-based PHDP counseling to improve adherence and retention of PLHAs into care and support services3) Support linkages of facility-based and home/community adult care and support services through use of community health workers (CHWs) and regular coordination meetings with outreach service providers.4) Provide prevention and treatment of OIs and other related infections such as Malaria and Diarrhea.5) Provide nutritional counseling and support (NACS) to all patients attending ART services at CTCs6) Strengthen integration of adult care and support services into other HIV/AIDS care, support and treatment services in the region, such as ART, PMTCT, HTC, VMMC, and OVC.7) Improve the M&E framework in the region by harmonizing data collection, analysis and reporting tools. Program targets and results will be discussed and shared for informed program implementation.

Rukwa region has a population of over 1 million people with the prevalence of 4.5%. It is estimated that there are 50,000 HIV positive people in need of services in this region. The Rukwa Regional Medical Office (RRMO) implements TB/HIV program based on the country TB treatment policy, coordinated by the National TB and Leprosy Program (NTLP). It is committed to providing quality TB/HIV services, both at the facility and community levels. TB treatment in Tanzania follows the WHO-recommended DOTS strategy. Although initially Tanzania had achieved significant success in TB care and treatment, the advent of HIV has significantly increased the number of cases and challenges of TB management. Low levels of awareness, lack of basic knowledge about TB and low case detection rate, especially among the HIV co-infected patients, have negatively impacted on the previous successes.

With COP 2012 funds, the TB/HIV portfolio of the Rukwa RMO will include the following activities:1) Improve regional efforts to provide quality TB/HIV services by providing technical support to districts and high-volume and satellite clinics, in-service training and on-the-job mentorship to HCWs on TB control practices and implementation of the three Is as well as establishment of TB/HIV coordinating bodies at district level;2) Scale-up TB/HIV services in the region through TB screening for PLWHAs and integration with other programs such as ART, HTC and PMTCT;3) Strengthen monitoring and tracking system to improve program performance, including availability and use of standard National TB/HIV tools, such as screening tools and clinical assessment forms;4) Continue strengthening of laboratory services including sputum smear microscopy and quality assurance to ensure quality TB care services; 5) Increase and strengthen regional and district capacity to provide quality TB/HIV services, in partnership with other stakeholders and with technical and financial support from DOD.

HIV prevalence in Rukwa region is 4.5%, with at least 5,000 children under 15 years of age in need of care and support within a network of 20 CTCs. All health facilities provide pediatric care and support services at varying levels.

Rukwa RMO will use COP 2012 funding to:

1) Strengthen provision of integrated pediatric care and support services that are linked to other services such as ART, OVC, HBC, TB/HIV, MCH, EPI, PMTCT and HTC;2) Scale-up cotrimoxazole prophylaxis and management of Opportunistic Infections (OIs);3) Strengthen quality of pediatric care and support services by improving skills of HCWs and CHWs in infant feeding counseling, nutritional assessments and support, palliative care, psycho-social support through strategic in-service training, on-the-job mentorship and support supervision;4) Improve M&E system by harmonizing data collection, analysis and reporting tools. Encourage that targets and results are discussed and shared for informed program implementation.5) Strengthen local ownership through community mobilization, and improve involvement of adolescents and children in PHDP services and formation of support groups in order to improve retention and adherence;6) Renovate selected health facilities to ensure pediatric-friendly services.

To ensure program sustainability, Rukwa RMO leverages on local resources such as central funding through MOHSW budget, basket funding, and cost sharing mechanisms.

Rukwa RMO will support VMMC activities in Rukwa region through routine on-site MC services and campaign approaches. Currently, only routine on-site VMMC services are conducted, although two campaigns are planned during the current fiscal year. With technical assistance from Mbeya Referral Hospital, a total of 17 MC clinicians have been trained (five teams). More clinicians will be trained ifor COP 2012 to perform more MC procedures.

In order to increase MC uptake, Rukwa RMO will provide a comprehensive MC package that includes HTC, client-appropriate behavioral messaging and referral to HIV care and treatment services, as well as on-site PHDP services for those found HIV-positive. Female partner participation will also be promoted to encourage a family-centered HIV prevention approach. Moreover, to improve MC coverage and leverage on available resources, linkages will be established with other stakeholders involved in HIV education and promotion. Print and electronic media messaging will be employed, including individual, small groups and community sensitization in order to create demand for MC services.

Availability of electricity in remote areas of Rukwa is erratic. To overcome this challenge, disposable MC kits will be the preferred option. Additionally, mobile MC units will be procured to improve availability of VMMC services in the region and in the new region of Katavi which was recently curved from Rukwa .Rukwa RMO will strengthen the M&E capacity in the region to ensure availability of quality MC services, monitor performance of available clinicians, and follow up on clients to assess and document complications and compliance (both treatment and preventive measures) through regular support supervision, on-the-job mentorship, and analysis of MC data to document average time for MC in the region as well as for each health facility.

Support to CHMTs will be provided so as to integrate MC services into routine health care services in all districts in the region. Rukwa RMO has also adopted the web-based JHPIEGO MC reporting system, which should ensure availability of quality data. For uniformity in data documentation and reporting, available tools will be harmonized.

Rukwa Regional Medical Office (RMO) supports the implementation of prevention, care, and treatment programs throughout its region, supporting 165 RCH sites providing supervision to the regional hospital and district level facilities. Quality PMTCT services in the region are critical given the HIV prevalence of 7.1% among pregnant women.

To improve MCH services in the region, Rukwa RMO will plan and implement decentralized integrated PMTCT services in collaboration with Council Health Management Teams (CHMTs).

