HJF and its local body, HJFMRI, have worked in Tanzania and East Africa since 1998. It supports local organizations with technical expertise in clinical, lab and M&E and has extensive experience in conducting scientifically rigorous studies to monitor and improve the quality and efficiency of services. In Tanzania, it supports the Mbeya Referral Hospital (MRH) and Regional Medical Offices (RMOs) in four regions to implement comprehensive HIV services: Mbeya, Ruvuma, Rukwa, and Katavi; with an HIV prevalence between 4.5-7.9% and a total population of 6 million. Advanced lab and clinical services are supported through MRH and facility-based services at regional hospitals and district CTCs through the RMOs. HJFMRI focuses on developing capacity of Regional Health (RHMT) and Council Health (CHMTs) management teams responsible for execution of HIV/AIDS M&E plans and to incorporate HIV interventions into their routine plans and budgets.

HJFMRI also supports local community organizations to improve technical competency of service delivery and administrative management. This ensures quality services for clients at all levels and points of care within the regions. To address the needs of key populations and PLHAs, scale-up of care/treatment services, and build capacity of indigenous organizations, fostering local ownership, HJFMRI will continue to support an integrated service platform tying in with the USG/T GHI Strategy.

Regions will be supported to improve quality and efficiency and decentralize services through supportive supervision, on-job mentorship, CQI, and strategic in-service trainings. Routine data collection and monitoring will be undertaken using standardized national tools.

Two vehicles will be purchase under COP 2013 - see vehicle justification narrative.

HJFMRI will ensure a two-way continuum of care between the community and facility. Outreach partners will be responsible for the provision of HBC services, offering referrals to an appropriate facility for clinical services and ensuring that care services reach underserved communities. Static facilities will refer clients to community service providers for social and psychosocial support and basic follow up. HJFMRI, in collaboration with its medical and outreach implementing partners, will strengthen linkages and integration within and outside health facilities and the community. Emphasis will be put on client retention and tracing LTFU in order to increase the number of eligible clients in care and treatment services. The FY2013 COP 2013 targets reaching a total of 49,682 clients with adult care and support services.

HJFRMI will contribute to program sustainability by building capacity of partner institutions and health care providers, as well as promoting community involvement.

The FY2013 COP plans the following activities:

1. Provide integrated adult care clinical services (CTX, STI management, management of diarrhea and pain), linking these clients/services to other services such as FP, CCS, ANC, PNC, and TB/HIV.

2. Use Community Home Based Care (CHBC) providers to trace clients LTFU and link them back to CTC.

3. Strengthen nutritional assessment, counseling and support (NACS) at CTCs and HBC.

4. Ensure availability of care-related diagnostics, mediations, commodities and supplies, including insecticide-treated nets and safe water treatment materials.

5. Support economic strengthening activities to PLHIV through small scale IGAs and facilitate formation of income-generating projects.

6. Strengthen community mobilization activities through individual, small groups and community sensitization to improve local efforts that address GBV, stigma and discrimination and home-based VCT.

7. Strengthen adult care and support services through strategic in-service training, supportive supervision and on-the-job mentorship of CHBC providers in collaboration with local government officials such as District HBC Coordinators.

8. Provide psychological, spiritual support as well as bereavement services to PLHIV and their families, and link PLHIVs with available support mechanisms including PHDP services.

9. Provide prevention services such as partner/couple HTC, condom provision, risk reduction counseling and adherence counseling.

10. Strengthen the capacity of health workers to respond to GBV cases using the GBV and Violence Against Children (VAC) national guideline, trauma and psychosocial counseling, training on proper collection and management of specimens for forensic evidence including post rape care, and management of physical and psychological trauma/injuries.

11. Strengthen M&E systems at the national and district level to capture information on provision of GBV services, including PEP within health facilities.

12. Improve M&E framework by harmonizing data collection tools, data recording and reporting and facilitate the roll out of HBC recording and reporting system, PHDP and new HBC guideline

13. Facilitate HBC stakeholder meetings to discuss program data and share results, experiences/challenges for program improvement and promote ownership and sustainability of services in the four regions.

