Title: Expanding HIV Care and Treatment Services in Kagera, Kigoma, Pwani, Zanzibar

Need and Comparative advantage

Columbia University (CU) supports ART services in Kagera, Kigoma, Pwani and Zanzibar (HIV prevalence

of 0.9%-7.2%) where currently there is an estimated 51,503 patients in need of ART. There is need to bring

services closer to PLHAs in order to reach all those eligible for ART. CU proposes to establish ART services

at lower level facilities. This will involve infrastructure rehabilitation, training of health care workers, and

establishing the systems that are necessary to support ART programs. CU has supported high quality

comprehensive HIV Care and Treatment services for adults and children in Tanzania since 2004, and is

well positioned to further expand these services in FY 2008.[* regional HIV prevalence]

Acomplishments

In FY 2007, CU supported ARV services in 24 hospitals. By June 2007, CU had enrolled 20,321 clients in

care and initiated 8,102 on ART (64% females and 36% males). Over 550 children under the age of 15 are

receiving ART. 55 pregnant women have started ART since the onset of the program. Early Infant

Diagnosis activities at CU sites have identified 754 HIV-exposed infants, of which 680 received an HIV test.

117 were noted to be HIV-infected and 65 are receiving Care and Treatment.

Actvities

1. Increase coverage of HIV Care and Treatment services through decentralization. Focus on children (15%

of total): 1a) Renovate health centers for ART provision; 1b) Train 372 staff in Integrated Management of

Adolescent and Adult Illnesses (IMAI) curriculum 1c) Provide clinical mentoring to staff in the provision of

ART and enhance health care workers' (HCW) skill to treat children; 1d) Ensure commodities and supplies

related to adult and pediatric ART provision and OI drugs are available on-site through capacity of the

Council Health Management Teams (CHMT) in forecasting and logistics, and gap filling; 1e) Ensure clients

not eligible for ART are enrolled into care programs; 1f) Ensure Pre-ART and ART registers are used to

monitor clients on Care and Treatment; 1g) Provide care, treatment, and support through OVC programs to

HIV-exposed and infected children. This includes screening for HIV; HIV testing by DNA PCR for infants;

establishing referral linkages for care, including cotrimoxazole prophylaxis, and adherence support by

community health workers; 1h) In collaboration with the Ministry of Health and Social Welfare (MOHSW),

expand roll-out of the early infant diagnosis program to all four zones in Tanzania; including training zonal

trainers and health facilities; 1i) Implement Provider Initiated Testing and Counseling (PITC) at pediatric

inpatient and outpatient departments; 1j) Implement active case-finding at immunization clinics and ensure

mother's PMTCT status is documented on the child health card.

2. Provide comprehensive services at HIV Care and Treatment sites: 2a) Ensure CU supported sites

provide Pediatric ART, PMTCT, EID, TB/HIV, PITC and HBC services; 2b) Ensure strengthened linkages

between services; 2c) Establish sample transportation systems; 2d) Provide prevention with positives

services to clients attending care and treatment; 2e) Adherence support to clients enrolled into ART

programs 2f) Establish partnerships with programs providing commodities, nutritional, psychosocial, and

income generating support; 2g) Coordinate with existing palliative care programs; 2h) Establish PITC at all

entry points in CU supported facilities.

3. Ensure high quality ART service provision at all CU supported sites: 3a) Implement standards of care and

evaluate quarterly; 3b) Strengthen paper-based systems at all sites and computerized systems at 20 sites;

3c) Strengthen the capacity of sites, districts and regions in the collection, analysis and interpretation of

data and empower in data ownership; 3d) Conduct regular data feedback sessions 3f) Hire additional data

clerks at high volume ART sites;

4. Ensure ART service delivery is sustainable: 4a) Empower Regional Health Management Teams (RHMTs)

and CHMTs in planning, implementation, and supportive supervision, and ensure ART related activities are

all included in the Comprehensive Council Health plans; conduct supportive supervision with CHMT and

RHMT; 4b) Support one local NGO in each region; utilize community groups to provide psychosocial

support, link PLHAs to community support groups, and conduct defaulter tracing. 4c) Empower PLHA

groups (at least one per region) to conduct adherence support activities; 4d) Address policy issues around

the use of lay counselors and task shifting amongst HCWs at national level;

5. Expand public-private partnerships: 5a) Identify urban sites with shortage of health care providers; 5b)

identify private health care workers providing medical services in the same urban sites; 5c) Engage local

authorities and private practitioners in dialogue regarding collaborative provision of services; 5d) Train

private practitioners in the NACP ART training curriculum, mentor and supervise service provision; 5e)

Document process and outcome and disseminate results to national stakeholders and other implementing

partners; 5f) Explore working with private for-profit businesses to initiate and/or strengthen care and

treatment services as part of their package of health services to employees and dependents; leverage

resources in the provision of ART for employees at the work place, and support HIV counseling and testing

for the community with links to care where possible (NB This portion of the activity includes a rapid

response capability to be mobilized in support of specific workplace program requests); 5g) Continue

providing training on clinical care and M&E to Kagera Sugar Hospital and other companies with on-site

health clinics. These clinics are staffed, managed, and stocked by their respective companies.

