The objective of this HIV Workplace Program is to increase HIV prevention by focusing on behavioral and biomedical drivers of the epidemic and to maintain and expand quality care, treatment and support services for 32,000 military personnel, dependents, and approximately 300,000 civilians from communities surrounding the Tanzanian People's Defense Force (TPDF) camps and clinics. Clinical services include VCT, care and treatment, HIV/TB, and PMTCT/RCH in most sites.

The program is planned and implemented by TPDF headquarters staff, clinics, colleges, community support groups, MOHSW, Home Affairs, and TACAIDS. Close collaboration with RHMTs and DHMTs have been established so that TPDF sites benefit from MOHSW resources. Sensitization of top commanders has increased efficiency of implementation and TPDFs preparedness to contribute to more of the costs of healthcare and pre-service training. PharmAccess (PAI) provides TA and manages the donor funds.

HSS is done through on-job training of HCWs and upgrading of more than 50 clinics countrywide. In FY 2012, the focus will be on less costly infrastructure maintenance and on-the-job mentorship. Future clinical and prevention trainings will be done by TPDF TOTs, while prevention trainings are now part of the standard curriculum in TPDF colleges. Gender and alcohol abuse are key elements of peer education and life-skills trainings.

TPDF headquarters and all sites have trained staff on electronic data-entry and M&E. Data on progress of activities is shared with NACP and between HQ, PAI, and all TPDF clinics during quarterly meetings. Continued project monitoring and supervision to all sites requires a strong 4x4W car for which $60,000 is requested.

PAI, using the health facilities as the point of contact, will use the trained community volunteers to provide HBC services (physical, psychological, spiritual, adherence counseling, social, and prevention services) to HIV infected adult, children, and their families.

The HBC providers will provide support after a needs assessment and prioritization is conducted. The PHDP components and nutrition assessment, counseling and supports (NACS) will be strengthened. PAI will support its clients to form associations and groups to maintain the strength of care and support services.

PAI will continue supporting TPDF throughout Tanzania, implementing HBC services by integrating and strengthening linkages with other services, such as CTC, VCT, PMTCT and other related programs, using quarterly coordinating meetings and standardized referral forms. Other linkages will include working closely with the LGAs and community organizations to improve services, local ownership, and sustainability. PAI will continue to establish patient support groups, or post test clubs, and PLWHAs will be supported to participate in planning committees and program implementation.

The IP will use standardized tools to improve recording and quarterly reporting. These tools will also track coverage, impact of the PHDP program, and progress of activities which will be monitored by PAI and TPDF program managers. In addition, PAI will conduct quarterly supervision with spot checks to validate data and reported activities in order to provide constructive feedback.

PharmAccess International (PAI) is DODs international implementing partner (IP). PAI works with the Tanzania Peoples Defense Force (TPDF) in DOD-supported PEPFAR activities in the military across Tanzania. Most servicemen and women live in barracks and around their camps, although their partners and families, usually women and children of servicemen, have to leave the barracks when the army person dies. Previously, the main focus of DOD support in TPDF has been on care and treatment with limited support for OVC. However, the increasing need for support of OVC has become unavoidable as some orphaned and vulnerable children are forced, by circumstances, to live with relatives, family friends, and neighbors of their deceased parents within TPDF barracks or in communities nearby with fragile and inadequate support. Subsequently, most will never be enrolled in schools, while those already enrolled drop out due to lack of support and guidance.

In FY 2012, PAI will expand its OVC program to support eight zonal military hospitals to expand the provision of comprehensive OVC care package needed for reducing the impact of the disease.

This support will be modeled after a pilot program that PAI and TPDF have been implementing in Mbalizi Military Hospital in Mbeya, Southern Tanzania since FY 2009. Specifically, care providers in the five hospitals will be trained, eligible children identified, and provided with basic needs such as school materials (provision of uniforms, school fees, and stationary), assistance with medical needs where appropriate, and nutritional care and support. To alleviate the economic burden of HIV/AIDS, families and guardians will be involved in identifying and implementing suitable income generating activities (IGAs) to strengthen household incomes and transitioning to local OVC support systems. Children without parental support will be provided with foster parenting to ensure parental guidance and support under close follow-up of social workers and care providers at the eight military hospitals and nearby LGAs. Linkages will be established between national and community support mechanisms. Where support mechanisms are strong, children will be graduated into a system for long-term support.

Identification of eligible children will be done by the Department of Social Welfare (DSW) in TPDF. DSW will also facilitate the training of care providers in the respective hospitals if none exists and map other OVC services in the surrounding communities using the DSW identification tool.

TPDF will use the national Data Management System tool to collect data from the targeted beneficiaries and caregivers trained. Data will be entered and monitored through the national OVC database. M&E activities will be coordinated by the OVC coordinators at the hospitals with support from experienced local NGOs to create synergies and to avoid service duplication.

