Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 1135
Country/Region: Tanzania
Year: 2009
Main Partner: Mbeya Regional Medical Office
Main Partner Program: NA
Organizational Type: Host Country Government Agency
Funding Agency: USDOD
Total Funding: $4,675,000

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $550,000

THIS IS AN ONGOING ACTIVITY FROM FY 2008. ACTIVITIES LISTED HAVE BEEN INITIATED AND

WILL PROCEED DURING FY 2009 AS IN THE PREVIOUS YEAR. ACCOMPLISHMENTS WILL BE

REPORTED IN THE FY 2008 APR. PLEASE NOTE THAT THE ACTIVITY NARRATIVE REMAINS

UNCHANGED FROM FY 2008.

The funding for this activity has increased from 350,000 to 550,000.

FY 2009 PMTCT targets have been modified

*END ACTIVITY MODIFICATION*

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

Activity Narrative: 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

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.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16410

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16410 16410.08 Department of Mbeya Regional 6536 1135.08 $350,000

Defense Medical Office

Emphasis Areas

Gender

* Addressing male norms and behaviors

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Malaria (PMI)

* Safe Motherhood

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $80,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $20,000

Economic Strengthening

Education

Water

Table 3.3.01:

Funding for Care: Adult Care and Support (HBHC): $700,000

ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY2008 COP.

TITLE: Expanding care and support in Mbeya Region

NEED and COMPARATIVE ADVANTAGE: Mbeya is one of the regions with the high prevalence (7.9%). 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 care and treatment.

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

the highest ranked local Ministry of Health and Social Welfare representative in this region. Through its

Regional AIDS Control Programme and strong working relationship with District Medical Officers, the

MRMO leads planning and execution of health services for its region.

ACCOMPLISHMENTS: In FY 2008, the MRMO is supporting treatment services in 18 established care and

treatment centers (CTCs). Under this same funding, MRMO will train an additional 100 healthcare workers

on ART provision, bringing the total trained in the region to 300. By September 30, 2008, the MRMO has

enrolled over 18,000 in facility-based care and support.

ACTIVITIES: All hospitals in the Mbeya region now support ART and pre-ART care and support, though the

majority of patients are still identified 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.

As part of FY 2008 and FY 2009 activities, the Department of Defense (DOD) will continue working with the

MRMO in developing strategies beyond provider-initiated testing and counseling (PITC) to decentralize

identification and 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 2009, ART will be expanded to 20 more health centres focusing on high density areas along trade

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

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

54 by September 2010; ensuring services are available in over 77% of all facilities and to more than 95% of

the population. Specificically, MRMO will:

1. Expand services and support to a total of 20 primary health care facilities in the region covering all eight

districts. Work with the District Health Management Teams (DHMT) and facility directors in developing

facility-based work plans and implementation of these plans. Assist in the acquisition of reagents,

medications and clinical supplies through local distributors when not available through central mechanisms.

2. Continue to improve the quality of care. Strengthen and reinforce implementation of standard operating

procedures for laboratory monitoring and maintenance of patient records. Expand mentoring and

supportive supervision beyond the district level facilities through regional medical teams. Improve patient

record and data collection, working with DOD, DHMT and facility staff to analyze data to inform

improvement of services.

3. Reinforce and expand PITC to all facilities. Train 60 staff in inpatient wards and outpatient clinics in

CTCs, actively promoting PITC for all patient contact points. Continue to sensitize hospital staff and clients

in care and treatment as a regular part of all out patient services, including the TB clinic.

4. Expand services and support to a total of three hospitals and 20 primary health care facilities in the

region, covering all four districts. This will be at a rate of three to four health centres per district. Work with

the DHMT and facility directors in developing facility-based work plans and implementation of these plans.

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

available through central mechanisms. Work with facility pharmacists in improving capacity in forecasting,

stock management, and ordering.

