The goals for the International Center for AIDS and Treatment Program (ICAP) link to the Partnership Framework in Tanzania mainly through building capacity, scaling effective prevention interventions, and laying the foundation for sustainable country programs in Kigoma, Kagera, Pwani, Lindi, and Zanzibar. ICAP plans to operate within all six goals of the PF: service maintenance and scale up of comprehensive HIV care and treatment; prevention through PMTCT, male circumcision, family planning, and STI screening; leadership, management, accountability, and governance through direct support to RHMT/CHMT; sustainable and secure drug and commodity supply; human resources development; and evidence-based and strategic decision-making through regular data analysis, evaluation, and research.

To become more cost efficient, focus will be on improved budgeting, planning, program execution, and fiscal accountability at the district level. The transition plan to a local organization (THPS) will be fully functional during the operational plan timeframe, with technical assistance provided by ICAP. It is anticipated that TPHS will directly manage activities and continue working in partnership with RHMTs and CHMTs to encourage efficiency and quality of services, facilitate establishment of private-public partnerships, improve skills in performance management and accountability for a sufficient and productive workforce, and strengthen human capacity development for strategic information.

Monitoring and evaluation will be done through dedicated M&E and research units. ICAP and THPS will ensure data quality and continuous support for data collection, analysis and evaluation, and overall human capacity development for strategic information at the national level.

ICAP will continue working closely with NACP and ZACP and RHMTs/CHMTS to increase enrollment and retention of PLHIV into HIV care program. ICAP will continue strengthening the facility and non facility counseling and testing entry points, and ensuring the linkages to CTC of all individuals testing positive. Furthermore, ICAP will continue to ensure programmatic efficiencies and quality service provision through:

1. Organization of need-based in-service trainings, clinical system mentorship and supportive supervision as way of capacity building for HCWs;

2. Provision of services such as family planning, STI screening, discordant couples counseling as well as implementation of the entire package of PHDP according to the national guidelines;

3. Infrastructural support including renovations and supply of need based medical equipment;

4. Financial support through sub-grant award, including hiring of additional staff as needed;

Evidence-based data from the previous fiscal year have shown that these interventions improved the retention of clients to care and facilitated the re-introduction of clients to services, which will ICAP will implement to strengthen the retention and adherence of patients enrolled into care:

1. Ongoing adherence counseling by HCWs and peer educators who are themselves PLHIV;

2. Establishment of psychosocial support groups and strengthening of linkages of CTC with community support and home-based care services to maximize adherence and organize successful defaulter tracing activities

3. Strengthened linkages to community-based organizations that provide nutritional, psychosocial and financial support

4. Establish activities to strengthen OIs and management, nutritional support, counseling, and innovative QI activities to improve patient care services and improve retention and minimize loss to follow-up.

ICAP will continue tracking and evaluating clinical outcomes and other performance data through regular monitoring and evaluation of program using data generated from sites on monthly, quarterly and annually basis. Data generated are compiled, analyzed and shared with sites/districts/regions during quarterly data sharing meetings and during the regular site support visits for the purpose of continuous quality improvement.

ICAP will collaborate with Tanzanian Health Promotion System (THPS), a local NGO founded by ICAP, and RHMTS/CHMTS to establish local ownership and hence sustainability of the program. RHMTs/CHMTS will receive capacity building assistance from ICAP to improve HIV program service planning, implementation and furthermore ensure incorporation into the comprehensive council health plans (CCHP).

Through the ongoing palliative care program with Ocean Roads Cancer Institute that has now been rolled out to zonal referral hospitals, the program will ensure drug availability and accessibility through regular supply of oral morphine to lower facilities and pain medication to community level. The implementation strategies will focus on strengthening current palliative care teams at all four Zones and 35 Facilities through mentoring and CME; ensure uninterrupted supply of medication; support training activities at each zone; develop a regional and district mentorship team; and ensure availability of M&E tools and their use by the supervisory teams.

In line with the countrys national policies and strategic plans for increasing TB/HIV collaborative activities, ICAP will continue strengthening TB/HIV integration at the national, regional, district, and site levels. The strategic direction of the program will be to provide a sustainable program by ensuring the availability of a sufficient number of trained personnel, providing regular on site mentorship and supportive supervision, initiating performance-based awards, and collaborating with CHMT to retain trained staff.

