PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
ACTIVITY HAS BEEN REVISED: Columbia will work with the MOH to establish a local NGO that can
manage implementation of Family Support Groups in the country, building upon the mothers 2 mothers
(m2m) program model. Data has also been updated.
Title:
Scale up and provision of comprehensive Family focused PMTCT Services in 3 Regions in Tanzania
Need and Comparative Advantage
Use of PMTCT programs as an entry point to care and treatment services is critical to ensuring a continuum
of care for HIV-infected pregnant women, their partners, and HIV-exposed children. Using innovative
approaches CU supported the Ministry of Health and Social Welfare (MOHSW) in implementing
comprehensive PMTCT services in 3 regions of Tanzania (Kagera, Kigoma, and Pwani) where HIV
prevalence ranges from 2% to over 7%. The main focus in 2009 and beyond is ‘elimination of MTCT' by
scaling up the innovative approaches used to ensure broader coverage, including: increased uptake
through opt-out testing and counseling; the use of more efficacious regimens; integrating ART services into
the RCH clinic; retention of newly diagnosed HIV-positive women into care and treatment through
establishment of special clinic days for follow-up of positive mums; establishment of support groups for HIV
+ mums and families; strengthening safe infant feeding practices; and early identification and management
of exposed infants. CU expanded experiences in the establishment of the Reproductive Child Health (RCH)
platform providing counseling and testing, efficacious PMTCT regimens, ART treatment services, and
psychosocial support in the same facility, ensuring a comprehensive package of PMTCT care and treatment
services are linked into the continuum of care under one roof, leading to improved uptake and quality of
services. Long distances in the predominantly remote areas that CU works in are a major limiting factor to
adherence and long term engagement into the continuum of care. Capacity of health centres to provide
ART care and treatment for pregnant women will be expanded to bring comprehensive more efficacious
PMTCT and care and treatment services closer to the HIV infected mothers and their families.
Accomplishments
In FY 2007, a total of 19,962 pregnant women received HIV counseling and testing (18,699 at ANC and
1,263 at L&D) and 374 mother-infant pairs were provided Nevirapine prophylaxis at L&D.
In FY 2008, a total of 71,360 pregnant women received HIV counseling and testing (this includes from ANC
and maternity) and 1,072 mother-infant pairs were provided nevirapine prophylaxis at L&D. Implementation
of the new PMTCT guidelines using more efficacious regimens was accomplished in 14 health facilities, to
further impact decrease transmission rate. Identification and early diagnosis of HIV exposed Infants has
been scaled up to all Regional and District hospitals and high Volume health centres in all 3 CU supported
regions. By June 31st 2008, 761 HIV Exposed Infants (HEI) had been identified at 8 sites in 3 regions and
627 of these were given cotrimoxazole prophylaxis. HIV positive infants diagnosed through DBS DNA PCR
testing were referred to the Care and treatment clinics.
In FY 2009, 85,945 pregnant women will receive HIV counseling and testing and 2,922 HIV positive women
will receive PMTCT prophylaxis.
Activities
1. Expand PMTCT services to 65 new lower level facilities in Kigoma, Kagera and Pwani regions and
ensure quality of care in collaboration with the district management teams.
CU will Partner with Council Health Management Teams (CHMTs) to plan, implement, and strengthen
PMTCT services in the district. Support to 151 existing sites will continue, with further scale-up to 65 new
lower-level facilities to bring services nearer to the mostly rural communities in CU supported Regions.
Training of Health care workers in the new PMTCT guidelines, mentoring of site staff and on-site CME's will
capacitate site staff in implementing the PMTCT program. Increased male involvement in PMTCT services
by provision of partner invitation letters and community mobilization efforts; Support of minor renovations in
the facilities to create room for service delivery; Support communication and stationary required;
procurement of test kits and related consumables and joint supervision with CHMT will continue to ensure
quality of service delivery.
2. Create and/or strengthen linkages to adult and pediatric care and treatment and expand early infant
diagnosis activities; The care clinics will: provide services to HIV-infected mothers, their HIV-exposed
infants and partners; strengthen use of two way referral forms and physical escort by providers; and link
basic sites to CTC through the peer support program. CU will support minor renovations and furniture;
purchase motorcycles for blood sample transportation and systems to strengthen CD4 testing and
documentation of pregnant women to link them to appropriate efficacious PMTCT prophylaxis; supply adult
and pediatric cotrimoxazole for prophylaxis; supply standard package of opportunistic infection drugs; train
276 staff on clinical staging and management of opportunistic infections; provide polymerase chain reaction
early infant diagnosis HIV-testing via dried blood spot for HIV-exposed infants identified in all PMTCT sites.
3. Promote use of efficacious regimens for PMTCT.
All district and regional hospitals and high volume health centres will be capacitated to implement the
efficacious regimens. The Regional district managers will be oriented on the new guidelines and trained on
the logistics; and site staff will be trained to implement the new guidelines. Refresher training package will
be rolled out to all districts and CU will provide intensive on-site mentoring on the use and monitoring of
these new regimens and follow-up the training with on-site CME's to reinforce knowledge and skills in the
use of the efficacious regimens. Training in the monitoring and evaluation tools will be implemented and job
aids distributed to assist quality assurance. Provision of comprehensive family focused PMTCT care and
treatment, implementation of the new efficacious regimens within the RCH setting will be scaled up to
include 10 sites per region. Antenatal, intrapartum, postpartum follow-up of the HIV positive women will be
strengthened and their families will be invited to be counseled and tested and linked to services under the
same roof in a family friendly environment.
4. Establish Family support groups for PMTCT and develop national tools and guidelines for Roll out.
CU will scale up formation of family support groups for HIV positive mothers and their families in the ICAP
regions and will work with the NACP, WHO, Unicef and USG partners to adopt a standard package of tools
Activity Narrative: for national scale up. FSGs will be established in an additional 20 sites, with onsite trained coordinators
and active follow up. Appointment systems will mesh with FSG tracking to ensure good adherence to care.
FSGs will link with other community groups and resources to provide nutrition support, treatment for OIs,
acccess to ITNs, safe water, income generation and other supports. FSGs will provide a leverage for
delivery of Prevention in Care and Treatments as well as build capacity for PLHIV+ women. ICAP will work
closely with USG and MOHSW to establish a local NGO that can manage implementation of Family Support
Groups in the country, starting in ICAP supported regions and possibly High Prevalence Areas.
5. Support the national PMTCT program by providing technical assistance on policy issues, monitoring and
evaluation of the National PMTCT program, and data use for decision making. Provide technical assistance
on roll-out of PMTCT monitoring and evaluation tools; provide technical assistance in developing
psychosocial support program for PMTCT.
Linkages
CU will partner with community-based and faith- based organizations through the district Council HIV/AIDS
multisectoral Coordinator (CHAC). Through the RCHCO CU will link up with Traditional Birth Attendants
(TBA) to support local communities and work closely with people living with HIV/AIDS (especially HIV+
pregnant mothers); as they are key players in promoting PMTCT services, reducing stigma and
discrimination, promoting male involvement and participation, and addressing other related maternal and
child health issues. Linkages to care and treatment, family planning, child survival, nutrition, TB/HIV,
Malaria, RCH and OVC programs will be actively strengthened.
M&E:
CU will continue technical support to the NACP in roll-out of training and site support in use of the new
PMTCT national M&E tools. CU will work with partners to train, pilot, and implement the tools; b) Data will
be collected and reported using national PMTCT tools: ANC and L&D registers, and monthly summary
forms (MSF); c) CU will promote data synthesis & use at the site, district, regional, and national level; d)
Data quality will be ensured through CU and district teams conducting regular site supervision visits with
review of registers and consistency checks of MSFs; e) CU will train 150 HCWs and provide technical
assistance to 226 facilities, 21 districts and 3 regional offices; f) Once the national database is completed,
CU will implement it at 20% of the sites. At CU, an Access database will be developed for storage of MSFs
from all CU supported sites; g) CU will assist PMTCT teams at supported facilities to provide monthly,
quarterly, and semi-annual/annual reports to the district, regional, and national levels as appropriate. CU
will provide reports to PEPFAR as required.