5. Increase enrollment of HIV-positive adults in care and support services. Promote routine counseling and

testing at all contact points. Continue to strengthen pre-ART within the CTC for evaluation and follow-up for

treatment. Ensure all TB/HIV co-infected patients are initiated on cotrimoxazole prophylaxis, as

appropriate.

6. Increase emphasis in provision of positive prevention to PLWHA. PLWHA will be provided with

counseling, and linked to support groups or peer-led interventions through the Home-based Care (HBC)

system. There will be increased involvement of PLWHA in providing information about ways they can

protect their own health, prevent common illnesses, and access safe water and improved hygiene practices.

MRMO will ensure that interventions address the comprehensive needs in an environment free from stigma

and discrimination. All sexually active PLWHA will be provided with condoms, which is an essential

component of prevention of further HIV transmission. PLWHA will be referred for family planning, if

relevant. Coupled with condom provision, PLWHA will be linked with sexually transmitted infection

treatment services and high-risk behavioral counseling. MRMO will discuss specific strategies with PLWHA

for disclosing one's HIV status to sexual partners and offer confidential HIV testing to the partners of and

children born to all PLWHA in coverage areas. Several specific activities will be implemented by sites to

provide positive prevention services. These include: procurement and/or distribution of Insecticide Treated

Nets to PLWHA and promotion on correct usage; cotrimoxazole prophylaxis for prevention of opportunistic

infections; and water treatment tablets and water vessels in order to provide safe drinking water.

7. Intensify efforts in nutritional support for PLWHA. Specifically, MRMO will support CTCs to conduct

anthropometric measurements and determine nutritional status using Body Mass Index (BMI) calculations

Activity Narrative: for and other appropriate measurements such has mid-upper arm circumference (MUAC) and weight for

age. Tunajali will procure the necessary equipment required to carry out effective nutritional assessment

such as weighing scales, MUAC tapes, and stadiometers. Training in the use of these tools will be

conducted, as well as in dietary assessments of patients and the provision of nutrition counseling and

education. In addition, MRMO will link with other organizations addressing household food security and

economic strengthening to ensure PLWHA have access to these services.

8. Reinforce comprehensive nature of clinical services. Strengthen and formalize referrals to and from

community-based organizations (CBOs), non-governmental organizations (NGOs) and faith-based

organizations serving patients in their communities through facility social workers.

LINKAGES: This activity is linked to activities under this partner in prevention of mother-to-child

transmission (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 NGOs, CBOs and home-based care 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 for the community organizations.

M&E: Quality assurance and control of clinical services are 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 technical assistance from the DOD

SI team based at the MRH. Data at each CTC is collected using standardized forms based on NACP and

facility data needs, entered into the electronic medical record system and transported to the DOD data

center located at Mbeya Referral Hospital for synthesis, generation of National AIDS Control Programme

and USG reports as well as to provide feedback to CTC teams for use in patient management.

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

and 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.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16530

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16530 16530.08 Department of Mbeya Regional 6536 1135.08 $200,000

Defense Medical Office

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $175,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $15,500

Economic Strengthening

Education

Water

Table 3.3.08:

Funding for Treatment: Adult Treatment (HTXS): $2,925,000

ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY 2008 COP.

1. Adult Treatment Information (09-HTXS)

TITLE: Expanding Adult ART in Mbeya Region

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

(7.9%). 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 FY8, the MRMO is supporting treatment services in18 established CTCs. Under

this same funding, MRMO will train an additional 100 health care workers on ART provision, bringing the

total trained in the region

to 300. As of June 31, 2008, the MRMO supported 10,300 people on treatment, 6% of which were children,

and has enrolled over 18,000 in care.

ACTIVITIES: All hospitals in the Mbeya region now support ART, though majority of

patients are still identified 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.