As of the FY 2012 APR, facilities in the regions of the Southern Highlands supported by HJFMRI screened 93,307 patients for TB, 94% of the target, of which 3,061 were started on TB treatment. In the FY2013 COP, HJFMRI will expand service delivery points and strengthen intensification of case finding, referrals and the practice of proper infection control. TB/HIV activities will be implemented in close collaboration with regional medical partners (Mbeya Referral Hospital (MRH) and Mbeya, Rukwa, Ruvuma and Katavi RMOs) and community groups. The improvement of TB diagnostics and services will continue to be executed with the NTLP, ensuring all activities are aligned with national priorities and policies. The involvement of PLHIV, TB patients and communities in planning and implementation will be critical to success. HJFMRI also continues to participate as a member of the PEPFAR/T treatment partners' group to share in lessons learned and address PEPFAR/T requirements for improving services in TB/HIV management and data quality.

A formal TB cohort review was conducted in 2013 at MRH, showing that introduction of the Gene Xpert MTB/RIF was associated with increased case detection of pulmonary TB, with a greater effect seen in HIV co-infected patients. It was also associated with a reduction in time to TB treatment of about two days. Analysis found that only about 35% of TB/HIV co-infected patients in the TB clinic were on ART. Implementation of a One Stop Shop for TB and ART services in Tanzania shows improvement in increasing the number of PLHIV receiving TB and ART treatment. The Songea Regional Hospital and a few sites in Tukuyu integrated ART into TB clinics recently. In the next year, all TB clinics at the MRH and the regional and district hospitals will be integrated with ART services using this model. Similar cohort reviews are planned for the regions to understand the impact of interventions.

Planned activities for the FY2013 COP include:

1. Scale-up TB/HIV Services at regional health facilities, improve screening, referral and integration of TB/HIV services into ART, HTC, PHDP and PMTCT and strengthen the linkages between RCH and CTC to improve pediatric uptake.

2. Expand quality TB/HIV services with TA to districts through in-service training, and on-the-job mentorship to HCWs on TB control practices and scale up of the three Is, identifying high prevalence/high volume sites in collaboration with RMOs and NTLP for strategic targeting of resources and increasing of trained and qualified staff.

3. Strengthen community-based referrals of TB suspects identified by HBC providers, incorporating TB identification as part of VCT and patient management through HBC.

4. Expand/improve TB lab diagnostics and QA, including fluorescent LED microscopy and placement of new Gene Xpert machines in strategic labs throughout the regions, with TA from the MRH advanced TB diagnostics lab.

5. Expand mobile TB diagnostic and treatment services to hard-to-reach and under-capacitated areas, extending the reach of the successful Mobile Diagnostic and Training Centre.

6. Improve the TB component of M&E system at 150 care and treatment health facilities by increasing the availability and use of national TB screening tools, and provide TA on the proper collection, management, analysis and use of data using these tools, as well as on the execution of routine data audits and chart reviews to improve overall data quality and patient managem

HJFMRI supports local referral to dispensary level health facilities in the implementation of clinical care services for HIV- infected children and their families in Mbeya, Ruvuma, Rukwa and Katavi. Pediatric HIV activities are implemented in collaboration with Baylor International Pediatric AIDS Initiative (BIPAI) and will leverage MOHSW's basket funding and cost sharing mechanisms. HJFMRI will continue to support HCW participation in the Baylor pediatric HIV clinical attachment program, providing clinical mentoring and TA on the treatment of pediatric HIV/AIDS. FY2013 COP funding will expand the number of pediatric service delivery points from the current 149 facilities to provide care to 165,068 children.

HJFMRI has planned the following activities for the FY2013 COP:

1. Expand PCR testing for EID to all PMTCT sites and quick enrolment of HIV+ infants, focusing on instituting fast track protocols to work with families and caregivers. PMTCT, HCT and community groups will work collaboratively to improve access to testing for children at all points.

2. Expand pediatric services in PMTCT and adult programs. Sites will be modified to provide family friendly/centered services and improved referrals between programs.

3. Facilitate regular meetings between HCWs at PMTCT, pediatric and adult out-patient clinics. Specially trained staff in each clinic and in the community will facilitate referrals for children and caregivers, ensuring that community based services are received to improve follow up and management of women and children. Where possible, mother/child pairs will be escorted to health care facilities and/or community based services improving outreach to families and decreasing LTFU.