Sustainability
CU will work with District Councils to include PMTCT activities in Comprehensive Council Health Plans and
support resource mobilization from Global Fund and other sources. Full integration of PMTCT into RCH
services will help to ensure sustainability. The implementation process will involve existing management
systems and human resources. National guidelines will be used to ensure continuity of the implemented
activities. Capacity building of the regional and council health management teams in program specific
training, supportive supervision, and mentoring skills will be included to ensure continuity of their
supervisory roles and program ownership. Capacity building at the national level will help to ensure
continuity of program monitoring and evaluation for decision-making.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13457
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13457 8219.08 HHS/Centers for Columbia 6509 1221.08 $2,040,000
Disease Control & University
Prevention
8219 8219.07 HHS/Centers for Columbia 4530 1221.07 $1,050,720
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 $520,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
It reflects FY08 achievements and planned activities in FY09. At the request of the GOT, the USG will
implement a pilot male circumcision program through 5 partners including: Jhpiego, Columbia University,
AED/TMARC, Pharm Access and Mbeya Regional Hospital. Jhpiego will provide technical oversight,
training and support with systems development (i.e., supervision, quality improvement, etc.) to the other
implementing partners as well as implement the MC demonstration program at Iringa Regional Hospital.
Jhpiego will also conduct formative research on traditional circumcisers in Mara. Columbia University will
implement the MC demonstration program in Kagera, Mbeya Regional Hospital will implement in Mbeya,
and Pharm Access in Dar es Salaam (with the TPDF). AED/TMARC will work closely with Jhpiego in the
development of appropriate communications initiatives targeting health care providers as well as
surrounding demonstration site communities. Refer to the narrative below for specific changes.
TITLE: Male Circumcision Demonstration Project and Advocacy Efforts
NEED and COMPARATIVE ADVANTAGE: Ongoing HIV transmission in sub Saharan Africa necessitates
vigorous prevention efforts. However, to date the availability of an effective HIV vaccine or microbicide
remains an elusive but important goal. Thus, the compelling evidence of effectiveness of male circumcision
as an HIV prevention intervention has been met with great excitement. Three randomized clinical trials
conducted in Kenya, South Africa and Uganda demonstrated that male circumcision of HIV uninfected men
provided between 50-60% protection against HIV acquisition. As a result, this intervention is being
considered for implementation and scale-up in communities with high rates of HIV infection and low rates of
circumcision of men. However, it is also widely acknowledged that scaling up of this intervention is
complicated by various factors that require careful monitoring and evaluation. In FY 2007 and 2008, USG
Tanzania worked with the national government to assess factors that could impact the initiation of male
circumcision services. These factors included religious, cultural and societal beliefs and norms in addition to
the feasibility of integrating adult male circumcision into existing medical service provision.
At the request of the Government of Tanzania Male Circumcision Technical Working Group and in
collaboration with WHO, USG Tanzania has been requested to implement a demonstration project in four
regions and among enlisted men in TPDF. This demonstration project, using data from the situational
analysis to tailor service delivery, will assess the capacity of HIV programs to implement safe male
circumcision, training, outreach, message development, service delivery and client follow-up.
Columbia University/ICAP has been instrumental in Tanzania's MC activities for the past two years and it is
poised to transition to service delivery as part of the demonstration project team.
ACCOMPLISHMENTS: ICAP, in collaboration with the World Health Organization (WHO) country office,
worked with the Ministry of Health to form a male circumcision task force in November 2007. The task force
has had numerous meetings and has successfully adapted the WHO situational analysis toolkit for the
Tanzanian context. The situational analysis will be conducted to determine: the prevalence and
acceptability of male circumcision; the feasibility and current capacity of the Tanzanian medical
infrastructure to delivery male circumcision services; the current policy environment; and the associated
costs with male circumcision.
With support from WHO and ICAP, the National Institute of Medical Research carried out a pilot test of the
situational analysis tools in Mwanza Region in March 2008 to determine the suitability of the tools for more
widespread use in Tanzania. Results were shared with stakeholders in May 2008 and it was determined
that the tools would be fine-tuned and implemented in Mbeya, Mara and Kagera Regions, with results
available by September 2008. Clearance for the activity has been secured through a national review
process and ICAP and CDC approval are expected in the coming weeks. A meeting of key stakeholders
including the Ministry of Health and Social Welfare (MHSW) staff will be organized upon completion of the
project. Data from every aspect of the effort will be shared including feasibility, acceptability, and costs. In
addition, materials and tools developed for the purpose of scale-up of this intervention will be also shared
with meeting attendees. All information will be collated in a compendium for use by stakeholders and other
interested parties.
ACTIVITIES: In order to appropriately plan for possible implementation and scale-up of male circumcision in
Tanzania, a coordinated effort is required. FY 2009 funds are requested to respond to ministry's request for
a demonstration project and assistance planning for future expansion of male circumcision services in
Tanzania. As part of harmonized approach in Tanzania, ICAP will implement demonstration activities for
one year at the regional hospital in Kagera, a region with an HIV prevalence rate of 3% and male
circumcision coverage of 26%. The other regions included in the demonstration project include: Iringa,
where male circumcision prevalence is low (38%) while HIV prevalence, at 15% is the highest in the
country; and Mbeya are 34% for MC and 8% for HIV. Male circumcision services will also be provided to
enlisted men in Tanzania's Peoples Defense Force.
Kagera, the region in which ICAP will implement services, has relatively low rates of both male circumcision
and HIV but is one of the regions being assessed through the situational analysis where data will be
collected to inform relevant programming efforts for regions with lower HIV prevalence. The ministry views
this region as an important balance to the other demonstration sites because Kagera presents an
opportunity to implement a scientifically efficacious intervention before HIV rates escalate and become
excessively problematic.
Male circumcision services will not be a stand alone intervention, but part of a comprehensive prevention
strategy, which incudes: the provision of HIV testing and counseling services; treatment for STIs; the
promotion of safer sex practices; the provision of male and female condoms and promotion of their correct
and consistent use; and linkages and referrals to prevention interventions and other social support services.
An additional emphasis will be on appropriate counseling of men and their sexual partners to prevent them
from developing a false sense of security and engaging in high-risk behaviors that could undermine the
Activity Narrative: partial protection provided by male circumcision. Appropriate communication tools and messages will
highlight accurate information regarding the protective effect of male circumcision, need for continued use of
other preventive behaviors (e.g. condom use), risks and benefits of the procedure, appropriate post-
operative wound management and the need to abstain from sex until certified complete incision healing.
The provision of accurate information regarding these important facts will be needed in order to achieve
successful and safe scale-up of male circumcision.
JHPIEGO, a globally recognized leader in this area, will provide technical assistance and training for the key
partners in each of the demonstration regions. Specifically, ICAP will receive assistance with the following:
•Introductory meetings and onsite orientation workshops (2-3 days);
•Site strengthening in preparation for service delivery;
•Provider training for provider teams from the regional hospital, with follow-on counseling-specific training as
necessary; and
•Onsite supportive supervision.
As a continuing member of the ministry's male circumcision task force, ICAP will participate in meetings to
review results of the situational assessment and design strategy for implementation of MC services,
workshops to develop service delivery guidelines, review/adapt MC training package and develop
reporting/recording forms, and workshops to develop and pilot test performance standards for quality MC
service delivery.
To assist with future scale-up of male circumcision throughout the country, Columbia University and other
male circumcision partners will regularly share lessons learned and best practices with the national
Technical Working Group.
The activities will be completed in consultation with the PEPFAR male circumcision task force.
LINKAGES: Lessons learned and data from every aspect of the effort, including feasibility, acceptability and
costs, will be shared with the Ministry of Health, National AIDS Control Program, WHO, colleagues in the
demonstration project, and other prevention and treatment partners. In addition, materials and tools
developed for purpose of scaleup of this intervention will be also shared.
