Tanzania Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

TANZANIA

Project Title: Tanzania Fiscal Year 2008 Country PEPFAR Operational Plan (COP)

Budget Summary:

	Field Programs Funding by Account						Central Programs
	Notified November 2007			Notified February 2008			Notified as of February 2008	Allocations to Date
Implementing Agency	GAP	GHCS - State	Subtotal: Field Programs Funding	GAP	GHCS - State	Subtotal: Field Programs Funding	Subtotal: GHCS Central Programs	Grand Total:  Field & Central Funding
DOD	-	-	-	-	24,050,444	24,050,444	-	24,050,444
DOL	-	-	-	-	-	-	-	-
HHS	-	1,252,896	1,252,896	3,883,000	86,661,556	90,544,556	23,469,328	115,266,780
Peace Corps	-	-	-	-	1,097,100	1,097,100	-	1,097,100
State	-	-	-	-	10,220,111	10,220,111	500,000	10,720,111
USAID	-	500,000	500,000	-	132,689,606	132,689,606	4,563,231	137,752,837
TOTAL	-	1,752,896	1,752,896	3,883,000	254,718,817	258,601,817	28,532,559	288,887,272

HIV/AIDS Epidemic in Tanzania:
Adults (aged 15-49) HIV Prevalence Rate: 6.5% (UNAIDS, 2006)
Estimated number of People Living with HIV: 1,400,000 (UNAIDS, 2006)
Estimated number of Orphans due to AIDS: 1,100,000 (UNAIDS, 2006)

Country Results and Projections to Achieve 2-7-10 Goals:

Tanzania	Total # Individuals Receiving Care and Support	Total # Individuals Receiving ART
End of FY 2004*	25,600	1,500
End of FY 2005**	413,000	14,700
End of FY 2006***	568,800	44,300
End of FY 2007****	745,400	96,700
End of FY 2008*****	804,510	148,658
End of FY 2009*****	1,088,205	209,111

^* "Engendering Bold Leadership: The President�s Emergency Plan for AIDS Relief.� First Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, March 2005.
^** �Action Today, a Foundation for Tomorrow: The President�s Emergency Plan for AIDS Relief.� Second Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U. S. Department of State, February 2006.
^*** "The Power of Partnerships: The President�s Emergency Plan for AIDS Relief.� Third Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, February 2007.
^**** "The Power of Partnerships: The President's Emergency Plan for AIDS Relief." 2008 Annual Report to Congress submitted by the Office of the U.S. Global AIDS Coordinator, U.S. Department of State, January 2008.
^***** Projections from FY 2008 Country Operational Plan

Program Description/Country Context:

Tanzania is facing its most critical health and development crisis to date. The mainland faces a generalized HIV/AIDS epidemic, with an estimated 7% prevalence rate among those aged 15 and 49 years of age, with females having a slightly higher rate (7.7%) than males (6.3%). Zanzibar has a concentrated HIV epidemic. While only 0.6% of the general population is infected with HIV, there is a prevalence rate of 26% among injecting drug users (IDU). According to the Ministry of Health and Social Welfare (MOHSW), in 2005, about 50% of all smear-positive tuberculosis (TB) patients were HIV-positive.

Of the 38 million Tanzanians, an estimated 1.5 million individuals are living with HIV; approximately 10% are children. An estimated 140,000 Tanzanians die each year, resulting in disruption of family structures and an increase in the estimated 1.1 million HIV orphans and vulnerable children (OVC) in Tanzania. About 80% of HIV transmission in Tanzania occurs through heterosexual contact, approximately 18% through mother-to-child transmission, and 1.8% through medical transmission or traditional practices. There continues to be a significant difference in the prevalence among urban (10.9%) and rural (5.3%) areas of the country. There is no single HIV epidemic in Tanzania; rather, there are probably several localized HIV epidemics with poorly understood dynamics.