As part of FY 2008 and FY2009 activities, the DOD will continue working with the MRMO in developing

strategies beyond Provider Initiated Testing and Counseling (PITC )to decentralize identification/enrollment

of patients to increase uptake 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 2009, ART will be expanded to 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 increase the total number of ART sites supported in the region

by September 2010, ensuring services are available in over 77% of all facilities and to more than 95% of

the population. Activities will include: Expand services and support to primary health care facilities in the

region

covering all six districts; Work with District Health Management Teams (DHMT) in finalizing the identification

of new health centers for introduction of ART services; Work with the DHMT and facility directors in

developing facility based-work plans and implementation of these plans; Renovate space at 20 health

centers to support CTC; Train health providers/clinical staff in ART and TB/HIV co-management; Work with

facility pharmacists in improving capacity in forecasting, stock management and ordering; Continue to

improve the quality of care and treatment services; Provide ongoing mentoring and supportive supervision

through combined zonal and regional medical teams; 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;Improve patient record/data collection, working with DOD, DHMT and facility staff to

analyze data for improvement of services; Reinforce comprehensive nature of clinical services; Strengthen

prevention for positives counseling among all staff providing treatment at CTC; Strengthen of referral

system between services points at the MRH; Strengthen referral systems for services within a facility among

wards and clinics; Use site coordinator to conduct daily checks on registers in outpatient clinics, in-patient

wards, MCH and the TB clinic to keep track of patients referred to the CTC; Strengthen and formalize

referrals to and from CBO, NGO and FBO serving patients in their communities through facility social

workers.

Laboratory Services:

Train 30 lab technicians on PMTCT lab activity such as Syphilis testing, rapid HIV test trainings and Rapid

HIV quality assurance activities; Train 28 counselors which are mainly focused on counseling and testing

lab Activities such as PITC, VCT. The training will be focused on Rapid HIV testing and Quality Assurance

of Rapid HIV testing;Strengthen TB/HIV lab activities by training 14 lab technicians on rapid HIV testing, TB

diagnosis acid-fast method; DOD will continue to procure reagents for hematology, chemistry and CD4 and

viral load for all CTC hospital lab's in Mbeya Hospitals.

6e Continue to roll out HIV Early infant diagnosis, to 20 health centers in Mbeya,by training health workers

on sample management, transportation; MRMO will continue implement the external laboratory quality

assurance scheme in collaboration with MRH and DOD; MRMO will continue implement the external

laboratory quality assurance scheme in collaboration with MRH and DOD; MRMO will continue to service bi-

annually hematology, chemistry and facscount equipments in the zone by using the technical skills of DOD

hired Tanzanian medical engineer

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

Activity Narrative: 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 34 and 54 by Sept 2009 and Sept 2010 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.

April 2009 Reprogramming:

$75,000 Reprogrammed to (activity id 9237.23465.09) support procurement of lab reagents through SCMS.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13519

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13519 3386.08 Department of Mbeya Regional 6536 1135.08 $3,238,000

Defense Medical Office

7749 3386.07 Department of Mbeya Regional 4557 1135.07 $850,000

Defense Medical Office

3386 3386.06 Department of Mbeya Regional 2837 1135.06 $600,000

Defense Medical Office

Emphasis Areas

Construction/Renovation

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $309,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Care: Pediatric Care and Support (PDCS): $80,000

ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY 2008 COP

TITLE: Expanding Pediatric HIV Care and Support in the Mbeya Region

NEED and COMPARATIVE ADVANTAGE: Mbeya is one of the regions with a high HIV prevalence (7.9%).

It is estimated that there are 300,000 HIV-positive people in need of services in this region, 20% of whom

should qualify for antiretroviral therapy (ART). It is estimated that of these 300,000 individuals, 70,000 are

children less than 15 years of age.

ACCOMPLISHMENTS: In FY 2008, the Mbeya Regional Medical Office (MRMO) supported pediatric

treatment services in 18 established care and treatment center (CTC) sites. The program trained 100

health care workers on provision of antiretroviral services, including pediatric ART, bringing the total trained

in the region to 300. As of the end of FY 2008, MRMO has over 18,000 people enrolled in care and

support, approximately 6% of whom are children.

