Bugando Medical Centre implements program interventions in the areas of HIV care and treatment, HIV counseling and testing, male circumcision (MC), and maternal mortality reduction interventions. These programs are linked, integrated, and coordinated to ensure synergy and efficient utilization of resources. The catchment areas are Mwanza, Shinyanga, Tabora, Kigoma, Kagera, and Mara with a combined population of 16 million people. These areas are considered to have some of the highest HIV burden in the country.

The main goal of HIV care and treatment is geared towards strengthening provision of quality ART Services. HIV counseling and testing seeks to increase access to HIV testing for health care seekers, TB patients, pregnant women and their spouses, and for the general population. The overarching goal of the MC program is to provide services to men 10-49 years and build capacity for delivery of MC services. The main goal of the maternal mortality reduction program is to reduce maternal mortality in the 36 hospitals in four regions. All the goals are linked to the National HIV/AIDS Strategic Plan, Partnership Framework, and Global Health Initiative, which will ultimately support URT to reach its targets. The programs activities will be implemented in a network model, linking district and regional stakeholders to capitalize on synergy, fostering cooperation, and leveraging resources from other partners. By strengthening district health systems, promoting program ownership, planning and budgeting for project activities, districts will be able to take over these programs.

M&E of program activities will use both national and PEPFAR indicators. Two 4WD vehicles are planned for extensive travel and for the transport of voluminous materials.

A high priority goal is to improve the quality of life for PLHIV by providing integrated and high quality HBC services through trained community volunteers, and forging linkages for relevant support services for PLHIV. ComprehensiveCcare and support programming for BMC and support programming will focus on early identification of HIV individuals and provision of a complete and high quality clinical care package that will include physical assessment, WHO staging, CD4 and other lab monitoring, nutritional assessment, counseling and support, detection and management of Opportunistic Infections, Cotrimoxazole prophylaxis, ART management, screening for cervical cancer, Positive Health Dignity and Prevention (PHDP), pain management and end of life care. The partner will also conduct supportive supervision and mentorship to ensure quality delivery of this package. The partner will improve the linkage system to successfully enroll a newly diagnosed individual into care and treatment.

Bugando Medical Centre (BMC) will strengthen TB screening and case detection by implementing Intensified Case Finding (ICF) at care and treatment clinics (CTC), among pregnant women, OVC, pediatrics, uniformed forces and in congregate settings. The partner will also support the identification of TB suspects, diagnostic evaluation of suspects and treatment of of TB/HIV co-infected patients. BMC will support the provision of Isoniazid Preventive Therapy (IPT) for individuals who screen negative for TB symptoms, as well as implement infection control measures to prevent TB transmission in both TB and CTC settings. PHDP will be integrated into TB clinical settings, and comprehensive HIV care and treatment services (including ART initiation) for TBHIV co-infected patients will be provided. Provision of HIV services in TB clinics will be scaled up through increasing the number of TB clinics with "One Stop" TBHIV services and/or renovation of TB clinics to allow for the provision of comprehensive care and treatment services. Scale up of pediatric TB/HIV services will also be supported.

PDCS funds will go toward scale up of Cotrimoxazole prophylaxis for HIV-exposed and infected children, and support nutrition assessment, nutritional counseling, and referrals for severely malnourished children. These funds will also support incentives to community support groups to improve retention through tracking of lost to follow up among children and families. BMC will collaborate with other HBC partners to maximize efficiency and ensure a continuum of care for families.

This activity links to activities HLAB MOHSW 7758, 7779 NIMR, CDCBase 7834, CLSI 7696, APHL7682, AIHA7676, ASCP 7681, AMREF 7672, RPSO 7792, ZACP 8224, DoD 7746; Track 1 ART CU7697/7698, EGPAF 7705/7706, HARVARD7719/7722, AIDSRelief 7692/7694, DoD7747, Blood Safety; CT NACP 7776, TB/HIV 7781, PMI, SCMS 8233, FHI 7712; SI NACP 7773, MOHSW 7761.

