Partnering to Reach an AIDS

Free Generation in Tanzania

RMO/DMO Meeting

September 2015

35M PLWHA 52M PLWHA

44M PLWHA

79M PLWHA

48M PLWHA

Ending AIDS Scenario: New HIV Infections Total number of people living with HIV/AIDS (PLWHA)

$8B in

additional

Tx

cost/year

$31B in

additional

Tx

cost/year

Source: UNAIDS 2014 GAP Report 2

PEPFAR/Tanzania Goal Statement

To reach 80% of PLHIV with

lifesaving treatment by 2020,

starting in districts of highest need

3

Tanzania Funding Levels

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

in millions

Tanzania Strategic Pivot

for Epidemic Control

RIGHT PLACES

• Districts

• Sites

• Populations

RIGHT THINGS

• PEPFAR-support for core interventions

• Budget for Impact

5

Geographic Pivots for Epidemic Control

6

42 Scale-Up Districts to reach 90/90/90 by 2020

Represents 55% of PLHIV in Tanzania

27 Scale-Up to Saturation Districts: 80% PLHIV

on ART by 2017

15 Aggressive Scale-Up Districts: 13 districts

with increased rate of ‘new on ART’ to achieve

saturation by 2018/2019 + 2 Key Population Hot

Spot districts

129 Sustained Districts

District Prioritization

7

PLHIV by District PEPFAR Scale-Up District Focus

Legend

PLHIV

35 - 3476

3477 - 7483

7484 - 12424

12425 - 28241

28242 - 96119

±

Liwale DC

Mlele DC

Chunya DC

Manyoni DC

Sikonge DC

Ulanga DC

Iringa DC

Kilwa DC

Mpanda DC

Uvinza DC

Tunduru DC

Kaliua DC

Simanjiro DC

Namtumbo DC

Uyui DC

Rufiji DC

Nkasi DC

Kiteto DC

Mbarali DC

Kilosa DC

Kibondo DC

Kilolo DC

Ngorongoro DC

Kilombero DC

Morogoro DC

Ikungi DC

Meatu DC

Serengeti DC

Nzega DC

Mufindi DC

Lindi DC

Ludewa DC

Bahi DC

Kasulu DC

Longido DC

Igunga DC

Kilindi DC

Same DC

Chamwino DC

Bukombe DCMonduli DC

Bagamoyo DC

Handeni DC

Bariadi DC

Kondoa DC

Kalambo DC

Itilima DC

Mbulu DC

Njombe TC

Missenyi DC

Songea DC

Chemba DC

Babati DC

Mpwapwa DC

Mvomero DC

Nyasa DC

Biharamulo DC

Urambo DC

Mbinga DC

Momba DC

Iramba DC

Karagwe DC

Mbozi DC

Kisarawe DC

Geita DC

Nachingwea DC

Makete DC

Nanyumbu DC

Kishapu DC

Lushoto DC

Kahama DC

Maswa DC

Mtwara DC

Kongwa DC

Ngara DC

Hanang DC

Chato DC

Karatu DC

Muleba DC

Njombe DC

Sumbawanga DC

Bunda DC

Kwimba DC

Mbeya CC

Korogwe DC

Shinyanga DC

Mkinga DC

Mkalama DC

Ileje DC

Kyerwa DC

Kahama DC

Gairo DC

Singida DC

Dodoma MC

Mkuranga DC

Rorya DC

Misungwi DC

Ruangwa DC

Masasi DC

Kigoma DC

Wanging'ombe DC

Sengerema DC

Masasi DC

Butiama DC

Kakonko DC

Newala DC

Mbongwe DC

Magu DC

Mwanga DC

Siha DC

Pangani DC

Tarime DCBukoba DC

Meru DC

Kibaha DC

Tabora MC

Rombo DC

Moshi DC

Tandahimba DC

Muheza DC

Hai DC

Buhigwe DC

Rungwe DC

Geita TC

Kahama TC

Busega DC

Arusha CC

Lindi MC

Nyang'hwale DC

Kasulu TC

Musoma DC

Kyela DC

Sumbawanga MC

Masasi TC

Handeni TC

Kibaha TC

Kati DC

Singida MC

Temeke MC

Tanga CC

Mafia DC

Makambako TCBusokelo DC

Songea MC

Mafinga TC

Babati TC

Ilala MC

Ukerewe DC

Kinondoni MC

Iringa MC

Kusini DC

Shinyanga MC

Wete DC

Mpanda TC

Arusha DC

Mbeya DC

Ilemela MC

Morogoro MC

Mkoani DC

Kaskazini B

Kaskazini A

Korogwe TC

Micheweni DC

Lindi MC

Mtwara MC

Bukoba MC

Ukerewe DC

Kigoma Ujiji MC

Mafia DC

Musoma MC

Mafia DC

Mkoani DC

8

Site-Level Pivots

Legend

Number of sites with Clients on ART/PMTCT/HTC in Scale - up Districts

Zero Clients

< 100

≥ 100

PLHIV

65 - 3516

3517 - 7213

7214 - 12820

12821 - 28928

28929 - 98296

±

Mlele

Liwale

Chunya

Manyoni

Iringa

Ulanga

Sikonge

Kilwa

Uyui

