Dar es Salaam Region is the most populated in Tanzania with 4 million people and an HIV prevalence rate of 9.7%. Since November 2004, the program has successfully enrolled over 116,000 PLHIV into comprehensive HIV care and support whereby over 76,000 have been initiated on ART. The program has been a role model in providing quality HIV counseling and testing in 50 private and public health facilities as well as providing PMTCT services to 180 reproductive and child health clinics. The Harvard PEPFAR program is now transitioning its obligations in program management and clinical services to Management and Development for Health (MDH), which is a local institution. In FY 2012, MDHs goal is to build district capacity to provide quality HIV ART services through increasing access to and maintaining patients on ART by addressing critical gaps in service coverage and strengthening capacity of the CHMTs. MDH seeks to accomplish the following objectives: (1) Maintain quality of care and treatment services within the existing 50 public and private sites in the Dar es Salaam; (2) Support districts to identify innovative and cost efficient models of care with limited resources and to identify priority areas in program support; and (3) Strengthen health systems to improve efficiency and effectiveness. MDH will build up the existing M&E system where all HIV indicators will be reported using data from the available MOH tools. Health care providers will be trained on data management and utilization for QI. MDH will use a supervision checklist to ensure data quality. For data analysis, MDH will generate, process, and set outcome indicators through the already merged clinical data and national CTC2 database as feedback to site staff, districts, and MOHSW.

MDH will maintain and strengthen provision of integrated high-quality HIV care and support aimed at extending and optimizing the quality of life for HIV-infected clients and their families. These services will include TB screening, diagnosis prophylaxis and treatment, STI screening, including cervical cancer primary screening, psychosocial counseling, gender based violence services, and food by prescription. The ability to implement these services will be achieved through clinical mentorship of health care providers. Training and needs assessments will be undertaken and offered to new staff using both the national basic ART and refresher ART training where all the trainings have components on opportunistic infections diagnosis, treatment, and prevention. The providers will be trained to monitor and screen for the development of opportunistic infections, including TB and ART toxicity at all patients visits. In order to achieve the above, health systems will be strengthened. District laboratories will be strengthened to perform all tests as stipulated in the national guidelines, including CD4 counts and percentages, hematology, and chemistries as well as including other important OIs tests, such as cryptococcus antigen test and Toxo IgG. The comprehensive care package will also include prevention and treatment of other HIV related illnesses, including malaria and diarrhea. These will be targeted innovatively through prevention messages to the patients in health talks and provision of IEC materials, provision of insecticide treated nets (ITNs), and provision of safe drinking water. Gender based violence (GBV), which is a new component of HIV care packages, will be established in care and treatment health facilities. GBV services will include post exposure prophylaxis (PEP) provision, STI prophylaxis, provision of emergency contraception for women of reproductive age, medical treatment of injuries, trauma counseling and psychosocial support, and referral of survivors to network partners for support. Integration with other key services (PMTCT, RCHS, TB etc):

Nutrition assessment, counseling and support (NACS) activities aim to optimize the quality of life of PLHIV by assessing their nutritional status and providing counseling and support according to their specific condition. NACS programs involve screening for malnutrition to identify those at risk of malnutrition and those malnourished, provision of nutrition counseling to all new cases, and cases that need this service. On availability, all severely malnourished cases are treated with therapeutic food and moderately malnourished cases are supplemented with fortified blended flour. Prevention with positives has been one of the key areas in reducing the risk of transmission and re-infection among HIV positives. MDH will strengthen the provision of quality comprehensive packages of prevention with positives interventions, including strengthening the adherence and disclosure counseling, with more emphasis on making patients disclose their status to their partners, which in return, will enhance patient adherence to medication and improve the goals of ARV in general. Furthermore, sites will establish patients psychosocial clubs for both adults and pediatrics. Risk reduction will be given more emphasis in the health talks given to patients while waiting for services.

