The goal of the project is to improve the health and well being of PLHA and their families in Tanzania with increased access to and quality of comprehensive community-level services through district coordination and community engagement. The objectives are to:

1) Facilitate quality CHBC/PHDP services for 45,000 PLHAs in 19 districts and five regions with emphasis on self-care/prevention and linkages to care and treatment clinics (CTC);

2) Offer an integrated package of family-centered services to 6,600 OVC in two councils in Shinyanga;

3) Provide home-based HIV counseling and testing, ensuring quality test results and supportive community-based follow-up for 94,800 persons;

4) Strengthen institutional capacity with 19 CHMTs and the Tanzania Red Cross Society (TRCS) in five regions;

5) Increase national capacity for quality IEC and BCC programming through support to NACP, ZACP, and MUHAS;

6) Strengthen community-facility linkages for GBV survivors.

Implementation of cross-cutting M&E activities will go hand in hand with a gradual handover of HBC/HBCT program to TRCS, strengthening TRCS national capacity to manage and meet PEPFAR funding requirements while positioning TRCS to receive LGA funding for community-based HIV/AIDS activities. The program will strengthen links between care and treatment services and procure a vehicle for TRCS to reduce operating costs and ensure adequate coverage and effective monitoring and supervision in Shinyanga.

Transitioning management to TRCS will save costs due to reduction in Pathfinder staff time and increases in PLHAs self-managing. At the same time, development of graduation plans for districts and families through LGAs and self-help groups will ultimately increase in-district funding for community-based services.

In FY 2012, Pathfinder will implement HBC programs in a total of 19 districts in five regions. In addition to increasing client enrollment in facility care, the Tutunzane II (Lets take care of each other) program will continue to increase the number of clients enrolled to at least 45,000. Program sustainability will be emphasized by:

(1) Supporting HBC providers to offer a range of integrated services as per PHDP and GHI strategy, to strengthen self-management and care, palliative care, food security, home hygiene, improved prevention and treatment adherence, nutritional assessment, FP counseling and contraceptive provision, emphasizing dual protection, malaria prevention and management, support to pregnant women to access ANC and PMTCT, counseling and testing for household members, and identification of TB infections. Lessons from community-based GBV programming from Dar es Salaam and other regions will also be incorporated;

(2) Continuing to strengthen TRCS capacity to manage HBC and HBCT services. Pathfinder will continue to work with TRCS to implement a transition plan that allows for program shifting to TRCS. Transition of Pathfinder-led activities in Arusha to TRCS management will be explored. Milestones under the transition plan will be reviewed and revised regularly;

(3) Strengthening local government capacity to manage and provide technical direction to HBC programs. The program will engage existing community structures to develop and implement sustainability/graduation plans and play a supportive role with HBC providers in their community. Graduation plans will be developed with each district to carefully delineate roles and responsibilities;

(4) Gradually shifting model of care to reduce dependence on HBC providers by enhancing capacity of families and clients to self-care and self-management of a chronic illness. With shifts in Tanzania's criteria for entry into treatment, more clients will be entering chronic care programs, thus support to self-care with fewer visits from HBC providers will be needed. Client role shifts to reliance on self and family resources to manage chronic illness moves HBC providers to become a resource to provide multiple community-based services. A well established process, such as "Pathways to Change" and "community action cycle" will be used to strengthen community action and responses to HIV. Eligible households will be linked to economic opportunity activities, while PLHA support group formation will be encouraged and a developed process to "graduate" households from the program will be created. Materials will be developed in collaboration with other organizations, such as PSI, IMARISHA project, and FANTA II, to support household decision making on issues, such as safer water, better home hygiene, complementary protein meals based on locally available grains and legumes supplemented by lower cost animal proteins; and

(5) Continuing expansion of the use of mobile phones for HBC data collection and adherence to home visit protocols through partnership with D-Tree International. Phone-based messaging systems may be developed to reinforce PLHA self-management at household level.

Pathfinder will continue to work with districts to assess the provision of HBC services through regular data review, DQA, and analysis. Pathfinder will provide monitoring and evaluation oversight to implementing partners in both activities and institutional capacity strengthening.

Pathfinder, in collaboration with Save the Children, continues to work in two councils in Shinyanga Region to support OVC and MVC. In FY 2012, Tutunzane II (Lets take care of each other) will focus on building a sustainable OVC program. In order to transition the program, the various activities will need to take place:

(1) Support 6,600 OVCs as identified by the district MVCCs. Services will focus on educational support for eligible OVCs, enrollment into community health funds, and support for vocational training for older OVCs, including job placements. In FY 2012, focus will shift away from only providing OVC households with supplies to strengthening family capacity as the primary means of supporting children. Families will receive economic strengthening support (with TA from Imarisha) through participation in Village Community Bank (VICOBA) savings and loans groups, as well as income generation activities (IGA), to improve both economic and food security;

(2) Work closely with Tanzania Red Cross Society (TRCS) and CHMTs to ensure that eligible families receive integrated HBC/OVC/HBCT/FP services that are linked closely with CTCs. Pathfinder will also ensure that TRCS supervised HBCT providers identify pediatric cases of HIV, offer testing to members of caretaker families, and enroll eligible families for HBC/OVC programming support;

(3) Support at least 3,300 OVC households with nutrition interventions. MVCCs at the district, ward, and village level will receive refresher training and job aids to include nutritional information and actions to improve diets. Working in close collaboration with Department of Social Work (DSW), Tanzania Food and Nutrition Center (TFNC), and Food and Nutrition Technical Assistance 2 (FANTA 2) project, materials will be adapted to help household members focus on safer water, better home hygiene, and complementary protein meals based on traditional and common dishes using locally available grains and legumes supplemented by lower cost animal proteins. Based on 2010 WHO and National PMTCT guidelines of exclusive breastfeeding for the first six months, introduction of complementary foods and prolonged breastfeeding will be supported;