Intensified case finding of TB among PLHIV at CTC, RCH, OPD, and adult/pediatric wards shall be strengthened using the TB screening questionnaire and work-up of TB suspects in accordance with the national diagnostic algorithm. With these funds, ICAP will strengthen CXR reading skill of Health Care Workers through CXR reading mentorship by expert radiologists together with establishment of x-ray digital equipment points at selected health facilities. ICAP will work in strengthening the TB IC measures at all units within supported health facilities. ICAP will support the role out of the national IPT pilot program and continue providing technical assistance in the development and dissemination of childhood TB guideline. TB/HIV data triangulation will be conducted regularly to improve data recording and reporting at CTCs and TB clinics.

ICAP will also continue to scale-up the TB club model through sub granting of a national NGO, which also works to increase community awareness of TB/HIV and educate the public to access early treatment of both diseases.

ICAP, in collaboration with Tanzanian Health Promotion System (THPS), a local NGO founded by ICAP, RHMTs/CHMTs will regularly review and report high-quality data using the national TB/HIV M&E framework and national standard of care indicators to track progress towards the stated objectives and targets. A continuous effort shall be exerted to incorporate TB/HIV activities in the Comprehensive Council Health Plan (CCHP), helping to sustain the program through local ownership. In addition, ICAP will work closely with other partners working on TB/HIV in leveraging additional resources. ICAPs track record in implementation of successful evidence-based program is a basis for planning the proposed activities above.

At the national level, ICAP will continue to provide technical assistance to MOHSW in developing and reviewing pediatric HIV guidelines and training curriculum for HCWs, as well as participating in technical working groups and partners meetings. ICAP will spearhead the efforts of the MOHSW in ensuring quality implementation of EID and treatment to reach 75% of all HEI, as per the PEPFAR target.

The implementing mechanism targets the pediatric population infected by HIV in all ICAP operated geographic areas, while aiming to reach at least 10% children among all clients enrolled at all ICAP supported care and treatment clinics. The target will be achieved through formal training, CMEs, clinical mentoring, joint supportive supervision, integration with other HIV/AIDS programs (PMTCT, EID, PITC, TB/HIV and APSS), as well as community linkages. In particular, psychosocial support will be provided through the establishment of psychosocial support groups for children and adolescents to improve well being, retention, and child participation in treatment plans.

To ensure proper functioning of the EID program, ICAP will continue to support the Bugando Medical Centre laboratory for the HIV diagnosis through dry blood sample (DBS) and will expand support to include three zonal referral hospitals. ICAP will also support the availability of uninterrupted supply of reagents and other consumables by creating a strong collaboration with government and non-government organizations involved in the supply chain. ICAP will also be engaged in gap filling purchases and distribution of these supplies and reagents to avoid service interruption.

Furthermore, ICAP will collaborate with Tanzania Food and Nutrition Center (TFNC) to initiate nutritional support at 12 ICAP supported sites to ensure the wellbeing and survival of HIV-infected and exposed infants and children. The facility-based nutritional support activity include routine provision of Nutrition Assessment and Counseling (NAC) and provision of nutritional support for those who are in need through strong collaboration with government and non-government organizations that provide nutritional support. ICAP will also work in the development, adaptation or adoption of nutrition related IEC materials. Annual program review and assessment of 12 additional sites will be conducted at the end of the current COP.

As part of the national quality improvement plan, ICAP will work in building the capacity of district mentors, while performing regular assessments of the national standard of care for pediatric care and treatment.

ICAP will continue providing national level laboratory assistance through support to Bugando Medical Center (BMC) in strengthening the early infant diagnosis (EID) service for Lake Zone regions. This will be executed through sub-agreement of BMC to hire key lab personnel, which has proven to strengthen the EID service provided in the region and ensure sustainability.

ICAP will also continue seconding seven staff (PCR Specialist, EID Logistician, Laboratory Epidemiologist, Hematologist, Parasitologist, Microbiologist, Molecular Biologist and Clinical Biochemistry specialist) to the Tanzanian National Health Laboratory Quality Assurance and Training Center (NHLQA-TC) under MoHSW. The partner will continue strengthening Zanzibar laboratory services at Mnazi Mmoja Hospital Pathology Laboratory, to achieve the accreditation scheme of ISO 15189 standards. ICAP will also continue providing support for three regional and two district laboratories to achieve the WHO set standard laboratory accreditation scheme.

