The TUNAJALI II program, signed in FY12, builds on the achievement of its predecessor program TUNAJALI to scale-up comprehensive and sustainable clinical and community-based HIV/AIDS services in the following four regions: Iringa, Morogoro, Dodoma, and Singida. TUNAJALI II will achieve the following results by the end of the project period: (1) Improved leadership and management capacity of local governments for quality HIV services delivery; (2) Improved capacity of CSOs for HIV and AIDS service delivery; (3) Increased revenues and resources available for integrated HIV and AIDS care; (4) Improved access to quality, integrated and comprehensive HIV care and treatment services; and (5) Improved woman & girl child responsive HIV treatment, Care and Support.

The program contributes to PF Goal 1 that refers to service maintenance and scale up and supports activities at both facility as well as community levels. Facility based-care and support services include provision of counseling and testing services, palliative care, TB/HIV screening and treatment services, management of opportunistic infections, cervical cancer screening, family planning and reproductive health services, provision of insecticide treated nets, malaria prophylaxis, Positive Health Dignity and Prevention (PHDP) services, and nutritional assessment counseling services (NACS).

TUNAJALI II builds local capacity and ensures sustainability by working through existing local organization and government systems and establishing and strengthening referral networks and linkages to civil society organizations (CSO), faith-based networks, and services provided by non- governmental organizations (NGO).

In Tanzania, HBHC partners implement a standard package of care activities. TUNAJALI II will be implemented in Morogoro, Iringa, Dodoma, and Singida regions. It will combine two components of care packages; first being clinical care and second community home-based care.

With COP 2012 funds, TUNAJALI II will continue to support partners providing HBC services through the network of community home-based care providers who are already trained using the revised curriculum. In line with the reviewed home-based care guidelines, initial assessments will be done to ascertain the number of existing CHBCP and the coverage of the services. Those trained using new curriculum will be taken aboard while those trained using old curriculum will be provided with refresher training.

Services to patients will be tailored as to the stage and general outlook of the disease. Tailored services include community based palliative care, provision of PHDP package, linkage to and provision of safe drinking water options and sanitation services, linkage to and provision of household food security, and economic strengthening activities. These community based activities and CHBCP activities will be linked to facility based care and support services. CHBCPs will play a bigger role in linking the facility services to the community by acting as community agents for care and treatments, PMTCT, TB/HIV, Pediatric HIV and Family planning. In the community CHBCPs will link with the facility to track loss to follow up and drop outs from CT clinics and PMTCT and refer them back to the facilities. They will also monitor patients on DOTS treatment for TB. CHBCPs will increasingly carry out health promotion activities like nutritional assessment and counseling, lay counseling for home counseling and testing and when the MOH issues permission, conduct home testing for HIV. To achieve this range of services and gain program efficiencies, the program will capitalize on the community and facility referral and linkages, civil society organizations (CSOs), faith based organizations (FBO), and services provided by non-governmental organizations (NGOs). To ensure sustainability and transition to local organization and local government TUNAJALI II will be implemented using the government guidelines and existing structures.

TA will be provided to ensure that partners involved in implementing this project practice improved administrative, financial and technical efficiencies over the time of the project. TA will be provided to sub grantee and local government in the areas of M&E, quality improvement measure, project management etc. At the service delivery point support will be provided to CHBCPs to enable them carry out their roles effectively. this support will range from centrally procured HBC kits, IEC materials and trainings. Innovative approaches will be used through program integration, use of other financing schemes and other opportunities existing locally to leverage resources to support the community activities for a long term sustainability.

In Tanzania, particular partners working in TB implement a standard package of services throughout the country. This follow-on TB/HIV program will contribute to supporting national efforts to strengthen collaborative TB/HIV activities, focusing on the regions of Iringa, Morogoro, Dodoma, and Singida. COP 2012 funds will be used to support active TB case finding and screening among PLHIV. Activities will include supporting the scale up of intensified TB case finding, infection control (IC), and the provision of isoniazid preventive therapy (IPT). The program will support the initiative to increase the number of health facilities providing IPT, while also effectively practicing infection control activities.