The Ministry of health and social welfare (MOHSW) has decentralized HIV/AIDS laboratory infrastructure and capacity building to the zonal referral laboratories to expand HIV/AIDS lab capacity and to embrace the network model for a continuum of HIV/AIDS prevention care and treatment services. BMC is a referral and teaching hospital for the six neighboring regions of the lake zone with a catchment population of approximately 13 million. The lake regions are Mwanza, Kagera, Shinyanga, Kigoma, Mara and Tabora.

The Bugando Medical Center (BMC) zonal referral laboratory capacity is currently inadequate and an obstacle in achieving the emergency plans for care and treatment goals of the lake zone.

BMC is being funded for the first time in FY 2007 with special focus to the laboratory services at the center. BMC will apply the quality system approach to build its own capacity as a center of excellence and support a network of regional, district faith based and private laboratories supporting HIV/AIDS prevention, care and treatment in the lake zone. The BMC will train staff at the BMC lab to perform testing for HIV diagnosis, disease staging and treatment monitoring in order to optimize prevention, care and treatment services, train laboratory and non-laboratory staff from other facilities providing similar services and support and help monitor performance through supportive supervision.

BMC had started to implement activities to strengthen laboratory capacity in collaboration with various implementing partners including Columbia University , HHS/CDC Tanzania, National Institute for Medical Research (NIMR), African Medical and Research Foundation (AMREF), the Association of Public Health Laboratories (APHL) the Clinical and laboratory standards Institute (CLSI), the American society for clinical pathology (ASCP), GTZ, JICA, AXIOS, Clinton Foundation, Track 1 partners and other ART partners. The high volume chemistry, Hematology and CD4 equipment have been procured by HHS/CDC Tanzania with FY 2005 funding and installed. Training of laboratory technologist on HIV/AIDS standard of care tests, equipment maintenance and preventive maintenance for users, rapid HIV test training to laboratorians and non lab staff from other intervention areas like PMTCT, Counseling and testing (CT), TB/HIV and introduction to Quality system approach in the laboratory services were implemented in FY 2006

With FY 2007 funding BMC laboratory will, in collaboration with partners implement quality system in the BMC laboratory and establish a network from which all laboratories levels will be supported. The Quality system implementation will follow active gap analysis strategy and focus on areas of specimen management, Quality assurance,

MC reduces female to male HIV transmissions by 50-60%. However, the HIV protective role of MC to female partners has not been established in Sub-Saharan Africa. Based on this evidence, WHO and UNAIDS recommend MC in areas where HIV prevalence is 15% or higher and MC prevalence is less than 20%. Where there is lower HIV prevalence and/or higher MC coverage, male circumcision should target higher risk male populations within these regions. The goal of the BMC MC program is to increase access to male circumcision interventions to contribute to the reduction of new HIV infections among male fishermen, and indirectly among their female sexual partners, in the fishing communities of Lake Victoria Islands in Mwanza region. The target will be to provide MC services to 7,000 men while linking them to other HIV prevention and care and treatment services. This will ensure provision of a comprehensive HIV prevention package and early access to HIV care and treatment services.

The BMC MC interventions will target hard to reach, high-risk HIV fishing communities in Lake Victoria Islands. Although the Tanzania Health Indicator Survey (THIS) 2007-2008 found that HIV prevalence in Mwanza is 5.5% and the MC rate is at 54%, fishing communities are quite a heterogeneous mixture of different tribes, cultures, and religions. Higher HIV prevalence and lower MC rates are anticipated to be lower than the regional average.

