UNAIDS - Youth Leadership and HIV response in Eastern and Southern Africa

1. Integrating HIV and SRH Services:
Tanzania’s Progress
By Dr. Subilaga K. Kaganda (TACAIDS) & Dr. Deborah Kajoka
(MOHSW)
HIV CAPACITY BUILDING PARTNERS’S SUMMIT,
Johannesburg, RSA
20th March 2013

2.  Introduction
 Overview of HIV/SRH integration
 Opportunities for Integration through PMTCT &
other HIV services
 Examples: Integration efforts in Tanzania
 Challenges
 Future Directions

3. Tanzania National statistics, targets,
Statistics, 2010 &2012
• Population : 44.9 Million
• CPR: 20% (modern method)
• Unmet Need: 22%
• High fertility rates 5.7
• MMR: 454/100,000
• HIV: 5.7% (6.6% women, 4.6% men)
2007/08 THMIS
• HIV (pregnant women): 6.9%
National Targets, 2007
• Increase CPR to 60% by 2015
• Reduce MMR to 193 by 2015
• At least 80% of women living with
HIV and attending PMTCT receive
Sources: TDHS 2010; THMIS 2007/08; ANC sententinel FP by 20154

4. Kagera 7.7%
3.4% 5.6% Mara
Mwanza Arusha National Average: 5.7%
7.4% 1.6% Kili.
Shinyanga
1.8% Manyara 1.9%
12%
Kigoma 1.5% Tanga
6.4% 2.7% Pemba 0.3%
Tabora Singida 3.3% 4.8%
Dodoma Unguja 0.8%%
4.9% Moro- Dar- 9.3%
Rukwa Iringa goro 6.7%
Pwani
9.2% 15.7% 7.0-15.7%
Mbeya 5.1% Lindi
3.8% 3.1-6.9%
Percent of women 5.9%
3.6% Mtwara 0.3-3.0%
and men age 15-49 Ruvuma
who are HIV-positive
2007-08 THMIS: NBS, TACAIDS, and Macro
International, Inc.

5. Age
2007-08 THMIS- NBS, TACAIDS, and Macro
International

6. Percent HIV-
positive
women and
men 15-24
2007-08 THMIS- NBS, TACAIDS, and Macro
International

7.  Integrating Reproductive Health, HIV and AIDS policies,
programs, and services has been considered essential for
meeting International and National goals and targets (MDG 4,5
& 6 and MKUKUTA)
 Tanzania developed the National Road Map Strategy (2008 –
2015) to accelerate the reduction of maternal, newborn and
child deaths in Tanzania.
 The MOHSW has also reviewed National HIV and RCH Policy
Guidelines and strategies to lay down frameworks for
integration of RH and HIV services.
 Initial focus has been on integrating FP into various HIV
services such as FP into PMTC, FP into VCT and FP into CTC.
 Development of National Operations Guidelines for Integrating
MNCH & HIV
 National Multisectoral Strategic Framework III (2013-17) has
highlighted the importance of integration

8.  At the lower level of facilities such as dispensary and
health centers, services like PMTCT, SRHs are
provided under one roof and in dispensary it may be
carried out by the same provider
 At regional and district levels (Regional & Council
Health Management Teams)
 At national level RCH section and NACP are two
separate institutions under one directorate
(Preventive)

9. Policy, 2007
 Policy review in 2007 : Several HIV and FP policies mandate
integration (initial focus was on FP/HIV integration)
• HIV Policies: FP recognized as a core intervention for PMTCT;
FP services to be offered to HIV clients
• Comprehensive STI case management /FP
• Focused Antenatal Care (FANC)-ANC/Syphilis/Malaria
• Integrated Logistic system- HIV/FP commodities, Condoms
• FP Policies: Universal access to HIV testing
Gap:
• Minimal integrated service delivery (passive)
• Policy not translated into practice ; lack of “how to”
guidance
 Leading to missed opportunities

10. Processes…
Stakeholders consultation meeting (2008) - key
recommendations:
• The two MoHSW arms (NACP & RCHS) agreeing that
integration has a mutual benefit to each of their program
• To Formulate the FP HIV Technical Working Group- DONE
• To have evidence based programming- on going
• To develop the National Strategic Framework for
integration- DONE

11. A processes…
Since 2008, Tanzania has
 Ensured an enabling policy environment
 Continued to do Evidence based programming
- conduct research to inform policy and service
delivery (on going)
 Continued strengthening health system to
deliver effective integrated SRH & HIV services

12. Enabling policy environment
 In 2009, the FPHIV TWG (Technical Working Group) was
established, co chaired by the NACP and RCHS unit of the
MoHSW (secretariat – partner rotation).
 Advocacy strengthened
Outcomes
 Integration one of the MoHSW priority
 Structural adjustment – PMTCT was reallocated from NACP to RCHs to
enhance integration
 Increase donor attention/support
 Resource mobilization- Tanzania National Coordinating Mechanism
(TNCM) endorsed inclusion of FP in the GF round 10 proposal
 Just finalized National Operational Guidelines for Integrating MNCH &
HIV (2012)
 ASRH and HIV integration on going through provision of YFS (youth
friendly services- slow scale up)

