The overall goal of the project is to improve the quality of HIV care, treatment, and support services while working towards the sustainability of ongoing programs in Tanzania. The main objectives are to improve access to quality PMTCT services for HIV positive pregnant women in Mwanza and Mara regions; increase access to treatment for HIV/AIDS through ARV drugs and services for HIV positive people; and build and strengthen technical and institutional capacity of local partners for the sustainability of health and HIV/AIDS service delivery.

The program will contribute to the various principles and goals as outlined in the PF strategy in support of the national response to HIV/AIDS. The PF supports national plans and emphasizes capacity building to strengthen the ability of stakeholders to plan, manage, and improve a sustainable national response to HIV/AIDS.

The target population will be the general community, especially adult, pediatric, and pregnant women. CSSC will focus on building and strengthening the technical and institutional capacity of the district councils and LPTFs to effectively plan and coordinate comprehensive HIV/AIDS services, collaborate with councils and other stakeholders to ensure decentralized HIV and health programs are aligned with national guidelines, and build linkages between facility and community based programs for continuum of care and sustainability.

M&E will include methods of verification to track progress and measure the effectiveness of the program, which will be implemented through supervision, data collection, and verification reports. CSSC plans to procure another vehicle as the existing fleet is inadequate for effective support, monitoring and supervision of the 9-10 sites added for COP 2012.

CSSC will continue to collaborate with the district councils to support LPTFs to link and strengthen collaboration with the existing community care and support groups to intensify patient identification, support adherence for ART and TB treatment, follow-up of patients, improve clinical and nutritional mentoring, and increase regular supportive supervision. The limited engagement of health personnel in HBC services necessitates the involvement of community support groups and the community at large in the provision of these services. There are a number of challenges and gaps, which have been noted, that need to be addressed to effectively improve linkages between the health facilities and the communities in order to facilitate efficient, seamless, and effective referrals.

CSSC will work in four districts, to address challenges identified during regular supportive supervision and mentorship. CSSC will hold coordination meetings with stakeholders and collaborate with community care and support groups. CSSC will also perform community advocacy for HIV services and capacity building, through training of health care providers. The program will focus on training 40 adherence counselors to maintain and improve patients ARV adherence, execute TB case findings, and conduct proper follow up of patients in the community. It will continue to provide on-site TA and mentorship to staff in order to improve patient retention and adherence counseling for treatment and follow-up.

The program will also train a minimum of four peer educators and lay counselors from each LPTFs in order to support the clinical teams at the CTCs to improve exit interview counseling and follow-up of patients in the community. Further, the program intends to support the LPTFs to strengthen and establish PLHA support groups at the facility and community levels that link with other support groups, encourage new enrolled patients to adhere to treatment, track lost to follow-up, etc.

CSSC will make use of existing structures and leadership at the council and community to advocate and sensitize the community on the use of available CTC and PMTCT services. Regular quarterly program review meetings, which include the district council teams, LPTFs CTC staff, and the program team, will be held to review and discuss the information and data collected from the sites, patient enrollment and retention status, program implementation challenges, and strategies to rectify them. CSSC will also support biannual stakeholders meeting for the four districts to share and discuss the program implementation status, areas for improvement, collaboration in HIV/AIDS and other services, and future sustainability.

In order to effectively involve the community in supporting HBC services and patient adherence to treatment, collaboration with the district councils to plan two campaigns on PMTCT, EID, CTC services, and adherence to ARVs within the four districts will be initiated. Further BCC materials will be developed and disseminated for the purpose of educating, sensitizing, and promoting self care and adherence to ARVs and widely shared information on available care and treatment services. The developed materials will be distributed during community sensitization meetings, at LPTFs-CTC and RCH clinics, and to remote and hard to reach areas. Periodic review and documentation of the achievements and challenges of HBC services will be done for the purpose of sharing and planning.