CHECK BOXES: Gender: addressing male norms and behaviors
Male circumcision
Adults (men and women 25 and over)
Discordant couples
M&E: As progress towards actual implementation begins, ICAP will advocate for the development of a
sentinel surveillance and reporting system for the region. This is particularly important for tracking adverse
events and the system will be developed in consultation with members of the demonstration project team.
SUSTAINABILITY: ICAP will work in partnership with local government authorities in the target regions,
including relevant coordinators working within district/regional CHMTs, to build their skills in program
implementation and coordination. Similarly, management and staff at the regional hospital will be actively
involved in planning and implementation so that they take ownership of this initiative.
Continuing Activity: 13389
13389 12384.08 HHS/Centers for Columbia 8547 8547.08 UTAP $200,000
12384 12384.07 HHS/Centers for To Be Determined 6161 6161.07 Male
Disease Control & circumcision
Prevention assessment
Table 3.3.07:
ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY 2008 COP.
TITLE: Scaling-up Availability of Palliative Care and Pain Management Services in Tanzania
NEED and COMPARATIVE ADVANTAGE: Approximately 1.4 million people in Tanzania are HIV-positive,
and require some form of care and support. Columbia University (CU) provides facility-based care and
support to patients through the Care and Treatment clinics they support in Kagera, Kigoma, Coast, and
Zanzibar. In addition to these facility-based services, CU works with Ocean Road Cancer Institute (ORCI),
designated leader in the delivery of palliative care to HIV/AIDS patients in Tanzania. ORCI works closely
with the Ministry of Health and Social Welfare (MOHSW) on expanding palliative care for HIV/AIDS to
include more comprehensive pain management, initially through zonal centers. This is an important need,
as, 80% of HIV patients presenting at stage three or four have pain as a symptom and few receive pain
management and symptom control services. Lack of access to services is directly related to lack of skilled
providers in assessment and management of pain in a broad sense, and lack of access and skill to use pain
medications, including morphine. Currently 95% of morphine in the country remains unused, and only six
facilities nationally actively dispense to HIV/AIDS clients. Columbia University (CU) will further expand
these services in FY 2009 to link with partners working in regional hospitals and select faith-based facilities.
Assessment of palliative care activities at the four zonal hospitals has already been done, followed by
training of palliative care teams to 30 healthcare workers from the four zonal hospitals under initial funding
of FY 2008. Multi-disciplinary teams serve as trainers of teachers to selected regional hospitals in each
zonal referral hospital to facilitate the delivery of palliative care services and pain management.
ACCOMPLISHMENTS: In FY 2008, CU provided facility-based palliative care to over 21,000 people by in
Kagera, Kigoma, Coast, and Zanzibar at the Care and Treatment Clinics (CTCs). Also, through ORCI, CU
supported facility-based services to an additional 700 PLWHA. In addition, pain management activities
have begun through ORCI and four zonal centers in July 2008.
ACTIVITIES: With FY 2009 funding, CU will:
1. Deliver facility-based palliative care services in Kigoma, Kagera, and Pwani regions. Focus on facility-
based and outreach services to ensure all PLWHA identified through routine counseling and testing have
immediate access to Cotrimoxozole, treatment for opportunistic infections (OIs, psychosocial support,
adherence counseling, and linkages for other key services in the community (e.g., bed nets and safe water)
Emphasis will be given to prevention for positives interventions (patient disclosure; access to condoms;
referral for family planning, if appropriate; behavioral counseling for reduction of risk for transmission;
referral for sexually transmitted infections; etc.. CU will also strengthen linkages with Home-based Care
(HBC) programs in Kagera and Kigoma, where currently few services for basic care are provided by HBC
workers. Ensure availability of holistic palliative care including pain management and symptom control is
available at initiating sites.
2. Focus additional attention on food and nutrition needs of clients receiving care and support, given that the
importance of nutrition in determining clinical outcomes for people on antiretroviral treatment is becoming
increasingly more apparent. CU will conduct nutritional assessment and counseling, to inform the clinical
management of PLWHA. Specifically, CU will conduct anthropometric measurements and determine
nutrition status using body mass index calculations and other age appropriate measurements, provide
dietary assessments and nutrition education and counseling to maintain or improve nutritional status.
In FY 2009, USG Tanzania will be initiating a therapeutic supplemental feeding program, using ready-to-use
therapeutic food products targeting eligible clients. CU will be a part of this program through case
identification and progress monitoring following the set entry and exiting criteria. CU will use FY 2009 for
procurement of necessary equipment required to carry out effective nutritional assessment (adult and
pediatric weighing scales, stadiometers, mid upper-arm circumference tapes, etc.); procurement, logistics
and inventory control costs. In addition, CU will use FY 2009 funds to support the rollout of nutritional
assessments; trainings will be conducted to equip health care workers and HBC providers with necessary
tools and curricula to implement these services. Linkages will be made to other USG entities and/or
community services to provide patients with other community initiatives addressing household food security
and economic strengthening.
3. Expand palliative care and pain management in all four zones and selected regional hospitals. Continue
to build palliative care teams for HIV at Kilimanjaro Christian Medical Centre, Bugando Medical Centre,
Mbeya Referral Hospital, and Muhimbili National Hospital, and select an additional six sites to launch.
Procure equipment and help set up palliative care teams. Ensure availability of oral morphine for pain
management at sites. Train 250 healthcare workers in pain management and symptom control services
using the national curriculum developed by ORCI. Facilitate site certification for morphine dispensing.
Finalize and disseminate the Kaposi Sarcoma and pain management protocols. Work with Tanzania Food
and Drug Administration and Medical Stores Department (MSD) to ensure that pain relief and symptom
control medications are available at the implementing sites. Provide onsite mentoring and technical
assistance. Develop an M&E system for management of pain services, hold a national palliative care
meeting to agree on guidelines, and develop training materials and supports.
LINKAGES: Forge linkages with Balm in Gilead and other HBC providers. Work with African and Tanzanian
Palliative Care Associations (in which ORCI is the chair), to expand services and bring USG care and
treatment partners into networks to ensure smooth implementation, as well as Family Health International in
their systems strengthening role. In regions where CU is primarily responsible for treatment and PMTCT,
CU will work closely with authorities of Coast, Kagera, and Kigoma to provide palliative care services;
facility-based and home outreach. Supplies of Cotrimoxozole and other OI drugs will be assured through
Diflucan partnership, with MSD, Abbott, and CU. CU will work with the USG, T-MARC, Population Services
International, and MSD/Supply Chain Management System to ensure an adequate supply of condoms,
family planning methods, bed nets, and safe water. CU will link with non-governmental organizations
(NGOs) involved in the provision of HBC services.
Activity Narrative: M&E: CU will collaborate with the NACP/MOHSW and sites to track palliative care service provision and
utilization; participate in the planning and development of a national monitoring system for palliative care
and its implementation, once completed; support the use of electronic patient data in data in program M&E;
and conduct technical support visits at least quarterly to conduct data quality assurance.
SUSTAINABILITY: CU will continue to build ORCI's capacity as the institution is envisioned to become a
premier regional training institution for palliative care, and will expand its ability to offer training services to
other institutions and Government of Tanzania staff at a fee. In the regions, CU will ensure sustainability of
these services by engaging local authorities in all decision-making processes, and by working closely with
leaders to integrate palliative care into existing healthcare services. CU will continue to build the technical
capacity of the healthcare workers at health facilities and that of the local government authorities.
Continuing Activity: 16352
16352 16352.08 HHS/Centers for Columbia 6509 1221.08 $750,000
Estimated amount of funding that is planned for Human Capacity Development $630,500
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $50,000
and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Commodities $100,000
Table 3.3.08:
ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY2008COP.