In the general population, social and behavioral norms such as multiple and concurrent partners and trans-generational sex are factors affecting the ongoing spread of HIV. Approximately 27% of sexually active men report having two or more sexual partners in the past year, and almost 10% of sexually active 15- to 19-year-old females had sex in the past year with a male partner who was 10 or more years older. In addition, there are identified high-risk groups that warrant more aggressive targeting, including: military and uniformed services, individuals involved in prostitution, mobile populations (e.g., truckers and communities along the transport corridors), and a growing urban population of IDUs. Youth are another high-risk group, with 4% of women aged 15-24 years and 3.4% of men in the same age group being HIV positive.

PEPFAR funding will be focused on the following areas to achieve the 2-7-10 targets:

Prevention: $60,940,494 ($51,593,785 Field; $9,346,709 Central) (23.6% of prevention, care and treatment budget)

Prevention activities in Tanzania include prevention of mother-to-child transmission (PMTCT), abstinence and faithfulness (AB) programs, blood and injection safety, and other behavioral prevention initiatives, including those that focus on high-risk populations. In FY 2008, USG will continue to partner with the Government of Tanzania (GOT) to rapidly expand comprehensive PMTCT through regionalization of implementing partners, with USG treatment partners leading the scale-up and support of quality PMTCT services within their assigned geographic regions. Regionalization will expand coverage dramatically, strengthen linkages between treatment and PMTCT services, and support an integrated approach to care and treatment. FY 2008 funds will support expansion of PMTCT to additional sites where pregnant women will receive PMTCT services, including counseling and testing. Finally, the USG will strengthen efforts to follow children born to HIV-positive mothers with an expansion of early infant diagnosis, identification of these children at routine health visits, provision of cotrimoxazole to HIV-exposed infants, and nutritional support, if needed. Finally, the USG will support a Government of Tanzania feasibility study introducing male circumcision as a medical prevention intervention.

The USG will continue to support high-quality behavioral change programs, including life-skills training, community outreach, and support for standardized messaging in accordance with the GOT National HIV/AIDS Communications and Advocacy Strategy. In FY 2008, the USG will continue to strengthen prevention programming with youth, particularly in addressing primary and secondary abstinence, delayed sexual debut, and the development of personal risk reduction strategies. Youth programming will also focus more intensively on �gatekeepers� such as teachers, parents, and community, and religious leaders to foster a more supportive and enabling environment. Additionally, the AB portfolio will bring to scale programs targeting youth and adults with strengthened �B� activities addressing socio-cultural and gender norms that promote high risk behaviors such as multiple partners, trans-generational sex, gender-based violence, and increased sexual risk related to alcohol use/abuse as well as other substance abuse.

In FY 2008, the USG will strengthen and scale up efforts to reduce new infections among higher risk populations such as truckers, individuals involved in prostitution, uniform service members, high-risk youth, migrant populations, substance abusers, including injecting drug users, and communities that live in close proximity to these focus populations. This will be the primary focus of prevention in Zanzibar. Behavior change communication will include peer education programs, interpersonal communications, and other activities that directly interface with target groups in high HIV transmission areas. USG partners will increase the variety of �edutainment� methods used and increase the social marketing of condoms and associated behavior change. .

Finally, in order to prevent medical transmission, the USG will strengthen systems for blood collection, testing, storage and handling. The USG is providing financial and technical support to strengthen the National Blood Transfusion Service (NBTS). With FY 2008 funds, the USG will support the scale up of the Infection Prevention and Control � Injection Safety programs to additional health centers and dispensaries in Tanzania.