Strategically selected TB clinics will be refurbished or receive minor renovations in order to alter the clinics into one-stop shops (for both TB and ART), which will help increase the proportion of TB/HIV patients starting on ART. The program will also support the integration of the 3Is activities into PMTCT, VCT, and pediatrics clinics based in the focus regions. Other partners and initiatives will be sought to strengthen laboratory services to improve TB diagnosis and programmatic management of MDR-TB. Special focus will be geared to design and implement activities aimed at mainstreaming gender in TB services provision.

The program will strengthen M&E in TB/HIV by ensuring national guidelines and M&E tools are available, improving data collection systems, and training service providers on filling out care and treatment monitoring tools. CHMT annual review meetings will be facilitated and strengthened, while support of activities in the focus districts and regions will be aimed at strengthening coordination of TB services.

Program integration, use of other financing schemes, and other opportunities existing locally will be explored in order to leverage resources to support community activities on a long term basis.

With COP 2012 funds, TUNAJALI II will play a key role in improving the health and well-being of children within the four regions of Iringa, Morogoro, Dodoma, and Singida, as the program implements a standard package of care interventions. The care program will enhance and strengthen linkages between facility and community-based services by integrating nutrition assessments counseling and support (NACS), offering counseling and support across care programs, and promoting integration of OVC, maternal newborn and child health (MNCH), PMTCT, and pediatric AIDS interventions to children infected by HIV.

Specifically, the program will enhance the roles of community care providers in promoting a more integrated community response. The program will build on the successful results of the community care/MCH Community Health Workers training.

Through enhanced community services, the program will strengthen the continuum of care for HIV-affected children from birth through adolescence. Focus will be in the provision of cotrimoxazole prophylaxis to eligible children, linking and integrating cotrimoxazole provision with MNCH services, and improved documentation on child health cards. In a collaborative effort with the OVC program, child protections issues will be addressed as the program seeks to pilot and scale up the community-based child protection model. Working with the OVC program, the follow-on program will strategically intensify interventions to improve the well-being of girls.

To contribute to program sustainability, the program will build the capacity and strengthen the skills of community and facility-based care providers through human resource for health (HRH) activities in the focus regions, while also addressing food security and nutrition issues for children living with HIV/AIDS and OVC.

The program will strengthen M&E in care and treatment by ensuring national guidelines and M&E tools are available, improving data collection systems, and training service providers on filling out care and treatment monitoring tools. CHMT annual review meetings will be facilitated and strengthened, while support of activities in the focus districts and regions will be aimed at strengthening coordination of care and treatment services.

In Tanzania, the decision to regionalize partners working in PMTCT took place in 2007. Since then, a fairly standardized package of services is implemented throughout the country by multiple partners in their respective regions. The TUNAJALI II will continue to support PMTCT services within the four regions of Iringa, Morogoro, Dodoma, and Singida. The target population includes men, women of reproductive age, and their families. The base funding will be used to increase quality of PMTCT services related to both the mother and her child to achieve and maintain strategic high geographical PMTCT coverage.

The goal will be to scale-up PMTCT services to cover 90% of the facilities providing RCH services in the focus regions. It will support services that include HIV testing (in ANC and labor and delivery as well as at the FP clinic), partner testing, counseling on infant feeding options, strengthening of counseling on FP methods to HIV+ mothers during postpartum visits, referrals to care and treatment, clinical staging of the HIV+ pregnant women at the RCH clinic by the PMTCT service providers with linkages to CTC, roll-out of more efficacious regimen to facilities with the capacities, provision of ART prophylaxis to HIV+ pregnant women who are not eligible for ART, provision of Cotrimoxazole to all eligible pregnant women and exposed infants, PMTCT outreach services in hard to reach areas, and quarterly supportive supervision by the RHMT to ensure quality of services.

