Partnering to Reach an AIDS Free Generation in Tanzania RMO/DMO Meeting September 2015
Ending AIDS Scenario: New HIV Infections Total number of people living with HIV/AIDS (PLWHA) 35M PLWHA 52M PLWHA 79M PLWHA $8B in additional Tx cost/year $31B in additional Tx cost/year 44M PLWHA 48M PLWHA 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 in millions $450 $400 $350 $300 $250 $200 $150 $100 $50 $0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
RIGHT PLACES Districts Sites Populations Tanzania Strategic Pivot for Epidemic Control RIGHT THINGS PEPFAR-support for core interventions Budget for Impact 5
Geographic Pivots for Epidemic Control 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 6
District Prioritization PLHIV by District PEPFAR Scale-Up District Focus Legend PLHIV 35-3476 3477-7483 7484-12424 12425-28241 Missenyi DC Kyerwa DC Bukoba MC Rorya DC Bukoba DC Tarime DC Musoma MC Karagwe DC Butiama DC Ukerewe DC Muleba DC Musoma DC Ukerewe DC Bunda DC Serengeti DC ± Longido DC Busega DC Ilemela MC Ngara DC Bariadi DC Geita DC Sengerema DC Magu DC Biharamulo DC Geita TC Itilima DC Misungwi DC Chato DC Kwimba DC Ngorongoro DC Siha DC Rombo DC Nyang'hwale DC Kakonko DC Maswa DC Arusha CC Mbongwe DC Meru DC Meatu DC Arusha DC Moshi DC Kahama DC Hai DC Bukombe DC Shinyanga DC Shinyanga MC Karatu DC Monduli DC Kishapu DC Mwanga DC Kahama TC Mbulu DC Kibondo DC Kahama DC Babati DC Mkalama DC Babati TC Same DC Simanjiro DC Nzega DC Igunga DC Buhigwe DC Iramba DC Hanang DC Kasulu TC Lushoto DC Kigoma DC Singida DC Kasulu DC Kondoa DC Mkinga DC Kigoma Ujiji MC Singida MC Kaliua DC Tabora MC Micheweni DC Uyui DC Korogwe DC Tanga CC Ikungi DC Wete DC Urambo DC Kiteto DC Korogwe TC Muheza DC Chemba DC Kilindi DC Handeni TC Mkoani DC Pangani DC Mkoani DC Handeni DC Bahi DC Uvinza DC Kaskazini A Mpanda DC Sikonge DC Kongwa DC Gairo DC Kaskazini B Dodoma MC Kati DC Bagamoyo DC Kusini DC Mpanda TC Manyoni DC Mvomero DC Mlele DC Kibaha TC Kinondoni MC Mpwapwa DC Chamwino DC Morogoro MC Kibaha DC Ilala MC Temeke MC Kilosa DC Kisarawe DC Mkuranga DC Morogoro DC Iringa DC Nkasi DC Chunya DC Iringa MC Kilolo DC Mafia DC Sumbawanga MC Rufiji DC Mafia DC Kilombero DC Mafia DC Sumbawanga DC Mbarali DC Mafinga TC Kalambo DC Mufindi DC Momba DC Mbeya DC Makambako TC Mbozi DC Busokelo DC Wanging'ombe DC Ulanga DC Mbeya CC Kilwa DC Makete DC Njombe DC Liwale DC Ileje DC Rungwe DC Kyela DC Njombe TC Ludewa DC Lindi MC Ruangwa DC Lindi MC Lindi DC Mtwara MC Songea DC Nachingwea DC Namtumbo DC Mtwara DC Masasi DC Songea MC Newala DC Tandahimba DC Mbinga DC Masasi TC Tunduru DC Nanyumbu DC Masasi DC Nyasa DC 28242-96119 7
Site-Level Pivots 8
Site-Level Pivot: Scale-Up Districts Missenyi Kyerwa Bukoba Urban Rorya Bukoba Tarime Musoma Urban Karagwe Butiam Ukerewe Muleba Musoma Ukerewe Bunda Serengeti ± Longido Ilemela Busega Bariadi Ngara Biharamulo GeitaSengerema Magu Ngorongoro Geita TC Itilima Misungwi Chato Kwimba Siha Nyang'hwale Rombo Kakonko Maswa Arusha Meru Hai Meatu Monduli Moshi Mbogwe Shinyanga Urban Karatu Arusha Urban Kahama DCShinyanga Bukombe Kishapu Mwanga Kahama Township Authority Mbulu Kahama DC Kibondo Babati Mkalama Babati Urban Same Nzega Simanjiro Kasulu Igunga Buhigwe Iramba Hanang Kasulu Township Authority Lushoto Kigoma Singida Kondoa Mkinga Kigoma Urban Singida Urban Kaliua Tabora Urban Micheweni Uyui Korogwe Tanga Urban Ikungi Wete Kiteto Korogwe Township AuthorityMuheza Urambo Chemba KilindiHandeni Mji Mkoani Handeni