Title: Expanding HIV Care and Treatment Services in Kagera, Kigoma, Pwani, Zanzibar
Need and comparative advantage: Columbia University (CU) has supported high quality comprehensive
HIV Care and Treatment services for adults and children in Tanzania since 2004. It is well positioned to
further expand these services in FY 2009. CU supports ART services in areas (HIV prevalence of 0.9%-
7.2%) where there is currently an estimated 51,503 patients in need of ART. In response to the Ministry of
Health and Social Welfare's (MOHSW) need to decentralize services, CU is supporting the establishment of
ART services at lower-level facilities. This involves infrastructure rehabilitation, training of health care
workers (HCWs) and establishing systems that are necessary to support ART programs.
Results: During FY 2008, CU supported ARV service in 44 health facilities (HFs) (31 hospitals, 13 health
centers (HCs)) increasing from 27 in September 2007. By June 2008, CU enrolled 10,281 new clients in
HIV care, and initiated 4,601 on ART (64% females and 36% males). Among the new enrollments, 88%
were screened for active TB, 8% were identified as TB suspects, 37% were diagnosed with tuberculosis
and initiated on treatment. 489 (68%) of the TB/HIV patients started co-trimoxazole preventive therapy
(CPT). Since the onset of the program, 115 pregnant women started ART and over 300 children under the
age of 15 received ART. Through early infant diagnosis (EID) activities, 1,101 HIV-exposed infants were
identified. Of those, 975 received an HIV test, 123 tested HIV-positive, and 50 received HIV care and
treatment (CT). The International Center for AIDS Care and Treatment Programs (ICAP), working with
district and regional health management structures, initiated sub grant programs in all 18 of their mainland
and Zanzibar districts.
Ensure high quality ART service coverage. Decentralize ART service to peripheral HFs, focusing on
primary care facilities; improve infrastructure at peripheral HFs for ART provision; continue expanding
continuing medical education (CME) program for HCWs, focused on improving treatment outcomes,
monitoring side effects and treatment failure; implement the Family Testing Model for all clients receiving
ART; ensure linkages between different services (care and treatment, PMTCT, TB etc) are established, and
strengthen both the facility and the community; implement partner-initiated counseling and testing (PITC)
linked to ART at district and regional hospitals, focusing on in-patient wards; strengthen the capacity of
sites, districts and regions in the collection, analysis and interpretation of data, and empower them in data
ownership; conduct regular data feedback sessions with implementers, regional authorities and MOHSW;
hire additional staff at high volume ART sites.
Ensure sustainability of ART service
Capacity building. Empower Regional and Council Health Management Teams (RHMTs and CHMTs) in
planning, implementation and supportive supervision. Ensure that ART-related activities are included in the
Comprehensive Council Health Plans. Train and clinical mentor HCWs on ART provision. Facilitate the
ART service provision task-shifting process. PLWHA groups will conduct ART adherence support activities.
Develop a training program for pharmacists on forecasting and ordering of ARVs.
Partnerships. Expand ART service to private organizations and faith-based HFs. Engage local authorities
and private partners (PPs) on collaborative provision of ART service. Identify urban and Para-urban sites
with a shortage of priority health care packages (PHCPs) where private groups can initiate ART services.
Train PPs on ART management. Collaborate with private for-profit businesses to provide ART for
employees at the work place.
System strengthening. Ensure uninterrupted ARV/opportunistic infection (OI) drug management through
regular Report & Recording at pharmacy level and strengthening the capacity of RHMTs and CHMTs in
forecasting and gap filling.
Strengthen laboratory network. Upgrade laboratories for ART provision at lower level health centers.
Ensure access to CD4 testing at baseline and every 6 months for all clients on-site or through linkages.
Train staff on laboratory management and practices and OI diagnosis. Provide a minimum package of
laboratory equipments and reagents to the regional, district, and HC laboratories. Strengthen the sample
transportation system. Support laboratories' supplies chain management. Establish a laboratory data
management system. CU will support MOHSW quality assurance/quality control activities by supporting
regional and facility Quality Assurance Officers in supportive supervision of all regional and district CTCs in
their four regions. Support equipment services and maintenance by training 100 lab staff and two Zonal
Engineers on planned preventive maintenance.
Linkages: CU will strengthen partnerships with; PLWHA organizations/NGOs on improving the quality of
ART services; Population Services International (PSI) and Mennonite Economic Development Associates
(MEDA) on strengthening commodity provision; STRADCOM on information education and communication
(IEC)/behavior change communications (BCC) and ART radio programs; Interchick, Kagera Sugar, Uvinza
Salt, KabangaNickel Mines, Nyanza Cooperative Cotton growers on ART program for workers and
surrounding communities; WFP and faith-based organizations on enhancing nutritional support.
M&E: CU will collaborate with the National AIDS Control Program (NACP)/MOHSW to implement the
national M&E system in four regions. Data will be collected and reported using paper-based and electronic
National CTC tools to generate national and OGAC reports. CU will promote site feedback and data use by:
continuing the monthly feedback of achievements in enrolment of patients with HIV, training staff to
generate quarterly, semi-annual/annual reports; and planning future interventions. A data quality assurance
protocol for paper-based and electronic data will be implemented at all sites with one quality assurance
supervision visit per quarter. The NACP Access database will be scaled up. CU will train HCW in M&E
systems and provide technical assistance to all CTCs across 21 districts, three regional offices and
Zanzibar. CU will undertake critical reviews of the data, and 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
PLWHA organizations/NGOs for ART service sustainability and treatment adherence.
Continuing Activity: 13459
13459 3461.08 HHS/Centers for Columbia 6509 1221.08 $7,130,000
7698 3461.07 HHS/Centers for Columbia 4530 1221.07 $4,733,257
3461 3461.06 HHS/Centers for Columbia 2865 1221.06 UTAP $2,130,000
Estimated amount of funding that is planned for Human Capacity Development $861,250
Table 3.3.09:
ACTIVITY HAS BEEN REVISED SIGNIFICANTLY FROM FY 2008 COP
TITLE: Pediatric Care and Support
NEED and COMPARATIVE ADVANTAGE: By the end of FY 2008, Columbia University (CU) had enrolled
over 30,000 HIV-positive patients into care, only 2,280 of whom were children under 15 years. In Tanzania,
an estimated 130,000 children are born to HIV-positive women annually. Columbia has been a leader in
setting up Early Infant Diagnosis (EID) systems, but there are many other components of pediatric care and
support that need additional attention.
ACCOMPLISHMENTS: CU established the model of HIV/AIDS services on a maternal and child health
(MCH) platform in Tanzania, integrating antiretroviral therapy (ART) into reproductive health services. CU
has successfully supported the Ministry of Health and Social Welfare (MOHSW) to develop national
guidelines, trained national and zonal trainers, and provided training and technical support to all USG
partners and the Clinton Foundation to implement the EID program in all zones. More than 2,600 HIV
Exposed Infants (HEI) have been identified, over 2,000 of whom have begun Cotrimoxazole preventive
therapy and were tested for HIV using DNA polymerase chain reaction (PCR). Over 310 HIV-positive
infants and children have been diagnosed through this program. Currently 379 (17%) of the 2,280 pediatric
patients ever enrolled into care at CU-supported sites are children below two years; the target is to increase
the enrolment to 30%.
ACTIVITIES: In 2009, CU will intensify support to care and treatment centers (CTCs) and antenatal feeder
sites to address pediatric care through specialized training, additional staffing, and site mentoring. CU will
also introduce specialty clinics, support structures, and Child-Friendly Corners. In addition, the program will
develop four regional hospitals into pediatric model centers providing family-focused pediatric units
equipped with all infrastructure and resources for provision of comprehensive HIV/AIDS care and treatment.
The hospitals will also serve as training units where health care workers from other facilities come for
practical demonstration on how to care for HIV-exposed infants (HEI) and HIV-positive children. These
models will be developed in consultation with the new Baylor Pediatric Initiative, in order to take advantage
of their experience in other countries and to share materials and tools that have already been developed.
