Integrated Management of Adult & Adolesecent illness The Government of Tanzania (GOT) began providing ARVs to AIDS patients in October 2004. The national target is to provide ART to approximately 440,000 patients by the end of 2008. As of July 2006, approximately 40,000 patients had been started on ARV's in the 200 NACP-designated treatment sites. These are all at the tertiary and secondary level. Beginning in 2007, the plan is to expand ARV services to an estimated 500 primary level facilities.

Integrated Management of Adolescent and Adult Illness (IMAI), developed by the WHO, is an integrated approach to scaling up comprehensive HIV/AIDS care, treatment and prevention within the framework of existing health systems. Integrated service strengthening builds capacity for decentralized HIV services within parts of the health network, specifically district hospital and satellite health centers (HC). WHO has developed a comprehensive curriculum to train health care workers (HCW) in the delivery of IMAI. The approach is based on the principles of standardization, decentralization and integration, and ensures comprehensive management of HIV/AIDS incorporated with prevention. A unique aspect of the IMAI training approach is the use of PLHA as expert patient-trainers (EPTs). Involvement of PLHA as patients who are experts in their own illness is a valuable educational strategy to support the training of HCW. During IMAI trainings, PLHA are trained to role play specific HIV cases with the HCWs during the skill stations sessions for two hours per day in addition to joining small groups during the interactive classroom training. PLHA's trained as EPT's add much needed experience and realism. An additional feature is the use of "task shifting" to respond to human resource constraints. Here, each level of HCW may be trained to provide services outside of their standard responsibilities. For example a nurse may take on the role of adherence supporters, PLHA taking on the role of ART counselors and the community, simple patient monitoring.

The Ministry of Health and Social Welfare (MOHSW) in collaboration with WHO country office and other care and treatment partners have adapted generic WHO IMAI documents for use at primary health facilities; HC and dispensaries. The system was field tested in the regions of Arusha (November 2005) and in Mtwara (July 2006). HCW from 23 HC's around the country attended the trainings. A number of these HC's, including all participating HCs in Mtwara, Lindi and Dar es Salaam, are now initiating ART services.

For this system to be truly operational, a number of activities must be implemented. In FY 2007, the WHO country office seeks financial support from PEPFAR to continue supporting the MOHSW in the final adaptation and printing of materials, training and coordination.

Support for materials adaptation: 1)Recognizing the scarcity of HCWs at the primary health facilities, compounded by lack of professional specialization at this level, MOHSW decided that the integration of the IMAI guidelines modules on Chronic HIV care with TB/HIV co-management will be necessary. WHO Generic TB/HIV training materials are only now available in country and this funding will support the merging of these curricula.

2)Recently distributed generic Integrated Management of Childhood Illnesses (IMCI) training materials for HIV management in children and adolescents will also be adapted to the country context and will then be integrated into the IMAI chapters on Paediatric management of HIV/AIDS.

3)All IMAI documents will be translated into Swahili.

Support for training and coordination: 1)HIV Care and Treatment teams will undergo 2 week IMAI training. These teams will consist of clinical officers, nurses, adherence counselors, and pharmacy technicians (3-4 HCWs from each primary facility). The team will be led by a doctor or assistant medical officer from the district hospital who will then supervise all health centres in their district, and will be designated an IMAI District Supervisor. With the inclusion of TB/HIV co-management and IMCI package the IMAI training duration will be extended for three to five days more.

2)The WHO country office will support the training of multidisciplinary teams of

zonal/regional facilitators. In order to organize and conduct these IMAI trainings at regional and zonal levels, each training site will need zonal/regional IMAI course coordinators (a health worker and an expert patient trainer), about 15 multidisciplinary IMAI training facilitators for HCWs and 20 Expert Patients trainers.

3)Each HIV Care and Treatment Team will receive on-going clinical mentoring. The WHO Generic Tools on clinical mentoring will be adapted and monthly post training supportive supervision of trained care and treatment teams from health centres and dispensaries will be done by the district and regional levels every month during the first six months and thereafter every three months.

4)Quarterly meetings of IMAI district supervisors and IMAI course coordinators will be held in each region to allow them to exchange experiences and lessons learned. The coordinating team will also share IMAI experiences and best practices with at the regional level during quarterly meetings and annually at the national level. When required, a few coordinators will participate in international conferences/workshops.