ACTIVITIES: All hospitals under the MRMO in the region support the provision of pediatric ART services,

though a majority of children are still identified through the Mbeya Regional Hospital (MRH). As part of FY

2008 and FY 2009 activities, the US Department of Defense (DOD) will continue working with the MRMO

and MRH to strategize the decentralization of identification and enrollment of patients to lower-level facilities

in order to increase uptake of services. More health facilities will be renovated and health workers trained

on pediatric ART management, including early infant diagnosis (EID) and psychosocial counseling to

improve adherence and disclosure in children. Collection and transportation of dried blood specimens

(DBS) to the zone reference laboratory will be improved. These will be key components of the overall

improvement of pediatric ART services at the district level, including expansion to health centers. Existing

CTC staff will receive refresher training on pediatric ART management and scale-up. The specialized

pediatric HIV/AIDS outpatient center is developed through FY 2009 - FY 2010 at the MRH in partnership

with Baylor International Pediatric AIDS Initiative (BIPAI). The pediatricians working within this facility will

conduct outreach services to mentor pediatric ART providers and provide specialized services where

required. This latter partnership will be executed through the MRMO, and will significantly augment

activities in support of the pediatric HIV services scale-up throughout the region.

In FY 2009, ART services, including pediatric care and support, will be expanded to 20 more health centers.

Focus will be on high density areas along trade routes while 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 CTC sites supported in the region to 54 by September 2010. Pediatric services will be

available in over 77% of all facilities, and to more than 95% of the population.

Specifically, MRMO will:

1. Expand pediatric HIV care and support services, using the revised national ART guidelines, to a total of

20 primary healthcare facilities in the region covering all eight districts (Mbeya Urban, Mbeya Rural, Mbozi,

Kyela, Rungwe, Ileje, Mbarali and Chunya). Work with the Council Health Management Team (CHMT) and

facility directors to develop and implement facility-based work plans and program linkages. Scale up EID

services to all primary health care facilities, and ensure that all HIV-exposed children are initiated on

Cotrimoxazole prophylaxis as appropriate.

2. Continue to improve the quality of pediatric care, link with and implement the national quality

improvement initiative. Provide nutritional education and counseling with nutrition support to HIV/AIDS

malnourished children after Body Mass Index assessments, and counseling services to caregivers to

prevent and manage food- and waterborne diseases, and improve infant and young children feeding

practices. Provide psychosocial support and counseling to include disclosure. The program will link with

the Presidential Malaria Initiative for the distribution of insecticide-treated nets to infants and HIV-positive

children. Ensure all HIV-exposed children are initiated on Cotrimoxazole prophylaxis based on national

guidelines. Strengthen and reinforce implementation of standard operating procedures for laboratory

monitoring. Expand mentoring and supportive supervision beyond the district-level facilities through

regional medical teams. Improve pediatrics record/data collection, working with DOD, CHMT, and facility

staff to analyze data that informs improvement of services.

3. Increase the number children on ART. Promote and support routine counseling and testing of mothers

and their children at all contact points in the health facilities, including antenatal clinics (ANC), labor and

delivery wards, immunization clinics and pediatric inpatient wards. Conduct mobile pediatric care and

support services to the rural areas including hard-to-reach poor communities. Continue to roll-out EID to 20

health centers in Mbeya by training health workers on sample management and transportation. Train ANC,

CTC, and postnatal clinic staff on EID with an emphasis on collection and transportation of DBS, which will

be sent to the MRH.

3. Reinforce and expand provider-initiated testing and counseling (PITC) to all facilities. Train 60 staff in

pediatric inpatient wards and outpatient clinics in HIV counseling and testing, actively promoting PITC for all

patient contact points, including immunization clinics, and antenatal clinics. Continue to sensitize hospital

staff and clients in counseling and testing as a regular part of all outpatient services, including the TB clinic.