6. Strengthen regional laboratory network in 4 regions: 6a) Upgrade14 laboratories and train 40 staff/region

on laboratory management, opportunistic infections diagnosis and good laboratory practices; 6b) Upgrade

infrastructure in six new laboratories; 6c) Upgrade 20 health center laboratories to perform hematology,

chemistry tests and diagnose opportunistic infections; 6d) Create and provide minimum package of

laboratory equipments and reagents to the regional, district, and health center laboratories; 6e) Create

sample transportation system between lower tier and higher tier laboratories; 6f) On-site training for the six

new labs on HIV monitoring; 6h) Establish a communication system between laboratories to ensure

accurate reagents procurement, forecasting, and provide training on estimation of existing stock, sample

transportation, and data collection; 6g) Establish laboratory data management system in 40 laboratories;

6h) Technical Assistance by in-country and regional CU lab Advisors

Linkages

PLHA organizations will be supported to assist in basic care and adherence support CU works closely with

the NACP, the diagnostics unit and the National TB and Leprosy Program (NTLP) in implementing

Activity Narrative: comprehensive HIV/AIDS activities. CU has created effective linkages with TADEPA, a local NGO in

Kagera providing community mobilization and defaulter tracing services. Further linkages will be formed

with the Kagera Zone AIDS Project to provide adherence support to PLHAs. Population Services

International, Mennonite Economic Development Associates in commodity provision. IEC/BCC partnerships

with STRADCOM. In Zanzibar, the Zanzibar Association of People Living with HIV/AIDS and Zanzibar non-

governmental organization cluster will provide adherence support to PLHAs. CU works closely with Clinton

HIV/AIDS Initiative on Zanzibar. New partnerships with private sector groups such as Interchick (Pwani),

Kagera Sugar, Uvinza Salt, Kabanga nickel mines, Nyaza Cooperative Cotton outgrowers will be explored.

CU will not provide food support directly, but will explore linkages with the World Food Program (WFP) and

faith-based organizations in order to leverage resources for nutritional support.

Check Boxes

General population, most at risk populations, and others will be targeted through testing activities and the

provision of ART. Patients on wards targeted through PITC. Employees will be targeted for job satisfaction,

increased retention. Activities related to renovation will be conducted in an effort to improve the capacity of

health centers to provide care and treatment services. Human capacity development activities revolve

around in-service training of health care workers. Workplace programs will be part of public-private

partnership (PPP) activities. CU will continue providing technical assistance to the MOHSW M&E unit.

M&E:

a) CU will collaborate with NACP/MOHSW to implement the national M&E system in all regions b) Data will

be collected & reported using paper-based and electronic National CTC tools. National and OGAC reports

will be generated c) CU will promote site feedback and data use d) A data quality assurance protocol for

paper-based and electronic data will be implemented at all sites with one QA supervision visit/quarter. e)

The NACP access database is currently implemented at six sites & will be scaled up to 20 sites by Sept 08

f) CU will train 126 HCW in M&E systems and provide technical assistance (TA) to all 42 CTCs g) CU will

support sites/districts/regions to share their data at stakeholder meetings, workshops and conferences.

Sustainability

This year's focus will be local governments, private sector engagement, and work with PLHA organizations

for sustainability and adherence.

Title of Study: Development, Implementation, and Evaluation of a Comprehensive Prevention Intervention

for HIV Care and Treatment Settings (multi-country PHE with Kenya and Namibia which is centrally directed

and funded).

Expected Timeframe of Study:

funds for this project were received in December 2006. It is anticipated that this will be an 18-month study.

Funds:

$500,000 central funds ($400,000 for implementation and $100,000 for evaluation)

Local Co-investigator:

Amy Cunningham, Columbia University Country Director, will be responsible for preparing the study

protocol for submission to relevant institutional review boards in collaboration with USG staff. Ms.

Cunningham will also be instrumental in hiring project staff, supervising data collection and analysis, and

disseminating findings

Project Description:

Prevention interventions for HIV-infected individuals are an essential part of a comprehensive HIV

prevention strategy. This is an interventional study focusing on provider-delivered prevention messages

(disclosure, partner testing, condom use), family planning referral, Sexually Transmitted Infection (STI)

screening and treatment, and use of community counselors that will be performed in three countries to

evaluate the effectiveness of these clinic-based interventions. We will enroll and follow a cohort of HIV-

positive patients receiving routine care in selected HIV clinics to assess these interventions' effectiveness at

increasing partner testing and disclosure of serostatus, decreasing risky sexual behaviors, alcohol use,

unintended pregnancies and STIs in HIV-infected persons.

Status of Study: CDC headquarters staff is finalizing intervention materials and preparing a draft evaluation

protocol.

Lessons Learned: None to date since project has not started.

Information Dissemination Plan:

The findings will have strong programmatic implications in Tanzania and throughout Africa by guiding policy

on prevention interventions in HIV care and treatment clinical settings. The results of the study will be

disseminated to Tanzania's Ministry of Health and Social Welfare at the national, provincial, and district

levels and regionally. Information may also be disseminated through peer-reviewed journals and

conference presentations.

Planned FY 2008 Activities: To begin enrollment of participants and implementation of the intervention, and

perform data analysis.