In collaboration with local government authorities, bi-annual supportive supervision will also be carried out in the focus regions. To increase adherence and retention to care, collaboration with community support groups to form psychosocial support groups will be a key activity. This program will also ensure the availability of HIV test kits by procurement to fill gaps, ensure adequate supply of drugs for more efficacious regimen based on needs and support printing and distribution of IEC materials and job aids.

TA will be provided to strengthen M&E in PMTCT and will ensure guidelines and M&E tools are available. Service providers will be trained to fill out the PMTCT monitoring tools and engage in Data Quality Assurance activities to improve the data collection systems. The program will strengthen and facilitate CHMT annual review meetings, support the formation and integration of regional PMTCT task forces into reproductive and child health, facilitate regional quarterly partners meetings, and strengthen linkages and referrals.

In Tanzania, treatment partners implement a standard package of services throughout the country in their respective regions. This follow-on program will continue to support adult ART services within the four regions of Iringa, Morogoro, Dodoma, and Singida. The target population includes men, women, and their families.

The program will take a district approach to work jointly with district and regional health management teams to plan, implement, and monitor ART programs. Activities for the program will include increasing the number of pregnant women who are initiated on treatment, improving linkages and referrals between HIV program areas, strengthening support groups in facilities and communities, improving health seeking behaviors, integrating family planning methods in HIV/AIDS care and treatment services, and introducing point of care CD4 testing (PIMA).

TUNAJALI II supports the URTs initiative of adopting the latest WHO recommendations and roll out implementation of the guidelines in a phased approach. The program supports initiation of ART for all HIV positive pregnant women with CD4 counts below 350. In addition, irrespective of CD4 counts, all TB patients co-infected with HIV, all HIV positive children below the age of 24 months, and all patients with clinical stage 3 and 4 will be initiated on ART through the program. Patients identified in need of treatment from feeder systems (such as PMTCT, TB/HIV clinics, PITC, and EID) will be accommodated, while treatment support for HIV-infected pregnant women to reduce maternal mortality and prevent HIV-transmission to the baby will be prioritized. Point of care CD4 tests at ANC will be deployed, once endorsed (PIMA currently being in the final evaluation phase) , and ARV services will be integrated into TB and ANC clinics. Through their regions and districts, providers will be supported to build their capacity through refresher training and mentoring.

The program strengthens M&E in care and treatment by ensuring national guidelines and M&E tools are available, improving data collection systems, and training service providers on filling out care and treatment monitoring tools. CHMT annual review meetings are facilitated and strengthened, while support of activities in the focus districts and regions will be aimed at strengthening coordination of care and treatment services.

In Tanzania, treatment partners implement a standard package of services throughout the country in their respective regions. The TUNAJALI II will continue to support adult ART services within the four regions of Iringa, Morogoro, Dodoma, and Singida.

Activities will focus on improving the quality of services being provided to children infected with HIV, with a specific focus on scaling up early diagnosis and treatment through Early Infant Diagnosis (EID). Focus on provider initiated testing and counseling (PITC) for older children in all pediatrics entry points, including MCH, pediatrics wards, malnutrition rehabilitation wards, care and treatment clinics, and OPD.

The program will strengthen follow-up and linkages to treatment. The revised PITC and PMTCT guidelines will be utilized, while early identification of HIV exposure will be prioritized. Adoption of WHO guidelines, including earlier treatment for infected children below two years, will be incorporated into the program. Onsite mentoring, training, and resources to health care providers will be supported to improve their capacity and competency in the implementation of pediatric care and treatment interventions. Links to PMTCT and pediatric HIV care and treatment will initiate efforts to scale up comprehensive PMTCT and pediatrics HIV care, treatment, and support services. The program will promote the provision of pediatrics care and treatment services at RCH sites, which includes early identification of HIV status and infection, and follow up of HIV exposed infants.

The program will strengthen M&E in care and treatment by ensuring national guidelines and M&E tools are available, improving data collection systems, and training service providers on filling out care and treatment monitoring tools. CHMT annual review meetings will be facilitated and strengthened, while support of activities in the focus districts and regions will be aimed at strengthening coordination of care and treatment services.