According to NTLP report of 2008, Dar es Salaam is found to have the highest number of TB cases nationally (22%). MDH supports 50 health facilities in the region offering TB/HIV services, of which 17 sites offer TB/HIV services under-one-roof. This accounts for 28% of all TB/HIV under-one-roof PEFPAR supported sites. The MDH Quarterly report of April-June 2011 states a total of 36,018 patients received HIV care and, out of those, 32,893 patients (91.3% vs. target of 80%) were screened for TB symptoms. Working closely with MOHSW and NTLP, MDH was also involved in the development of a national training curriculum for the implementation of 3Is (TB Infection control, Intensified TB case finding, Isoniazid prophylaxis), while two MDH supported sites currently are involved in a phased IPT implementation. Along with the NTLP strategies of establishing mechanisms for collaboration between HIV and TB programs, of which reduce the burden of TB in PLHA and the burden of HIV among TB patients, the following activities will be implemented in FY 2012: (1) Support of collaborative TB and HIV/AIDS programs through establishing TB/HIV exchange information meetings between CTC and TB staff at the health facility level by meeting with the TB/HIV coordinators, DTLC, facility I/C and Care and Treatment Center personnel in charge;

(2) Collaborate with Dar es Salaam municipalities to expand under-one-roof TB/HIV services in all MDH supported ART initiating CTCs with TB clinics; (3) Support TB infection control by collaborating with PATH and NTLP through RTLC/DTLC in provision of health education to staff and patients, in addition to displaying TB/HIV related posters; (4) Collaborate with NTLP and other partners to support the implementation of the national 3Is program through training and mentorship of HCWs on the 3Is at CTCs, PMTCT/RCH, VCT, IPD, and OPD; (5) In collaboration with municipalities, the program will continue strengthening the strategies for improving intensified TB case findings by performing on-the-job trainings, clinical mentorships, and supportive supervisions to attain a 5% target of CTC patients on anti-TB; (6) MDH will continue collaborating with NTLP in rolling out a phased IPT implementation to the identified facilities; (7) Collaborate with NTLP in training and mentorships of HCWs in the TB diagnosis of children using the newly developed pediatrics TB/HIV management guideline; (8) Support URT in the implementation of advanced TB diagnosis strategies by putting into place systems and SOPs for identification of patients who require the services and logistics for sample transportation and results; (9) Provide technical support during supervision to ensure quality of care is given to TB/HIV co-infected patients; and (10) Support and assist facilities activities for M&E by training site staff on quality documentation and timely reporting of nationally revised TB indicators.

Pediatric care and support aims to extend and optimize quality of life for HIV infected clients through provision of clinical, psychological, social, and prevention services. A quarterly MDH report from June 2011 showed that the program had a pediatric enrolment of 9.3%, which is below the CDC and national targets of 15% and 20%, respectively. Geographical scale up of EID will increase from 80 to 120 (60%) sites and will be prioritized to help achieve the national target of reaching 65% of HIV exposed infants. The quantification and forecasting of DBS supplies into the district supply chain will be strengthened. MDH will support transportation of DBS samples and results. RCH staff will be trained and mentored on EID implementation, data recording, and reporting. The program will improve follow-up, retention, and referrals of HIV exposed and enrolled infants and children by promoting the use of RCH and CTC data at facility level. District CHMTs will be supported to improve coordination and linkages of HIV pediatric services for OVC, TB/HIV, and EID programs. Fears of clinicians starting children on treatment will be addressed through clinical meetings, continued medical education, mentoring, and technical supportive supervision. MDH, in collaboration with NACP, are in the process of planning a PITC mentorship program at all pediatric entry points, such as malnutrition wards, IPD, OPD, CTC, and ANC/RCH, with the aim of increasing the number of pediatrics with known HIV sero-status in the community, and thus improve pediatric enrollment in CTC. Sensitization meetings with CHMT, the health facility in charge, and site managers will be conducted with more focus on pediatrics. Advocacy of important messages to encourage breastfeeding will be promoted. The program will ensure constant HIV supplies and commodities, including availability of HIV rapid test kits, DBS kits, testing reagents, hemcue machines, and point of care/CD4 machines. ARV and non-ARV medications will be quantified and procured by the district supply chain office and the program supply chain coordinator will be assisting the district team in ensuring sites have enough back up stock. Other supplies will include recording and reporting tools, such as CTC1 and CTC2 cards, HIV exposed cards, TB scoring charts, all HIV registers, and their summary forms. These tools will be supplied from the district and, in case of shortages, the program will have a few copies as backups. Assessments and referrals to nutritional supplements, like nutty pest and plumpy nuts, to malnourished children will be made. For adolescents with HIV, the program will continue to educate teenagers on HIV preventive methods during their clinic visits. Youth will be encouraged to formulate their own support groups and to encourage one another, which will facilitate better learning. A youth-friendly clinic environment and supportive measures towards adherence issues will be created. Program staff will conduct quarterly joint technical supportive supervision of the sites with district teams and program coordinators. On-site mentoring of service providers will be performed. Community linkage services in under five child survival intervention and support services, like pain and symptoms management, insecticide treated nets project and safe water initiatives, will be taught through on-site training and mentoring, advocacy, community mobilization, and establishment of coordinating committees.