4. Strengthen and expand nutrition assessments and counseling, including additional training for caregivers in the principles of good nutrition, with an emphasis on better implementation of routine growth monitoring.

5. Develop counseling messages, capacity building and training to discourage high risk infant feeding practices (e.g. mixed feeding, unhygienic preparation/storage of food), directed at service providers, PMTCT programs, out-patient clinics, as well as PLHIV support groups and HBC networks.

6. Strengthen mechanisms for referral of GBV & Violence Against Children (VAC) survivors to respective services (e.g. community NGOs, legal, social welfare, police, safe homes, etc.) using the GBV & VAC national guideline.

7. Hold quarterly Zonal Pediatric meetings in collaboration with Baylor to exchange updates on clinical care issues, provide consultation on difficult cases, coordinate pediatric care activities in the zone, and identify and strengthen linkages.

8. Support trainings and distribution of job aids for nutritional support.

9. Improve the capacity of caregivers on pediatric treatment adherence and developmentally appropriate psychosocial support.

10. Establish a system of treatment supporters who will play a key role in linkages between different clinics and treatment services. and between facilities and communities.

11. Strengthen QA/CQI and mentoring, to ensure the HIV+ children are provided with basic health care and support (e.g. OI prophylaxis and treatment of OIs, screening for TB and related lab services, management of HIV complications and emotional support). All sites will receive regular onsite supportive supervision, QA, and TA visits from joint HJFMRI/Baylor teams, with an emphasis on CQI.

HJFMRI supports facility-level provision of accessible quality laboratory services required for HIV diagnosis, care and treatment, through a tiered structure with a bottom-to-top referral network. Through a comprehensive approach, the HJFMRI supports the expansion and improvement of laboratory capacity at Mbeya MRH, Regional Hospitals, CTCs, and the majority of PMTCT sites and TB clinics.

The FY 2013 COP activities include:

1) Availability of quality laboratory services required for scale-up of ART services: By September 2012, three supported regions reported a total of 140 facilities with lab capacity, 40 in Rukwa, 60 in Ruvuma and 40 in Mbeya. Due to interrupted national support services in this period, HJFMRI plans to fund processes allowing for equipment service and replacement and to strengthen procurement of reagents and supplies to ensure continuous service at sites. To guarantee quality, all lab personnel will be trained on QA processes that include supply planning, budgeting and forecasting, and GCLP. HJFMRI will also expand the reach of the successful Mobile Diagnostic and Training Centre (MDTC), which provides HIV and TB testing along with other OI diagnostics to more remote and under capacitated communities.

2) Access to EID: HJFMRI has been supporting the EID program in partnership with the URT-MOHSW and other partners. To improve access to this service to cover at least 80% of all PMTCT sites in the regions served, HJFMRI plans to install new instrumentation improving capacity and reducing test costs at the zonal EID lab. An improved electronic results feedback mechanism using SMS printers and courier delivery of hard copies is planned.

3) Diagnostic capacity for TB among PLHIV: To reduce mortality due to HIV-related TB, HJFMRI plans to continue support for improved diagnostic services. In the past year, integration of TB/HIV services has proven a successful strategy in effective delivery of services and utilization of resources. Plans to support the availability of LED smear microscopy and Gene Xpert MTB/RIF at high volume CTC sites, which will increase early case detection of TB and can reduce mortality in TB/HIV co-morbidity.

4) Quality Assurance and Accreditation: Provision of timely accurate and consistent laboratory services is a major priority for the HJFMRI Laboratory Program. It will support the implementation of laboratory Quality Management Systems (QMS). Under this effort, the MRH lab is enrolled in an international accreditation process under ISO 15189 while three regional labs and five district labs are enrolled in WHO/SLMTA accreditation process. HJFMRI will continue supporting QMS at these labs through training and mentorships.

5) Transition and Sustainability: the HJFMRI lab program will execute skills transition and promote sustainability through provision of technical and financial support to RMOs. HJFMRI regional lab managers will provide training mentorship and support to MOHSW facilities to increase and strengthen the capacity to deliver sustainable quality lab services for HIV/AIDS care and treatment. Through QMS and particularly SLMTA, HJFMRI will use these processes to set goals which empower facilities as they work toward accreditation. HJFMRI will continue to train/mentor staff and collaborate with partners for transition of skills to the facilities, ensuring quality lab results and improvement of clinical health services.