Rufiji

Kaliua

Uvinza

Nkasi

Mpanda

Tunduru

Kiteto

Simanjiro

Namtumbo

Mbarali

Kilosa

Songea

Kilolo

Kibondo

Ikungi

Meatu

Kilombero

Ngorongoro

Morogoro

Lindi

Bahi

Nzega

Serengeti

Mufindi

Kilindi

Same

Kasulu

Ludewa

Igunga

Longido

Babati

Monduli

Chamwino

Chemba

Bukombe

Nyasa

Itilima

Bagamoyo

Bariadi

Handeni

Kondoa

Mpwapwa

Kalambo

Urambo

Mbinga

MombaMbozi

Iramba

Mbulu

Makete

Kishapu

Maswa

Chato

Lushoto

Mtwara

Kongwa

Nanyumbu

Karatu

Bunda

Hanang

Njombe

KyerwaMissenyi

Butiam

Masasi

Mvomero

BiharamuloGeita

Karagwe

Kisarawe

Ngara

Nachingwea

Ileje

Muleba

Mbeya

Kwimba

Sumbawanga

Mkinga

Korogwe

Gairo

Mkalama

Kahama DC

Shinyanga

Rorya

SingidaKigoma

Mkuranga

Masasi

Misungwi

Magu

Siha

Mbogwe

Ruangwa

Hai

Newala

Kakonko

Sengerema

Njombe Urban

Meru

Wanging'ombe

Tarime

Moshi

Bukoba

Kibaha

MwangaKahama DC

Pangani

Rombo

Muheza

Rungwe

Buhigwe

Arusha

Busega

Dodoma Urban

Tandahimba

Kyela

Kati

Nyang'hwale

Musoma

Geita TC

Tabora Urban

Mafia

TemekeIlala

Lindi Urban

Handeni Mji

Sumbawanga Urban

Kusini

Ukerewe

Busokelo DC

Kinondoni

Wete

Kibaha Urban

Singida Urban

Kahama Township Authority

Tanga Urban

Songea Urban

Babati Urban

Ilemela

Kasulu Township Authority

Shinyanga Urban

Mkoani

Iringa Urban

Makambako Township Authority

Masasi Township Authority

Magharibi

Micheweni

Mpanda Urban

Mafinga Township Authority

Kaskazini B

Arusha Urban

Mbeya Urban

Kaskazini A

Morogoro Urban

Mtwara Urban

Lindi Urban

Mafia

Ukerewe

Korogwe Township Authority

Mafia

Kigoma Urban

Bukoba Urban

Musoma Urban

Mkoani

Site-Level Pivot: Scale-Up Districts

Low and high volume site overlap in Scale-Up Districts

Site Prioritization: Scale-Up Districts

Plan for detailed analysis to determine appropriate client referrals

PLHIV

65 - 3516

3517 - 7213

7214 - 12820

12821 - 28928

28929 - 98296

Legend

Number of sites with Clients on ART/PMTCT/HTC in Sustained Districts

Zero Clients ( 849 sites )

< 100 ( 2352 Sites )

≥ 100 ( 509 Sites )

±

Site-Level Pivot in Sustained Districts

In 129 low burden, Sustained

Districts:

• Discontinue support for 849

sites with no beneficiaries

• Sustain semi-annual quality

monitoring in 2,352 sites with

<100 clients

• Focus services in 509 high

volume ART facilities

90% of PLHIV know their status

12

Core Non-Core

• Demand creation for HTC targeting

Key and Priority Populations

(Adolescent Girls & Young Women)

• Scale-Up Districts: PITC, PMTCT

opt out testing, VMMC

• All Districts: Early Infant Diagnosis

and Pediatric HIV case finding

• Focus on testing OVC (HIV exposed

and malnourished)

• Community-Based HTC index case

finding

• Non-targeted HTC

90% are of PLHIV on ART

13

Core Near Core Non-Core

• Active identification,

enrollment and treatment

clients in pre-ART

• Active identification,

enrollment, and treatment

of HIV+ KP/PP (AGYW),

peds, pregnant women,

TB, discordant couples

• Strengthen PLHIV

networks and support

groups to track loss to

follow up and link back to

care

• FP integration

• CTX gap filling

• Procurement of

ARVs and

commodities to

cover needs

above Global

Fund support

• Basic care kit

• Hematology

and chemistry

• Infrastructure

for training

institutions

Viral Suppression

14

Core

• Routine viral load monitoring

• Focus on retention and adherence

• Laboratory EQA and Information

Management Systems

• Quality improvement methods

Package of Services in Scale-Up vs.

