TITLE: PMTCT Services in Mbeya.

NEED and COMPARATIVE ADVANTAGE: Mbeya is one of the regions with the highest HIV prevalence

(13.5%) with prevalence at antenatal clinics recorded at 12.7% It is estimated that there are 300,000 HIV-

positive people in need of services in this region, 20% of whom should qualify for treatment.

As part of Tanzania's decentralized health care approach, the Mbeya Regional Medical Office (MRMO) is

the highest ranked local MOHSW representative in this region. Through its Regional AIDS Control

Programme, and strong working relationship with DMOs, the MRMO leads planning and execution of health

services for its region. It has been executing PMTCT in 19 facilities, receiving technical assistance from

GoT, but is in need of funding and additional support in expanding the number of services site to reach

more of the population.

ACCOMPLISHMENTS: In FY 2006 the MRMO began to integrate PMTCT as part of HIV treatment services

where ART was available. It also began to rapidly scale-up basic PMTCT services by introducing them to

additional health centers serving neglected rural communities. In FY 2007, facilities under the MRMO tested

16,862women and provided prophylaxis to 2,145 HIV+ women, 12.7% of those identified as positive.

ACTIVITIES: With PMTCT regionalization by the USG, PEPFAR funds will be awarded to DOD partners to

directly support PMTCT sites (both current as well as planned) originally served by funding through the

MOHSW. As a result, the existing referral system will be further developed so that HIV+ women identified

will be linked to nearby treatment centers.

1) Expand PMTCT sites to a total of 33 by September 30, 2009.

1a) Train health care workers at each new site using a "full site" approach similar to Engender Health, and

whenever possible, ensuring at least four ANC staff per site are trained.

Adopt an opt-out counseling and testing policy in both an ANC setting and labor ward and delivery.

1b) Renovate ANCs where needed to improve confidentiality.

1c) Procure commodities, such as rapid test kits, when not available through central procurement

mechanisms.

2) Strengthen PMTCT interventions and integration of PMTCT to ART services.

2a) Where ART is available, either at the same facility or a nearby service center, efforts will be made to

establish formal referrals from PMTCT services/sites with counseling and testing centers (CTCs) to support

the delivery of comprehensive HIV services.

2b) Evaluate HIV+ women for eligibility for Highly active anti retroviral therapy (HAART), and provide ARV

regimens based on the new revised guidelines following the WHO-tiered approach for ARV prophylaxis to

ensure HIV positive women and HIV-exposed children receive the most efficacious treatment Zidovudine

(AZT) and Nevirapine (NVP or single dose Nevirapine (SDNVP).

2c) Provide "prevention for positives" counseling package based on the USG-developed approach in

Tanzania.

2d) Encourage HIV+ women to bring in family members for counseling and testing at either the ANC or the

hospital's VCT center

2e) Promote infant feeding counseling options (AFASS), linking mothers to safe water programs in the

region, and for those choosing to breastfeed, counsel them to exclusively breastfeed with early weaning.

2f) Infant feeding and nutritional interventions during lactation period will be promoted.

2g) Train ANC staff in collection of DBS for infant diagnosis.

2h) Send dried blood spot (DBS) to MRH which will be receiving equipment from the Clinton Foundation

and technical assistance from USG lab partners to conduct infant diagnosis for the entire Southern

Highlands.

2i) Ensure all HIV exposed and infected children are initiated on cotrimoxazole prophylaxis as appropriate.

3. Build capacity of regional and district health teams to plan, execute and monitor PMTCT activities.

3a) Acquire technical support for regional and district authorities with the assistance of other USG partners

(such as Engender Health) to work with the MRMO in conducting site assessments and supportive

supervision

3b) Use data collected to work with District Health Management Teams to assess site specific services and

develop a plan of action to address problems.

3b) Support DHMT to include PMTCT activities in council health plans.