Specifically, CU shall:
1. Increase identification and retention in care of HEI. Strengthen national and regional EID program
through training 240 healthcare workers; train and provide onsite clinical mentoring to staff on identification
of HEI from maternal antenatal records; follow-up HEI including regular provision of Cotrimoxazole
prophylaxis; counsel on safer infant feeding practices; and establish the final infection status of the child at
six weeks after weaning. Strengthen the current monitoring system and detect HIV infection occurring while
during breast feeding through monitoring of growth failure and other clinical signs and symptoms that can
alert health workers. Strengthen linkages of Expanded Program of Immunization (EPI) and MCH clinics
(where HIV-exposed infants receive basic care) and clinics for care and treatment. Strengthen adherence
and follow-up of HEI through mother-to-mother support groups. Continue to strengthen sample
transportation system for the Dried Blood Spot process and delivery of results.
2. Strengthen the coverage and quality of care and support for HIV-infected children and infants. All new
CTCs and major renovations will establish a Child-Friendly Corner. Increase enrolment by training 600
healthcare workers, and enhance clinical mentorship skills for Provider-Initiated Testing and Counseling in
MCH services, pediatric wards, and pediatric outpatient clinics. Support counseling and testing for siblings
of HIV-positive children and children of HIV-positive parents. Ensure HIV-positive children receive and
remain on Cotrimoxazole preventive therapy according to national guidelines. Introduce pain management
strategies at regional facilities through training, assessing, measuring, and managing symptoms. Develop
and enhance systems and linkages to maintain children in care through membership in CU's International
Center for AIDS Care and Treatment Programs (ICAP) Adherence and Psychosocial Support Groups and
the use of peer educators to trace missed appointments. Develop or use already developed pediatric
screening tools for TB infection, TB diagnostic algorithm, and TB/HIV job aids for children living with HIV.
Include nutritional assessments and child counseling, including anthropometric, symptom and dietary
assessment to support clinical management of HIV-positive children prior to and during ART. This will
include nutrition education and counseling to maintain or improve nutritional status, prevent and manage
food- and waterborne illnesses, manage dietary complications related to HIV infection and ART, and
promote safe infant and young child feeding practices. Procure pediatric equipment for effective nutritional
assessment (weighing scales, stadiometers, MUAC tapes, etc). Support the rollout of nutritional
assessments through training health care workers. Strengthen linkages to malaria control programs and
access to insecticide-treated bed nets. Capacitate four regional hospitals to provide exemplary pediatric
services and skill-building to health care workers from other lower level sites.
3. Adolescent-friendly services: Establish adolescent-friendly clinics at the three regional hospitals and
provide them with the psychosocial support necessary for comprehensive care including HIV/STI education,
promotion of healthy lifestyles, fostering healthy coping techniques, and promoting HIV/AIDS risk reduction.
4. Establish regional laboratory networks in four regions. Lab systems for integrating EID in the wards,
sample transport, effective lab tests, and analysis for children will be included in lab trainings.
LINKAGES: In addition to areas noted above, CU will partner with the National AIDS Control Programme
and MOHSW to track utilization of care and support service provision by monitoring EID and pediatric care
and treatment activities. CU will also link with the new Baylor International Pediatric AIDS Initiative to
ensure a cohesive approach to the provision of pediatric care and support and to reduce potential for
duplication of effort.
M&E: CU was a key partner in developing the national M&E tools for Prevention of Mother-to-Child
Transmission and EID, and these will be implemented at all CU sites. At 30 of the 70 sites to be supported
Activity Narrative: in FY 2009, patient-level CTC databases including pediatric data will be implemented.
SUSTAINABILITY: Please see Pediatric ART above. In addition, community and PLWHA groups are a core
component of ICAP's approach to ensure family-focused care, links to facility and community groups.
Estimated amount of funding that is planned for Human Capacity Development $15,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $5,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $15,000
Table 3.3.10:
THIS IS A NEW ACTIVITY.
Title: Pediatric Anti Retroviral Treatment (ART)
Need and Comparative Advantage: In Tanzania, an estimated 59,000 children below 15 years of age are
living with HIV. Unless they have access to early diagnosis and treatment, about half of children born with
HIV die before two years of age. The National Paediatric Technical Working Group, of which the
International Center for AIDS Care and Treatment Programs (ICAP)-Columbia University (CU) is a member,
is currently forging a dialogue with The Ministry of Health and Social Welfare (MOHSW) to adopt WHO
treatment guidelines for children under the age of 12 months. Concurrent with Early Infant Diagnosis (EID),
for early identification of HIV-infected children, ICAP desires to link HIV-positive infants to ART. Results:
By June 2008, CU had started 14,348 HIV patients on ART, 989 (7%) of whom were children under the age
of 15. The majority (589, 68%) of the children on ART were aged 5-14 years of age, while the rest were
children under 5 years of age.
Activities: 1. Increase coverage and quality of ART for children, especially infants. Increase coverage of
pediatric ART services to primary health care centers and ensure that a target of 10-15% of all clients are
children. Increase the proportion of infants among children on treatment from 18 % to 30 %. MCH Platform:
Establish HIV care and treatment services within the MCH at five high volume sites where pregnant and
nursing women can receive comprehensive care and antiretroviral medications for PMTCT. Renovate
health facilities for ART provision, including pediatric and adolescent friendly services at Tumbi Regional
Hospital (RH), Bagamoyo District Hospital and Maweni Regional Hospital and a pediatrics clinic at Kagera
RH. Train and clinically mentor health care workers to prescribe correct doses and appropriately dispense
antiretroviral medications to children. Ensure commodities for pediatric ART provision and opportunistic
infections (OI) drugs are available on-site. Use ART registers to monitor children on care and treatment and
establish appointment systems. Provide on-site continuing medical education (CME) on growth monitoring,
cotrimoxazole prophylaxis, and calculation of doses. See Pediatric Care narrative for complete package of
services for pediatric patients on ART. (2) Strengthen adherence of children to antiretroviral medications
and clinic visits. Train 150 health care workers (HCWs) at all CU-supported sites to provide pediatric and
adolescent adherence counseling, disclosure and psychosocial support. Utilize 113 peer educators to
support child caregivers by providing them with additional information and sharing their experiences on
positive living, disclosure and psychosocial support. Link caregivers with community-based support
services, especially the ICAP family support groups and adherence and psychosocial support (APSS) peer
educators, for economic and psychosocial support as well as tracking and tracing of missed appointments.
Explore the use of new technologies such as mobile phones, in the follow-up and promotion of adherence to
ART. (3) Ensure regular monitoring and evaluation for high quality ART service provision at all CU-
supported sites: Implement ICAP standards of care (growth monitoring and cotrimoxazole prophlaxis) and
evaluate them quarterly; strengthen paper-based systems at all sites and computerized systems at 20 sites;
strengthen capacity of sites, districts and regions in the collection, analysis and interpretation of data, and
empower in data ownership; conduct regular data feedback sessions; hire additional data clerks at high
volume ART sites; include indicators among routine M&E indicators and targets that measure enrollment
and treatment of infants. 4. Ensure ART service delivery is sustainable: Empower Regional Health
Management Teams (RHMTs) and Council Health Management Teams (CHMTs) in planning,
implementation, and supportive supervision. Ensure all ART related activities are included in the
Comprehensive Council Health plans; conduct supportive supervision with CHMT and RHMT. Support local
NGOs to link PLWHAs to community support groups, and conduct defaulter tracing. 5. Establish a regional
laboratory network in four regions. See entry above in adult care. Basic lab services will be provided and
linked at the MCH platform sites.
Linkages: Pediatric clients need strong linkages both within the clinic and with community groups to ensure
comprehensive care. ICAP is partnering with community groups, identified through the Council Multisectoral
AIDS Committees (CMACs) and Ward Multisectoral AIDS Committees (WMACs); active connections are
sought, particularly for OVC, school support, nutrition, counseling and family support. These linkages are
helping ensure no missed appointments. Children who miss appointments shall be traced with the help of
peer-educators, community health workers, outreach by facilties' health workers and CBOs working with
OVCs. The activity aimed at both training health care workers and upgrading their skills, and at
strengthening systems to provide care and support for HIV-infected patients on treatment (with an additional
emphasis on children below two years of age).