The HIV/AIDS-TB collaboration component was incorporated in the TPDF HIV/AIDS workplace program in 2007. Currently, 25 clinics (eight hospitals and 17 health centers) serve as TB-DOT sites.

Twelve laboratories at new TB providing clinics will be upgraded, furnished, equipped with LED microscope, x-rays supported, and protective gears procured in case of shortages from the national supplies system. TB/HIV training, including x-ray interpretation, will be conducted for 50 health care providers from new sites and clinicians and nurses from continuing sites.

TB/HIV screening, using the MOHSW tool, is still low in military clinics. In FY 2012, usage of the tool will be strengthened through trainings, supportive supervision by staff from Lugalo and DHMTs, and by continuous promotion at the quarterly meetings. Quarterly meetings take place with representatives from all clinics, TPDF headquarters, experts from PAI, and other partner organizations. Each meeting focuses on specific themes, serves as a forum for mentorship, program developments are discussed, and best practices are shared. Initiation of cotrimoxale and INH prophylaxis for opportunistic infections (OIs) will be strengthened.

One TPDF hospital in Lugalo has been included in the national 3Is (intensive case finding, infection prevention, and isoniazid prophylaxis) pilot-program under MOHSW. Implementation of 3Is in other sites will start in seven TPDF hospitals in FY 2012 under the supervision of Lugalo staff.

Diagnosing TB among those in-patients with advanced AIDS (approximately 20% of patients) remains difficult as the routine diagnostic tests (AFB smear microscopy and/or chest X ray) are neither very sensitive nor very specific, therefore undiagnosed TB remains a major cause of mortality in this group. To enhance TB diagnosis in this group, there is a high need to invest in sophisticated TB diagnostic tests, such as liquid culture and line probe assays.

Community sensitization and counseling is needed in order to create an informed community regarding issues related to early health seeking behavior for management of OIs, such as TB. In collaboration with community HBC volunteers and leaders, sessions will be organized in a more effective manner.

Supportive supervision for quality improvement will be achieved through on site mentorship done in collaboration with RHMTs, DHMTs, TPDF, and PAI staff using MOHSW guidelines and tools. To cascade the process, there will be a series of orientations to HQ and eight military hospitals, including selected supervisors to build their supervision capacities.

Monitoring and evaluation is done through the national system using registers, monthly forms, and screening tools while data is collected electronically for processing and reported to RHMTs, DHMTs, TPDF HQ, and PAI.

PharmAccess supports approximately 332,000 military personnel, dependents and civilians. The IP implements pediatric care and support services to at least 3,200 children under 15 years of age in need of care and support within a network of 29 CTCs.

In FY 2012, planned activities include:

1) Strategic in-service training, on -job mentorship and support supervision of HCWs and CHWs including peer counseling and education to improve adherence and retention;

2) Strengthen infant feeding counseling, nutritional assessments and support, palliative care at facility and community levels;

3) Expand enrolment into pediatric care and support services through involvement of adolescents and children in PHDP services and support groups and community mobilization and sensitization through individual, small groups and community channels to engage the community in paediatric care and support activities, especially OVC and HBC programs;

4) Improve coverage of cotrimoxazole prophylaxis and management of opportunistic infections (OIs) among paediatric patients; and

5) Improve referrals of paediatric patients and linkages to other services e.g. ART, HTC, PMTCT, EID and TB/HIV;

6) Stakeholder engagement in pediatric care and support activities such as meetings to discuss targets and results;

7) Improvement of physical infrastructure to ensure child responsive services through renovations and creation of child-friendly environment.

PharmAccess (PAI) supports MC services in TPDF sites throughout Tanzania through on-site and campaign based approaches. Currently, three TPDF sites offer MC services in collaboration with PAI (Mbalizi Military Hospital in Mbeya, Makambako, and Lugalo), while three more sites are planned for FY 2012 in Mwanza, Shinyanga, and Tabora.

In FY 2012, more MC clinicians will be trained to increase the availability of MC services at TPDF sites. In addition, linkages with other stakeholders involved in health education and promotion will be strengthened through individual, small groups and community MC-related health education and SBCC to increase MC uptake and adoption of appropriate preventive behaviors.

MC services are provided as a comprehensive prevention package that includes counseling and testing, behavioral interventions to prevent new infections, and linkage to care, treatment and other services. Encouragement of female partner participation in MC services will also be done to improve family-centered HIV preventive services.

Print and electronic media messages will be provided to communities in the region as well as improving community participation in planning and implementation of MC services in order to create demand for services.