CSSC will continue to strengthen TB/HIV collaborative activities in the 17 supported LPTFs, including RCH units focusing on proper screening using nationally adopted screening tools and identifying, referring, and treating TB/HIV co-infections according to the national 3Is strategy scaling up initiative. Through strengthening the referral system between CTC and TB units, the entry points for HIV prevention, care, and treatment will be effectively utilized. To facilitate the implementation of this strategy, CSSC will ensure constant availability of TB screening tools in potential entry points (CTC, TB clinics, and reproductive and child health unit), sensitize facility staff to administer TB screening tools during clinic days, and link TB suspects with laboratory services. Moreover, CSSC will also support the referral of TB suspects with negative sputum to the nearest available chest x-ray services for further diagnosis.

CSSC plans to improve the linkages between CTC and TB units to properly manage CTC clients diagnosed with TB/HIV co-infection. Emphasis will be made on TB infection control, including increasing the number of LPTFs managing TB/HIV co-infection under one roof as an effective infection control strategy. Other infection control strategies will focus on having a BCC program at both the facility and the community level using existing volunteer groups. To facilitate this, CSSC will equip 20 HBC providers with skills on intensified case finding and proper follow-up of TB suspects in the community.

With regard to building the capacity of the staff in TB/HIV co-infection management, CSSC aims to train 20 staff from these facilities on 3Is protocol based on the national curriculum, which includes implementing three facilitators for five days, as well as linking them with training opportunities offered by other TB/HIV implementing partners. In addition, CSSC will collaborate with MOHSW and Bugando Medical Center to conduct training for 20 LPTF laboratory staff on AFB smear for TB diagnosis. CSSC will continue to equip the staff with knowledge and skills on TB/HIV co-infection management through routine on-site mentorship, technical assistance, and quarterly joint supportive supervision in collaboration with district TB/HIV focal people and other TB/HIV partners to ensure sustainability of the TB/HIV program.

CSSC will support the refitting of four LPTF TB units, four TB diagnosis microscopes, and provision of national guidelines and job aids. CSSC will implement the national TB/HIV M&E framework and tools in tracking the progress of the TB/HIV collaborative activities in all 17 LPTFs, including facilitating linkages of M&E activities with CQI activities for improving good patient outcome levels by providing good clinical and health practices.

From each LPTF, two staff will be oriented on proper documentation of TB/HIV cases, transcription of TB/HIV information into the CTC2 form, and following-up accurate data filling that will be used for generating monthly and quarterly reports. Furthermore, CSSC will implement planned TB/HIV activities based on best practices and lessons learned from the first year, including improved administering of the TB screening tool, good clinical practices, and establishment of under one roof TB/HIV management in two sites of Sengerema.

CSSC will support the 17 LPTFs in integrating pediatric care and support services into MNCH services to improve access for children to HIV/AIDS care and support services, including EID, nutrition assessments, growth and developmental assessments, adherence, and psychosocial counseling to optimize the quality of life for HIV infected children and their families. This integration is cost effective because it creates a system whereby HIV exposed infants and infected children access services in one clinical setting, which reduces the need for referrals and shifting service providers.

CSSC will strengthen and support linkages into pediatric care and support services for HIV exposed infants and infected children identified in potential catchments areas (such as ANC, MCH and RCH clinics, labor ward, pediatric ward, OPD, outreach services and community) to increase the pediatric enrollment rate. To increase pediatric enrollment, CSSCs clinical team will conduct on-site mentorship and TA visits on a monthly basis in all supported LPTFs to equip staff with skills in improving pediatric care and support services according to the national guidelines, including EID, preventing and treating OIs, adherence, clinical monitoring and management of infected children, facility-community linkages, and integration with MNCH services as well as PWP activities. In addition, LPTF staff will be mentored on how to integrate HIV services, such as EID, during outreach MNCH services and link with local OVC partners.

Quarterly joint reviews with other implementing partners and district mentors will be conducted in monitoring the quality of services offered as well as provision of essential equipment, such as pediatric BP machines, weighing scales, tape measures, and oxygen concentrators to improve the quality of pediatric care services. Furthermore, essential reference materials, including job aids and guidelines for pediatric care and support services, will be supported by CSSC.