M&E: CU will partner with the the National AIDS Control Program (NACP)/MOHSW to track pediatric ART
service provision. National Pediatric ART monitoring tools will be implemented at all CU sites. Detailed
information in ART Adult above.
Sustainability: Pediatrics is in great need of intensive systems development, direct support and training and
mentoring to ensure children are prioritized. Skills transfer and motivation will be strengthened through
building the MOHSW's district and regional capacity for mentoring as well as ICAP's own on-site mentoring.
Workplace Programs
Estimated amount of funding that is planned for Human Capacity Development $101,600
Table 3.3.11:
TITLE: Scaling up TB/HIV collaborative activities at Care and Treatment Centers (CTC) in Kagera, Kigoma,
Pwani and Zanzibar
In collaboration with the Ministry of Health and Social Welfare (MOHSW) through the National Tuberculosis
and Leprosy Program/National AIDS Control Program (NTLP/NACP) and the Regional Health Management
teams (RHMT)/Council Health Management Teams (CHMT) Columbia University will continue provide
support to collaborative TB/HIV activities initiated in the Country Operational Plan 2008 (COP08). The focus
for FY2009 will be to provide technical assistance to Columbia supported site to strengthen intensified TB
case finding and carry out a pilot for Isoniazid Preventive Therapy (IPT) program at one site, within the
framework of the MOHSW plans for roll out, strengthen Intensified TB Case Finding (ICF) at Care and
treatment clinics (CTC), ensuring availability and regular and proper use of the TB screening questionnaire.
Columbia University will Print and disseminate guidelines, job aids, SOP for collaborative TB/HIV activities
including those for ICF, IPT and TB Infection Control. TB diagnosis to be improved that includes improving
TB smear microscopy through procurement and maintenance of microscopes, ensure availability of
reagents for direct sputum smear microscopy, procurement and maintenance of radiological machine,
supply of radiological films. Training sessions on Chest X-ray interpretation targeted people involved in
chest X-ray reading and interpretation. Laboratory staff will also be trained and supervised to ensure quality
of results. TB/HIV collaborative activities will be implemented in reproductive and child health in clinics and
Antenatal clinics (ANC) targeting HIV positive pregnant women and children. TB screening targeted to
family members of TB/HIV co-infected patients will be strengthen. In collaboration with NACP, NTLP and
other partners Columbia University will review and develop guidelines for pediatric TB/HIV co-infection.
These guidelines will include TB screening tool and diagnosis among children living with HIV. The
guidelines will be printed and disseminate to all RCH and PMTCT clinics. Organize training sessions on
TBHIV co-infection targeted to Peer Educators. Print and disseminate job aids for Peer Educators on
TB/HIV .Ensure all TB patients are offered HIV preventive methods including condom demonstration and
provision and ensure availability of condom at TB clinic.
NEED and COMPARATIVE ADVANTAGE: Columbia University (CU) supports comprehensive ART
services in Kagera, Kigoma, Pwani and Zanzibar where there is currently an estimated 51,603 patients in
need of ART. 10% of patients enrolled in care and treatment are estimated to have active TB while 50 -70%
of TB clients are likely to be HIV positive according to the Tanzania DHS 2004/5. HIV patients with TB
needs prompt TB treatment as a measure to reduce transmission amongst vulnerable HIV clients attending
care and treatment. Similarly, TB clients who are HIV positive will need to engage in HIV care and treatment
as a measure to reduce morbidity and mortality. CU has conducted intensified TB case-finding at many
supported sites, and is well positioned to further expand these services in FY 2008.
ACCOMPLISHMENTS: In FY 2007, CU supported ARV services in 24 hospitals and 1 Health Center.
Intensified TB case-finding was established at all care and treatment clinics using a 5-question symptom
screening tool that was developed by CU. Clients who were diagnosed as TB suspects based on the
screening tool were investigated according to the National TB diagnostic algorithm. Linkages were
established with the TB clinics and at all facilities in wards, and clients diagnosed to have TB were promptly
referred for TB treatment. Data from April - June 2007 show 69% of the 2,791 patients enrolled at CU
supported sites were screened for TB, and four were diagnosed to have active TB. Overall, 3% of the
11,099 patients who received care during the quarter were on TB treatment.
ACTIVITIES: 1) Provide technical assistance in collaboration with the Ministry of Health (MOH) through the
National Tuberculosis and Leprosy Program/National AIDS Relief Program (NTLP/NACP) in implementation
of Infection Control to other ART partners. 1a) update training guidelines for HIV/AIDS and for TB to include
infection control measures: 1b) organize training sessions with USG partners on TB infection control in CTC
settings; 1c) train additional health care workers (HCW) at select hospitals in training of trainers (TOTs)
programs for TB infection control at care and treatment clinics. 1d) print and disseminate training guidelines
for TB infection control through MOH. 1e) assist in development of job aids for HCW for infection control.
1f) print and disseminate job aides.
2) Decrease the burden of TB in PLHAs 2a.Strengthen intensified TB case-finding at existing CU supported
sites; 2b) Establish intensified case-finding at newly supported CU sites; 2c)Ensure, through renovation, TB
infection control measures are in place in 30 health care settings; 2d) Ensure all family members of PLHAs
with TB are actively screened for TB. 2e) Ensure linkages between HIV and TB clinics are established and
strengthened through regular information meetings and follow-up of referral forms. 2f) Train 176 HCW from
all CTC sites in the national TB/HIV training curriculum; 2g) Do refresher training for 40 lab technicians in
TB diagnostics;2h) Procure 30 microscopes and lab supplies required to strengthen TB diagnostics; 2i)
Establish care and treatment services for TB clients at 1 TB clinic in 1 district hospital (Kagera). This will
require employing HCW, training in the NACP curriculum, renovating the TB clinic for infection control
purposes; 2j) Roll out TB/HIV co-management in all 18 districts in Pwani, Kagera and Kigoma with some
support as needed in Zanzibar.
3) Decrease the burden of HIV in TB patients. 3a) Ensure all TB clients are offered HIV counseling and
testing at CU supported sites in Kagera, Kigoma, Pwani and Kigoma; 3b. Ensure all TB patients with HIV
are on cotrimoxazole therapy through improved use of CTC tools and through training of dispensers,
pharmacists and clinicians in essential use of cotrim for HIV+ individuals; 3c) Print laminated TB screening
tool for use in 21 regions in Kagera, Kigoma, Pwani and Zanzibar - provide training and hands on
mentoring in use of the tool; 3c)Distribute electronic and 200 printed copies of International Center for AIDS
Care and Treatment Programs' (ICAPs) TB/HIV integration booklet with evidence and instruction on use of
the screening tool; 3d) Ensure all TB clients with HIV are promptly engaged in HIV care and treatment by
carrying out Provider Initiated Testing & Counseling (PITC) with district hospitals and health centers
delivering TB services; 3e) Ensure all TB clients receive counseling on HIV preventive methods through
training at district and health center levels; 3f)Ensure linkages between the TB clinics and HIV clinics are
Activity Narrative: strengthened through two-way referrals and HIV management committees - use the referral forms
developed by ICAP and expert patients or HCW staff to accompany patients.
4) Establish mechanisms for TB/HIV collaboration. 4a)Coordinate with the NTLP, regional, district and
facility-based TB/HIV bodies in the implementation of TB/HIV activities 4b) Participate in the National
TB/HIV planning and share information at district, regional and site level through our annual stakeholder
meetings and regular support to the districts and sites. 4c)Participate in national TB/HIV M&E activities to
further refine TB management tools; 4d) support the Regional Health Management Teams (RHMT) to
increase integration of TB and HIV services at the regional level through improved supervision by carrying
out training and improving communication and technical assistance in clinical management and use of data;
4e hire a TB/HIV advisor under ICAP to strengthen activities and provide technical assistance and training;
4f) include TB/HIV integration as part of the Clinical Mentors (ICAP staff) core tasks in the 21 districts CU
supports; 4g) provide training and support to the regional TB member of the RHMT and the District TB
coordinators to support improved integration of services; 4h) work with other groups such as PATH (a
TB/HIV implementing partner) to improve linkages through regular communications and meetings.