Through the Laboratory team, ICAP will actively participate in the national quantification of HIV test kits, reagents and consumables to ensure availability all the time. Furthermore, the partner will continue to procure and distribute these crucial laboratory reagents and consumables to avoid service interruption, when shortages arise.

Additionally, ICAP will continue supporting laboratories in all ICAP supported health facilities in terms of human resource capacity building through training of staff, regular Clinical System Mentorship and need based renovations; strengthening the quality control activity through the different quality assurance schemes; strengthening the sample transportation activity; supporting the lab equipment maintenance; and strengthening the laboratory commodity supply management system. ICAP will continue collaborating with government and NGOs in leveraging resources for strengthening the laboratory system in the country. The partner will also provide material supports through the national system (MSD), including installation of laboratory equipments and gap-filling of HIV test kits and CD4 reagents when stock outs have been confirmed at the MSD.

ICAP will assist laboratories in the operation zone to meet PEPFAR II indicators for measuring the provision of quality laboratory services and provision of critical information for more accurate forecasting, planning and budgeting of laboratory reagents, consumables and equipment.

In collaboration with Tanzanian Health Promotion System (THPS), a local NGO founded by ICAP, and government bodies (RHMT and CHMT), ICAP will continue to conduct regular on site mentorship and supervision to ensure good laboratory practices and laboratory quality control. This collaboration with strengthen local ownership and hence sustainability of the program.

In FY 2011 and 2012, a total of 10,000 male circumcisions (MC) are planned for Kagera Region. The main geographical coverage areas will be Kagera Mainland and the Lake Victoria Islands, with 55% estimated coverage of MC in Kagera Region. To reach this proposed target, strategies will include outreach campaigns and use of mobile services both in the Mainland and Islands.

The MC program assistant, who is based in Kagera, will be responsible for providing supportive supervision to static sites in the Mainland. Quality assurance activities will follow the WHO guidelines for self assessment and external quality assessment by the PEPFAR and MOHSW team.

Since the main modality in reaching adult men for MC services is through campaigns, a local drama group will be used to disseminate communication information through community mobilization and distribution of IEC materials. In addition to disseminating information, these drama group activities will create demand for people to come out for circumcisions, especially during the campaigns.

MC will be provided as a comprehensive package for HIV prevention which entails risk reduction counseling, STI screening and treatment, HIV counseling and testing, and MC counseling. Sexual partners of MC clients will be encouraged to attend MC services for educational purposes and HIV testing and counseling. Outreach campaigns will aim to sensitize the community about the importance of partners and couples attending MC services together. If a MC client is found to be HIV positive, he is directly linked to an HIV care and treatment clinic through a formal referral process.

In order to have enough human resources to carry out the envisioned campaigns, approximately 48 health care workers will be trained on the MC for HIV prevention package following the national training curriculum using, which uses national materials.

ICAP will continue providing support to the Tanzanian MOHSW in developing national guidelines, training, and M&E materials related to HIV counseling and testing. ICAP will also continue strengthening HIV counseling and testing services in Kagera, Kigoma, Zanzibar, and Lindi by:

(1) Strengthening PITC entry points and VCT services in all supported health care facilities;

(2) Conducting focused outreach and mobile VCTs, especially during special events such as World AIDS Day and other national initiative campaigns; and

(3) Supporting provider-initiated and client-initiated HIV testing and counseling as part of the medical male circumcision, prevention with positives, and MARPs services.

The service targets high risk groups, such as discordant couples, MARPs, pregnant women, children admitted in pediatric wards, and those receiving care at RCH clinics and families and siblings of PLHIV in care at CTC.

Capacity building of health care workers through on-the-job training, usage of different approaches of clinical system mentorship, and joint supportive supervision will ensure:

(1) Counseling and testing will be offered to all clients attending health facilities;

(2) The use of national HIV testing algorithm and quality assurance; and

(3) Two-way referral and linkages to other programs, such as adult and pediatric HIV care and treatment services, and tracking or follow-up of HIV-positive individuals, through peer-educators, who were not enrolled in care or treatment after testing positive.