Mwanza Region has 12 big islands. In FY 2012, four islands will be targeted accounting for one third (1/3) of the big islands. Providing access to MC to hard to reach high-risk fishing communities in the Lake Victoria Islands will augment other HIV interventions in these communities, such as early linkage to care and treatment for those found to be HIV positive. BMC MC programs on the Islands will provide a unique opportunity for males, specifically adolescents who are more vulnerable to HIV acquisition (10-24 age group), to access evidence-based HIV prevention interventions. MC will also provide opportunities for on-site testing according to national guidelines. MC will be integrated into and linked to other HIV prevention services, such as counseling and testing, to help ensure a comprehensive HIV prevention package is offered.

Supportive supervision and mentorship to MC static sites will be conducted to empower district health authorities to provide MC supportive supervision and mentorship to the health care workers in the MC intervention sites. Trainings will utilize the national curriculum along with a strategy to ensure post-program funding sustainability. Mass and mini campaigns will be conducted while mobilization of community and religious leaders will help perform mobile MC outreach services to selected islands. Increasing community awareness, acceptance, and demand for MC services will be communicated through mass media, posters, brochures, leaflets, and T-shirts. Education on the MC protective impact against HIV and other sexually transmitted infections will also be provided.

VMMC implementation takes place at 77 Islands in four Mwanza districts, involving extensive travel and transport of personnel and of bulky equipment. Two vehicles are required: one 4WD hard top and on 4WD large body pick-up. Monitoring and evaluation will be undertaken using national tools and National AIDS Control Program database. Monthly reports will be analyzed locally and shared with stakeholders for performance improvement.

Bugando Medical Centre (BMC) will use three testing modalities, namely voluntary counseling and testing (VCT), provider initiated testing and counseling (PITC), and mobile community outreach HIV testing and counseling. More emphasis will be put on PITC and mobile community outreach services, which have been found to be associated with increased early access to HIV testing and enrollment to care, treatment, and support services. The target population will be the hard to reach are of Lake Victoria Islands and fisher folks where HIV prevalence is relatively higher than the mainland. Areas with limited HIV testing services will also be targeted.

The program will use mobile community outreach HIV testing in collaboration with respective community health medical teams (CHMTs). Mobile community HIV testing will be conducted during special events, such as AIDS Day, to maximize access to HIV testing. PITC will continue to be routinely provided at BMC for all health care seekers in both outpatient and inpatient departments, such as ANC, medical, surgical, cancer wards, out-patient, and TB clinics. The program will also support home-based HIV testing in collaboration with the home-based care program. Couples HIV testing and disclosure will also be promoted.

In order to strengthen successful referrals and linkages to care, treatment, and support services, the program will track HIV-positive individuals through referral and feedback forms. HIV infected clients who are identified as not showing up will be tracked through home-based care programs using their addresses. The program will conduct in-service trainings on PITC to health care providers with special emphasis on couples counseling and quality assurance. To ensure quality services, BMC will conduct quarterly supportive supervision and regular mentoring to the six Lake Zone regional hospitals in collaboration with USG regional partners. The regional teams will be trained in quality Improvement, supportive supervision, and mentorship using national curricula.

HIV testing, including couples testing and disclosure, will be promoted through mass media, posters, brochures, leaflets, and T-shirts. Monitoring and evaluation will be undertaken, while both paper based and electronic tools will be used to capture trainees profiles and addresses using the electronic database, TrainSMART®. A national tool will be used to capture data on all who are tested. Data quality procedures will be followed and data will be used to improve quality of care. Quarterly reports will be analyzed locally and shared with stakeholders for performance improvement.

In 2009, the problem of high maternal mortality rate in the country was approximately 590/100,000 live births. In order to address this problem, Bugando Medical Centre (BMC) initiated a pilot maternal mortality reduction program in the two regions of Shinyanga and Mara, implementing targeted interventions aimed at reducing facility based maternal deaths. The baseline survey identified causes of maternal mortality and barriers to their reduction. The assessment also showed that in the two regions, over 75% of all maternal deaths occurred in hospitals. The major causes of hospital maternal deaths identified were obstetric hemorrhage, eclampsia, anemia, obstructed labor, and sepsis. Identified barriers to reduction of maternal deaths in the two regions were lack of appropriate skills, lack of essential basic supplies and equipment, inadequate proper supervision and mentoring of labor ward staff, and low morale.