LINKAGES: CU works closely with the NACP, NTLP and the MOH diagnostics unit in implementing TB/HIV
activities. CU will continue to utilize existing MOH referral and reporting mechanisms to assist with
identification and referral between TB and HIV clinics. HIV management teams which include TB and care
and treatment coordinators based in the facilities or districts will meet regularly to review data on the
referrals from all TB and HIV clinics and will be empowered to identify and trace those lost to follow up. In
Pwani and Zanzibar, CU will collaborate with PATH in the implementation of TB/HIV activities. Because of
our strong regional presence with offices in Kagera, Kigoma, Coast and Zanzibar we have a regularly
updated list of programs with wraparound services and regular contacts with groups working in HIV/AIDS
activities.
CHECK BOXES: The areas of emphasis were chosen because activities will include training of health
workers. Strategic information activities will help inform the program on its achievements and challenges.
The general population and PLHAs will be targeted through HIV or TB testing activities and the provision of
ART or TB therapy.
M&E: a) CU will collaborate with the NACP and NTLP to implement national M&E systems for TB/HIV
diagnosis and treatment in the 3 regions & Zanzibar; b) the TB Screening Questionnaire (TSQ) will be
implemented at all sites and 12,954 newly enrolled HIV patients screened for TB; c) TB/HIV referrals will be
documented using the 2 way referral form between CTCs and TB clinics; d) CU will provide technical
assistance (TA) at all 42 sites for implementation of TB/HIV M&E systems and share quarterly and
semiannual/
annual reports on TB/HIV integration at the site, district and regional levels; e) data quality will be
ensured through regular supervision visits; f). 126 HCWs will be trained in TB/HIV M&E and 42 CTC's, 21
districts & 3 regions will be supported.
SUSTAINAIBLITY: CU will continue to build the technical and financial capacity of the local staff at the
health facilities and that of the local government authorities. Capacity will be built through training of clinical
staff in the co-management of TB/HIV and through training local government authorities in conducting
needs assessments, determining priority sites and activities, work planning, budgeting and M&E programs.
Emphasis will be made in strengthening quality assurance of programs. Capacity will also be enhanced in
grant writing as well as technical and financial report writing.
Continuing Activity: 13458
13458 12461.08 HHS/Centers for Columbia 6509 1221.08 $500,000
12461 12461.07 HHS/Centers for Columbia 4530 1221.07 $300,000
Table 3.3.12:
TITLE: Expanding HIV Testing and Counseling in Kagera, Kigoma, Pwani and Zanzibar
NEED and COMPARATIVE ADVANTAGE: Columbia University (CU) supports comprehensive HIV/AIDS
care and treatment services in four regions of Tanzania - Kagera, Kigoma, Pwani and Zanzibar.
Additionally, national level support includes technical assistance and support to the Ministry of Health and
Social Welfare (MOHSW) and Bugando Medical Center (BMC) for national HIV early infant diagnosis;
support to ORCI for scaling up palliative care, including pain management and symptom control; improving
PMTCT M&E with NACP; and in 2008 support to the National Quality Assurance and Training Laboratory in
Dar es Salaam. Since 2005, CU has incorporated testing and counseling as part of case-finding for HIV
positive individuals to link to care and treatment. With Regionalization, CU will continue to provide voluntary
counseling and testing (VCT) services, tailoring such services to the needs of the regions and populations.
ACCOMPLISHMENTS: From 2004 to September 2007, 401,610 people will have received testing and
counseling in CU-supported VCT, PMTCT, and care and treatment sites. CU has supported and established
44 VCT sites, and ensured clients are linked to care and treatment through the district network approach.
CU has conducted mobile VCT services in hard to reach areas and for most at-risk populations (MARPs).
ACTIVITIES: In FY 2009, CU will:
1) Expand HIV testing and counseling to MARPs through: a) Monthly CT outreach targeting fishing islands
where there is a known high HIV prevalence through GOT health center clinics in Kagera; b) Training and
funding to ZANGOC(Zanzibar NGO Cluster) for delivery of CT targeted to MARPs in Zanzibar; c) Providing
CT outreach to mining areas in Kagera and Kigoma through GOT or NGO; d) Supporting mobile CT as part
of community activities in Pwani region linked to care and treatment at nearest clinics; and e) Strengthening
referral systems between VCT and ARV services through the district network approach. All activities will be
planned and implemented in collaboration with other CT partners to maximize resources and reduce
duplication.
2) Provide HIV CT services as a screening for men seeking male circumcision services. Consistent with
WHO/UNAIDS guidance, all men interested in circumcision in the CU-supported demonstration site in
Kagera must be tested and be HIV negative.
3) Strengthen existing facility-based HCT service delivery at CU-supported regional and district hospitals
and selected health centers by: a) Supporting the training of 50 staff in HIV testing and counseling b)
Procuring additional HIV test kits and expendable supplies to fill gaps and meet scale-up needs; and d)
Supporting lay counselors and additional staff where needed in 21 districts to intensify HCT linked to care.
*END ACTIVITY MODIFICATION *
Dar es Salaam. Since 2005, CU has incorporated testing and counseling as part of case-finding for
HIVpositive
individuals to link to care and treatment. With Regionalization, CU will continue to provide voluntary
counseling in CU-supported VCT, PMTCT, and care and treatment sites. CU has supported and
established 44 VCT sites, and ensured clients are linked to care and treatment through the district network
approach. CU has conducted mobile VCT services in hard to reach areas and for most at-risk populations
(MARPs).
ACTIVITIES: In FY 2008, CU will:
referral systems between VCT and other ARV services through the district network approach. All activities
will be planned and implemented in collaboration with other CT partners to maximize resources and reduce
2) Strengthen existing facility-based VCT service delivery at CU-supported regional and district hospitals
and selected health centers by: a) Supporting the training of 50 staff in VCT; b) Undertaking minor
renovations and repairs at CU-supported VCT health centers; c) Procuring additional HIV test kits and
expendable supplies to fill gaps and meet scale-up needs; and d) Supporting lay counselors and additional
staff where needed in 21 districts to intensify VCT linked to care.
LINKAGES: CU will ensure strong links with care and treatment services when initiating VCT and outreach
CT services in Kagera, Kigoma, Pwani and at Ocean Road Cancer Institute. ZANGOC will target MARPS
on Unguja and Pemba; ZAPHA+ in Zanzibar will target family members and partners of PLHAs for HCT. All
sites implementing VCT will ensure strong referral network system for PLHAs for nutrition, psychosocial
Activity Narrative: OVC support. CU will ensure PLHAs from remote islands in Kagera receive ‘wraparound services' for this
displaced group with high numbers of HIV+ women and their children. With MSD/Supply Chain
Management Systems (SCMS), CU will strengthen supply chain management systems for full supply of HIV
test kits and expendables. CU is working with FHI in Pwani to link those testing positive with home-based
care to receive adequate care and treatment services. CU will link with PSI and TMARC so that HIV positive
and
HIV negative persons receive robust prevention support (e.g., condoms, behavior change).
M&E: The national registers were launched in July 2007. CU will collaborate with the NACP/MOHSW to
implement the national CT M&E system across all CU-supported HTC sites using 8% of the budget. Data
will be collected in the national CT registers and summarized in monthly summary forms (MSFs). After the
national database is completed, CU will implement it at 20% of the sites. At CU, an Access database will be
developed for storage of MSFs from all CU-supported sites. Data quality will be ensured through regular site
supervision visits with review of registers and range and consistency checks of MSF's. Finally, CU will share
quarterly and semi-annual/annual reports with the HCT teams at the site, district and regional levels.