LINKAGES: This activity is linked to activities under this partner in ART, TB/HIV, and palliative care. It is

also linked to other USG partner entries in the program area which can provide additional technical

assistance such as Engender Health or EGPAF.

Linkages for services will include pre and post-test counseling (group or individual). Those testing negative

are given education on protective measures and practices for avoiding infection while those testing HIV+

are evaluated for ART as described above. Both populations are linked to RH services. In addition, the

MRMO will continue to promote outreach services from the facilities to the communities for HIV positive

clients. Each facility will have lists of NGO's, CBOs and HBC providers involved in HIV/AIDS support,

indicating geographical coverage and types of services offered. These lists will be displayed in the CTCs

and other clinics/wards so health staff can refer clients to those organizations as necessary. These

referrals, as well as referrals from community organizations to the facility, will be further strengthened

through facility staff serving as points of contact (POC) for the community organizations.

CHECK BOXES: This funding will fully develop PMTCT services covering all the districts including health

centers and dispensaries. Funding will support the introduction and/or improvement of PMTCT services in

the region. Emphasis will be put into training of health care workers in the district hospital, health centers

and dispensaries, renovation counseling and delivery rooms, and commodities for services when not

available through central procurement mechanisms.

M&E: Quality Assurance/Quality Control of services will be provided by MRMO staff conducting quarterly

site assessments (more frequently for new sites). Technical assistance will also be sought by other USG

PEPFAR partners such as Engender Health which is executing a successful "full site" approach to PMTCT

and is initiating PMTCT support in the nearby region of Iringa in FY 2008.

Data will be collected using both paper-based tools developed by MOHSW, and adaptation of the electronic

medical record system (EMRS) (see DOD SI entry) to incorporate PMTCT data. On site electronic data

Activity Narrative: entry will take place. All sites will have laptops with a data base and output functions as developed by UCC

for the National C&T program. Data clerks will be retrained, and the data collected will be reported to NACP

and the USG.

SUSTAINABILITY: The MRMO is ensuring sustainability through capacity building of health care facilities

and its staff, sensitization of community members, and advocacy through influential leaders. This is also

accomplished by strengthening "systems," such as the improved capacity of the Regional AIDS Control

Programme, the District Health Management Team (DHMT), through regional supportive supervisory teams

as part of already existing zonal support, and routine MRMO functions. Most of this funding will be spent at

the district and health facility level, thereby building capacity and sustainability at the level where the

services are provided.

TITLE: Facility-based Palliative Care in Mbeya

Mbeya Regional Medical Office is a treatment in Mbeya, and provides palliative care to most of those

registered in their Care and Treatment Clinics (CTCs). This includes both patients on Anti-Retroviral

Therapy (ARTs) and not yet eligible on ARTs. Patients receive WHO staging, provision of cotrimoxazole in

accordance with national guidelines, diagnosis and management of opportunistic infections, including

tuberculosis screening and referral and cryptococcal infection, nutritional assessments/counseling (and

referrals), symptom and pain management (for outpatients, pain management is currently restricted to non-

opioid medicines such as ibuprophen and paracetamol), and psychosocial support. General counseling

addresses disclosure of HIV status, adherence to care and treatment, behavior change counseling for

prevention of HIV transmission, and other individual specific issues, as appropriate. Pediatric formulations

of cotrimoxazole are available for children.

In FY 2008, after an assessment of nutritional supplement options are evaluated, an expanding number

may receive nutritional support. A growing number of people living with HIV/AIDS are involved as peer

counselors and in assisting with linkages to local organizations that can help to promote adherence, provide

psychosocial support, and to handle referrals for community services (e.g. income generating activities and

legal service).

An important linkage is between facility-based palliative care and community home-based care (HBC). This

link is critical as all palliative care cannot be done at the facility. There are two-way referrals from the CTC

to the community HBC program and from the community HBC program to the CTC. The program strives to

have 100% of patients registered in Care and Treatment be referred to a community home-based care

program.