All the factors identified as contributing to the high maternal deaths and the major causes of deaths helped to inform the design of targeted interventions to reduce maternal mortality. These targeted interventions included training and retraining of key maternal ward staff on obstetric management skills, management of the identified major causes of maternal mortality, provision of adequate and proper supportive supervision and on site mentoring to ensure standards of obstetric care, and requirements that core competencies are maintained. Other measures included provision of basic supplies and equipment required for standard obstetric care provision and inexpensive incentive motivation for the labor ward staff.

These replicable, evidence-based interventions resulted in a phenomenal reduction of maternal deaths by 23% in these hospitals. After soliciting funding from CDC in FY 2010, these interventions were replicated in the 12 hospitals of two other regions of Mwanza and Kagera. Training, procurement of equipment, and supportive supervision were conducted during FY 2011. In FY 2012, supportive supervision and mentorship to build capacity of the targeted hospitals in the four regions will be continued. Supportive supervision and mentorship in 36 hospitals will ensure maintenance of quality maternity services, resulting in expected to reduce maternal mortality in targeted hospitals and increase survival of newborns, which is in line with the Global Health Initiative.

Supervision and mentorship will be conducted by a team of supervisors from BMC and from the regional mentors. There will be limited training for regional mentors to address the problem of attrition. Teams consisting of an obstetrician and a midwife will physically visit targeted hospitals. Labor monitoring and quality of care will be evaluated as well as providers' skills to manage pregnancy related complications and infection control in maternity wards. Availability of relevant essential drugs in labor rooms at all times will also be assessed. During supervision, identified gaps will be addressed by mentoring. Mentorship will be web-based so that health care workers can also post their management questions. Feedback will be given to health care providers and hospital administrators. Quality of obstetric services will be monitored using a quality assessment tool by both internal and external quality evaluations.

The HIV care and treatment program will train district Trainer of Trainers teams to help build the capacity of districts to conduct trainings using their district budgets as a sustainability strategy. In the previous years, capacity building through training has been a main focus. However, training will be scaled down for FY 2012.

Bugando Medical Centre (BMC) will focus on quality improvement of HIV/AIDS services delivery through supportive supervision, onsite and web-based mentorship, and clinical attachments. These funds will help to build capacity of health care workers to deliver quality HIV/AIDS services, to develop the districts' capacity to train health care workers, and to conduct supportive supervision and mentorship in their catchment areas. BMC will provide Training of Trainers courses to district teams on in-service training on HIV/AIDS and pediatric HIV/AIDS care and treatment in order to decentralize training to the districts and meet training needs of regional USG partners and Regional Health Management Teams (RHMT). All trainings will be conducted in accordance with the national curriculum as well as provide onsite supportive supervision and mentoring to the six regional hospitals.

BMC's target population for training is the entire Lake zone. BMC is one of the local partners receiving direct funding from CDC, although they are also a sub grantee to AIDSRelief on HIV/AIDS care and treatment, TB/HIV integration, and early infant diagnosis. It has scored the highest grades amongst AIDSRelief sub grantees in local partners capacity assessments. BMC uses TrainSMART database to track and archive trainees information.

PDTX funds will enhance the identification of HIV-exposed children through scaling up EID services and PITC in OPD settings, immunization clinics, TB/HIV clinics, OVC services and family testing at CTCs. Support will also include pre-ART review of all children in care to determine eligibility for the new 2012 NACP guidelines and treatment of all HIV-infected children under 24 months. These funds will also be used to improve monitoring response and adherence to treatment. These objectives will be achieved through training, on-site mentorship, advocacy, community mobilization, and implementing pediatrics specific quality improvement initiatives.