Train health care workers on infant feeding counseling and improved practices using the national

curriculum.

4. Reinforce the comprehensive nature of clinical services by strengthening referral systems for services

within a facility among wards and clinics. Use site coordinators to conduct daily checks on registers in

pediatric outpatient clinics, inpatient wards, maternal and child health (MCH) and TB clinics to keep track of

patients referred to the CTC. Also, ensure appropriate referrals to other services, particularly the MCH

clinics so that children benefit from important child survival interventions. Strengthen and formalize referrals

of pediatric patients to and from community-based organizations (CBOs), non-governmental organizations

(NGOs) and faith-based organizations (FBOs) serving orphans and vulnerable children (OVC) in their

Activity Narrative: communities through facility-based social workers.

5. Ensure that appropriate commodities, equipment, and related skills are in place. Assist in the acquisition

of reagents, medications, and clinical supplies through local distributors when they are not available through

central mechanisms. Work with facility pharmacists in improving capacity in pediatric ART forecasting,

stock management and ordering. Procure the necessary equipment required to carry out effective

nutritional assessment such as weighing scales, MUAC tapes, and stadiometers. The program will conduct

training in the use of these tools, as well as in dietary assessments of patients and the provision of nutrition

counseling and education.

LINKAGES: This activity is linked to activities under this partner in prevention of mother-to-child

transmission (PMTCT) and adult care and support 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. It also is linked to the

BIPAI activity to scale up pediatric AIDS services and skills building in the zone.

The MRMO will continue to promote pediatric outreach services from the facilities to the communities

targeting rural and poor communities. Each facility will have lists of NGOs, CBOs, FBOs, and home-based

care providers involved in providing services to OVC and HIV-positive children, 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 point of

care for the community organizations. Finally, MRMO will link with other organizations addressing

household food security and economic strengthening to ensure PLWHA have access to these services.

M&E: Quality assurance and control for clinical services is conducted through the zonal and regional

supportive supervisory teams discussed above. M&E activities for all the CTCs under the MRMO are

supported by technical assistance from the DOD SI team based at the MRH. Data at each CTC is collected

using standardized forms based on National AIDS Control Programme (NACP) and facility data needs. It is

entered into the electronic medical record system and transported to the DOD data center located at the

MRH. There it is analyzed, NACP and USG reports are generated and feedback is provided to CTC teams

for use in patient management. The number of CTCs supported by MRMO will be 22 and 34 by September

2008 and September 2009 respectively.

SUSTAINABILITY: The MRMO is ensuring sustainability through strengthening of the facility and capacity

building of healthcare providers, sensitization of community members and advocacy through influential

leaders. This is also accomplished by strengthening systems, such as the improved capacity of CHMT, the

regional supportive supervisory team and the zonal weekly ART meetings (as part of existing zonal support

and routine MRMO functions). All pediatric HIV care interventions will be integrated in the districts'

comprehensive council health plans so that future support for the program is seen as part of the overall

district plans.

Geographic Coverage Areas: (Regions) Mbeya

New/Continuing Activity: Continuing Activity

Continuing Activity: 16530

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16530 16530.08 Department of Mbeya Regional 6536 1135.08 $200,000

Defense Medical Office

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

* Malaria (PMI)

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $5,000

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $10,000

Economic Strengthening

Education

Water

Table 3.3.10:

Funding for Treatment: Pediatric Treatment (PDTX): $320,000

THIS IS A NEW ACTIVITY.

TITLE: Expanding Pediatric ART in Mbeya Region

NEED and COMPARATIVE ADVANTAGE: Mbeya is one of the regions with a high prevalence (7.9%). 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. It is estimated that out of these 300,000 individuals, over 70,000 are children

less than 14 years of age.