These will be measured by strengthening the M&E system, for example review of referral forms, regular data triangulation between HCT register at all entry points, and pre-ART and ART register at CTC. As part of the evaluation, routine HCT PEPFAR indicators and additional standard of care indicators of the National Quality Improvement Initiative will be regularly collected and analyzed.

ICAP and Tanzanian Health Promotion System (THPS), a local NGO founded by ICAP, will collaborate with the regional and district health management teams (RHMTs/CHMTs) and provide joint supportive supervision and clinical system mentorship using the on-site district mentors and collaborate in systems strengthening by improving timely and accurate forecasting and ordering of HIV testing commodities, hence minimizing gap filling to avoid stock-outs. Continuous efforts to incorporate HIV testing and counseling activities in the Comprehensive Council Health Plans will be emphasized to enhance ownership and sustainability.

The allocated budget for commercial sex workers (CSW) is $100,000 with the target of 500 CSWs being reached. Activities for the program will include the purchases and promotion of condoms, STI and TB screening and management, HIV prevention education messages, referrals to HIV services, and other social services.

ICAP will continue working with ZACP to ensure evidence-based HIV prevention interventions will include behavioral prevention, condom and, stigma reduction, STI management, HIV testing, and linkages to HIV care. Integrated TB screening and referrals for diagnosis and treatment is also provided for the health and welfare of CSW communities. The above interventions have been selected based on the documented successes of the previous years work of a sexual prevention program in Zanzibar. Furthermore, the activities are integrated into other services and platforms delivered by the national health system.

Quality assurance will be promoted through continuing medical education among HIV care providers, training, standardized IEC and training materials, and supportive supervision. Standardized indicators are assessed and reported on quarterly. Data is reviewed by the program and implementing teams against targets, while gaps are evaluated and addressed. Data reports are shared with ministry officials and local authorities periodically and, when appropriate, disseminated to forums with stakeholders.

The target population of the program will be men and women between ages of 15-45 who use injection drugs (PWID) and people who use non-injection drugs in Mwanza City or Zanzibar (Unguja and Pemba).

There are well-established patterns of injecting and non-injecting drug use in Zanzibar, facilitated by a tourist economy (urbanization, instability among youth, economic instability) and the ease of availability and accessibility through international drug trade routes. While the overall HIV prevalence in Zanzibar is <1%, it is estimated to be 16% among drug users. The patterns of drug use in Mwanza, not yet formally assessed, are known through anecdotal information and observations. Mwanza is the second largest city in Tanzania and is growing quickly.

The program will be implemented in Mwanza City and Zanzibar with an expected coverage of 1,500 PWID (1,000 men; 500 women), 2,000 non-injection drug users (1,500 men; 500 women). Based on available estimates of target population size, this corresponds to 24% of PWID and 33% non-injecting drug users (assumptions: 6000 PWID; 8000 non-injecting drug users).

Evidence-based HIV prevention interventions will include behavioral prevention, bleach kits, medically assisted therapy (MAT), IEC materials, stigma reduction among health care workers, HIV testing, linkage to HIV care, and linkage to drug recovery programs. Additional interventions, such as needle exchange, may be included as policies are amended. The above interventions are based on study data suggesting the value of safe injection houses, or a similarly stable and safe environment, as a strategy to reduce harm associated with injecting among addicts with high levels of homelessness and mobility. Moreover, evidence-based interventions providing mobile harm reduction service needle exchange, HIV testing, sexually transmitted infections (STIs) screening, and harm reduction information demonstrated to be feasible and effective in reaching an otherwise disenfranchised, high-risk population.

Quality assurance will be promoted through continuing medical education among HIV care providers, standardized IEC and training materials, and training and supportive supervision. Standardized indicators are assessed and reported on a quarterly. Data will be reviewed by the program and implementing teams against targets, while gaps are evaluated and addressed. Data reports will be routinely shared with ministry officials and local authorities and, when appropriate, disseminated to forums with stakeholders. ICAP plays a key role in national committees and government agencies in the mainland of Tanzania and Zanzibar addressing MARPS and drug control. ICAP works in partnership with several community based local NGO implementing partners.