Total palliative care targets are de-duplicated at the national program level for patients who receive facility-

based services from this partner and home-based services from either this or other USG-supported

partners.

TITLE: Expanding and Integrating TB/HIV activities in Mbeya Region

NEED and COMPARATIVE ADVANTAGE: According to the National Tuberculosis and leprosy Program

(NTLP), TB /HIV dual infection contributes to 17.5 % of the total disease burden in Tanzania (Ministry of

Health and Social Welfare (MOHSW), Manual of National Tuberculosis and Leprosy Program in Tanzania,

Fifth Edition, 2006). Currently, the Mbeya Regional Medical Office (RMO) supports ART and TB services in

10 hospitals and four health centers and plans to provide TB/HIV services to an additional eight health

centers where we currently have a functional Care and Treatment Center (CTC). This integrated approach

will further strengthen collaboration between TB care and HIV/AIDS care, reducing the burden of TB among

PLWHA and reducing the burden of HIV among TB patients, resulting in more effective control of TB among

HIV-infected people.

ACCOMPLISHMENTS: Currently, the MRMO supports treatment services in all six districts in the region

and will continue to strengthen the monitoring of HIV patients who are on TB care. Monitoring TB patients

through the use of clinical forms with TB screening questions has been key to ensuring the screening and

referral of all HIV and TB patients. Patients referred both ways have been well documented in the care and

treatment clinics. Integration of HIV care and treatment and the TB diagnosis, as well as treatment and

follow up will be strengthened in FY 2008.

ACTIVITIES: In FY 2008, ART will be expanded to 12 more health centers focusing on high density areas

along trade routes, but also identifying isolated rural communities in which the health center provides the

only source of regular medical services.

1) All HIV infected patients receiving HIV care and treatment will be screened for TB disease routinely, and

those suspected will access TB diagnostic services. Those found positive for TB disease will be

immediately referred to the TB clinic to initiate an uninterrupted treatment using the Direct Observation

Therapy (DOT). 1a) Support making of the clinical forms with TB screening tool. 1b) Clinicians and nurses

at each site will be trained on TB/HIV collaborative activities including use of modified clinical forms to

routinely identify underlying TB signs and symptoms for all clients attending at CTC. 1c) Develop a referral

system for access of HIV-infected TB suspects to laboratory diagnosis and treatment for TB.

2) TB infection control practices will be implemented in the care and treatment clinics to prevent

transmission of TB among PLWHA as well as health providers. 2a) CTC staff at each site will be trained on

TB infection control practices. Ensure ventilation in Care and Treatment clinics.

3) Strengthen existing laboratory services needed to implement TB/HIV program activities. 3a) Supplement

supply of X-ray films.

4) Support outreach ART services to remote TB clinic in the regions.

LINKAGES: This activity is linked to activities under this partner in PMTCT, TB/HIV, and palliative care as

well as those of the other regions in this zone (Rukwa and Ruvuma). It is also linked to the DOD submission

under SI and other USG treatment partner submissions providing expertise in areas of pediatric care and

TB infection control.

The MRMO will continue to promote outreach services from the facilities to the communities. Each facility

will have lists of NGO's, CBOs and HBC providers involved in HIV/AIDS support, indicating geographical

coverage and types of services offered. These lists will be displayed in the CTCs and other clinics/wards so

health staff can refer clients to those organizations as necessary. These referrals, as well as referrals from

community organizations to the facility, will be further strengthened through facility staff serving as points of

contact (POC) for the community organizations.

CHECK BOXES: The areas of emphasis will include: initial and refresher training of staff in TB/HIV co-

management, infection control, provision of supplies and medications, and capacity building. Community

Health Management Teams (CHMTs) will be supported in planning and incorporating TB/HIV activities in

Council Comprehensive Plan (CCHPs).

M&E: Quality Assurance and Quality Control (QA/QC) for clinical services is conducted through the zonal

and regional supportive supervisory teams discussed above.