Mkoani Uvinza Pangani Kaskazini A Mpanda Sikonge Gairo Kaskazini B Kongwa Bahi Dodoma Urban MagharibiKati Manyoni Bagamoyo Kusini Mpanda Urban Mvomero Kibaha Urban Mlele Mpwapwa Kinondoni Chamwino Morogoro Urban Kibaha Kilosa Ilala Temeke Morogoro Kisarawe Mkuranga Iringa Nkasi Chunya Iringa Urban Kilolo Mafia Sumbawanga Urban Rufiji Mafia Kilombero Mafia Sumbawanga MbaraliMafinga Township Authority Kalambo Mufindi Low and high volume site overlap in Scale-Up Districts Momba Mbozi Mbeya Urban Makambako Township Authority Wanging'ombe Mbeya Makete Njombe RungweBusokelo DC Ileje Kyela Njombe Urban Ulanga Liwale Kilwa Ludewa Songea Mbinga Namtumbo Songea Urban Lindi Urban RuangwaLindiLindi Urban Mtwara Urban Nachingwea Mtwara Masasi Masasi Township Authority NewalaTandahimba Tunduru Nanyumbu Masasi Nyasa 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
Site Prioritization: Scale-Up Districts Plan for detailed analysis to determine appropriate client referrals
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 Legend Number of sites with Clients on ART/PMTCT/HTC in Sustained Districts Zero Clients ( 849 sites ) < 100 ( 2352 Sites ) 100 ( 509 Sites ) PLHIV 65-3516 3517-7213 7214-12820 12821-28928 28929-98296
90% of PLHIV know their status 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-Core Non-targeted HTC 12
90% are of PLHIV on ART 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 13
Viral Suppression Core Routine viral load monitoring Focus on retention and adherence Laboratory EQA and Information Management Systems Quality improvement methods 14
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.
Population Pivots 17
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 37,716 76,136 Children on ART by APR 2016
Determined, Resilient, AIDS-free, Mentored, and Safe (DREAMS) Kagera Mara Mwanza Shinyanga Arusha Kilimanjaro Kigoma Manyara Tabora Tanga Singida Dodoma Zanzibar 221,203 AGYW reached with combination prevention program including testing Rukwa Mbeya Iringa Morogoro Pwani Dar es Salaam In full alignment with VMMC, ART, and ACT interventions Ruvuma Lindi Mtwara 20
OVC Pivot to Contribution to Epi Control Rorya Musoma Urban Bukoba ± Muleba 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 Nyamagana GeitaSengerema Arusha Urban Kahama DCShinyanga Urban Kahama Township Authority Kahama DC Moshi Nzega Igunga Kigoma Urban Tanga Urban Korogwe Township AuthorityMuheza Tabora Urban Dodoma Urban Morogoro Urban Kinondoni IlalaTemeke Iringa Urban Chunya Find HIV+ OVC: Nutrition Assessments Out of School children who are not in family care Sumbawanga Urban Sumbawanga Mbarali Mufindi MboziMbeya Urban Wanging'ombe Mbeya Rungwe Kyela Njombe Urban Lindi Urban Lindi Urban Songea Urban Mbinga Legend Scale - up Saturation Districts Scale - up Aggressive Districts Sustained Districts OVC Program Engagement of caregivers to support ART adherence & retention for children
Budget Realignment for Program Sustainability
Scale-Up District? Above Site Decision Tree No Yes Crucial to Epidemic Control? Appropriate funding level? No Yes Reduce or Cut? Synergies between programs/hss/lab? Appropriate funding level?
Budget Realignment of Above Site to Reinvest in Increased Coverage Starting Point $94.7M Reinvest savings in treatment coverage, procurement, VMMC, KP/PP programming Category Pre-COP Review Post-COP Review 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% Percent Reduction
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