CSSC plans on training 30 staff on EID for six days using the national guidelines. To increase retention and tracking of children enrolled into pediatric care and support, CSSC will engage and orient existing lay counselors and community groups in four supported districts to participate in increasing pediatric enrollment. CSSC will also develop and support LPTFs with tailor-made client tracking forms, which will be used to capture details for demographic information and allow for easy follow-up and tracking of the enrolled children in the community. CSSC will strengthen laboratory services in supported LPTFs, including linkages to Bugando Medical Centre Reference Laboratory, for CD4 percentage measurement and EID. CSSC will support transportation of the collected DBS and CD4 samples to Bugando and also facilitate the communication of results from the testing facility to increase the turn-around time. Procuring pediatric OI drugs through a buffer system will help deal with OI drug shortages at the national pipeline.

To raise awareness of the importance of enrolling pediatrics into care, CSSC will use IEC materials to sensitize and promote pediatric enrollment. One community group per district will be involved in promoting enrollment. CSSC will also support the establishment of pediatric friendly clinics in four district hospitals to provide friendly and conducive environments for service provision, eventually leading to an increase of retention rates of pediatrics.

CSSC will continue to focus mainly on strengthening HIV/AIDS related laboratory services in the supported districts, to improve the quality of clinical assessments and monitoring of enrolled clients.

To achieve this, CSSC will continue to support facilities with laboratory equipment, reagents and supplies to fill the gap during national stock-outs, and procure 15 Hemoglobin analyzers to support facilities identified by a high volume of enrolled clients and inadequate laboratory equipment.

CSSC will also continue to print and distribute job aids, guidelines, SOPs, reporting tools and other reference materials to guide and standardize laboratory services in the supported facilities. In addition, CSSC will strengthen the transportation of DBS samples and results to and from the Bugando PCR laboratory, shortening turnaround time of DBS results by entering into contractual agreement with relevant stakeholders.

For sustainability, CSSC will strengthen the Regional and District Health systems in overseeing laboratory services, including troubleshooting equipment problems, conducting joint supportive supervision on quarterly basis in each of the supported District, and providing technical assistance in creation of a line item for lab equipment maintenance in the Comprehensive Council Health budget. CSSC has budgeted for Planned Preventive Maintenance of selected laboratory equipment, especially CD4 count machines, during the transition of financial responsibility.

CSSC will mentor and coach district laboratories on quality improvement through the Strengthening of Laboratory Management Towards Accreditation (SLMTA) process, with a target of at least one laboratory (Nansio District Hospital Laboratory) achieving one STAR WHO stepwise accreditation.

CSSC will focus on increasing access and utilization of PMTCT services in the 17 LPTFs in line with the PEPFAR country strategy, Global Health Initiative and related MDGs (3, 4, and 6) as well as improving access to efficacious prophylactic interventions to prevent transmission of HIV to infants. Strengthening tracking systems of HIV-positive pregnant women and exposed infants, increasing access to both HIV staging and ART for eligible pregnant women, and strengthening linkages of HIV infected pregnant women contribute to the full continuum of HIV care. So far, CSSC has managed to build and strengthen working relationship with HIV/AIDS stakeholders in supported Districts with a particular emphasis on increasing PMTCT uptake. Moreover, CSSC has advocated for the integration of EPI/HIV services to improve maternal and child survival. CSSC plans to conduct the following activities: counseling and testing of 80% of pregnant women attending Antenatal Clinics to increase the number of pregnant women with known HIV status, and providing Antiretroviral therapy to all HIV infected pregnant women and prophylaxis to HIV exposed infants within 72 hours after delivery. This will be done cost-effectively using both existing skilled facility staff and national supply chain systems for PMTCT related commodities such HIV test kits, reagents and ARVs to reduce unit cost per client. In addition, linkages between RCH and CTC will be strengthened to improve access for clients to CD4 testing, ART, adherence and other care and support services. Volunteer groups will be engaged in facilitating bi-directional linkage and improving retention rates of clients. Biannually, CSSC will involve 4 community groups (1 from each District) that are comprised of 10 people, each to mobilize and sensitize the community by using songs & cultural dances for 3 days. Groups will also address barriers that hinder PMTCT services uptake such as low male involvement, gender based violence and undesirable traditional practices such as widow inheritance and cleansing which are common practice in the program area. Also, IEC materials will be developed and distributed to promote PMTCT services uptake in all 4 supported Districts. For effective implementation of planned activities, a 12 day PMTCT training will be conducted for 30 staff from supported LPTFs using 6 facilitators as per National Curriculum. LPTF staff will be equipped with PMTCT skills such as feeding counseling, care and supportive services and an effective bidirectional referral and tracking system of clients to improve retention rate. Furthermore, accurate documentation, data use and reporting and timely ordering of PMTCT related commodities will be emphasized during quarterly on site mentorship. Also, LPTFs staff will be mentored on implementing EPI/HIV integration. Task shifting strategies will be utilized in LPTFs with shortage of staff. In addition, CSSC will build the capacity of regional/district health systems to sustain the services provided through engaging 2 Regional and 4 District RCH Coordinators from the 4 Districts and Regions in mentorship/supportive supervision visits to monitor the quality of services offered twice a year. CSSC will also facilitate the availability of national guidelines and job aids to the supported LPTFS as well as essential equipment for PMTCT service such as BP machines, weighing scales and HB machines for quality service delivery.