Under DoD guidance, a package of standard interventions will be implemented in COP 2012:

1) Improve Emergency Obstetric Care (EmOC) package by: linking services within government and non-governmental health facilities. Provider skills in EmOC will also be strengthened through strategic on-job training using the national TOT model;2) Train health care workers at each new site using a full site model;3) Support improvement of the M&E framework (DQAs, integrated supportive supervision using standardized national tools) and BPE to ensure informed program implementation;4) Support and strengthen provision of integrated services: TB/HIV, ART, Pediatric HIV, FP and Focused Antenatal Care (FANC) services as well as provision of More Efficacious Combination Regimens (MECR) to achieve the goal of putting 95% of all women on MECR prophylaxis in 2012 and 100% by 2013. This will include training MCH care providers in ART and pediatric HIV management according to national guidelines, including supporting EID logistics (transportation of samples and DBS results);5) Support renovation of selected sites to offer friendly MCH services and provide comprehensive RCH services;6) Support participation and uptake of PMTCT/RCH services through individual, small groups and community sensitization and provision of PHDP counseling services.7) Scale-up PMTCT services to ensure that 80% of all women attending ANC receive HTC, 80% of HIV positive women receive MECR prophylaxis;9) Provide comprehensive PHDP counseling services to PLHIV;10) Improve HCWs PMTCT knowledge and skills through strategic in-service training, mentorship and supportive supervision;11) Improve EID services in the region through training of ANC and laboratory staff, DBS collection and logistics and ensure provision of cotrimoxazole prophylaxis to all HIV exposed and infected children;12) Complement procurement of drugs, reagents, and other essential supplies in case of stock-outs;13) Promote good infant feeding and nutritional practices during lactation, and promote infant feeding counseling options;14) Support CHMTs to include PMTCT activities in council health plans and budgets.

Rukwa region has a population of over 1 million people with a prevalence of 4.5%. It is estimated that there are 45,000 HIV positive people in need of services in this region.

Full recruitment of patients in the region started in 2005. By the end of FY2011 the region had a cumulative number of over 14, 698 patients on ART with 2,502 new patients enrolled. Despite the follow-up challenges, the proxy retention rate was 91.5% (APR 2011). Efforts to improve retention include linkages with CBOs to track patients in the community and use of support groups and CHWs for adherence counseling and tracking of patients in their homes.

For COP 2012, Rukwa RMO will implement the following activities:

1) Improve quality of HIV care and treatment services in the region through on-the-job training, mentorship and support supervision;2) Strengthen service integration (MCH, TB, PITC, and EPI) and linkages as well as referrals to improve availability and accessibility;3) Work with the RHMTs to strengthen administrative and financial capacity of partners to improve program execution. Additionally, DHMT and facility directors will be assisted to develop and implement facility based-work plans. In addition a contractor will be retained to build RMOs capacity in budgeting and financial reporting. As another region has been curved out of Rukwa (Katavi region), Rukwa RMO, with support from DOD, will support the establishment of administrative, management and physical structures in the new region;4) Complement procurement of drugs, CD4 machines, reagents and other supplies for patient monitoring when not available through central mechanism; improve pharmacists' capacity in forecasting, stock management, and ordering. Besides improving the quality of care, these measures will also improve lab efficiency;5) Strengthen prevention for positives counseling among all staff providing treatment at CTC;6) Continue to provide evaluation for malnutrition and nutritional counseling to all HIV positive clients;7) Improve M&E system by supporting CQI in CTCs and electronic data capture. To achieve this, high volume sites will be selected strategically and installed with solar power to improve electronic data collection, analysis and reporting. Gaps identified during quarterly performance appraisals will also be incorporated into regional work plans; RHMT and CHMTs in the region will be strengthened for better coordination of Care and Treatment services;8) Participate in zonal ART meetings with Mbeya Referral Hospital to discuss treatment roll out, identify areas of need, determine solutions and coordinate resolution;9) Renovate space at selected CTC sites and build efficient and environmentally friendly incinerators at high volume sites to improve service quality and waste management respectively.

HIV prevalence in Rukwa region is 4.5%, with at least 5,000 children under 15 years of age in need of care and support services. COP 2012 funding will be used to scale-up the quality of pediatric care and treatment services. Rukwa RMO is tasked with coordinating and overseeing the quality of pediatric treatment services in the region, in collaboration with Baylor International Pediatric AIDS Initiative (BIPAI), based at MRH. These activities will be achieved through support supervision, community mobilization, training, and on-the-job mentorship. Rukwa RMO has a catchment area that includes five districts with a population that exceeds 1 million people.

Rukwa RMO will support provision of quality paediatric care and treatment services in the region including expansion of pediatric PITC, supply of pediatric drugs and commodities, improved supply of diagnostics, adherence counseling, and strengthening linkages and referrals. Adherence counseling and tracking of children lost to follow-up, and linking children to health facilities will be strengthened through CHWs and other community support groups. Infrastructural improvement will be made to address pediatric care and treatment needs.

To strengthened the regional M&E system, data collection tools will be harmonized and data analysis and reporting done. Results will be utilized to inform the program and discussed in zonal technical and national partner meetings

To ensure availability and accessibility of services, paediatric care and treatment services will be integrated into other services such as HBC, OVC, PITC, EPI, PMTCT, TB/HIV to increase child enrollment into care and treatment. The integration of these services leverages national referral system to ensure quality, sustainable care, and support. The USG/T supported activities will continue to be incorporated into the regional health plans through national funding such as central funding through MOHSW budget, basket funding, and cost sharing mechanisms.