To ensure the availability of quality MC services, performance of available trained clinicians will also be tracked through regular support supervision and on-the-job mentorship and analysis of MC data to document average time for MC. PAI will also improve follow-up of clients to assess and document complications and compliance (both treatment and preventive measures). In addition, other elements of service will be assessed and strengthened to improve quality of MC services. PAI has adopted the web-based JHPIEGO MC reporting system, which should ensure availability of quality data. National forms will be used to document program performance and ensure uniformity in data collection, handling, and reporting.

Under sexual prevention, PharmAccess (PAI) in collaboration with the Tanzania Peoples Defense Force (TPDF) will target youth in schools and other young adult men and women within the community through peer education. Focus on key drivers of the epidemic, such as alcohol reduction, multiple concurrent partnerships, GBV and gender norms, and transactional and cross generational sex will be supported through the use of LGAs and peer educators (PEs). This will be done through one-on-one and small group sessions. PAI has developed peer health education materials with life-skills modules. These modules will be used for peer education training sessions at least twice a month.

The AB activities will be implemented in all TPDF sites and surrounding communities. With technical assistance from the government facilitators, the available training materials, facilitators, and PEs will be used to maintain standards and quality. Quarterly and monthly meetings will be conducted to assess PE performance and to address challenges as well as provide feedback on lessons learned.

The AB program will link with other program areas such as HTC, care and support, treatment, and PMTCT. PAI will use standardized tools to improve recording and quarterly reporting. These tools will also track coverage and impact of the AB program. In addition, PAI will conduct quarterly support supervision visits with spot checks to validate data of the reported activities and provide constructive feedback.

PharmAccess (PAI), in collaboration with the Tanzania Peoples Defense Force (TPDF), will provide both static and mobile counseling and testing services in TPDF sites in the country covering all districts. These activities are client-initiated testing HTC, targeting the general population through static and mobile VCT and campaign activities.

The HTC activities will be implemented in all TPDF sites and surrounding communities. The IP will focus its HTC program activities in priority areas, such as couples counseling, VMMC through community sensitization, counseling for Positive Health Dignity and Prevention (PHDP) through HBC, and counseling and testing for nutritional support.

PAI will implement HTC and link related activities with other services, such OVC, CTC, VCT, and PMTCT and ensure that clients are referred appropriately to foster a continuum of care. Other linkages will include working closely with LGAs, health facilities, and community organizations to improve services and local ownership and sustainability. Community leaders and social service committees will actively be involved in planning and implementation to improve the quality of HTC services. PAI will continue to establish patient support groups, or post test, clubs as well as create community demand in high transmission areas.

The IP will use standardized tools to improve recording and quarterly reporting. These tools will also track coverage and impact of the PHDP program. PAI will work with TPDF to conduct quarterly supportive supervision to address challenges and understand the progress and impact of activities thus far. Quarterly and monthly meetings will be conducted to assess the HTC program performance as well as to address challenges and provide feedback on lessons learned.

PAI will continue to strengthen the existing referral system to cater to all clients who test positive, linking them to care and treatment and home-based care. PAI will strengthen the referral system by working closely with health facilities and develop patient tracking system to minimize lost to follow-up.

PharmAccess (PAI), in collaboration with the Tanzania Peoples Defense Force (TPDF), will address HIV transmission through activities that are aimed at condom promotion, palliative care services (through Positive Health Dignity and Prevention), and other prevention messaging.

PAI will work in all TPDF and surrounding communities countrywide to assess the extent and type of GBV and gender norms that are prominent, seeking community assistance to address issues related to sexuality, gender roles, and cultural practices that increase vulnerability to HIV.

PAI is working to address HIV prevention among the youth, young adults, and adult males and females at-risk to HIV infection driven by peer pressure, poverty, concurrent multiple partnerships, and excessive alcohol use.

PAI will continue to implement the related activities through peer education, condom promotion and distribution, brief motivational intervention initiative, income generating activities, and strategic in-service trainings. Furthermore, PAI will work with TPDF to ensure integration of activities into other health service delivery platforms. The IP will link with other program areas, such as HTC, care and support, treatment, and PMTCT, through coordination meetings and use of OP focal persons.

PAI will use standardized tools to improve recording and quarterly reporting. These tools will also track coverage and impact of the OP program. In addition, quarterly meetings will be conducted to assess OP performance and address challenges as well as provide feedback on lessons learned.

PharmAccess supports approximately 332,000 military personnel, dependents, and civilians. During FY 2010, PAI achieved the following: expansion of PMTCT services (from one facility in FY 2009 to 29 in FY 2010); increased trained providers, (all PMTCT sites have at least one trained PMTCT provider); increased coverage (16,058 pregnant women tested- 7.2 % were HIV positive and 2,822 received ART to reduce MTCT) APR 2010.