CSSC will strengthen health systems by improving HIV clinical monitoring and management, availability of supplies, and CTC community linkages. To address supply shortages, CSSC will conduct quarterly on-site mentorship visits of LPTF staff that will focus on proper inventory management. In addition, CSSC will also build capacity of two pharmacy staff on pharmaceutical management for three days, while two additional staff will be trained on pharmacovigilance for three days to improve therapeutic management of adults on treatment. Therapeutic committees within the four district hospitals will be strengthened to improve information sharing on drug issues. In order to buffer the shortages of supplies, CSSC will procure these commodities on the basis of 30% of patients on care and treatment.

Infrastructure support includes pallets and shelves for the 17 LPTFs, four air conditioners, and 17 wall thermometers for temperature monitoring. To strengthen laboratory services, two six-day trainings will be held for 20 participants using three facilitators each on QA system and inventory management. Also, the CSSC laboratory focal person will conduct a five-day joint on-site supportive supervision training on a quarterly basis within each district, as well as providing job aids, SOPs, and guidelines to improve lab services. In addition, biochemistry machines and hematology analyzers for the two newly established district hospitals will be procured, along with supporting routine preventive maintenance for the CD4 and biochemistry machines and hematology analyzers, which are in five supported hospitals.

To improve patient flow and services, refitting of four CTCs will be done in highly congested LPTFs. A six-day basic ART training for 60 staff using 10 national facilitators will be held to improve clinical outcomes of adults on treatment. CSSC will also advocate to the facility owners on the importance of allocating key CTC staff, including adherence counselors and community outreach workers. The CSSC clinical team will provide on-site mentorship and TA to the LPTFs for five days on a monthly basis to equip staff with skills in clinical assessment and management.

Support of triage equipment, such as furniture, BP machines, weighing scales, and thermometers will be purchased to increase effective clinical monitoring of patients. Through its vast community experience, CSSC will increase retention of patients on ART through strengthening CTC-community linkages, such as patients attachment to PLHA support groups and the use of two lay counselors, each in the 17 CTCs, to give health talks during CTC clinics. To improve data demand and information use (DDIU), CSSC will purchase six computers and printers for six LPTFs. Moreover, DDIU will be used as part of the CQI strategy to activate CQI teams in four district hospitals to improve patient outcomes.

CSSC will conduct two six-day trainings to 20 LPTF staff, with three facilitators each, on data collection and CTC2 database/IQ tool. Also, CSSC will train 20 district mentors for six days using seven facilitators, as per the national curriculum, who will be engaged in quarterly joint supportive supervision to promote sustainability of ART service delivery. To improve programmatic efficiency, three CSSC staff will continue to strengthen LPTFs key operating systems, such as human resources and financial grants management through on-site mentorship and TA.

According to the transition plan agreed by CSSC, all 46 health facilities in Mwanza providing comprehensive care and treatment services will be transitoning from the LEAD project to CSSC.