ACCOMPLISHMENTS: In FY08, the Mbeya Regional Medical Office (MRMO) supported pediatric treatment

services in 18 established CTC sites. The program trained 100 health care workers on ART provision,

including pediatric ART, bringing the total number trained in the region to 300. As of June 31, 2008, the

MRMO supported 10,300 people on treatment, 6% of whom were children, and has enrolled over 18,000 in

care.

ACTIVITIES: Hospitals under the MRMO in the Mbeya region support a majority of the pediatric ART

patients in the region, though majority of those children are still identified through the Mbeya Regional

Hospital (MRH) As part of FY 2008 and FY2009 activities, the DOD will continue working with the MRMO

and MRH to develop strategies to decentralize identification/enrollment of patients to lower level facilities,

increasing uptake of services. More health facilities will be renovated and health workers trained on

pediatric ART management, including early infant diagnosis (EID) and psychosocial counseling to improve

adherence and disclosure in children. Collection and transportation of dried blood specimens (DBS) to the

zone reference laboratory will be improved. These will be key components of the overall improvement of

pediatric ART services at the district level, including expansion to health centers. Existing CTC staff will

receive refresher training on Pediatric ART management and scale-up. As the specialized pediatric

HIV/AIDS outpatient centre is developed through FY 2009/2010 at the MRH in partnership with Baylor

International Pediatric AIDS Initiative (BIPAI), the pediatricians working within this facility will conduct

outreach services to mentor pediatric ART providers and provide specialized services where required. This

latter partnership will significantly add to those activities' being executed through the MRMO in support of

pediatric HIV services throughout the region.

In FY 2009, ART services, including pediatric ART, will be expanded to more health centers. Focus will be

on high density areas along trade routes in addition to identifying isolated rural communities in which the

health center provides the only source of regular medical services. Pediatric care and treatment activities

will also expand to these sites. This will ensure pediatric services are available in over 77% of all facilities,

and to more than 95% of the population.

Funds will be used for expansion of Pediatric ART services to primary health care facilities in the region

covering all eight districts. (Mbeya urban, Mbeya Rural, Mbozi, Kyela, Rungwe, Ileje, Mbarali and Chunya) ;

Work with Council Health

Management Teams (CHMT) to finalize the 20 new health centers' introduction of ART, including pediatric

ART service; Supervise and coordinate scale-up of pediatric ART throughout the zone; Continue to provide

evaluation of malnutrition and nutritional counseling to all pediatric HIV-positive clients as part of treatment;

Renovate space At identified health centers to support CTC including pediatric ART; Train an additional

health providers/clinical staff in pediatric ART management; Work with facility pharmacists in improving

capacity in pediatric ARV forecasting, stock management and ordering and continue to improve upon the

number of individuals trained to identify pediatric cases early through provision of provider initiated testing

and counseling (PITC) at antenatal clinics, during post-natal follow up, as part of immunization clinics, at out

-patient clinics and through in-patient wards

FY 2009 funds will also be used to continue to improve the quality of care and treatment service through:

Provision of pediatric ART and counseling on ART adherence in main MRH CTC, Meta and at

satellite/health centers. Care elements, including the basic prevention package, for these patients under

treatment are detailed in the Pediatric Care and Support entry for this partner; Strengthen and reinforce

implementation of standard operating procedures for pediatric clinical services and maintenance of patient

records; Provide ongoing pediatric ART mentoring and supportive supervision through combined zonal and

regional medical teams; Participate in weekly zonal ART meetings with the Mbeya Referral Hospital to

discuss treatment roll out and conduct mobile pediatric ART services to the rural areas including hard-to-

reach poor communities

Funds will be used to increase the number children on ART from 6% to 12% of the total patient population

through strengthening referrals between antenatal clinics, PMTCT, TB services and CTC for evaluation of

HIV-positive children for treatment initiation; Train prenatal clinic (PNC) and CTC staff in the collection of