Sustained Districts

• Facility packages are the same across all districts

• Treatment targets in Sustained Districts assume

passive enrollment

• Service package in Scale-Up Districts will include:

• Demand creation for HTC at community level

• Viral load testing

• Continuous service and data quality improvement

• Completed referrals

• Focus on key populations

• Policy directive: No duplication of funding from

clinical partners that are now under the national

Results-Based Financing program (eg: allowances,

renovation) 15

Continuation of Non Scale-Up Support

• Central Support Sites:

– Overarching PEPFAR national support and QA/QI

will continue to ensure quality services

– Non-Core site specific activities will transition no

later than March 2016

• Lab- Chemistry and Hematology

• Sustaining Commodities:

– PEPFAR will coordinate with GFATM and GOT to

continue to commodity support to sites even

without PEPFAR site level support.

17

Population Pivots

Key/Priority Populations – Key Pivots

1. Increased focus on detecting and successfully treating

Key Populations

• Targets and budget have increased

2. Only one focus “Priority Population” instead of 7:

Adolescent Girls & Young Women (AGYW)

• Utilize Sex Worker and AGYW platform for condom

promotion and HTC linkage for high-risk men

3. Additional $4.2 million directed to condom

programming to fill the gap in Global Fund support

4. Study to learn more about the military population;

Military sites are aligned with Scale-Up Districts in

Tanzania

Priority Populations: Children/Adolescents

• Accelerating Children’s Treatment (ACT)

– Focused from 170 40 districts

– Aligned with Adult Prioritization and OVC programs

• Implementation of Test & Treat for children <15yrs

regardless of CD4

Children on ART by

SAPR 2015

Children on ART by

APR 2016

37,716 76,136

20

Zanzibar

Iringa

Kigoma

Tabora

Rukwa

Mbeya

Singida

Shinyanga

Kagera

Mwanza

Mara

Pwani Morogoro

Ruvuma Mtwara

Lindi

Dodoma

Manyara

Arusha

Tanga

Dar es Salaam

Kilimanjaro

Determined, Resilient, AIDS-free, Mentored,

and Safe (DREAMS)

• 221,203 AGYW reached with

combination prevention

program including testing

• In full alignment with VMMC,

ART, and ACT interventions

OVC Pivot to Contribution to Epi Control

• Reduction in districts and full alignment

with PLHIV: 136 to 27 Scale-Up to

Saturation Districts

• Scale up of OVC Case Management Model

– Identify and refer OVC for testing,

adherence and retention

• ACT & DREAMS

– Find HIV+ OVC:

• Nutrition Assessments

• Out of School children who are not

in family care

• Engagement of caregivers to support ART

adherence & retention for children

Legend

Scale - up Saturation Districts

Scale - up Aggressive Districts

Sustained Districts

OVC Program

±

Chunya

Mbarali

Nzega Igunga

Mbozi

Mufindi

Mbinga

Geita

Muleba

Mbeya

Sumbawanga

Kahama DC

Rorya

Sengerema

Njombe Urban

Wanging'ombe

Moshi

Bukoba

Kahama DC

Muheza

Rungwe

Dodoma Urban

Kyela

Tabora Urban

TemekeIlala

Lindi Urban

Sumbawanga Urban

Kinondoni

Kahama Township Authority

Tanga Urban

Songea Urban

Shinyanga Urban

Iringa Urban

Arusha Urban

Mbeya Urban

Morogoro Urban

Nyamagana

Lindi Urban

Korogwe Township Authority

Kigoma Urban

Musoma Urban

Budget Realignment for Program Sustainability

Scale-Up District?

No

Crucial to Epidemic Control?

No

Reduce or Cut?

Yes

Synergies between programs/HSS/lab?

Appropriate funding level?

Yes

Appropriate funding level?

Above Site

Decision Tree

Category Pre-COP Review Post-COP

Review

Percent

Reduction

Health Systems $37.5M $18.8M 50%

Above Site Level $28.3M $19.1M 32%

G2G $19.5M $11.9M 39%

Strategic Information $5.3M $3.7M 30%

Lab $4.0M $2.4M 42%

TOTAL $94.7M $55.9M 41%

Starting Point

$94.7M

Budget Realignment of ‘Above Site’ to

Reinvest in Increased Coverage

Reinvest savings in

treatment coverage,

procurement, VMMC,

KP/PP programming

Quarterly Monitoring

Quarterly calls with PEPFAR HQ will be

aligned with Executive Committee and CSO

Engagement

• Updates on implementation of initiation of

CD4 500

• Review SIMS visits and data

• Review MER Indicators

• Review Updates on Human Rights

25

PEPFAR Tanzania’s Health Diplomacy

Priorities

• Implementation of CD4 500 eligibility: Jan

2016

• GoT assume funding for a phased and

increasing proportion of activities that

PEPFAR is currently funding.

• Continued attention to human rights of PLHIV

and Key Populations

ASANTENI