At the national and policy levels, ICAP will actively be participating in the national PMTCT technical working group as well as partake in the development and revision of the national guideline and training materials on PMTCT. At the health facility level, ICAP will provide regular clinical system mentorship and supportive supervision by ICAP regional and central technical teams. PMTCT service regions are currently supported in Kigoma, Kagera, and Pwani. Capacity building of RHMTs and CHMTs in will focus on monitoring skills that will enable the teams to follow up on the PMTCT services in their respective regions and facilities. Activities will focus on:

(1) HCT of all ANC attendees and laboring mothers with unknown HIV status using the opt-out approach;(2) HCT of partners of pregnant women coming for ANC and L&D;(3) Determination of CD4 for all identified HIV positive infected women; (4) Stengthened linkages between ANC and labor and delivery wards, with HIV CTCs, TB/HIV service, nutrition centers, and FP clinics; (5) Improved administration of more efficacious regimens;

(6) Initiation of ART for all eligible pregnant women with CD4<350;(7) Initiation of RCH platform to integrate ART services in the RCH clinics of selected high volume facilities;(8) Roll out of the new national PMTCT guideline; (9) Initiation and strengthening of psychosocial support groups in selected high volume health facilities.

ICAP will strengthen its collaboration with organizations that provide community linkages and promotion (i.e. WAMA, SHIDEPHA+, and TADEPA) to increase PMTCT uptake and address issues of stigma, discrimination, male involvement, and couple counseling and testing. The MAISHA ZAIDI campaign on MCH will be extended to focus on HCT, follow up of mother-infant pair, infant feeding options, uptake of CD4, ARVs and retention in care. Community level advocacy for MNCH, community sensitization and mobilization for utilization of services for pregnant mothers will be emphasized. To improve MCH services, ICAP also intends to:

(1) Initiate BEmONC in selected health facilities;(2) Provide ART services in four additional high volume facilities within ICAP supported regions. Space for storage of ARVs will be identified and staff capacity will be built to enable daily ART services. Facilities to ensure timely CD4 enumeration for pregnant women, including transportation of DBS samples from HIV exposed infants, will be put in place;(3) Intensify and scale up cervical cancer screening and prevention using VIA services in Pwani and Kigoma to ensure that HIV positive women are screened per national guidelines. Women who have unknown status will receive HCT as part of the package;(4) Procure refrigerators to be placed in the labor ward of two facilities in each region (a regional and a district hospital) to serve as a mini blood bank, linked with zonal blood centers;

(5) Build capacity of health care providers working at RCH clinics to effectively identify and follow up on HIV positive mothers and children under five in the immunization clinic, mainly through CMEs, clinical mentorship using the pools of district mentors, and supportive supervision.

M&E of the program shall be executed through quarterly program monitoring and annual evaluations. ICAP will continue its effort to use QI initiatives, like the District Mentorship Initiatives, in collaboration with RHMTs and CHMTs to facilitate the incorporation of these activities into CCHPs.

ICAP will continue working closely with MOHSW in mainland and Zanzibar, RHMTs and CHMTs in the operating regions to increase early initiation of ART among PLHIV, through community mobilization, HF staff training and mentorship and timely referral from the key entry points (OPD, IPD, PMTCT). By way of supporting the MOHSW in adopting the new WHO adult care and treatment guideline, ICAP will actively participate in the technical working group, reviewing ART management guidelines and training materials. ICAP will also support the subsequent dissimination of the guidelines to HCWs in ICAP supported regions. TA will be provided to the RHMTs and CHMTs to ensure TB/HIV co-infected patients, children, discordant couples, and pregnant women with CD4 up to 350, are enrolled into ART. ICAP will continue to ensure the provision of family focused care and treatment programs in all supported facilities. ICAP will also continue to ensure programmatic efficiencies and quality service provision through various activities:

1) Coordinate needs based in-service trainings, clinical system mentorship (CSM), on-the-job training, and supportive supervision as a way of capacity building of HCWs. To increase efficiencies, ICAP will strengthen the use of the different approaches of CSM, like CMEs, telephone mentorship, MDT, etc.

2) Continue supporting innovative strategies like family clinics at CTC; early ART initiation at TB clinics

3) Infrastructural support, including renovations and supplying medical furniture

4) Support of materials, including installation of laboratory equipment and gap filling of ART and OIs drugs

5) Regular assessment of standard of care related to ART and providing feedback to the health care providers and RHMT and CHMT members

6) Strengthen the innovative District Mentorship Initiative by recruiting additional district mentors and conducting a joint mentorship program with the ICAP mentors with the aim of building the capacity of the district mentors

7) Financial support awarded to sub grant partners, including hiring of additional staff, as needed

ICAP will support retention of patients initiated on ART by:

1) ART adherence counseling by health care providers and peer educators who are PLHIV. Data from the last fiscal year show that peer educators have traced up to 70% defaulters and have been successful at re-engaging them into ART

2) Conducting and strengthening outreach treatment services

ICAP will continue tracking and evaluating clinical outcomes and other performance data through regular program monitoring and evaluation. Data will be generated from sites on a monthly, quarterly, and annually basis. Generated data will be compiled, analyzed, and shared with sites, districts, and regions during quarterly data sharing meetings and during regular site support visits for the purpose of continuous quality improvement

ICAP will collaborate with Tanzanian Health Promotion System (THPS), a local NGO founded by ICAP, RHMTS, and CHMTS to establish local ownership and, hence, sustainability of the program. ICAP will continue building the capacity of RHMTs and CHMTS to improve ART service planning, implementation, and evaluation. Additional COP 2012 funds will go to support ART in Mtwara, following closure of CHAI in the area. While treatment services will be implemented, the partner will focus on developing local skills for transitioning activities to the government.

At the national level, ICAP will continue to provide technical assistance to MOHSW to develop and review pediatric HIV guidelines and training curriculum for HCWs, as well as participating in technical working groups and partners meetings.

The implementing mechanism will contribute to scaling up pediatric treatment for HIV infected children 0-15 years of age in order to reach at least the 10% target of all those who are initiated on ART within all ICAP supported CTCs. ICAP will work with RHMTs, CHMTs, and health facilities in rolling out the new WHO guidelines to initiate ART for all children less than two years of age. The provision of a quality, comprehensive, family-focused, and sustainable pediatric ART program will be achieved through formal training of service providers and supervisors (RHMTs, CHMTs, and district mentors), provision of regular clinical system mentorship and joint supportive supervision, integration with other HIV/AIDS programs areas (PMTCT, PITC, TB/HIV and APSS, laboratory, and pharmacy), as well as linkages with community-based organizations, community mobilization, and having child participation in all ICAP supported care and treatment clinics.

As part of the innovative models, ICAP will assist in strengthening and establishing 18 child-friendly clinics to create a conducive clinical environment where the entire family with children can be regularly assessed and pediatric clinical equipment, including toys and learning materials, are available for the clients; this model will be linked to the pediatric and adolescent psychosocial support groups to further reduce lost to follow up, improve long-term outcomes, and facilitate transitioning to adult services. ICAP will continue integrating the provision of ART at RCH clinics through the establishment of the RCH platforms at 15 high volume sites with the aim of making HIV care and treatment services accessible for the mother and child in a one-stop shopping concept. This, in turn, will improve pediatric ART service by creating a friendly environment for the clients (the mother and child), therefore leading to better adherence and retention on ART. The RCH platforms will also be linked to nutrition support programs and other community based activities, which again will enhance the pediatric ART service positively, i.e. increasing enrollment, initiation of ART, and retention into care and treatment.

Efforts will also continue to strength the national pediatric care and treatment M&E through collaboration with USG and non-USG partners. The site level data collection, analysis, and use for continuous quality improvement shall be strengthened through on-site mentoring of health care workers, data clerks, and data managers. Data sharing during monthly multi-disciplinary teams and quarterly regional and district data review meetings shall be continued.

ICAP will collaborate with Tanzanian Health Promotion System (THPS), a local NGO founded by ICAP, RHMTs/CHMTs to establish local ownership and hence sustainability of the program. ICAP will continue building the capacity of RHMTs and CHMTs to improve ART service planning, implementation, and evaluation while supporting the incorporation of activities into the comprehensive council health plans.