MDH will support HLAB through a series of mentorship and capacity building activities towards laboratory accreditation of five district labs and three municipal laboratories (Amana, Temeke, and Mwananyamala). These activities will focus on accurate forecasting, planning and budgeting for laboratory program activities; expanded coverage of laboratory testing in the geographic area; development of training activities focused on laboratory management; and quality assurance of laboratory testing.

Using a district approach, MDH will support scaling up quality PMTCT services by providing TA through district PMTCT teams conducted through on the job trainings and mentorship. This will include couples counseling, counseling on FP, and infant feeding targeting 100% RCH site coverage. The program will focus on improving PMTCT effectiveness through provision of more efficacious regimens to all HIV positive women and their infants, according to new national guidelines. Clinicians at MNCH clinics will receive basic national ART training to build their capacity to initiate ART. The partner will verify that MNHC clinics have the capacity for an efficient supply chain system for ARV and OI drugs. In order to ensure that all ART eligible women are started on HAART, procurement back up reagents for CD4, hematology and chemistry tests will be readily available, enhancing timely testing, lab staging for ART eligibility and, eventually, ART initiation for all eligible pregnant women. PMTCT-ART integration with emphasis on point of care CD4 (PIMA) evaluation (once evaluated and endorsed) will support health facilities at all levels to perform clinical and lab staging for pregnant women who are eligible for ART, including hematology and chemistry tests in order to initiate 40% of all HIV positive pregnant women on ART within RCH. Cotrimoxazole prophylaxis will be used for managing and preventing OIs and follow up on mother-infant pairs. The program will conduct ART, PMTCT, and adherence trainings and mentorship to RCH staff on providing ART and more efficacious regimens for ineligible women; provide guidelines and SOPs to facilitate implementation of revised WHO PMTCT guidelines; and support transport logistics of laboratory samples and PMTCT commodities to and from the RCH facilities. The partner will conduct a PMTCT program evaluation of the ART initiation and patient retention in the PMTCT-ART integration model. In order to increase access, the program will link with EngenderHealth and seek their experience to improve the integration of FP and HIV at ANC, delivery, and postnatal periods as well as in FANC services. The program will identify gaps in maternal health services and support procurement of essential equipment, such as hemocue and blood pressure machines, weighing scales, and delivery beds. Coordination with Jhpeigo will complement an EmOC package through capacity building of RCH staff, and back up commodities for quality delivery of EmOC. Minor renovations of ANCs and labor wards will also be done, as needed. HCW will improve the engagement of men in RCH services by providing invitation cards to women for their partners, encourage the formation of support groups for males and mothers (through work with Mothers to Mothers), and rely on religious and community leaders for community sensitization on strengthening family-centered approach RCH services. The program will support various initiatives to promote health seeking behaviors for reproductive services through mass communication, use of cell phone SMS, and IEC and BCC materials to inform and remind communities of the importance of attending health facilities for RCH and other health issues. The program will build capacity of CHMTs to take leadership in the coordination and supervision of PMTCT services. The district teams will mobilize women and partners within their communities to access PMTCT services, with particular focus on WHO prongs 2-4.