Principal Partners: American Red Cross, Adventis Development and Relief Agency, Academy for Educational Development, AIDSRelief, American Association of Blood Banks, AMREF, Balm in Gilead, Columbia University, Elizabeth Glaser Pediatric AIDS Foundation, EngenderHealth, Deloitte Consulting Limited, Family Health International, Harvard University School of Public Health, International Rescue Committee, JHPIEGO, Kikundi Huduma Majumbani, Mbeya Referral Hospital, Mbeya Regional Medical Office, National AIDS Control Programme (NACP), PharmAccess, Rukwa and Ruvuma Regional Medical Offices, Selian Lutheran Hospital, University of Medicine and Dentistry, New Jersey, University Research Corporation, World Vision International, and Zanzibar AIDS Control Programme (ZAC)

Care: $70,987,171 ($69,057,400 Field; $1,929,771 Central) (27.5% of prevention, care and treatment budget)

Care activities in Tanzania include counseling and testing (CT), basic palliative care, support for integrating TB and HIV programs, and support for orphans and vulnerable children (OVC). In FY 2008, the USG CT program will focus on continued rollout of provider-initiated testing and counseling, increased training on the new national testing algorithm, continued advocacy for a transition to finger-prick-based HIV testing, continued demand creation for the estimated 93% of uninfected Tanzanians, and increased access to CT services, particularly in high prevalence areas.

Palliative care activities will comprise delivery of a basic package of care services to HIV-positive individuals and their families. At health facilities, clinical care will include basic pain and symptom management, opportunistic infection prevention and treatment, referrals for TB screening, and monitoring for treatment side effects and adherence. At the community level, palliative care activities will include strengthening community- and faith-based organizations to provide psychological and social support, prevention services, distribution of condoms, safe water, insecticide treated nets, and other support to individuals and families affected by HIV. Linking community care activities to health facilities for continuity of care will be a strong focus in FY 2008. Stigma reduction will be addressed through peer education and community sensitization tools; the participation of people living with HIV/AIDS (PLWHAs) in designing and administering care services; and linking PLWHA with support groups that work with community leaders.

The USG will continue to assist and advise the GOT in the screening, diagnosis, and treatment of TB disease among PLWHA, including strengthening laboratory capacity for TB diagnosis, and supporting TB infection control in clinics/hospitals with a focus on HIV treatment sites. The USG will support the improvement of overall diagnostic capabilities, offer screening for TB infection in HIV Care and Treatment Center (CTC) sites, and train clinicians in TB case management. It will also support the integration of initiation of antiretroviral treatment in TB clinics to catch infected persons early.

Support in FY 2008 will dramatically scale up the number of OVC served by USG-supported programs, with a focus on self-sufficiency of OVC while continuing to ensure high coverage, comprehensiveness, and quality of services. The USG works with all the major donors to assure availability of services in all districts by the end of 2009.

Principal Partners: African Palliative Care Association, Africare, Axios, Columbia University, Deloitte Consulting Limited, Family Health International, IntraHealth International, Mbeya HIV/AIDS Network, Mildmay International, NACP, National Tuberculosis and Leprosy Control Programme, Pact, Partnership for Supply Chain Management (SCMS), Pastoral Activities and Services for People with AIDS, Pathfinder International, Program for Appropriate Technology in Health, Salvation Army, and Selian Hospital.

Treatment: $126,372,526 ($109,116,447 Field; $17,256,079 Central) (48.9% of prevention, care and treatment budget)

Treatment activities in Tanzania include the provision of free antiretroviral (ARV) drug and services, laboratory support and the management of opportunistic infections. Continuing to benefit from the regionalization of treatment partners, this USG-funded program has grown to 124 treatment sites, with 71,584 patients on treatment at the end of March 2007. With FY 2008 funds, the USG will support the GOT focus of expanding to health centers to decongest hospitals and increase equity by moving services to rural populations, providing improved identification of pediatric cases and referrals for services, improved linkages with other programs to ensure and enhance a continuum of care, and improved quality of treatment services at all levels.

The USG collaborates with the MOHSW and its partners to strengthen laboratory infrastructure and capacity for HIV diagnosis, disease staging, therapeutic monitoring, and expanding infant diagnosis of HIV. In FY 2008, the USG will continue to improve laboratory services by implementing a standardized laboratory information system in regional hospital laboratories; renovating regional and district laboratories; supporting in-service and pre-service training; and strengthening the national quality assurance program. With FY 2008 funding, the USG will also provide training in HIV testing methods.