(4) From the DSW guidelines for MVCCs, Tutunzane II will continue supporting MVCCs at district, ward, and village levels to act as community-based advocates for vulnerable children and their families, mainly helping to access local government resources to keep MVCs in schools and increase access to health care. Advocacy activities with the district authorities will help to ensure selected care and treatment services reach OVC in rural communities and households that are unable to travel to distant CTCs. MVCCs will receive technical support from Tutunzane II and district governments to ensure their annual plan implementation is supported financially and technically;

(5) Based on the outcomes of the parasocial worker development program, Tutunzane II may support the enrollment of community-identified parasocial workers for training and placement back in their communities;

(6) Conduct monitoring visits with DSW to identify strengths and gaps in implementation of national standards for OVC support; and

(7) Develop a process of graduating OVC households and MVCCs from Tutunzane II support in collaboration with DSW and district MVCCs. Pathfinder will provide M&E oversight to Save the Children for activities and institutional capacity strengthening.

The program will be implemented in Arusha, Dar es Salaam, Tanga, and Shinyanga. In Kilimanjaro, the costs of maintaining the current program is minimal, therefore the program will be maintained, but providers who leave the area because of transfer or retirement will not be replaced. Increases in the number of providers trained to provide HBCT will be primarily focused in high prevalence districts, such as Shinyanga.

The program will maintain its focus on index patients. All members of households with index clients will be encouraged to test. Testing of men, discordant couples, and children in PLHA households will be encouraged. HBC providers will also provide focused attention to all pregnant women in the community to ensure they are tested in the home or at ANC clinics and supported to enter into PMTCT services. HBC providers will also continue to recruit door-to-door clients, especially in high-risk areas, such as Shinyanga. All clients, regardless of HIV status, will receive counseling on risk assessment.

Activities to support home-based couple counseling initiated in FY 2011 will be continued. In collaboration with NACP and other IPs, Pathfinder will develop materials and train existing home-based (HTC) counselors on couples counseling. A record will be kept of couples counseling sessions to ensure privacy is maintained, a safe environment is provided, and follow-up support is offered to ensure partner safety. A themed community-based promotion campaign may be developed to encourage couples to test jointly and disclose status with each other. Risk assessments will be carried out for all couples tested. In addition, counsel will be given regarding practicing safer sex and using dual protection. A total of 94,800 clients will receive their test results, counseling on risk assessments, safer sex, and dual protection through this program.

In collaboration with NACP, Pathfinder will support the development of tools and job aides to assist HTC counselors to provide follow-up services to all clients (including the development of phone-based reminder and confirmation systems). Referrals are already very strong and extensive through the HTC program, therefore simple systems will be developed to assess the number of confirmed referrals. Follow-up phone calls may be made to confirm clients who accessed available services.

In collaboration with NACP and local governments, Pathfinder and TRCS will implement QA standards outlined in the NACP HBCT guidelines. Pathfinder will provide monitoring and evaluation oversight to implementing partners in both implementation of activities and in institutional capacity strengthening.

Pathfinder will continue providing TA and support to MOHSW Information Education and Communication (IEC) units and staff as well as pre-service training facilitators and teachers at Muhimbili University to design materials, trainings and interventions, create standards, ensure QI for IEC and sexual behavior change communication (SBCC) efforts to be in line with international and national guidance, such as the new PEPFAR Prevention Guidance, and support the most effective HIV prevention, care and treatment interventions.

Contents of the materials, interventions, and trainings will include IEC and SBCC support for (a) couples communications, couples HIV testing and counseling, disclosure and support for discordant couple; (b) promotion of voluntary male medical circumcision services; (c) support for adherence of ART, TB, and STI treatment, with particular attention to specific groups, such as HIV positive pregnant women and youth. Contents of messages and programs will be constantly adjusted to align with emerging evidence and new guidance in areas such as early ART, pre-exposure prophylaxis, and other relevant effective prevention interventions as they emerge. In addition, the OP component of this activity will include support for development, review, and QI of materials and interventions to promote increased correct and consistent use of male condoms, promote female condom use among identified target groups, support Positive Health Dignity and Prevention (PHDP) and other interventions specifically designed to support PLHA. Creation of the relevant materials will give special attention to the needs of HIV positive girls and women and increase demand and up-take of comprehensive services among key populations such as sex workers and their clients, people who use and/or inject drugs, and men who have sex with men.

Specific activities to be supported include: (1) Strengthening of the NACP and ZACP IEC units, such as reviewing reporting lines and clear job descriptions that differentiate unit members roles and responsibilities; (2) Training for NACP and ZACP IEC and Muhimbili faculty staff; (3) Introduction and strengthening of IEC and BCC standards and QI tools that will enable NACP and ZACP IEC staff to review and assist with needed improvements, in particular for IEC and BCC programs developed and implemented by Tanzanian organizations; (4) Developing practical tools, job aides, and documented internal policies and procedures that will support the above described efforts and services; (5) Organizing quarterly or biannual prevention stakeholder meetings; (5) Supporting the design and technical contents of Muhimbili University's graduate degree course on HIV and health service promotion and social behavior change communications in line with emerging and existing evidence for most effective prevention interventions and services; (6) Mentoring Tanzanian faculty through international faculty advisors on teaching methodologies and interactive sessions; and (7) Supporting linkages for graduate students and faculty with relevant programs and partners for file level practice and pilots.