All efforts will be made to capture all the HIV care and treatment related data from both the CTCs and TB

clinics using NTLP data collection, recording and reporting tools. M&E data activities for all the CTCs under

the MRMO are supported by technical assistance (TA) from the DoD SI team based at the Mbeya Referral

Hospital.

SUSTAINABILITY: In order to sustain our efforts in integrating and expanding the TB/HIV services, MRMO

will continue working very closely with the National TB/Leprosy Control Program. The MRMO will ensure

sustainability through capacity building of health care facilities and its staff, sensitization of community

members, and advocacy through influential leaders. This is also accomplished by strengthening "systems",

such as the improved capacity of District Health Management Teams (DHMT), the regional supportive

supervisory team, and the zonal weekly ART meetings as part of already existing zonal support and routine

MRMO functions.

TITLE: Expanding ART in Mbeya Region

NEED and COMPARATIVE ADVANTAGE: Mbeya is one of the regions with the highest prevalence

(13.5%). It is estimated that there are 300,000 HIV positive people in need of services in this region, 20% of

whom should qualify for treatment. Over 10,000 have been initiated on ART to date through out the region

and at the Mbeya Referral Hospital (MRH) (separate entry). Even with these achievements, there are still an

estimated 46,000 in need of ART.

As part of Tanzania's decentralized health care approach, the Mbeya Regional Medical Office (MRMO) is

the highest ranked local MOHSW representative in this region. Through its Regional AIDS Control

Programme and strong working relationship with District Medical Officers (DMOs), the MRMO leads

planning and execution of health services for its region.

ACCOMPLISHMENTS: In FY 2007, the MRMO is supporting treatment services in 10 hospitals and four

health centers ensuring all six districts in Mbeya are supported with ART. Under this same funding, an

additional 38 health care workers are being trained in ART provision, bringing the total trained in the region

to 200 As of June 31, 2007, the MRMO supported 5,600 people on treatment, 6% of which were children,

and has enrolled over 15,000 in care.

ACTIVITIES: Though all hospitals in the Mbeya region now support ART, identification of a majority of

patients is still through the MRH. Here they undergo their initial evaluation after which they are referred

down to the regional and district hospital for management. It is believed this is due to the higher quality of

services and better infrastructure at MRH, including its large inpatient wards. This serves as a bottle neck in

increasing enrolment of patients and also means the MRH bears the brunt of the cost of bringing on new

patients in the region. As part of FY 2007 and F Y2008 activities, the DOD and MRH will work with the

MRMO in developing strategies beyond Provider Initiated Testing and Counseling (PITC )to decentralize

identification/enrollment of patients to increase up take of services. This will be a key component of the

overall improvement of services at the district level, including expansion to health centers.

In FY 2008, ART will be expanded to 12 more health centers focusing on high density areas along trade

routes but also identifying isolated rural communities in which the health center provides the only source of

regular medical services. This expansion will bring the total number of ART sites supported in the region to

34 by September 2009, ensuring services are available in over 77% of all facilities and to more than 95% of

the population.

1. Expand services and support to a total of 10 hospitals and 24 primary health care facilities in the region

covering all six districts.

1a. Based on NACP health center assessments and strengthening reports, work with District Health

Management Teams (DHMT) in finalizing the 12 new health centers for introduction of ART services

1b. Work with the DHMT and facility directors in developing facility based-work plans and implementation of

these plans

1c. Renovate space at 12 health centers to support CTC

1d. Train an additional 38 health providers/clinical staff in ART and TB/HIV co-management

1f. Assist in the acquisition of reagents, medications and clinical supplies through local distributors when not

available through central mechanisms

1g. Work with facility pharmacists in improving capacity in forecasting, stock management and ordering

2. Continue to improve the quality of care and treatment service.

2a. Strengthen and reinforce implementation of Standard Operating Procedures (SOP for clinical services,

laboratory monitoring and maintenance of patient records

2b. Provide ongoing mentoring and supportive supervision through combined zonal and regional medical

teams

2c. Participate in weekly zonal ART meetings with the Mbeya Referral Hospital to discuss treatment roll out,

identify areas of need, determine solutions and coordinate resolution

2d. Improve patient record/data collection, working with DOD, DHMT and facility staff to analyze data to

inform improvement of services

3. Reinforce and expand PITC.

3a. Train 200 staff in inpatient wards and outpatient clinics in HIV CT, actively promoting provider initiated

counseling and testing for all patient contact points

3b. Continue to sensitize hospital staff and clients in CT as a regular part of all out patient services,

including the TB clinic.

