TOOLS FOR COMPREHENSIVE SUPPORTIVE SUPERVISION ON HIV AND AIDS HEALTH SERVICES Second Edi

THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH AND SOCIAL WELFARE TOOLS FOR COMPREHENSIVE SUPPORTIVE SUPERVISION ON HIV AND AIDS HEALTH SERVICES Second Edi NATIONAL AIDS CONTROL PROGRAMME JUNE 2014

This is an annex to the Manual for Comprehensive Supportive Supervision and Mentoring on HIV and AIDS Health Services Second Edition (2014).

Contents: Part Tool User Target Page Acronyms All Supervisors i - iv Previous All Supervisors All Organizations 1 A B C D E Action Plan Regional and Council Tool Zonal Health Resource Centre Tool Health Facility Tool Reporting Formats National and Regional Supervisors National Supervisors RHMTs/CHMTs 3 Zonal Health Resource Centres All Supervisors All Health Facilities 9 1. General Information 9 2. Management and QI 10 3. PMTCT 11 4. STIs/RTIs 15 5. Care & Treatment 19 6. Collaborative TB/HIV 25 7. Community-based 29 HIV/AIDS Services 8. HTC 33 9. Laboratory 37 10. Pharmacy 41 11. VMMC 43 All Supervisors All Organizations 47 1. Cover 49 2. Executive Summary 50 3. Report (R/CHMT) 51 4. Report (ZHRC) 55 5. Health Facility 57 7 i

Acronyms ADR AE ALAT ANC AP ARH ART ARVs ASAT ASRH AZT BCC BMI C&T CBHS CBO CCHP CHMT CITC CSS CTC DACC DBS DCBHSCo DMO DNA PCR DNUFP DPharm DQA DRCHCo DTLC EBF EID EQA FBO FEFO/FIFO 5S (Five S) FP Adverse Drug Reaction Adverse Effects Alanine Amino Transferase Test (Liver Function) Antenatal Care Annual Plan Adolescent Reproductive Health Antiretroviral Therapy Antiretroviral Drugs Aspartate Amino Transferase Test Adolescent Sexual and Reproductive Health Zidovudine Behaviour Change Communication Body Mass Index Care and Treatment Community Based HIV and AIDS Services Community Based Organization Comprehensive Council Health Plan Council Health Management Team Client-initiated Testing and Counselling Comprehensive Supportive Supervision Care and Treatment Clinic District AIDS Control Coordinator Dried Blood Spot District CBHS Coordinator District Medical Officer Deoxyribonucleic Acid Polymerase Chain Reaction District Nutrition Focal Person District Pharmacist Data Quality Assessment District Reproductive and Child Health Coordinator District TB and Leprosy Coordinator Exclusive Breastfeeding Early Infant Diagnosis External Quality Assurance Faith Based Organization First Expired First Out / First In First Out Sort, Set, Shine, Standardize and Sustain Family Planning ii

GBV HB HBC HBHTC HF HIV HSPs HTC ICT IEC IMAI IMCI IPC IPD IPs IPT IQA ITN JICA KPs L&D LAB LTFU M&E MC MCH MO MOHSW MSD MTC MTUHA MVC NACP NACS NGO NNRTI NTLP OIs OPD OVC Gender-based Violence Hemoglobin Home Based Care Home Based HIV Testing and Counselling Health Facility Human Immunodeficiency Virus Health Service Providers HIV Testing and Counselling Information Communication Technology Information, Education and Communication Integrated Management of Adult and Adolescent Illness Integrated Management of Child Illness Infection Prevention Control Inpatient Department Implementing Partners Isoniazid Preventive Therapy Internal Quality Assurance Insecticide Treated Net Japan International Cooperation Agency Key Populations Labour and Delivery Laboratory Lost to Follow Up Monitoring and Evaluation Male Circumcision Maternal and Child Health Medical Officer Ministry of Health and Social Welfare Medical Service Department Medicine and Therapeutic Committee Swahili abbreviation of Health Management Information System (HMIS) in Tanzania Most Vulnerable Children National AIDS Control Programme Nutrition Assessment, Counselling and Support Non-Governmental Organization Non-Nucleoside Reverse Transcriptase Inhibitor National TB/Leprosy Programme Opportunistic infections Outpatient Department Orphans and Vulnerable Children iii

PDSA PEP PHDP PITC PLHA PLHIV PMTCT PPE PPP QA QI QIT R&R RACC RCBHSCo RCH RHMT RMO RNUFP RPharm RRCHCo RTLC RUTF SBCC SOPs SS&M STIs/RTIs TAT TB TB/HIV TBIC TFDA TLE TSQ VAC VCT VHWs VMMC WIT ZHRCs Plan, Do, Study and Act Post Exposure Prophylaxis Positive Health Dignity and Prevention Provider Initiated Testing and Counselling People Living with HIV and AIDS People Living with HIV Prevention of Mother to Child Transmission Personal Protective Equipment Public Private Partnership Quality Assurance Quality Improvement QI Team Report and Request / Request and Requisition Regional AIDS Control Coordinator Regional CBHS Coordinator Reproductive and Child Health Regional Health Management Team Regional Medical Officer Regional Nutrition Focal Person Regional Pharmacist Regional Reproductive and Child Health Coordinator Regional TB and Leprosy Coordinator Ready-to-use Therapeutic Food Social and Behavioral Change Communication Standard Operating Procedures Supportive Supervision and Mentoring Sexually Transmitted Infections and Reproductive Tract Infections Turnaround Time Tuberculosis Tuberculosis and HIV TB Infection Control Tanzania Food and Drug Authority Tenofovir, Lamivudine, Efavirenz TB Screening Questionnaire Violence against Children Voluntary Counselling and Testing Village Health Workers Voluntary Medical Male Circumcision Work Improvement Team Zonal Health Resource Centres iv

PART A: ACTION PLAN OF THE PREVIOUS SUPPORTIVE SUPERVISION: Referring to the previous action plan, discuss the implementation status of the agreed action points with the ZHRC/RHMT/CHMT/HMT/Health Facility when you arrive for follow-up supervision visit and document the progress accordingly. Action Plan developed during the previous visit CHALLENGE/ISSUE ACTION POINT RESPONSIBLE PERSON TIMELINE STATUS A Previous Action Plan Previous Action Plan The last column needs to be filled in while discussing the implementation status. 1

PART B: REGIONAL AND COUNCIL HEALTH MANAGEMENT TOOL 1. General Information Name of Institution Name of the Region Name of the District Date of Visit Previous visit date Supervisees Name Title/Designation Mobile/Email B RHMT/CHMT Supervisors Name Title/Designation Mobile/Email 2. Areas of Supportive Supervision that Cut Across All HIV and AIDS Health Services Discuss and check the status with R/CHMTs on the following areas in relation to HIV/AIDS health services (C&T, PMTCT, TB/HIV, STI/RTI, HTC, CBHS, SBCC, Condoms, KPs, Lab and Pharmacy) implementation. Q1-9 should be discussed with R/CHMTs and Q10-15 with R/DACC, R/DRCHCo, R/DTLC, R/DNUFP and R/DCBHSCo. 3

B RHMT/CHMT Action Points and Check Items Status and Comments Responsible Persons Q1. Coverage of HIV/AIDS health services (# HFs and % of people receiving the services), human resources status and training needs: a) PMTCT (including situation of Home-based deliveries) b) STIs/RTI c) C&T d) TB/HIV (incld. TB/HIV collaboration mechanism) e) CBHS f) HTC i) CITC ii) PITC iii) HBHTC g) VMMC Q2. (a) Source of Funds and (b) Percentage of budget allocated in the RHMT-AP/CCHP for: i) Supportive Supervision ii) Mentoring iii) Quality Improvement iv) Different intervention activities of HIV and AIDS Q3. Resource Management: a) Timely and complete disbursement of funds from sources b) Transparency in utilization of the HIV/AIDS budgeted funds c) Utilization of funds according to plan and budget d) Rational utilization of other resources (e.g. vehicles, motorcycles, computers etc.) Q4. Implementation status of HIV and AIDS activities as compared to the Plan Q5. Comprehensive Supportive supervision and mentorship to CHMTs and health facilities a) Trained supervisors b) Trained mentors c) SS Matrix d) Implementation e) Availability of SS&M reports f) Synergy meetings 4

Q6. Coordination with IPs on HIV/AIDS services at Council & Regional levels a) Joint planning b) Joint Implementation c) Joint Reporting d) Information sharing Q7. QI Activities a) QI team in place b) QI plan in place c) Regular QI team meeting d) Issues identified and dealt with through PDSA e) Documentation of the process f) DQA conducted to lower level g) Feedback from the level to which the reports were submitted Q9. Research a) Participation of local service providers b) Utilization of the findings by local authorities c) Collaboration of on-going studies in routine service provision B RHMT/CHMT The following questions refer to the following interventions: 1) PMTCT, 2) STIs/RTIs, 3) CTC, 4) TB/HIV, 5) CBHS, 6) HTC, 7) VMMC, 8) SBCC, 9) Condom, 10) Nutrition and 11) QI. The discussion requires the presence of R/DACC, R/DRCHCo, R/DTLC, R/DLT, R/DPharm and R/DCBHSCo. Check Items Status and Comments Action Points and Responsible Persons Q10. Availability, accessibility and use of latest Policies, Guidelines, SOPs and Protocols Availability: Use: Q11. Ask for availability of the recording and reporting tools since the last SS visit Q12. Reporting: a) Check for availability and timeliness of submission of monthly, quarterly and annual progress regional/district intervention reports or forms to higher level b) Check for proper filing and appropriate storage of reports c) Check for data analysis, presentation, interpretation, feedback and use Q13. SBCC: Availability, accessibility and dissemination of: a) SBCC material distribution list, ledger and report forms b) Community SBCC plan & implementation report 5

B RHMT/CHMT Q14. Condoms: Availability of male & female condoms, pelvic & penile models Q15. Implementation and follow-up of health sector work place interventions: a) Plan b) Budget c) Implementation reports Strengths General Challenges Summary of Action Points 6

PART C: ZONAL HEALTH RESOURCE CENTRE The following are the main areas to be discussed during supportive supervision to Zonal HealthResource Centres (ZHRCs) by the National Supervisors. 1. General Information Name of Institution Name of the Region Name of the District Date of Visit Previous visit date Supervisees Name Title/Designation Mobile/Email C ZONAL HEALTH RESOURCE CENTRE Supervisors Name Title/Designation Mobile/Email 7

2. Areas of Supportive Supervision related to Zonal Health Resource Centre Discuss the following items with the Zonal Health Resource Centre C ZONAL HEALTH RESOURCE CENTRE Check Items Q1. Availability and utilization of HIV/AIDS related latest policy guidelines, SOPs, protocols and training materials Q2. HIV/AIDS training and activities integrated into a) Business plan b) Annual work plan Q3. Coordination and implementation a) Coordination of trainings in the Zone b) Implementation status c) Human capacity for implementation Q4. SS to health training institutions a) Number of SS visits conducted b) Coverage of visits (regions and districts) Q5. Availability of inventory of trainers and trainees of HIV and AIDS service trainings Q6. Monitoring and evaluating implementation of activities Q7. Capacity to provide technical assistance to regions and districts. a) Identification of training needs b) ICT utilization c) Development of SBCC materials d) Post-training assessment Status and Comments Action Points and Responsible Persons Strengths General Challenges Summary of Action Points 8

PART D: HEALTH FACILITY TOOL 1. General Information: During the comprehensive supportive supervision at health facility, supervisors will first of all pay courtesy call to facility management to introduce objectives of the visit. Then, the supervisors will discuss the management and QI component with the facility management (Section 2). Thereafter the supervisors will divide into specific HIV health services and conduct some discussions at service delivery points using the Section 3 to 11. After completion of intervention-specific areas, the supervisors will then give feedback, discuss and develop an action plan with the Facility Management Team. Name of Health Facility: Ownership of health facility Name of the Region Name of the District Date of Visit Date of Preceding Visit Facility Management Team Government [ ]; Voluntary Agency [ ]; Private [ ]; Other, specify....... Name Designation Mobile/Email D HF: 1. General Information Supervisors Name Designation/Org Mobile/Email 9

2. Management and Quality Improvement D HF: 2. MANAGEMENT & qi Check Items Q1. QI Team a) Presence of QI Team and Work Improvement Teams (WIT) b) Composition of QI team Q2. Activeness of QI Team a) Number of QI meeting in the last quarter b) Number of issues improved through PDSA c) Indicators monitored d) Documentation of QI process Q3. DQA conducted Q4. Feedback from higher authority regarding reports/data Status and Comments Action Points and Responsibility Q5. Data analysis, presentation, interpretation, use and dissemination Q6. Linkages between different interventions a) Availability and use of referral forms b) Feedback on referrals c) How linkages are practiced Q7. Availability and functionality of Medicine and Therapeutic Committee (MTC) (availability of minutes) Strengths Challenges in management and implementation of QI 10

3. Prevention of Mother to Child Transmission (PMTCT) (The tool shall be used to supervise all PMTCT service delivery points at the health facility.) Supervisees Name Designation Mobile/Email Supervisors D Check Items Q1. HIV testing and counselling for pregnant & lactating women and their partners: a) Number of new ANC clients attended at facility during the last month b) Number of pregnant and lactating women tested for HIV during the last month c) Number of pregnant and lactating women identified HIV positive during the last month d) Number of couple counselled and tested during the last month e) Was there quality assurance for HIV test done within last month? (this includes external quality assurance testing) Q2. Availability and utilization of the following latest documents: a) National comprehensive guideline for PMTCT edition of 2013 b) Protocols (e.g. HIV testing algorithm, PEP, Good dispensing practices, ART paediatric dosing chart etc) Q3. Data management a) Availability and complete filling of Recording and Reporting Forms i. MTUHA registers and their monthly summary forms ii. ART register and quarterly facility based HIV care/art report) iii. Mother & Child follow up register and its quarterly summary report form iv. RCH card no.4 & RCH card no. 1 v. CTC 1& 2 cards vi. HIV Exposed Child card Status and Comments Action Points and Responsible Persons HF: 3. pmtct 11

D HF: 3. pmtct vii. PMTCT ARV dispensing register viii. Report form A3 for HIV test-kit ix. Report form A2 (R&R for ARV) x. Report form A6 xi. Ledger xii. ADR forms xiii. Referral/Transfer Form b) Timing of Report: Report to reach district by 7 th day of the following reporting month c) Filing and Storage of Data/ Reports d) Data analysis, presentation, interpretation, use, dissemination and feedback (Check if data been disseminated) Q4. Space adequacy and privacy: a) Waiting space b) Counselling rooms c) Testing room/area d) Record keeping space Q5. Loss to follow-up and how they deal with it: a) Availability of appointment and tracking registers b) Review the list of missed appointments for the past 3 months and record; c) Total number with missed appointments d) Total number traced e) Total number returned to care f) Total lost to follow up or dead g) Check for documentation of adherence counselling in column 15 of the CTC2 card Q6. Screening HIV +ve pregnant and lactating women for TB and Syphilis: a) Availability of TB screening tools b) Availability of Syphilis test kits Q7. WHO clinical staging and testing of HIV +ve pregnant and lactating women for CD4 Note: This is for patient monitoring only (For initiation use Option B+) Q8. Availability and accessibility of family planning services: a) Check for available methods of family planning b) Check for CTC2 if family planning is being provided c) Check for a room for family planning services 12

Q9. Availability of ART: a) Availability of TLE (Tenofovir-Lamivudine-Efavirenz) b) Check for availability of alternative regimen Q10. Provision of ARV prophylaxis to HIV exposed Infants after birth Check if: a) Nevirapine syrup is available for exposed infants. b) Nevirapine is given to infant up to six weeks of age. Q11. Cotrimoxazole prophylaxis given to HIV exposed infants 4-6 week of age? Q12. Availability/accessibility of EID/DNA-PCR: a) Availability of DBS-Kits b) Availability of trained staffs on DBS service provision c) Check for DBS results turnaround time; Randomly select 5 DBS results sheets, calculate mean turnaround time (between date of sample collection to date of results back), is turnaround time a. 2 months b. > 2 months? Why? Q13. Referral and linkage system in place: a) Internal b) External c) Availability of referral forms d) Linkage between PMTCT and other interventions/wards Q14. Staff trained on PMTCT service provision Q15. Availability of Social Behaviour Change Communication materials (SBCC) a) PMTCT specific materials b) Nutrition education materials (addressing EBF) c) Audio Visual equipment Q16. Male involvement a) Activities planned to promote male involvement b) Implementation of these activities c) Check the percentage of male involvement Q17. Availability and functionality of equipment and commodities: a) Examination and delivery beds b) Male condoms and penile model c) Female condoms and pelvic model D HF: 3. pmtct 13

D HF: 3. pmtct d) BP machine e) Stethoscopes f) Weighing machine g) Height measuring device h) Hb estimation machine and consumables i) Anaesthesia machine j) Suction machine k) Ambu bag Q18. Labour and delivery practice a) Check in the delivery book for unsafe delivery practices b) Availability of adequate number of delivery kits c) Check for the availability of HIV test kits at L&D d) Check for the availability of TLE at L&D e) Check for colour coded bins or bags liner and its final disposal f) Standard precaution (personal protective gears) g) Processing of instruments for re-use (decontamination, high level disinfection, sterilization and carbolization of delivery beds) Strengths Challenges in Providing PMTCT/ Option B+ Services Areas that need mentorship 14

4. Sexually Transmitted Infections and Reproductive Tract Infections (STIs/RTIs): Supervisees Name Designation Mobile/Email Supervisors D Check Items Q1.Number of: a) Clients attended in the past one month b) Adolescent and youth clients in the past one month c) Rape cases attended in the past one month (check registers) Status and Comments Action Points and Responsible Persons HF: 4. stis/rtis Q2. Availability and utilization of latest documents: a) National guidelines and manual for management of STIs/RTIs b) National ARH Guidelines and Standards c) Algorithm and job aids d) Protocols (e.g. PEP) Q3. Data management: a) Availability and usage of the current recording and reporting tools i. STI/RTI register ii. Monthly reporting forms iii. Laboratory request forms iv. Referral forms v. Contact tracing cards b) Data flow:(check date of submission reports) c) Check filling, filing and storage of data/reports d) Data analysis, presentation, interpretation, use and dissemination e) Participation in monthly facility sharing information meetings. 15

D HF: 4. stis/rtis Q4. Space availability, Adequacy &and privacy (auditory and visual) a) Waiting space b) Registration c) Consultation rooms(auditory and visual privacy) d) Record keeping space( check for availability of cabinet, shelves etc) Q5.Number of: a) STI/RTIs clients screened for HIV in the last month b) STI/RTIs clients with HIV screened for active TB in the last month c) STI/RTI clients screened for cervical cancer Q6. Contact tracing system Q7. 1st, 2nd and 3rd line STI regimen: a) Availability of the STIs/RTIs medicines in the past 3 months b) Number of clients on 2nd and 3rd line regimens(where applicable) Q8. Referral and linkage system in place (how is it done?) - Internal - External Q9. Number of Staff trained on Syndromic Management a) Clinicians b) Nurses c) Others providing STI/RTI services Q10. Availability and distribution of SBCC materials: a) STI/RTI specific b) Adolescent/youth specific c) Audio Visual equipment Q11. Availability of equipment and Commodities: a) Examination bed b) Speculum Lamp/torch c) Male and female condoms d) Penile and pelvic models e) Infection prevention and control supplies Q12. Availability of adolescent and youth friendly services. a) Number of staffs trained on ASRH friendly services b) Activities implemented at the facility for youth 16

Strengths Challenges in providing STI/RTI and ASRH Services: Areas that need mentorship: D HF: 4. stis/rtis 17

5. Care & Treatment (C & T) Supervisees Name Designation Mobile/Email Supervisors Check Items Q1.Number of HSPs at the CTC: List by cadre Status and Comments Action Points and Responsible Persons D HF: 5. C&T Q2. Staff training: Types of training and staff trained: Basic ART and TB/HIV Adherence counselling Nutrition training Infection Prevention Control Paediatric: Paediatric ART training TB in Paediatric Adherence counselling IMCI Q3. Paediatric services Proportion of children (<1yrs, <5yrs and <15yrs) initiated on ART in the last quarter Q4. Check both Availability and utilization of latest documents: A. National guidelines a) Management of HIV and AIDS Treatment guideline b) TB & Leprosy Treatment guideline c) Guideline for management of severe acute malnutrition d) GBV/VAC Guidelines e) IPC B. SOPs and protocols C. Job aids for Adult 2nd line ART 19

D HF: 5. C&T Q5. Data management A. Availability and usage of Recording and Reporting Forms /Tools a) CTC 1 and 2 b) Patient file c) Lab request forms d) Referral forms e) Pre-ART registers f) Appointment register g) Cohort analysis register h) ART dispensing register i) Cohort quarterly reporting form j) Missed appointments tracking register k) NACS register l) Electronic CTC2 Database m) Electronic Pharmacy Database n) Backup devices(flash disk, External hard drive) B. Data flow and timing - Reports from HF reaches to DMOs office by 7 th of each month C. Check for proper filing of Data/Reports D. Assess storage of data/reports E. Data analysis, presentation, interpretation, use, dissemination and feedback Q6. Space adequacy a) Waiting space b) Registration c) Area for triage d) Consultation rooms e) Counselling room f) Dispensing room g) Drug Storage room h) Record keeping room Q7. Patient flow and triage system a) Availability of patient flowchart b) Provision of health education including TB infection control c) Observe HSP conducting triage if s/he is: i) Identifying clients with immediate needs ii) Identifying clients with cough iii) Taking patient s anthropometric measurements iv) Retrieving files v) Filling CTC 1&2 vi) Directing patients to next unit 20

Q8. Laboratory Tests and Results a) Pre-ART and ART patients for CD4 at baseline and follow up every 6 months (check records) b) HB, ALAT, ASAT, Serum creatinine, Viral load Q9. Provision of prophylaxis to eligible HIV patients Check for availability of: a) Cotrimoxazole and eligibility criteria used b) IPT eligibility forms and their completeness c) Isoniazid tablets and Pyridoxine tablets d) Fluconazole Q10: Tb/HIV A. Availability and utilization of Intensified TB case finding tools a) TSQ in CTC2 files and its completeness b) Sputum investigation form c) Paediatric Tb score chart B. Tb/HIV Data a) Number of PLHA screened for Tb in the last quarter b) Number of PLHA tested Tb positive in the last quarter c) Number of PLHA initiated on Anti TB in the last quarter d) Number of PLHA initiated on IPT in the last quarter Q11. TB infection control (IC) A. Administrative: a) Presence of TB infection control plan b) Availability of TB IC meeting report for the last quarter c) Available TB infection control focal person d) Availability of through ventilation B. Environmental Measures: a) Presence of adequate natural ventilation at the CTC unit/sections b) Mechanical ventilation at the facility Q12. Availability of PEP services a) For HCWs with occupational Exposure b) For General public (e.g. Rape cases) c) PEP records, including follow up d) Information available to Clients (where and when to access PEP services) e) PEP focal person known to every service provider D HF: 5. C&T 21

D HF: 5. C&T Q13. Loss to follow-up (LTFU) tracking and prevention(check for both Adults and Children) a) Number of lost to follow-up patients in the last quarter b) Number of LTFU patients tracked c) Number of LTFU patients returned in the last quarter d) Tracking mechanism used Q14. 2nd line ARV regimen a) Availability and activeness of patients review team for shifting to 2 nd line ARV treatment b) Availability of 2 nd line medicine c) Proportion of patients on the 2nd line regimen Q15: Nutrition assessment: a) Check for BMI calculations b) Availability and utilization of growth monitoring chart c) Availability of therapeutic foods (RUTF) d) Number of malnourished clients identified in the last quarter by severity (Moderate and Severe) f) Number of patients received therapeutic foods last quarter g) Method of intervention in place(nutritional counselling, Vitamin supplementation and Feeding program) Q16. Referral and linkage system in place A. Referral: a) Availability of referral forms b) Types of referral Internal External c) Referral feedback(observe for referral feedback slip) B. Linkage: a) Home based care b) Spiritual support c) Legal support d) Financial support e) Mental health services f) Support groups (peer support, adolescent club, paediatric club) Q17. Availability of equipment and commodities a) Emergency tray with its medicines and supplies 22

b) Examination bed c) Stretchers/wheelchair d) BP machine e) Stethoscopes f) Thermometer g) ENT set h) Clinical torch Q18: Adherence Counselling Check CTC 2 records randomly for Adherence counselling Q19: Availability of Adolescent and Youth friendly services a) Specific clinic day for adolescent and youth b) Education for adolescents during clinic (health talks) c) Availability of room for SRH services Q20: Infection Prevention Control (IPC) Measures: a) Availability of Personal Protective Equipment(PPE):Gloves, Gum boots, aprons, Goggles etc b) Waste Management: i) Availability and utilization of safety boxes ii) Segregation of waste by colour coding iii) Methods of final waste disposal D HF: 5. C&T Strengths Challenges in Providing C&T Services Areas that need mentorship: 23

6. Collaborative TB/HIV Supervisees Name Designation Mobile No/ Email Supervisors D 6.1. HIV and TB collaboration Check Items Q1. TB/ HIV sharing meetings during last quarter? Status and Comments Action Points and Responsible Persons HF: 6. TB/HIV 6.2. TB/HIV (TB Clinic) Check Items Q1. TB/HIV Burden in last Quarter: a) Number of all TB cases b) Notified (Smear positive, Smear negative, Extra pulmonary) c) Number of registered TB patients screened for HIV d) Confirmed HIV positive among TB Patients e) Number co-infected registered at CTC f) Number of co-infected started ARV Status and Comments Action Points and Responsible Persons Q2. Availability and utilization of the following latest documents: a) National Policy/Treatment Guidelines (NACP /NTLP) b) Protocols/SOPS (e.g. HIV testing and TB diagnostic algorithms, PEP) Q3. A. Number and cadre of Staff trained in the following: a) Collaborative TB/HIV b) Three I s c) Comprehensive ART/Basic ART/IMAI d) Paediatric TB B. Number of staff trained and actually working in the TB clinic 25

D HF: 6. TB/HIV Q4. Check for availability of the following at the clinic: a) Test kits b) Cotrimoxazole/ Dapsone c) Male condoms d) Female condoms e) Penile model f) Pelvic model g) Anti TB h) Pyridoxine i) TB/HIV specific SBCC materials j) Relevant registers Q5. TB infection Control(TBIC) A. Administrative a) TBIC plan present in the facility b) Availability of TBIC focal person c) Provision of health education on TBIC d) Open door and window practice e) Sitting position in relation to wind direction f) Location of TB and HIV clinics B. Environmental Measures: a) Adequate natural ventilation at the facility b) Adequate mechanical ventilation at the facility C. Personal Protective measures: Availability of protective gears e.g. gloves, aprons, respirators (where applicable), boots Q6. Data management: a) Availability and complete filling of recording and reporting forms i) Quarterly TB/HIV summary form ii) Referral forms iii) TB/HIV treatment outcome b) Data flow c) Filing and storage of data/reports d) Data analysis, presentation, interpretation, use and dissemination (evidence of summary report in facility registers) Q7. TB/HIV office space adequacy: a) Consultation rooms b) Record keeping space Q8. Referral and linkage system in place: a) Referral systems for TB to HIV Clinic and vice versa(evidence of filled feedback forms) b) Linkage with other interventions 26

Q9. Community involvement a) Presence of Ex-TB groups/community volunteers for TB activities b) Roles of Ex-TB groups/ community volunteers c) Availability of outreach services d) Number of TB suspects/ patients contacted during the last quarter Strengths D Challenges in Providing TB/HIV Services: HF: 6. TB/HIV Areas that need mentorship: 27

7. COMMUNITY BASED HIV AND AIDS SERVICES 7.1 Facility-level Services Name Designation Mobile/Email Supervisees D Supervisors Check Items Q1. Number of clients attended per month Q2. Availability and utilization of the following latest documents: a) National guidelines b) Protocols (e.g. Testing algorithm, PEP), c) SOP, community loss to follow up tool, HBC kit monitoring tool. Q3. Provision of: a) ART adherence counselling b) Nutritional counselling c) Support services Q4.Number of clients LTFU from CTC and PMTCT who were tracked and returned back to ART Q5. Availability of prevention services a) Condom supply, b) Insecticide treated nets (ITN)supply c) Promotional activities on safe water and VMMC Q6.Male involvement and participation in: a) Caring of patients b) Accessing HTC Q7. Data management: a) Availability and usage of recording and reporting forms i) HBC Patient registration notebook ii) Monthly summary forms for community HBC provider iii) Monthly summary forms iv) Referral forms v) Tracking form b) Data flow c) Filing and storage of data/reports d) Data analysis, presentation, interpretation, use and dissemination Status and Comments Action Points and Responsible Persons HF: 7. CBHS 29

D HF: 7. CBHS Q8. HBC office and record keeping space adequacy Q9. Referral, linkage and networking system in place: a) Referral systems for PLHIVs to CTC, TB, RCH and FP, and social and legal services b) Support groups Q10. Staff training: a) HBC contact persons b) Community HBC providers Q11. Availability of HBC specific SBCC Q12. Availability of equipment and commodities: a) HBC kits b) Condoms and demonstration tools Strengths Challenges on Implementing HBC: Areas that need mentorship: 30

7.2 Community-Level Services Supervisees Name Designation Mobile/Email Supervisors D Check Items Q1. Availability and storage of equipment and commodities: a) HBC kits b) Condoms and demonstration tools Q2. Data management: a) Availability and usage of recording and reporting forms: i) HBC Patient register book ii) Monthly summary forms for community HBC provider iii) Referral forms iv) Tracking form b) Data flow c) Filing and storage of data/reports d) Data analysis, presentation, interpretation, use and dissemination Q3. History taking, nutritional assessment and Conduct physical/ general examination Status and Comments Action Points and Responsible Persons HF: 7. CBHS Q4. Psychological support skills Q5. Socio-economic, spiritual, nutritional support and linkage to PLHIV support groups Q6. Service Data a) Number of clients attended per month b) Number of children linked or referred to CTC/RCH Q7. Availability of Home based counselling and testing services Q8. Availability and utilization of the following latest documents a) National guidelines b) SOP, community loss to follow up tool, HBC kit monitoring tool. 31

D HF: 7. CBHS Q9. Provision of adherence and nutritional counselling, health education and support services to patients on ART including pregnant mothers Q10. Identification and linkage of pregnant mothers to RCH services Q11. Number of clients LTFU who are tracked and returned back to ART at CTC, TB and PMTCT Q12. Identification and referral/linkage of IDU and CSW to sober houses/hf for HIV and relevant services Q13. Availability of prevention services a) Condom demonstration and supply b) Insecticide treated nets (ITN) supply c) Promotional activities on safe water and VMMC Q14. Male involvement and participation in a) Caring of patients b) Accessing HTC c) PMTCT couple testing and counselling d) Home/Family Counselling and Testing Q15. Referral, linkage and networking Referral for PLHIVs to CTC, HTC,TB, RCH and FP, and social and legal services, Support groups Q16. Assessment and referral of people with special needs: a) Identification, referral and linkage of OVC/MVC, b) People with disabilities, c) Clients experiencing GBV to support groups, legal support, HIV services and other relevant services e.g. PEP for GBV. Q17. Training needs Q18. Availability of SBCC/IEC materials: Strengths Challenges of Implementing HBC: Areas that need mentorship: 32

8. HIV Testing and Counselling (HTC) Supervisees Name Designation Mobile No./Email Supervisors D Implementing Partner Check Items Q1a. Availability of HTC services: i) VCT ii) HBHTC iii) PITC Q1b. Sections of health facility providing PITC services (List the sections) Status and Comments Action Points and Responsible Persons HF: 8. HTC Q2. HTC service utilization: a) Number of PITC clients per clinician per day in OPD b) Monthly PITC performance for the IPD c) Number of clients received PITC per month in the facility d) Number of VCT clients per counsellor per day Q3.Testing and Counselling services provided to special groups: a) Children b) Adolescents c) Persons under 18 years d) Couples e) Persons with disabilities (Deafness,blind) f) Key Population Q4a. Availability and utilization of the following latest documents: a) National HTC Guidelines b) HTC SOPs c) Protocols (e.g. PEP and HIV testing algorithm, IPC/5S) d) Cue cards Q4b. Evidence of utilization of the documents 33

D HF: 8. HTC Q5. Data Management: a) Availability and Utilization of the recording and reporting tools: HTC Client register (Kiswahili) Monthly summary forms (Site & District) (Kiswahili) Parent/Guardian consent forms, Referral forms Client Identification cards b) Check recording and reporting tools c) Data Flow and timing d) Filing and storage e) Data analysis, presentation, interpretation and use, feedback and Dissemination Q6. HIV Counselling QA Measures a) Number of HTC providers trained using the Nationally approved HTC training (VCT, PITC, HBHTC) b) Number of HTC providers practising (VCT, PITC, HBHTC) c) Availability of a HTC focal person and his/her roles d) Client exit interviews conducted at the site Q7. HIV Testing QA Measures: a) HIV testing competence for testers b) Procedure for on-sit HIV test kits validation c) HIV testing algorithm in use d) Re-testing messages e) Availability of QA back stopping for addressing rapid HIV testing problems f) Internal quality control procedures g) Site participating in EQA i) Participation in Proficiency Testing (Observe the feedback report if any) ii) Assessment of the site h) Documentation in the National HIV logbook and Feedback Reports Q8. Space adequacy and privacy (auditory and visual): a) Reception/Waiting space b) Counselling/consultation room which ensures privacy c) Testing room/area Q9. Screening all PLHIV for TB: a) Availability of TB screening tool b) Check the records 34

Q10.Referral and feedback system in place: a) Availability and use of referral forms b) Feedback on Referrals c) How linkages are facilitated d) Challenges in linkages Q11. Availability of SBCC: a) List HTC specific SBCC materials b) Audio Visual Equipment c) Others (Specify) Q12. Availability of Supplies and Equipment: a) Male Condoms b) Female condoms c) Penile models d) Pelvic models e) Infection Prevention and control supplies including personal protective equipment (PPE) f) Necessary consumables (alcohol, chlorine, swab, lubricants etc.) Q13. Availability and Utilization of HIV Test Kits: a) Responsible person for HIV Testing commodities b) Average number of Test Kits Received in a month (Observe storage facilities) c) Test Kits Used within the unit d) Intra-facility distribution of the test kits e) Test Kits loss/adjustment f) Experiencing stock out g) Stock level at the facility Q15. Availability of HTC Promotional Activities: a) Mobile/Outreach Services b) Targeted community advocacy, sensitisation and mobilisation activities D HF: 8. HTC Strengths Challenges in Providing HTC Services: Areas that need mentorship: 35

9. Laboratory Services Supervisees Name Designation Mobile No./Email Supervisors Check Items Status and Comments Action Points and Responsible Persons Q1. Infrastructure (Availability & adequacy of space) a) Waiting bay with enough sitting facilities b) Specimen collecting room with privacy and ideal ventilation c) Working room(s) d) Record keeping space e) With storage room f) With pallets g) With shelves h) Secured i) Organized j) Sluice room k) Eye washing station with splashing taps l) Sign for limiting access for only authorised staff Q2. Availability and utilization of the working documents a) Different SOPs, Manual and guidelines b) Are these documents updated? c) Guidelines/Manual on safety precautions on Infection prevention d) Safe disposal of sharps e) Safe disposal of biohazard medical waste f) Use of protective gear g) Written guidelines for PEP for HIV & other blood born diseases h) Internal quality assurance i) External quality assurance j) HIV testing algorithm Q3. Maintenance of Equipment a) Check for routine records of refrigerator/freezer temperatures b) Check for maintenance record D HF: 9. LABORATORY 37

D HF: 9. LABORATORY c) Check for maintenance schedule for the equipment other than daily cleaning d) Ask how repairs are handled e) Check for the last date of service Q4. HIV testing a) Availability of HIV test kits b) Adequacy of the stock in the past 3 months c) Number of tests done in the past 3 months d) Number of test kits damaged/stolen/expired in the past 3months Q5. HIV Staging and Monitoring Test for clients a) Availability and functionality of CD4 machine Haematology machine Biochemistry Air Conditioner b) Availability of planned preventive maintenance equipment c) Sample transportation plan d) Known schedule of sample transportation and return of results Q6. Viral Load Test a) Availability b) Functionality c) Number of lower facilities sending samples d) Connection to SMS printer for results feedbacks e) Availability of equipment service contract/reagent rental contract f) Availability of a log book for recording the assessed samples referred to EID zonal laboratory g) TAT of samples referred to EIDs laboratory h) Known schedule of sample transportation Q7. Other supporting equipment and supplies a) Functioning Binocular Microscopes b) Gene X-pert machine c) LED Microscope for TB d) Refrigerator e) Freezer -20 to -80 Centigrade f) Tips, EDTA tube, plain tubes, vacutainer needle, e.g. alcohol, lancets, swabs, etc.) in the past 3 months 38

Q8. Logistics for laboratory reagents and supplies: A. Availability and accessibility of: a) Report and Request forms b) Ledgers c) Bin cards d) R&R forms for non-ordering sites e) Monthly physical count practiced B. Any shortage of reagents in the past 3 months (If yes, emergency order filled in for stock out?) Q9. Staff availability Are the following staff available: a) Laboratory Technologist b) Laboratory Technician c) Laboratory Assistant Strengths D HF: 9. LABORATORY Challenges implementing laboratory services: Areas that need mentorship: 39

10. Pharmacy Services Supervisees Name Designation Mobile No/ Email Supervisors D Check Items Q1.Storage Check the following: a) FEFO/FIFO practiced b) Adequate storage space c) Separation of damaged or expired products d) Room temperature maintained within required range (functional air condition, ceiling fan, thermometer recording) e) Adequate light and ventilation f) Cold chain being followed (if applicable) g) Adequate security (Assess locks, windows barred, etc.) h) Cleanliness Status and Comments Action Points and Responsible Persons HF: 10. PHARMACY Q2. Record Keeping Check for the following: a) Availability of ledgers/bin cards for ARVs, drugs for OIs and Nutritional Supplement b) Inventory being filled in and updated at the end of each month c) Availability and filling of dispensing registers d) Requisition & issue voucher being used e) Filing system of both invoices and local requisition & issue voucher Q3. Reporting and Ordering Check the following: a) Filling of R&R for ARV/ Nutritional supplements &OIs b) Timing of submission of R&R (be completed by 5 th, submitted for approval by 10 th and submitted to MSD by 14 th of the month) 41

D HF: 10. PHARMACY c) Timing of submission of Monthly ARV/OIs consumption reports for a refilling site (be completed and submitted to an enrolling site by the 5 th of the month) Q4. Commodities A. Tracer Items: Physically check the following items: a) Adult ARVs (1 st and 2 nd line) b) Pediatric ARVs (1 st and 2 nd line) c) Prophylaxis for OIs d) Nutritional Supplements B. Stock-out of ARVs /OIs/ Nutritional supplements in the last 3 months? (If Yes, number of days that the product was stocked out) C. Physical inventory conducted at the end of the most recent reporting period? D. Receipt of the quantities ordered in the last quarter/ month and timeliness Q5. Rational Use of Medicines, Pharmacovigilance a) Prescriptions are checked by the pharmacist before issuing drugs b) Are drugs rationally prescribed? c) ADR forms available at the facility d) Availability of a register for ADRs and reports e) Availability of a copy of the National Standard Treatment Guidelines for management of HIV and AIDS Q6. Availability of a counselling room for ART adherence Q7. Evidence of data analysis, presentation, interpretation and utilization Q8. Human Resources a) Number of staff who have responsibilities in logistics of ARVs and nutritional supplement &OIs b) Trained staff on ARVs & OIs Kit logistics Strengths Challenges in Providing Pharmaceutical Services Areas that need mentorship: 42

11. VMMC Services Supervisees Name Designation Mobile No/ Email Supervisors D Check Items Q1. VMMC site management: a) Availability of a focal person responsible for overall management of the site b) Check for a duty roster stipulating the roles and responsibilities of each member of the team c) Verify if monthly VMMC meetings take place with availability of minutes Q2. number of staff and year when trained on VMMC and emergency management: a) Clinicians b) Nurses c) Others (specify) d) Number of staff offering VMMC services Q3. VMMC medicine, commodities and equipment: Check availability, quantities and storage of: a) Plain Lignocaine/Bupivacaine b) STI/RTI drugs c) Broad spectrum antibiotics for post-op infection. d) Oral Analgesics e) PEP medicines in facility/outreach. f) VMMC Supplies. g) VMMC surgical set (review all instruments in the set Quantity/conditions). h) Surgical bed i) Lamp/torch j) Emergency functional resuscitation kit e.g. Bp machine for adults and peadiatric, stethoscope, Ambu bag adult, peadiatric size, airways, endotracheal tube, pulse oxypulsemeter, laryngoscope, drug-atripine,epinephrine,50% dextrose, Glucometer/ Strips Status and Comments Action Points and Responsible Persons HF: 11. vmmc 43

D HF: 11. vmmc promethazine, hydrocortisone, Tourniquet,normal saline, 3 sizes of IV canulae, oxygen cylinder and its accessories k) Stock-outs of medicines or supplies past 3 months. Review inventory list. If no list, ask providers. If yes, note which items. Q4. VMMC service provision: a) Minimum package provided at site HTC Active exclusion of STI/RTI and management Promotion and provision of male and female condoms Counseling on risk reduction and safer sex Male circumcision surgical procedures performed as per National guidelines Linkage to other services b) Number of days for VMMC services in a week c) Number of clients targeted to be circumcised in the last month d) Number of circumcisions in the last month e) Number of adverse events reported in the last month f) Number of clients tested for HIV in the last month g) Number of HIV positive clients in the last month h) Number of HIV positive clients referred to CTC i) Number of referred clients confirmed to be enrolled at CTC Q5. M&E A. Availability of recording and reporting tools: a) VMMC service register b) Client Record form c) Appointment card d) HTC register e) Theater register f) Monthly site summary forms g) Adverse events forms h) Referral forms B. Timing of report submission C. Filing and storage of reports 44

D. Data analysis, presentation, interpretation, use and dissemination Q6. Referral and linkage system in place:(probe how is it done) a) Internal b) External Q7. Availability and utilization of the latest versions of the following documents: a) HTC consent form for under 18 b) VMMC client consent form properly filled c) SOPs e.g. MC AE management d) Protocols e.g. PEP, Post-op Follow-up, HIV test Quality Control protocol and log of results e) National guidelines (STI/RTI management, HTC, MC, TB/HIV, IPC) f) Medication inventory lists (may be in pharmacy or supply room) g) Post-operative written instructions for clients Q8. Space adequacy and privacy:(auditory and Visual) a) Waiting bay b) Reception room c) Counselling rooms d) Surgical rooms e) Surgical scrub: Clean water and soap or hand gel, towels f) Record keeping space ( check for availability of cabinet, shelves etc) g) Sign-Posting: in clinic services available on-site or on-campus. h) Recovery Area: Sphygmomanometer present for BP monitoring; space is private; sufficient lighting Q9. Infection prevention control: a) IPC supplies b) Safe disposal of medical wastes(availability of functioning incinerator or other means of waste disposal) c) Mechanism for destruction of VMMC disposable kits d) Aseptic technique applied. Q10. Availability and distribution of SBCC materials: a) MC specific SBCC b) Audio Visual equipment c) Ask for MC promotion activities within facility and local community. D HF: 11. vmmc 45

Strengths Challenges in providing VMMC Services: D Areas that need mentorship: HF: 11. vmmc 46

PART E: REPORTING FORMATS: Format 1: Format 2: Format 3: Cover Page Executive Summary Supportive Supervision Report (RHMT/CHMT) Format 4: Supportive Supervision Report (Zonal Health Resource Centre) E Format 5: Supportive Supervision Report (Health Facility) REPORTING FORMATS 47

Format 1 THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH AND SOCIAL WELFARE E NATIONAL AIDS CONTROL PROGRAMME REPORT ON COMPREHENSIVE SUPPORTIVE SUPERVISION FOR HIV AND AIDS SERVICES REPORTING FORMATS: 1. COVER XXXX REGION Duration of CSS: Date of Submission: Prepared by: 49

EREPORTING FORMATS: 2. EXECUTIVE SUMMARY EXECUTIVE SUMMARY (Less than 2 pages) Format 2 1. Objectives 1) To review the implementation status of the previous action plan 2) To identify strengths and gaps/challenges in HIV and AIDS services of xxxx 3) To develop an action plan to improve the services 2. List of Supervisors Name Designation Organization Mobile 3. Sites visited and dates Day Feb 10 Mon 11 Tue 12 Wed 13 Thu 14 Fri Organization visited 4. Major gaps/issues identified including Red and Yellow Flag Issues 5. Major recommendations 50

SUPPORTIVE SUPERVISION REPORT (RHMT/CHMT) Format 3 1. General Information Name of the Organization Name of the Region Name of the District Date of Visit DD/MM/YYYY Previous Visit DD/MM/YYYY Supervisees Name Title/Designation Mobile/Email E Supervisors Name Title/Designation Mobile/Email REPORTING FORMATS: 3. rhmt/chmt Objectives: Methods: 2. Implementation Status of the Previous Action Plan Challenge/Issue Action Point Resp. Person Coverage, Human Resource and Training PMTCT: Timeline Status STI: 51

EREPORTING FORMATS: 3. rhmt/chmt C&T: TB/HIV: CBHS: HTC: VMMC: Resource Management Implementation of Plan Supportive Supervision to CHMTs/HFs Coordination QI Activities Research Availability of documents and M&E tools Reporting and Data Utilization SBCC/IEC Condom 52

Workplace Intervention Others 1.3 Strengths Identified E 1.4 Challenges Identified and Action Plan Challenge/Issue Action Point Resp. Person Coverage, Human Resource and Training PMTCT: STI: C&T: Timeline Status REPORTING FORMATS: 3. rhmt/chmt TB/HIV: CBHS: HTC: VMMC: Resource Management Implementation of Plan 53

EREPORTING FORMATS: 3. rhmt/chmt Supportive Supervision to CHMTs/HFs Coordination QI Research Availability of documents and M&E tools Reporting and Data Presentation, Analysis, Feedback and Utilization SBCC Condom Workplace Intervention Others 54

Format 4 SUPPORTIVE SUPERVISION REPORT (ZONAL HEALTH RESOURCE CENTRE) 1. General Information Name of organization: Region: Council: Date of visit: DD/MM/YYYY Previous visit: DD/MM/YYYY Supervisors: Name Designation/Organization Mobile/Email Supervisees: Name Designation/Organization Mobile/Email Objectives: Methods: 2. Implementation Status of the Previous Action Plan Challenges/Issues Action Points Responsibility Timeline Status Availability of national documents HIV and AIDS Training Coordination and Implementation Supportive Supervision E REPORTING FORMATS: 4. zonal HEALTH RESOURCE CENTRE Inventory of Trainers/Trainees Monitoring and Evaluation Provision of TA to regions and districts 55

EREPORTING FORMATS: 4. zonal HEALTH RESOURCE CENTRE 3. Summary of Strengths 4. Challenges Identified and Action Plan Challenges/Issues Action Points Responsibility Timeline Status Availability of national documents HIV and AIDS Training Coordination and Implementation Supportive Supervision Inventory of Trainers/Trainees Monitoring and Evaluation Provision of TA to regions and districts 56

SUPPORTIVE SUPERVISION REPORT (HEALTH FACILITY) Format 5 Name of the Facility Ownership of the Facility Government [ ], Police/Prison [ ], Military [ ], Faith-based Organization [ ], NGO [ ], Private [ ] Name of the Region Name of the District Date of Visit DD/MM/YYYY Previous Visit DD/MM/YYYY Supervisees: Name Title/Designation Mobile/Email E Supervisors: Name Title/Designation Mobile/Email REPORTING FORMATS: 5. HEALTH FACILITY Objectives: Methods used: 1. Implementation Status of the Previous Action Plan (developed on DD/MM/YYYY) CHALLENGE/ISSUE ACTION POINT RESP. TIMELINE Status PERSON PMTCT STI 57

EREPORTING FORMATS: 5. HEALTH FACILITY C&T TB/HIV Collaboration HTC LABORATORY PHARMACY HBC VMMC 2. Strengths Identified PMTCT STI C & T TB/HIV HTC LAB PHARM HBC Cross Cutting (QI, Mngmnt) Best Practices 58

3. Challenges Identified and Action Plan CHALLENGE/ISSUE ACTION POINT RESP. PERSON PMTCT TIMELINE Status STI E C&T TB/HIV Collaboration REPORTING FORMATS: 5. HEALTH FACILITY HTC LABORATORY 59

EREPORTING FORMATS: 5. HEALTH FACILITY PHARMACY HBC VMMC Cross Cutting (QI, Management) Mentoring needs identified Red flag issues requiring urgent attention 60