13. Evidence based programming - conduct
research to inform policy & service delivery
 Focusing on generating local evidence on feasible
and effective service delivery models
Counseling
&
Testing
PMTCT
HBC FP/MCH
Care
&
Treatmen
t

14. Evidence based programming - Conduct research to
inform policy and service delivery
Research Status (policy and practice)
Global FP/HIV • Inform improvement in the HMIS
Indicator
pilot, 2010
• Provided information on where we are with integration;
Rapid • Showed existing linkages between SRH & HIV within Tanzanians
policy, systems & services;
Assessment,
• Identified gaps in the policy and programmatic environment
2009
• Results greatly informed advocacy efforts
Site specific • SRH/HIV linkages seen in national RH and HIV policies & plans but
assessments integration guidelines not present
• At Facility level – HCWs supportive of integration but human
resources and technical capacity remains a challenge

15. Evidence based programming - conduct
research to inform policy & service delivery
Research/project Status (policy and practice)
FP CTC studies • Policy decision to scale up
2 studies looking at 2 different • Modality decided: Provision of condoms, pills,
modalities; 2009/10 injectables and implants at the CTC and referrals for
other long acting and permanent methods
FP VCT study • Piloting the intervention, VCT service providers to
provide pills and condoms
FP-HBC Project • Community HBC provides FP counseling; non clinical FP
methods and referrals for long acting and permanent
2 groups (HBC & FP methods
and HBC & FP counseling) methods
FP-PMTCT Project • Modalities of FP integration into ANC(PMTCT), PNC and
HIV/STI units assessed in 12 health facilities

16. FP into CTC:
 through facilitated referrals in Morogoro and Iringa regions by
FHI and through training of HCW in Pwani by ICAP. EFPAF-
Tabora
FP in PMTCT:
 Training of HCW in Manyara and Iringa- Engenderhealth
 FP into facility and community PMTCT in Morogoro- JHPIEGO;
EGPAF-Tabora (+cervical cancer screening)
PITC and FP in the framework of MNCH services in
Mwanza, Mara, Kigoma, Shinyanga, and Arusha by IntraHealth
and Iringa, Tabora, Dodoma, Singida, Tanga, Mtwara, Manyara
and Kilimanjaro by UHAI/JHPIEGO
FP in Home Based Care Programme by Path finder
International In Arusha, Kilimanjaro and Dar es salaam
FP and VCT By AMREF and Marie Stopes
SRH in HIV& AIDS : Lindi,Tanga, Mbeya& Mtwara by GIZ

17. Challenges
 Limitations in scaling up
 due to vertical funding streams- District planning process – skewed to
HIV compared to SRH programming – limited linkages
 Operational guidelines have just been finalized and yet to be
disseminated
 Integration not comprehensive enough
 Moving forward within the overburdened system
 Human resource shortage
 Coverage of trained providers in integrated service delivery are not
adequately trained.
 Inadequate funding for basic supplies and commodities

18. Lessons learned
 Policy
 Maintaining advocacy at all levels
 Importance of demonstrating mutual benefits of integration in both HIV
and SRH programs.
 Political commitment is critical
 FPHIV TWG is vital in moving and sustain the SRH/HIV integration agenda
 Health Systems & Service delivery
 It takes evidence to inform country to scale up
 Different service delivery models-One size doesn’t fit all

19. Future directions
 Policy
 Enhancing advocacy efforts
• Increase donors willingness to fund integration issues at country level
• MoHSW and Partners ready to adopt and scale up models
• Strengthen joint planning and implementation between SRH and HIV&AIDS at all
levels
 Ensure conducive operational policies to effectively provide integrated services
(NMSF III, Reviewed National HIV & AIDS Policy, Health sector RCH & HIV
guidelines)
 Health System/ service delivery
 Adopt studies findings into policy
 Scale up integrated service delivery models nationwide
 Finalize and put operational guidelines in use.
 Expand use of community based volunteers for FP/HIV /MNCH services

20.  delivered by Community Health Workers (CHW) approved by
the Ministry of Health and Social Welfare at household level
or health post and shall be predominantly promotional in
nature.
 These services can also be preventive and curative in nature:
Family planning, HIV Testing and Counseling, Maternal and
Child Health, Post Rape Care, Tuberculosis, Cervical,
breast, and prostate cancer screening
 Preventive messages shall include:
Benefits of knowing one’s HIV status, Safer sex practices (i.e.
abstinence, being faithful, Correct and consistent use of
condoms,) Early initiation and exclusive breast feeding,
Healthy timing and spacing of births) and Use of insecticide-
treated nets (ITN).

21. CHW also will provide services at community level:
• Contraceptive pills
• Male and female Condoms
• Informational materials
• Referrals

22.  Improved access to and uptake of key HIV and MNCH
services.
 Better access of PLHIV to MNCH services tailored to their
needs
 Reduction in HIV-related stigma and discrimination
 Improved coverage of underserved/vulnerable/key populations
 Greater support for dual protection
 Improved quality of care
 Decreased duplication of efforts and competition for resources
and better utilization of Human Resources
 Enhanced programme effectiveness and efficiency
 Better understanding and protection of individuals’ rights
 Mutually reinforcing complementarities in legal and policy
frameworks

23. ASANTE SANA!
THANK YOU!