Data quality and data use continue to be challenges, and are often results of poor data management systems. Quality data are essential to adequately measure client/patient-level outcomes and improve the quality of services provided. In addition, the analysis and use of routinely collected information to inform service improvement are not established processes among many of the indigenous organizations supported. HJFMRI will work with local community and facility based partners though similar though distinct approaches to improve data quality, management systems and data utilization.

Activities planned for the FY2013 COP include:

1. Provide TA to 150 care and treatment health facilities and 665 PMTCT health facilities on the collection, management, analysis and use of clinical and programmatic data in the areas of PMTCT, TB, HIV care and treatment, pharmacy, and laboratory services.

2. Strengthen utilization at existing facilities of the CTC2 electronic medical record established by the MOHSW, and install the CTC2 database at 90 new health centers.

3. Improve clinical staff capacity on CTC2 reporting, including paper-based and electronic-based systems, and use of pharmacy modules to improve service delivery through accurate forecasts of pharmacy and laboratory supplies.

4. Provide TA on conducting routine data audits and chart reviews to improve overall data quality and patient management. CHMTs and RHMTs will be trained to analyze CTC2 reports that will improve the basic quality of care and patient retention.

5. Establish patient cohorts at facilities to train staff on monitoring and measuring mortality, mean and median CD4 counts, missed appointments, and identify contributors to LTFU and site-specific challenges to improve the quality of care provided to patients.

6. Perform biannual assessments of data quality and health management systems at the facility level, through a facility data quality and systems tool available at district and regional hospitals, and develop action plans to address gaps in data management systems and service delivery and assess resources utilization.

7. Conduct joint quarterly supportive supervision in collaboration with local government authorities and/or umbrella organizations to outreach partners, focusing on data quality and review of proper use of national data tools and reporting systems. Provide on-the-job mentorship, strategic in-service training and data review/source verification.

8. Support community-based outreach partners in data analysis in relevant service delivery areas (e.g. HBC, VCT, behavioral prevention, GBV) both for improving services and for measuring the strength of established referral networks.

9. Strengthen the M&E system at the national and district level to capture information on provision of GBV services, including HIV PEP within health facilities, establishing a regular mechanism for data sharing and assessing impact of programs on survivors and taking into account program results and impact at the community level.

10. Develop or adapt existing GBV information management databases to enable storage, analysis and confidential sharing of GBV incident data and established referral pathways.

11. Conduct quarterly review meetings between facility and community partners on joint interventions (e.g. HCT, GBV, ART adherence and LTFU tracing) to strengthen collaboration, ownership and sustainability of program implementation improvement.

Currently, HJFMRI supports VMMC activities in the two priority regions (Mbeya and Rukwa) via static, mobile/outreach and mass campaign approaches in collaboration with the MRH and Rukwa RMO. There are sixteen static sites providing routine MC services in both regions. A total of 72 clinicians have been trained in 24 teams. MRH provides TA to the four Southern Highland regions supported by PEPFAR/T, including training the teams of MC clinicians. More clinicians will be trained in the FY2013 COP , and mobile surgical units procured with FY2012 COP funds will facilitate outreach services to perform more procedures to reach the target of 50,000 clients.

The standard VMMC package consists of advocacy and stimulation of informed demand through mass media and targeted community outreach to include engagement of community leaders. Education on risks and benefits and safer sex practices are provided both through oneonone counseling and group sessions. In addition to the MC procedure itself (provided under local anesthesia), clinical/VMMC teams receive training in waste management practices, wound care and safe healing, pre-op assessment and postop counseling.

Activities planned for the FY2013 COP include:

1. Continue to scale up VMMC services as a comprehensive prevention package that includes counseling and testing, behavioral interventions to prevent new infections, and linkage to PHDP services.

2. Promote female partner participation in MC services to encourage a family-centered HIV prevention approach.

3. Provide quality HCT through individual, group and couples counseling and testing modalities.

4. Strengthen two-way referral and escorting system to ensure all clients tested positive are linked into care and treatment services.

5. Expand mobile services initiated to reach beyond the populations within easy reach of current static. Based on a successful model being implemented by the Makarere University Walter Reed Project in Uganda, fully stocked surgical vans operated by expertly trained providers will be able to reach isolated, rural communities, broadening the access of populations to this service.

