Zimbabwe is one of the countries hardest hit by the HIV/AIDS epidemic. It is experiencing an enormous HIV-driven TB epidemic and is one the 22 high burden TB countries that account for 80% of the global TB burden. An estimated 80% TB patients are also HIV-positive.

In October 2008, USAID obligated Child Survival and Health funds to the Tuberculosis Control Assistance Program (TB CAP) to strengthen TB control in Zimbabwe. The coordinating partner for TB CAP in Zimbabwe is the International Union Against Tuberculosis and Lung Disease (The Union).

The output areas of the support have been:

a) strengthened leadership and management capacity at all levels of health care;

b) strengthened human resource capacity at service delivery levels; and

c) strengthened TB/HIV scale up.

In addition, through European Commission-funding, The Union has collaborated with Cities of Harare and Bulawayo since 2007 to develop an urban model for decentralized and integrated TB and HIV care that can be offered at primary health care level and is largely provided by nurses. Results so far show: all TB suspects undergo sputum microscopy, near universal daily DOT, declining default rates, high HIV test uptake, high cotrimoxazole uptake among HIV positive TB patients, and high ART uptake.

While improvements have occurred in TB control in selected areas, there are still many challenges in clinical TB and TB/HIV patient management, in programmatic issues, and overall collaboration between the HIV and TB units in the Ministry of Health and Child Welfare. To reduce disease burden and mortality from TB/HIV, it is imperative to scale up TB/HIV care, as well as strengthen the overall health system that provides these and other health services.

Goal: Increased access to quality integrated health care by persons with HIV infection and tuberculosis

Objectives:

To scale up decentralization of TB diagnostic and treatment services to primary health care (PHC) clinics in urban areas through activities based on the STOP TB Strategy;

To expand integration of HIV diagnostic and care services, including antiretroviral treatment (ART), into management of TB suspects, patients and their family members in these settings;

To expand integration of TB diagnostic and treatment services into management of persons living with HIV (PLHIV) and their family members in these settings;

To strengthen TB infection control measures in health facilities in urban areas; and

To strengthen recording and reporting of TB, TB/HIV and HIV care activities.

Expected outcomes:

enhanced human resource capacity for TB/HIV care at primary health care level;

high degree of clinical suspicion of TB in all patients visiting health care centers, among clinic health workers;

TB/HIV care decentralized to primary care clinics, including initiation of TB treatment and ART;

reduced barriers for HIV testing of TB suspects; reduced barriers for TB screening of HIV infected patients;

introduction of directly observed TB treatment at clinics;

improved rapport between TB and HIV patients on the one hand and health workers on the other;

local TB and HIV data analysis and use for planning.

Geographic coverage and target populations: Urban areas in provinces where The Union, through TB CAP funding, has been operating over the past two years, as well as provinces targeted for support through TB CARE. The cities and towns are:

Gweru (population 157,885) in Midlands Province - 7 clinics

Kwekwe (140,000) in Midlands Province - 7 clinics

Masvingo (150,000) in Masvingo Province - 8 clinics

Chitungwiza (350,000) near Harare - 4 clinics

Mutare (300,000) in Manicaland Province - 6 clinics

Gwanda (60,000) in Matebleland South Province - 6 clinics

Victoria Falls (45,000) in Matebeleland North Province - 7 clinics, and possibly

Bulawayo (population 720,000) or part of this population

Harare (population 1,531, 000) or part of this population

The primary target population are patients with TB and HIV infection, as well as non co infected TB and HIV patients. The secondary beneficiaries are the urban areas involved which will benefit through health systems strengthening.

Health systems strengthening: Apart from achieving the stated objectives the project will strengthen health systems by a) strengthening human resource capacity through training and support supervision b) technical and financial support for programmatic management of TB/HIV services, including local level supply chain management c) infection control training and practice d) refurbishment of existing facilities e) mentorship in basic management skills.

Strategic integration, coordination, leveraging, and private sector engagement:

All services will be integrated into existing municipal clinic infrastructure, and activities will be carried out by health professionals employed by the urban local authority Health Services Departments.

In most cities there are multiple health service providers who will be engaged in aspects of TB/HIV services that suit their skills profile and functions.

Woman-and girl-centered approach

The project will collaborate with PMTCT services and prioritize TB/HIV infected pregnant women to ensure optimum benefit to the mother and child;

Attention will be paid to minimization of barriers to access TB diagnosis and treatment and ART services by women, using targets based on the current national picture ie: a) at least half of TB suspects will be women and girls b) approximately 60-70% of PLHIVs accessing ARV drugs will be women and girls

Monitoring and evaluation data will be routinely gender disaggregated to ensure attention to gender equity

Cross-cutting programs and key issues: The whole thrust of the project is providing health services to persons with HIV and tuberculosis co infection. TB suspects, patients and their families will be tested for HIV infection and, if positive, will receive appropriate HIV care services. Similarly HIV suspects, patients and their families will be screened for TB and, if positive, will receive appropriate TB care services.

Achieving improved economies in procurement, coordinating service delivery with other partners in the public and private sector: The project will be integrated into existing health care services and will, as far as possible, link commodity procurement with local city, district, provincial or national procurement mechanisms to facilitate economies of scale. On service delivery, the project will collaborate with public private, local and international organizations involved in delivery of similar services in the area.

Monitoring & evaluation and operational research plans:

The current revised TB notifications and TB treatment outcome data tools and reports contain HIV-related indicators, and TB is included in the HIV care/ART monitoring tools. Reports generated will be used to monitor project implementation progress, and promote evidence based decisions.

Operational research will be conducted as necessary to answer program implementation questions, identify new strategies and better ways to implement them.