DBS for infant diagnosis; Continue to roll out HIV EID, to health centers in Mbeya by training an additional

health workers on DBS collection and transportation; Continue to strengthen TB/HIV co-management for

children identified in the PNC and CTC

Lastly funds will be used to strengthen referral system between pediatric HIV services points at the MRMO

by use an M&E officer to conduct daily checks on registers in outpatient pediatric clinics, in-patient pediatric

wards, MCH and the TB clinic to keep track of patients referred to the CTC and strengthen and formalize

referrals to and from community-based organizations (CBOs), NGOs and faith-based organizations (FBOs)

serving pediatric patients

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

Activity Narrative: will have lists of NGOs, CBOs and HBC providers involved in pediatric HIV/AIDS support. It will indicate

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 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: Quality assurance and control for clinical services is conducted through the zonal and regional

supportive supervisory teams discussed above.

M&E activities for all the CTCs under the MRMO are supported by technical assistance 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. It is then entered into the electronic medical record system (EMRS), transported to the

DOD

data center located at Mbeya Referral Hospital, synthesized, NACP and USG reports are generated, and

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

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

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

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

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

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

MRMO functions).

New/Continuing Activity: Continuing Activity

Continuing Activity: 13519

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13519 3386.08 Department of Mbeya Regional 6536 1135.08 $3,238,000

Defense Medical Office

7749 3386.07 Department of Mbeya Regional 4557 1135.07 $850,000

Defense Medical Office

3386 3386.06 Department of Mbeya Regional 2837 1135.06 $600,000

Defense Medical Office

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $32,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.11:

Funding for Care: TB/HIV (HVTB): $100,000

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAY

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

Mbeya Regional Medical Office (MRMO) will continue providing support for implementation of HIV care and

treatment services together with collaborative TB/HIV activities. In FY 2009, ART will be expanded to

health center level focusing on high density areas along trade routes, but also identifying isolated rural

communities in which the health center provides regular medical services. For TB/HIV activities in FY09

focus will be to improve Intensified TB case finding in care and treatment settings and TB infection control in

all care and treatment clinics (CTC). All HIV infected patients receiving HIV care and treatment will be

screened for TB disease routinely and those found to have active TB will be referred to TB clinic to initiate

an uninterrupted treatment using Directly Observed Therapy (DOT). Diagnosis of TB will follow national TB

and Leprosy guidelines. Referral, linkages and patients follow up from care and treatment clinic to

laboratory, TB clinic and to other HIV related services e.g. home based care will be improved. MRMO will

print and distribute all TB/HIV guidelines including guidelines for implementation of TB infection control. TB

infection control will be implemented to all care and treatment sites to prevent transmission of TB among

People Living with HIV/AIDS (PLWHA) as well as health care providers. Training on TB/HIV activities

including intensified TB case finding, use of TB screening tool, reporting and recording will be conducted to

health care providers working at HIV clinics. Health care providers will also be trained on TB infection

control practices, ensuring good ventilation at the clinics. Laboratory services will be improved making sure

sputum smear microscopy performed are of high quality. MRMO will strengthen existing laboratory services

needed to implement TB/HIV program activities including supplement HIV test kits and X-ray films.

Outreach ART services to remote TB clinic in the regions will be strengthen with improved referral system.

MRMO will advocate for integration of collaborative TB /HIV services in HIV clinics including PMTCT and

STI

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

comanagement,

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

Activity Narrative: 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.

New/Continuing Activity: Continuing Activity

Continuing Activity: 16442

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

16442 16442.08 Department of Mbeya Regional 6536 1135.08 $100,000

Defense Medical Office

Emphasis Areas

Health-related Wraparound Programs

* TB

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

Cross Cutting Budget Categories and Known Amounts Total: $646,500
Human Resources for Health $80,000
Food and Nutrition: Commodities $20,000
Human Resources for Health $175,000
Food and Nutrition: Commodities $15,500
Human Resources for Health $309,000
Food and Nutrition: Policy, Tools, and Service Delivery $5,000
Food and Nutrition: Commodities $10,000
Human Resources for Health $32,000