Support for equipment procurement for training sites and the country coordinating office will also be needed. This equipment may include a desktop computer, a laptop computer, one heavy duty printer, one heavy duty photocopier, five Flipchart stands, an LCD Projector and a digital camera.

WHO, in collaboration with MOHSW will initially concentrate in regions not supported by treatment partners. Thereafter, as partner efforts reach the level of health centers and dispensaries, they will collaborate with the ART partner and the NACP to train HCW in those regions. This adapted WHO IMAI approach will be considered the national standard for training HCW below the level of the district hospitals.

WHO Support for SI - National Monitoring Systems

This activity relates to activity IDs 7772- Support to national antiretroviral therapy ART monitoring; #-8060 - strengthening strategic information (SI) capacity; #7771 -National coordination of antiretroviral therapies ART services; #7776 - National AIDS Control Programme (NACP) counseling and testing activities; #7760 - NACP prevention of mother to child transmission (PMTCT) activities; # 8692 - NACP palliative care activities.

This activity will use funds allocated in the FY 2006 for a 24-month period beginning in October 2006. The activity has been expanded from supporting ART monitoring to supporting information systems and M&E activities for all HIV/AIDS interventions under NACP.

Specific tasks include: 1) recruiting a resident advisor, 2) providing technical support for training and supportive supervision for national monitoring systems for various HIV/AIDS interventions, and 3) coordinating all partner efforts in implementing national monitoring systems.

In FY 2006, there has been a deliberate attempt to coordinate various efforts to support the NACP/Ministry of Health and Social Welfare MOHSW in program monitoring activities. This activity builds upon those recent and ongoing efforts to identify the needs and deficiencies of the current ART monitoring systems in Tanzania. Under guidance from World Health Organization (WHO) experts, the MOHSW/NACP will strengthen the National Care & Treatment monitoring system to include a facility-based component. WHO chronic care registers will be adapted to the Tanzania situation and indicators will be defined at facility, district/regional and national levels. Data synthesis protocols and summary reports will be developed or adapted. The MOHSW/NACP will also depend on WHO experts to train trainers on the systems, who will in turn train the regional, district, and facility staff on the use of the system.

Other HIV/AIDS interventions such as Counseling & Testing (C&T), PMTCT and Home-based care (HBC) also require monitoring systems. These systems are primarily focused at facility level (point of service) where data can be collected, synthesized and used for program planning & management and to improve service delivery. National systems are currently under development. Tanzania requires technical assistance in maintaining these systems, ensuring all cadres of staff using the systems are adequately trained, and that supportive supervision is conducted to ensure data quality and to maintain data and report flow.

The overall goal is to fund the WHO to provide technical assistance and support to the MOHSW/NACP in Tanzania in the coordination of all national HIV/AIDS program monitoring efforts. This will include provision of a resident advisor to assist in coordinating development; maintenance and use of national monitoring systems; liaising with representatives from the USG, the World Bank, the Global Fund, and other donors which have direct or indirect interests in HIV/AIDS monitoring efforts in Tanzania. The scope of work will be to furnish all necessary personnel, facilities, and equipment, as appropriate to provide MOHSW/NACP with technical assistance and support services for program monitoring of all HIV/AIDS interventions under the NACP Surveillance, M&E Unit. The consultant will work closely with CDC SI team, NACP Surveillance, M&E Unit, in-country partners, and other agencies to: 1) to implement all program monitoring systems (specifically systems for Care & Treatment C&T, PMTCT, home-based care HBC), 2) train national training of trainers (ToT) and assist coordinating sub-national trainings, 3) ensure data quality at all levels of the system including coordinating the development and implementation of supportive supervision protocols, and 4) ensuring data and report flow from sub-national to national levels including facility feedback as necessary. At a central level, the consultant will ensure adequate utilization of electronic information to generate & disseminate reports for program improvement. The consultant will also provide support to the NACP in other M&E activities such as: 1) capacity building to enable the NACP to track progress against set goals/targets, 2) development of health sector M&E framework, and 3) development and implementation of a strategy to increase demand for use of program data.