6. Utilize outreach community-based partners and local dispensaries to engage communities as part of static services and/or prior to arrival of the mobile units, educating community members and creating demand as well as providing follow up care and reinforcing prevention messaging.

7. Continue participation in USG and nationally planned quality assurance reviews.

8. Assess VMMC services routinely to ensure availability of recommended MC equipment on-site through regular support supervision and on-the-job mentorship.

9. Assess standard clinician performance, and recording and reporting of adverse event rates and compliance (both to treatment and preventive measures) through use of harmonized data collection and reporting tools.

10. Continue use of web-based MC reporting system utilized by other implementers in Tanzania for routine reporting and improvement of MC data quality.

11. Leverage national efforts to integrate of MC services into routine health care, especially supporting CHMTs in all districts to implement early infant MC as per national guidelines in collaboration with the MOHSW, WHO, and other PEPFAR partners and stakeholders in the zone.

HJFMRI implements HVAB interventions mainly through four local CSOs that cover the four regions supported by DOD/WRAIR partners: SONGONET - HIV in Ruvuma; Resource Oriented Development Initiatives (RODI) in Rukwa; and Kikundi Huduma Majumbani (KIHUMBE) and Mbeya HIV Network Tanzania (MHNT) in Mbeya.

The target population will be men and women of reproductive ages (15- 49 years) and young boys and girls in and out of schools and training institutions. Interventions will address Multiple Concurrent Partnership, gender and GBV issues as well as inter-generational sex as factors that contribute to HIV infections. The program will also promote delay of sexual debut and address social and community norms to prevent HIV infections. Children and adults will be reached through the use of appropriate peer educators and home based care providers. A Community Resource Kit (CRK) tool will be used during small group discussions to facilitate and promote dialogues in order to eradicate sexual and cultural norms fueling the spread of HIV infections.

Activities planned for the FY2013 COP include:

1. Promote delay of sexual debut and secondary abstinence among youths through targeted messages to individuals, small groups and community members. Emphasis will be on providing individual and small group skills through peer education. Partners and regional governments will facilitate the commemorations of national and international events to increase targets and strengthen collaboration with respective government authorities.

2. Refine and distribute appropriate IEC materials and messages.

3. Promote Group education using the Men As Partners curriculum to create sustained behavior change impacting their lives and that of their partners and families.

4. Improve relationships and reduce the potential for violence using Couple Connect to maintain healthy and respectful marriages/partnerships.

5. Form community youth clubs to promote adoption of safer sex behaviors and to impart risk reduction skills.

6. Conduct protection and education activities, and advocate for mainstreaming of Gender/GBV issues in school curriculum.

7. Integrate HVAB services with HTC, PMTCT, VMMC, GBV, condom promotion, STI management, ART, and care and support programs.

8. Train Peer educators to trace LTFU clients and link them back to respective CTCs.

9. Use the Tanzania Out Monitoring System for non-medical HIV and AIDS interventions which are forwarded to the Council HIV/AIDS Coordinators for compilation and channeling to Council AIDS Multi Sectoral Committee and TACAIDS.

10. Conduct joint quarterly supportive supervision in collaboration with local government authorities and umbrella organizations to outreach partners. On-the-job mentorship, strategic in-service training, data review/source verification and TA will be provided to strengthen collaboration, ownership and sustainability of program implementation improvement.

11. Conduct quarterly meetings to coordinate HIV prevention programs with LGAs and other stakeholders to share progress and challenges and achieve program sustainability.

In the F Y2012 APR, HJFMRI trained 150 HCWs in HTC and counseled and tested a total of 495,583 clients, including PMTCT, exceeding the target of 435,711 (113.74%) in all modes of HCT services. The Southern Highlands has a population of approximately 6,000,000, with HIV prevalence ranging between 4.9-7.9% in the individual regions and an estimated HIV+ population of 382,100. In the FY2013 COP, support will be provided to improve site-level forecasting and ordering to improve the availability of rapid test kits and other commodities in support of the national supply system. In recognition of the scale-up across all care, treatment and support programs , HTC services, in collaboration with both treatment and outreach partners, will reach 707,808 clients across all HCT modalities, approximately 42,000 new HIV+ clients.