Principal Partners: Bugando Medical Centre, Catholic Relief Services, Columbia University, Deloitte Consulting Limited, Elizabeth Glaser Pediatric AIDS Foundation, Harvard University School of Public Health, Mbeya Referral Hospital, Mbeya, Rukwa, and Ruvuma Regional Medical Offices, SCMS, Pastoral Activities & Services for People with AIDS, PharmAccess, Regional Procurement Support Office, Selian Lutheran Hospital, University of Washington, and University Research Corporation.

Other Costs: $30,587,081

In FY 2008, the USG will strengthen human and infrastructural capacity to conduct strategic information activities at the national and sub-national levels, including: harmonization of indicators and data systems; collection, analysis and timely reporting of quality data; and promotion of data use for planning and implementation. Data quality will be improved through the adoption of tools, implementation of data assessments, and training. Under the umbrella of NACP and Tanzania AIDS Commission, program and survey data will be triangulated and linked with the Global Fund Five-Year Evaluation. Finally, FY 2008 funds will enable the USG to strengthen national monitoring through the use of computer and cell phone technology to transmit data from local to central levels, ensuring complete and quality data on a timely basis.

The success and sustainability of PEPFAR activities in Tanzania depend largely on crosscutting programs that encompass human capacity development, systems strengthening, policy, and stigma reduction. The USG will work to improve the skills of existing service providers, reduce turnover, increase the number of well-trained new providers, and overhaul select human resource systems that limit the effectiveness and productivity of workers. In addition, the USG will concentrate on strengthening leaders and national organizations to accelerate the pace of program implementation. Finally, the USG will make certain that key policies affecting the success of our programs, such as those related to use of lay workers for HIV testing, are approved and executed.

Principal Partners: American International Health Alliance, Family Health International, IntraHealth, Macro International, Management Sciences for Health, Ministry of Health, NACP, National Institute for Medical Research, Pathfinder International, Policy Project, University of North Carolina, University of Washington, World Health Organization, and ZAC.

Management and staffing funds will support the in-country personnel needed for USAID, HHS/OS, HHS/CDC, State, DOD and the Peace Corps. Working cooperatively, these agencies have developed innovative approaches and management structures that ensure program monitoring and accountability, capture the programming advantages of partner agencies, and ensure USG policy and technical leadership within the Tanzanian national response.

Other Donors, Global Fund Activities, Coordination Mechanisms

The United States is the largest bilateral donor for HIV/AIDS in Tanzania. In addition to the Global Fund to Fight HIV/AIDS, TB, and Malaria, other major donors include: the World Bank, Royal Netherlands Embassy, Canadian Cooperation Office and Japan International Cooperation Agency. The total amount of the Global Fund awards for both the mainland and Zanzibar is $510 million, approximately $325 million of which is for HIV/AIDS.

The primary coordinating bodies for HIV/AIDS are the Tanzania Commission on AIDS on the Tanzania mainland and the Zanzibar AIDS Commission on the island of Zanzibar. In addition to working with NACP, the USG meets regularly with key officials of individual Ministries to ensure that USG assistance supports the GOT goals within each program area.

Internally, the US Ambassador is responsible for the overall leadership of the PEPFAR/Tanzania program. He is supported by the Deputy Chief of Mission (DCM), the PEPFAR Country Coordinator (PCC) and four Agency Heads. Chaired by the PCC, the Interagency HIV Coordinating Committee (IHCC) meets bi-weekly to provide overall program direction and strategy. The PCC also chairs a weekly Management and Operations (M&O) meeting to address program implementation and interagency coordination and collaboration. The M&O team is comprised of one senior management advisor from each agency, each of the four Strategic Unit leads and the Strategic Information Liaison.

Program Contact: PEPFAR Coordinator, Tracy Carson

Time Frame: FY 2008 � FY 2009

Approved Funding by Program Area: Tanzania