In FY 2012, PAI plans the following activities:

1) Strengthen and support Emergency Obstetric Care (EmOC) in all sites through training on national TOT model; linking services to nearby facilities and complementing procurement and availability of tests reagents, equipment and other essential supplies for maternal and neonatal survival, including blood;

2) Train health care workers at each new site using a full site model and support HCWs training and mentorship to provide quality PMTCT services as per national guidelines;

3) Strengthen and support M&E framework (DQA, integrated supportive supervision using standardized national tools) and BPE to ensure informed program implementation;

4) Support provision of integrated PMTCT services including TB/HIV, ART, Pediatric HIV, FP and Focused Antenatal Care (FANC) services as well as provision of MECR to achieve the goal of putting all women on MECR by 2013. This will include training MCH health care providers in ART and pediatric HIV management, providing guidelines and job aids, supporting EID logistics (transportation samples and DBS results) and other essentials such as CD4, biochemistry and hematology tests;

5) Improve facility infrastructure through renovations of MCH and labor wards and ensure friendly and comprehensive MCH services;

6) Provide PHDP counseling package based on the harmonized USG/URT tools; and

7) Improve community sensitization and demand creation to improve participation in PMTCT/RCH services including encouraging HIV positive women to bring in family members for testing.

8) Work with districts (CHMTs) to plan and implement decentralized integrated PMTCT services to improve MCH services in the military.

The Tanzanian Peoples Defense Force (TPDF) health facility network supports a total of over 32,000 enlisted personnel, estimated 60-90,000 dependents, and approximately 300,000 civilians from communities surrounding TPDF camps and clinics.

By the end of FY2011, PAI had a cumulative number of over 11,643 patients on ART with 2,413 new patients enrolled. Despite this achievement, loss to follow up has been a big challenge to the program, with a retention rate of 60.7% (APR 2011). Efforts to improve retention include linkages with CBOs to track patients in the community, use of support groups, CHWs (HBC workers and community-owned resource persons) for adherence counseling, and tracking of patients in their homes.

For FY 2012, activities include:

1) Provide quality and integrated care and treatment services in the military CTCs through mentorship, on job training and support supervision to HCWs & volunteers; renovate space at selected sites, strengthen linkages to other programs (MCH, TB, PITC, and EPI); strengthen the referral system between the TPDF, district, and regional health facilities; develop and apply QA/QC mechanisms including standard operating procedures (SOP);

2) Procure drugs, commodities, and other supplies for services and patient monitoring when not available through central mechanism;

3) Strengthen prevention for positives counseling among all staff providing treatment at CTC;

4) Improve M&E framework: provide support to regional facilities (continuous quality improvement, CQI) to ensure quality services and improve patients' clinical outcomes and program performance; ) improve patient collection, analysis and reporting

5) Work with facility pharmacists in improving capacity in forecasting, stock management, and ordering;

6) Continue to provide evaluation for malnutrition and nutritional counseling to all HIV positive clients;

7) Discuss and review program performance through quarterly meetings with site representatives and experts in specific fields (ART developments, pediatrics, HIV/AIDS, TB, etc.);

Retention of health care workers in the military setting is high. The available and newly recruited health personnel will continue to provide sustainable care and treatment services.

PharmAccess (PAI) supports approximately 332,000 military personnel, dependents, and civilians. The IP implements pediatric care and support services to at least 3,200 children under 15 years of age in need of care and support within a network of 29 CTCs. FY 2012 funding will be used to scale-up quality of care and treatment services. PAI is tasked with coordinating and overseeing the quality of pediatric treatment services in the TPDF. These activities will be achieved through regular support supervision, training, and on-the-job mentorship. PharmAccess has a catchment area of all military forces, communities surrounding the barracks, and camps throughout the country.

PAI works in partnership with the USG regionalized treatment partners to improve pediatric care and treatment services. With FY 2012 funding, PAI will support pediatric PITC, supply of pediatric drugs and commodities, diagnostics, adherence counseling, strengthening linkages and referrals between pediatric care and treatment programs. CHWs will be supported to carry out adherence counseling, tracking of children lost to follow-up and linking children to health facilities and other community support groups to ensure a continuum of care.

Local manpower and systems will be strengthened to improve specialized pediatric care and treatment. In FY 2012, targets will be monitored and discussed during zonal technical meetings and national partner meetings. Feeder programs, including HBC, OVC, PITC, EPI, PMTCT, TB/HIV, and RCH will employ strategies to increase child enrollment into care and treatment programs. Infrastructural improvement will specifically address pediatric treatment needs. Technical support will be provided to adolescent support groups for peer counseling and education to improve retention into treatment and adherence to medications.

Pediatric care and treatment services at PAI are integrated into existing health systems and services. The integration of these services leverages national referral system to ensure quality, sustainable care, and support. The USG/T supported activities will continue to be incorporated into the regional health plans through national funding such as central funding through MOHSW budget, basket funding, and cost sharing mechanisms.