3c. Reinforce sensitization through rotation of staff from the HIV CTCs to assist regular hospital staff in

patient identification and provision of this service.

4. Increase the number of women and children on ART.

4a. Promote and support routine counseling and testing of mothers and their children at all contact points in

the health facilities, including ANC, labor and delivery wards, immunization clinics, and female and pediatric

inpatient wards

4b. Continue to improve and strengthen referrals between ANC PMTCT services/sites and CTC for

evaluation of HIV+ mothers for treatment

4c. Train ANC and CTC staff in the collection of DBS for infant diagnosis.

4d. Send DBS to MRH which will be receiving equipment from the Clinton Foundation and technical

assistance from USG lab partners to conduct infant diagnosis for the entire Southern Highlands.

4e. Ensure all HIV exposed and infected children are initiated on cotrimoxazole prophylaxis as appropriate.

5. Reinforce comprehensive nature of clinical services.

5a. Strengthen referral systems for services within a facility among wards and clinics

5b. Use site coordinators to conduct daily checks on registers in outpatient clinics, in-patient wards, ANC

and the TB clinic to keep track of patients referred to the CTC.

5c. Strengthen prevention for positives counseling among all staff providing CT services and care and

treatment at CTC

5d. Strengthen and formalize referrals to and from CBO, NGO and FBO serving patients in their

communities through facility social workers.

Activity Narrative:

LINKAGES: This activity is linked to activities under this partner in PMTCT, TB/HIV, and palliative care as

well as those of the other regions in this zone (Rukwa and Ruvuma). It is also linked to the DOD submission

under SI other USG treatment partner submissions providing expertise in areas of pediatric care and TB

infection control.

The MRMO will continue to promote outreach services from the facilities to the communities. Each facility

will have lists of NGO's, CBOs and HBC providers involved in HIV/AIDS support, indicating geographical

coverage and types of services offered. These lists will be displayed in the CTCs and other clinics/wards so

health staff can refer clients to those organizations as necessary. These referrals, as well as referrals from

community organizations to the facility, will be further strengthened through facility staff serving as POC for

the community organizations.

CHECK BOXES: The areas of emphasis will include: initial and refresher training of staff in ART, TB/HIV co-

management, and CT; infrastructure improvement for new sites; provision of equipment, supplies and

medications; strengthening linkages with TB/HIV, PMTCT and community groups.

M&E: QA/QC for clinical services is conducted through the zonal and regional supportive supervisory teams

discussed above.

M&E data activities for all the CTCs under the MRMO are supported by TA from the DoD SI team based at

the Mbeya Referral Hospital. Data at each CTC is collected using standardized forms based on NACP and

facility data needs, entered into the electronic medical record system (EMRS) and transported to the DoD

data center located at Mbeya Referral Hospital for synthesis, generation of NACP and USG reports as well

as to provide feedback to CTC teams for use in patient management. The number of CTCs supported by

Mbeya RMO will be 22 and 34 by Sept 2008 and Sept 2009 respectively.

SUSTAINABILITY: The MRMO in ensuring sustainability through capacity building of health care facilities

and its staff, sensitization of community members and advocacy through influential leaders. This is also

accomplished by strengthening "systems", such as the improved capacity of DHMT, the regional supportive

supervisory team and the zonal weekly ART meetings as part of already existing zonal support and routine

MRMO functions.