HJFMRI will prioritize PITC and couples counseling modalities, among other HTC approaches. All clinical service delivery points will be engaged (i.e. at RCH/ANC, PMTCT, TB, STI clinics and inpatient/outpatient wards) and mobile TC services will strategically focus on high prevalence but low coverage areas, specifically geared towards attracting men and at-risk population such as market sellers, trans-border traders, mens groups, fishing communities, and mining communities. Furthermore, collaboration with Baylor in pediatric PITC and the CSOs will ensure that both clinical and community programs are in alignment with targets. HTC services will also support partner and family members testing from index patients.

Those who receive HTC services will be recorded, reported and followed up using national tools, including referral forms for those found HIV positive. The program will also establish a system of referral coordinators at community and facility levels to coordinate and audit referrals between service delivery points. Also, the referral coordinators at the community level will ensure those that come from community TC services are well-supported to reach care and treatment or other health service delivery points. HTC clients will also be referred to other services including care and support services, PMTCT, TB/HIV, ART, FP and VMMC as needed. More emphasis will be made to ensure referral networks between community groups, social service providers and health care providers happen and are maintained.

Focused messages and demand creation activities will be done in identified locations to specifically expand HTC among. HTC awareness campaigns will employ peer-to-peer communication, with peer educators addressing issues of discordance and services addressing the youth and young couples.

HJFMRI will also support HCWs' trainings to improve capacity to execute the program interventions and build ownership. Based on the national training curriculum, refresher trainings to 200 HTC counselors/testers and supervisors will be conducted. HJFMRI will support expanding the pool of regional and district TOTs, and will participate in teams to ensure routine mentorship and support supervision. Lab mentors will be used to strengthen QA/QC practices to ensure that facilities send samples to referral hospitals for QA as per national guidelines.

HJMRI will continue to work with local partners to implement community programs to increase the adoption of safe sex and reduce risky behaviors. Services are provided through health facilities and local community partners such as SONGONET - HIV in Ruvuma; Resource Oriented Development Initiatives (RODI) in Rukwa; and Kikundi Huduma Majumbani (KIHUMBE) and Mbeya HIV Network Tanzania (MHNT) in Mbeya. HJFMRI also supports the implementation of both facility-based and home/communitybased activities for preventing and responding to GBV.

The primary target population of men and women of reproductive ages (15- 49 years) includes couples, at-risk populations such as fishing communities and small-scale miners, and communities along the Trans-African highways and in border towns with neighboring countries Zambia and Malawi. Other targeted groups will include workers in coffee plantations, truck drivers, food vendors, at-risk youth, alcohol users, mobile populations and people involved in transactional sex. Programs will aim to address related to sexuality, gender and cultural practices that fuel the spread of HIV among these groups.

Sub-partners will establish and adopt a combination prevention approach involving behavioral, structural and biomedical interventions. These activities will include provision of HIV and AIDS education and linkages to HTC, STI and PEP management, GBV service sites, and Family Planning services. HJMRI will reach its target groups through the use of peer education program. The Community Resource Kit (CRK) tool will be used during small group discussions to facilitate and promote community dialogues.

Activities in the FY2013 COP will include:

1. Procure, distribute and promote consistency and correct use of condoms in general population and in identified at-risk populations and high-risk areas;

2. Establish and strengthen existing condom outlets and ensure availability of both female and male condoms.

3. Link prevention activities to other service delivery platforms such as PHDP, HTC, care/support, ART, MC, STI and PEP management, PMTCT, family planning and GBV service delivery sites.

4. Promote Group education using the Men As Partners curriculum to create sustained behavior change, and reduce the potential for violence using Couple Connect to maintain healthy and respectful marriages/partnerships.

5. Promote changes in community norms, attitudes and behaviors through community mobilization, mass media campaigns and support to local leaders by engaging/building their capacity in raising awareness about violence in their community.

6. Strengthen the mechanisms for referral of GBV and Violence Against Children.

7. Support sexual behavioral change communication, including messaging on MCPs, transactional and intergenerational sexual practices, age at sexual debut and alcohol use.