SUSTAINABILITY: The "district network approach" used by CU ensures sustainability of activities in the
public sector settings through direct engagement with existing district health systems. Agreements are
determined through discussion with the District Executive Director and District Medical Officer in each of the
21 districts where CU works. Funds are provided to the District for implementing activities. Regional health
authorities are engaged in supportive supervision, training, and oversight of activities. Existing NGOS and
FBOs are strategically selected to scale up HCT services.
Continuing Activity: 16448
16448 16448.08 HHS/Centers for Columbia 6509 1221.08 $300,000
Table 3.3.14:
In FY 09 Columbia University (CU) will continue to support the national early infant HIV diagnosis
program. This support will include the National EID PCR technician and the National EID coordinator at the
NHLQATC who oversee the Quality Assurance and implementation of the early infant diagnosis program
in Tanzania on behalf of the Ministry of Health and Social Welfare. CU will continue to support and
strengthen the Implementation of Quality Management System at Mnazi Mmoja referral hospital laboratory
in Zanzibar.
*END ACTIVITY MODIFICATION*
TITLE: Establishment of systems to support National Infant HIV diagnosis program, National Laboratory HIV
Quality Assurance and Training Center and Mnazi Mmoja Hospital in Zanzibar
NEED and COMPARATIVE ADVANTAGE: HIV disease progression during infancy is extremely rapid
Where over a third of children succumb to HIV by 12 months of age and one-half die by 24 months. Early
diagnosis of HIV is therefore critical and now possible in limited resource settings through use of dried blood
spot (DBS) sampling and DNA PCR testing. This intervention feasibly and effectively allows for case finding
of HIV-infected children early and engaging them in life-saving HIV care and ART services. CU has
supported the establishment of a first DNA PCR laboratory at Bugando Medical Center that provides HIV
diagnosis services for infants for the Lake Zone and rest of Tanzania. CU will continue to support the
systems for expansion of Early Infant Diagnosis services in partnership with CDC, MOHSW, African Medical
Research Foundation (AMREF) and others to the rest of Tanzania. These include support of staff at the
national level, trainings, technical assistance, guideline and training curriculum development. QA/QC will be
established for DNA PCR to ensure the quality of the results delivered.
ACCOMPLISHMENTS: In FY 2007 the only center in the country providing PCR-DNA using DBS was set
up and is functioning at Bugando Medical Center in Mwanza. Early Infant Diagnosis (EID) program results
included procurement of lab equipment and consumables, development of standard operating procedures,
training of 186 health care workers in DBS collection; clinicians in pediatric care and treatment; pediatric
patient referral mechanisms to the clinics in 21 centers. Through this intervention, 750 HIV exposed infants
have been identified, 679 tested and 117 (17%) identified as positive and referred for care and treatment.
CU also helped support MOHSW to develop the Early Infant Diagnosis guidelines that were finalized and
adapted by MOHSW September 2008.
ACTIVITIES: Columbia University (CU) will support the national early infant HIV diagnosis program through
provision of Technical Assistance to the MOHSW on implementation of EID services; training and retraining
of health care workers on EID services in four zones and Zanzibar; building the capacity of the Regional
Health Management Team (RHMT) and Council Health Management Team (CHMT) on supportive
supervision on EID activities including QA/QC; CU will hire additional staff to manage scaled up EID
national program including one staff seconded to the MOHSW and one CU staff.
CU will support the establishment of EID capability at the (NHLQALTC). This will include the hiring of a
PCR technician to oversee the services both at the NHLQALTC and nationally being responsible for EID
Quality assurance. CU will work with MOHSW to strengthen systems for forecasting and procuring related
consumables by providing technical assistance on methods of forecasting. CU will provide TA on a
quarterly basis by an external Advisor on EID
Cu will support the implementation of quality systems (QS) at Mnazi Mmoja Referral Hospital Laboratory
(MMH). MMH lab is a referral lab for Zanzibar lab services, and currently does not have capacity to support
the laboratory services network as a referral center for HIV/AIDS in Zanzibar. The laboratory recently
conducted SWOT analysis towards implementation of the twelve elements of quality system and came up
with a list of strengths and weaknesses checklist. In a yet another activity by Clinical and laboratory
standard institute (CLSI) the referral hospital labs were assessed for international accreditation by using
ISO 15189 in which a gap analysis was presented to the participating labs MMH lab being among them.
With FY 2008 funding, the gaps as identified in the QS and accreditation gap analysis will be addressed.
MMH will be assisted to establish and strengthen internal and external QA/QC systems for HIV diagnosis,
HIV monitoring tests and opportunistic infection diagnosis tests, establish schedules and support systems
for QA/QC site visits for all laboratories in Unguja and Pemba, provide training to all Laboratory staff and
non lab on specimen management, document and record, laboratory management tools for pre-analytical,
analytical and post analytical. Perform Continuous improvement and laboratory safety
LINKAGES: CU-ICAP will partner with the MOHSW - Diagnostic unit and NACP, US Government partners
(FHI, Harvard, AIDS Relief, DoD, EGPAF), the RHMT and CHMT, MOHSW health facilities, faith based
hospitals to scale up the early infant HIV diagnosis, QA/QC activities in the region and a networking among
the regional labs. Close linkages will grow with USG partners in every region to roll out the Early Infant
Diagnosis Program and also with the Clinton HIV/AIDS Foundation who provide technical assistance for
forecasting and quantification and who will assist MOHSW with the procurement of reagents and supplies
for the EID program. With CHAI CU is collaborating with EID on Zanzibar and planning to partner closely as
the national program scale up with hopes that CHAI will support the national reagents supply and DBS
logistics, CU will support the programmatic training, Bugando Medical Center PCR laboratory and national
QA/QC; Other partners with the National Quality Assurance and Reference lab set up by CDC will be key
partners in the coming year to fully staff and capacitate this important center. CU will partner with the
MOHSW and ZACP in Zanzibar and strengthen regional HIV and OI diagnosis and monitoring QA/QC
systems and TA.
CHECK BOXES: Health systems will be improved through a regional network of laboratories that will ensure
a large menu of tests are provided and services are close to the clinics thus improving the local health
system capacity and elevate the overall quality of clinical laboratories in-country. Services will include
Activity Narrative: renovations, capacity building and establishment of laboratory management systems
M&E: M&E: a) 5% of the budget will be dedicated to M&E activities b) Data on number of lab tests
performed per month will be collected from lab registers at sites using the CU monthly data collection tool.
c) Data on the targeted tests for HIV(140,000),TB diagnostics(14,000), Syphilis tests (14,000) and HIV
disease monitoring(30,000) will be collated in excel sheets for quarterly & semiannual PEPFAR reports d)
Data quality will be ensured through regular site supervision visits and on-site training and re-training of lab
technicians who complete the lab registers. e) There will be regular feedback of data to the CU lab advisor
and CU will also share quarterly and semi-annual/annual reports with the lab teams at the site, district and
regional levels. QA/QC data management and monitoring will include the EQA activity for EID from Atlanta
in all labs working on EID
SUSTAINAIBLITY: Program is focused at both national level (EID program in Four Zones of Tanzania), and
the regional level (CU Treatment and PMTCT regions). At national level our support will strengthen
MOHSW management and implementation of the national EID program through staffing, technical
assistance, ongoing training and support. CU support for training in the zones will empower other USG
partners and the regional and district authorities to carry out the program beyond the initial training and
follow up. With other partners such as CHAI, AMREF also supporting the national EID network, our inputs
are likely to be more strategic and sustainable. At the regional level our work is in line with plans under the
MOHSW for laboratory networks and CU inputs will strengthening labs for not only HIV/AIDS services, but
for the wider health care needs.
Continuing Activity: 13460
13460 12483.08 HHS/Centers for Columbia 6509 1221.08 $710,000
12483 12483.07 HHS/Centers for Columbia 4530 1221.07 $250,000
Table 3.3.16:
