Partnering to Reach an AIDS Free Generation in Tanzania DPG-Health Meeting September 2015

Ending AIDS Scenario: New HIV Infections Total number of people living with HIV/AIDS (PLWHA) 79M PLWHA 52M PLWHA 35M PLWHA $31B in additional Tx cost/year $8B in additional Tx cost/year SOCO: There is not enough funding within the USG or globally to continue putting people on treatment without enhanced focus on epidemic control. Preventing new infections is our common PEPFAR goal. We need to change the trajectory of new HIV infections and get on the Green Line trajectory. This can happen with accelerated and expanded coverage of Combination Prevention interventions in priority locations and among those most in need. 44M PLWHA 48M PLWHA 2 Source: UNAIDS 2014 GAP Report

PEPFAR/Tanzania Goal Statement To reach 80% of PLHIV with lifesaving treatment by 2020, starting in districts of highest need

Tanzania Funding Levels 2005 $100 2006 $129.9 2007 $205.4 2008 $313 2009 $311.17 $50 2010 361.17 = $307.97 $30 $20 2011 357.19 = $307.19 $30 $20 2012 270.56 = $220.56 $30 $20 2013   347.98 2014 375 Base PF     PMTCT

Tanzania Strategic Pivot for Epidemic Control RIGHT PLACES Districts Sites Populations RIGHT THINGS PEPFAR-support for core interventions Budget for Impact

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

District Prioritization PLHIV by District PEPFAR Scale-Up District Focus

Site-Level Pivots

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

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 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 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 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)

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

Key/Priority Populations – Key Pivots Increased focus on detecting and successfully treating Key Populations Targets and budget have increased 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 Additional $4.2 million directed to condom programming to fill the gap in Global Fund support 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

Determined, Resilient, AIDS-free, Mentored, and Safe (DREAMS) Zanzibar Iringa Kigoma Tabora Rukwa Mbeya Singida Shinyanga Kagera Mwanza Mara Pwani Morogoro Ruvuma Mtwara Lindi Dodoma Manyara Arusha Tanga Dar es Salaam Kilimanjaro 221,203 AGYW reached with combination prevention program including testing In full alignment with VMMC, ART, and ACT interventions

OVC Pivot to Contribution to Epidemic 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

Budget Realignment for Program Sustainability

Above Site Decision Tree Scale-Up District? No Crucial to Epidemic Control? Reduce or Cut? Yes Synergies between programs/HSS/lab? Appropriate funding level? Above Site Decision Tree

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 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%

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

PEPFAR Tanzania’s Health Diplomacy Priorities Implementation of CD4 500 eligibility: Jan 2016 Tanzania 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