MDHs main objectives will be to utilize existing strengths to support the provision of quality ART services to reach more people who are in need of ARV drugs, improve ART M&E systems, ensure availability of ARV drugs and drugs for OI prophylaxis and treatment, establish efficient systems within the management of the supply chain for ARV and other drug procurements, and ensure strong laboratory services and infrastructure are established. MDH will provide oversight and technical support to the MDH district medical officers to provide ongoing technical support to clinicians in all care and treatment clinics of Temeke district through frequent supportive supervision and mentorship visits. Provision of OI prophylaxis and provision of PEP services will also be implemented. In order to continue capacity building and service delivery, MDH will conduct various trainings focusing on clinical mentorship and supportive supervision. The district approach model will be used to conduct on-site supervision to the sites supported by the program, which will be done by the MDH district teams who work hand in hand with the respective council health management teams (CHMTs), according to the national supportive supervision and mentoring guidelines. The supported clinics will be assisted technically to implement M&E using the national patient monitoring tool, i.e. CTC2 database both in paper based and electronic forms. A strong monitoring and evaluation program is critical and will be incorporated from the beginning. District-level capacity will be developed so that district personnel can use the data collected for program quality improvement activities at the sites and local, decentralized decision-making can be made. MDH, using its existing technical capacity on quality improvement, will ensure that all sites will be improved based on standardized measures of quality in technical service provision. All sites will have quality improvement plans and active quality improvement teams regularly reviewing the core indicators and developing quality improvement projects to address the gap identified in quality of care provided. In order to support and improve the retention of patients, health education for patients will be given daily during visits and pairing of nurse counselors to patients will be emphasized. The tracking system will be strengthened to allow patients to be seen by the same clinician/counselor during their follow-up clinic visits, thus improving communication, openness, and trust between the patients and health providers. This will improve adherence as a whole. MDH also supports shared disclosure and adherence counseling, which will improve the overall clinical outcome. MDH will build districts capacity in program management through a joint assessment of ART service needs. Conducted together with the CHMT, MDH will help to identify district strengths and limitations in health programs and systems. The district officials will be kept informed about the progress of the program through regular feedback meetings, thereby keeping them engaged on an ongoing basis. In order to build broader support for ART services, MDH will use influential figures to conduct intensive community sensitization and promotion of activities, which will help build demand for these services. MDH will also support district capacity in the maintenance of quality HIV care and treatment within the existing public and private sites.

Currently, 7% of patients enrolled in Dar es Salaam who on ART are children < 15 years of age. Up to 80 (40%) of RCH sites in the region implement EID with about 60% of children born to mothers living with HIV being tested for HIV using DNA PCR. There are no health facilities that concentrate on pediatric HIV care and treatment; rather all supported sites have a special day dedicated for pediatric services. The program has a member in the pediatrics care and treatment TWG and has taken and active role in reviewing the national guidelines on the management of pediatric HIV/AIDS. The program has also embarked on the creation of pediatric friendly clinics. In FY 2012, the following activities are to be implemented: (1) Consolidate implementation of the revised WHO pediatric ART guidelines; scaling up pediatric enrollment in ART to 2,163 new children; (2) Increase identification and diagnosis of HIV in children through expanding EID and PITC coverage, while creating linkages with CTCs, RCH, TB/TB-HIV clinics, OPDs, and IPDs;

(3) Conduct comprehensive pediatric HIV care and treatment trainings. The program will identify and develop mentors in pediatric HIV care to deploy them to facilities to mentor and standardize quality of pediatric HIV care, eligibility assessments, and ART initiation; (4) Implement mentorship activities on new pediatric WHO guidelines for ART, whereby all children below two years of age will be initiated on ART. Furthermore, regular mentorship will be done with a focus on management of OI infections in children, including diagnosis and management of TB. All HIV exposed children will receive cotrimoxazole to prevent OI infections. The program will also use these funds to build capacity of site and district pharmacists in quantification and ordering of pediatric ARV formulas to ensure a constant supply; (5) Consolidate implementation of QI projects on pediatric HIV care to ensure high quality of care is maintained; (6) Develop counselor-mentors on pediatric counseling, adherence, disclosure, and nutritional issues with the goal of deploying them to sites to transfer their knowledge and skill set, help standardize care, and assist with difficult cases; (7) Work closely with the DMOs/DACs/RCH to make use of the existing national tools to conduct supervision and M&E activities. The program will make use of the existing district teams to pair up with CHMTs and provide technical support to the districts in coordinating these activities. (8) Work with DMOs/DACs/RCH Coordinators/district pharmacists/district lab coordinators to ensure that all district CD4 FACS Caliber machines (which are located in all three district labs), zonal viral load machines, and DNA PCR machines at MNH lab work smoothly to process CD4, VL, and DNA-PCR tests, respectively for enrolled and exposed children. Availability of reagents and other commodities to support sample collection and processing will be ensured at all times, while the flow of investigation samples and results to and from the sites to the labs will be ran efficiently; and (9) Develop adolescent support groups while engaging DACs/RCH Coordinators to recognize, support, and encourage adolescent support groups by providing health education and incorporating them into PwP activities.