8. Train peer educators to trace LTFU clients and link them back to respective care and treatment clinics

9. Promote coverage of HVOP services through individual, small groups and community sensitization messaging.

10. Support implementation of the Brief Motivational Intervention to address high-risk from alcohol use.

11. Conduct joint quarterly supportive supervision visits to support quality service provision.

HJFMRI supports the implementation of the global and national agenda on elimination of mother to child transmission of HIV (eMTCT) and reduction of maternal morbidity and mortality. In the Southern highlands zone, PMTCT services through the HJFMRI occur in 676 facilities through the Rukwa, Ruvuma, Katavi and Mbeya RMOs. The RMOs also support the implementation of facility-based adult care and treatment programs at the regional hospitals and all CTCs at district and other hospitals in their respective regions.

PMTCT services are highly required in these regions given the high ANC HIV prevalence rates of 12.6% in Mbeya, 7.2% in Rukwa and 8.2% in Ruvuma. In the FY2012 APR, HJFMRI reported 192,350 women who were counseled and tested for HIV and received results , and scaled up PMTCT services to 704 sites, surpassing the target of 648 sites. However, information on unit cost of infant-mother pair reached with PMTCT is not yet available.

Activities planned for the FY2013 COP include:

1. Scale up of PMTCT services to new sites in the four regions, including testing and counseling for all women attending ANC, L&D as well as improvement of adherence counseling to improve retention.

2. Complement emergency obstetric care (EmOC), FP and Focused Antenatal care packages through national TOT model by collaborating with district authority and health programs that support EmOC.

3. Integrate ART and TB/HIV services into PMTCT sites including supporting PMTCT sites to provide ART and more efficacious combination regimens. Training will continue for MCH health care providers in ART and pediatric HIV management, providing guidelines and job aids, and also CD4, biochemistry, hematology machine. HJFMRI ma participate in the roll out of Option B+ according to national planning and guidelines.

4. Procure ARV drugs, lab reagents, and essential supplies when not available through central procurement mechanisms.

5. Strengthen and support monitoring and evaluation and BPE, including PMTCT costing studies, to document gaps and support use of data to access site specific services and develop a plan of action to address challenges.

6. Promote infant feeding counseling options, linking mothers to safe water programs in their regions. For mothers choosing to breastfeed, the program will counsel them on breastfeeding and complement with either the mother or infant is on ARV prophylaxis. Evidence-based and -informed infant feeding and nutritional interventions during lactation will be promoted.

7. Continue training and mentoring of HCWs to provide quality PMTCT services according to the new national PMTCT guidelines, including training HCWs at each new site using a full site model.

8. Build capacity of regional and district health teams to plan, execute and monitor PMTCT activities, and support DHMTs to include PMTCT activities in council health plans and budgets.

9. Support community partners to establish expert mothers groups and link HIV positive mothers and their families to HTC, ART, VMMC and other services such as community support groups. HIV infected-pregnant women will be linked to care and support services, including TB/HIV, FP and other prevention services including gender-based violence.

As of the FY 2012 APR, HJFMRI reported 78,020 current on treatment in the Southern Highlands with an estimated HIV+ population of 382,100. ART coverage reached approximately 52% of those who are estimated to qualify for ART at more than 146 ART facilities and 676 PMTCT sites referring HIV+ mothers and exposed infants. Retention rate for the area is >75%. In the FY2013 COP, scale-up of enrollment will continue to reach 92,340 current on ART, approximately 60% of estimated treatment eligible, and a total of 156,326 with comprehensive care. By the end of FY14, HJFMRI will reach 106,660 with ART (70% of treatment eligible) and 182,610 with care.

HJFMRI will continue to build local skills for program sustainability and ownership. This includes training of RMO, RHMT, CHMT and facility-level staff in routine patient/facility data analysis for monitoring, QI and service planning, and TA in financial management, forecasting and budgeting. Service level TA will focus on improving the quality of ART clinic management, maintaining medical records, improving patient retention, strengthening community networks between facilities and NGOs, and increasing involvement of PLHIV to ensure local ownership of clients well-being and needed services at all levels.

HJFRMI and partners will focus on key areas to increase enrollment and expansion of services through program efficiencies. This will include the activities below as well as reviews of current pre-ART adult and pediatric registries for patients who meet new ART eligibility criteria, scale-up of PITC and integrated PHPD services, and expansion of POC diagnostics at more remote sites.

Planned activities in the FY2013 COP include:

1. Implement a quality package of services and standard of care consistent with MOHSWs national guidelines ensuring integration of prevention into treatment.

2. Provide skill and competency based trainings and on-going clinical mentoring to physicians, nurses and pharmacist at all points of service.

3. Strengthen adherence and support services including individual and group counseling, patient education, strengthening referral linkages, patient follow up, linkages to community based adherence support and defaulter tracing programs.

4. Collaborate with CSOs to establish networks of community volunteers, including PLHIV, to provide adherence counseling, treatment support and recover LTFU clients.

5. Distribute ART reference tools, including pocket guides, ART dosing cards, posters and detailed SOP.

6. Strengthen linkages between entry points, including PMTCT, ANC, TB, STI OPD and inpatient wards, HTC and palliative care services.

7. Execute pharmacy assessments and performance improvement plans. Capacity development will include all aspects of drug management, dispensing and storage, instruction in national treatment guidelines and SOP on security, quality control, storage and disposal.

8. Provide solar power to 40 rural health facilities and provide generators.

9. Prioritize linking patients to livelihood opportunities as well as HBC, support, community and social services and strengthen existing referral channels and support networks.

10. Monitor service with formal QI mechanisms, such as regular site visits by HJFMRI and RMO CQI staff on a quarterly basis or as needed. HJFMRI will convene and coordinate monthly zonal ART meeting with MRH and RMOs to discuss CQI findings and treatment rollout, identify areas of need, determine solutions and coordinate

As with pediatric HIV care, pediatric HIV ART services in the FY2013 COP will be implemented in collaboration with Baylor International Pediatric AIDS Initiative (BIPAI) as well as leverage MOHSW's basket funding and cost sharing mechanisms. HJFMRI will continue to support HCW participation in the Baylor pediatric HIV/AIDS clinical attachment program which provides clinical mentoring and TA on the treatment of pediatric HIV/AIDS.

The Southern Highlands program has a total catchment population of over 6 million people. The HIV prevalence ranges from 4.5% to 7.9%, with at least 23,500 children under 15 years of age in need of care and support services. Currently over 5,000 children receive treatment at over 149 facilities. The current pediatric enrollment rate is 8% but the aim is to achieve nearly15% based upon epidemiological estimates.

A primary objective of the program in addition to maximizing enrollment of HIV+ children is to mitigate barriers to prevention, care and treatment, and improve quality of services. Several of these steps are outlined in the PDCS section, with pediatric ART building upon those activities. FY2013 COP funding will be used to scale-up ART services including scaling up of PITC and linking to services such as palliative care, psycho-social support and home-based care services. Particular emphasis will be placed on provision of the continuum of care services to improve pediatric enrolment, retention and adherence to ART. FY2013 COP targets 2,908 children to be newly initiated and 7,806 maintained on ART.

Activities planned for the FY2013 COP include:

1. Integrate and strengthen linkages of pediatric care and treatment with other systems such as PMTCT, EID, maternal health, PITC, GBV, OVC, M&E and HBC to improve the continuity of care and quality of care and mitigate LTFU.

2. Expand adolescent-friendly and family-friendly services to more facilities to break down barriers to accessing pediatric treatment, including increased utilization of CHWs and nurses to ensure more access points for care and better continuity of care.

3. Ensure quality of care, central to the pediatric program, utilizing a system of mentorship, supervisory supervision, CQI and standardized evaluation tools to assess partners and facilities for lab, clinical, M&E and administrative services.

4. Strengthen adherence and support services including individual and group counseling, patient/care giver education, strengthening referral linkages, patient follow up, linkages to community-based adherence support and defaulter tracing programs. Collaborate with NGO partners to establish networks of community volunteers including PLHIVs to provide ongoing support to caregivers of pediatric patients to improve pediatric adherence to treatment and recover LTFU clients.

5. Implement updated pediatric-focused national care and treatment guidelines and WHO treatment guidelines, including treatment of all HIV-infected children <24 months.

6. Ensure utilization of specialized laboratory services such as viral load testing, PCR, and viral resistance testing capacity as required.

7. Strengthen overall monitoring and reporting of HIV-positive expectant women that receive treatment. An improved M&E system will reinforce the linkage between PMTCT and EID by tracking the cascade effect of women tested and counseled, women receiving treatment, infants born to HIV-positive women, infants tested and counseled, and infants receiving treat