Operational Plan Report



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Zambia
Operational Plan Report
FY 2010

Operating Unit Overview

OU Executive Summary
Key demographic, socio-economic, health and HIV Statistics:
Zambia continues to face a health, economic development, and humanitarian emergency as a result of the HIV/AIDS epidemic. The 2007 Demographic and Health Survey (DHS) estimates that 14% of Zambian adults aged 15-49 are HIV positive. The problems associated with the pandemic have become more complex and difficult to address as Zambia’s epidemic matures and stabilizes. In Zambia, HIV is primarily spread through heterosexual activity and from mother-to-child transmission. High risk groups (including HIV discordant couples, Commercial Sex Workers and their clients and partners, long distance truck and bus drivers, migrant fish camp traders and agricultural workers, miners, refugees, prisoners, and members of the uniformed services) warrant more attention. The 2007 DHS concludes that around four in ten Zambian children under age 18 in the households sampled were not living with both parents; this figure translates to approximately 1.2 million AIDS orphans.
Women account for over half of the country’s infections. This can be attributed to numerous factors including economic status, biological and social norms. In Zambia, domestic violence occurs across all socio-economic and cultural backgrounds. Almost half of all women have experienced physical violence since they were 15 and one in five women reported that they have experienced sexual violence at some point in their lives. The HIV infection rate is 16% among women compared to 12% among men. For adult women, the HIV prevalence peaks at 26% in the 30-34 age group, which is four times the rate among women aged 12-19 and about twice the rate among women aged 45-49. While the overall prevalence of HIV has decreased from the previous estimate of 15.6% in 2004, young, urban, females have the highest HIV prevalence in the country at 23%.
An estimated 21% of all married couples in Zambia are discordant. Gender inequality, alcohol and substance abuse, high-risk sexual behavior, and sexual violence help fuel HIV transmission. Those with sexually transmitted infections are especially susceptible. Orphans and vulnerable children (OVC) face the prospect of homelessness due to property grabbing by relatives, sexual exploitation, physical abuse, and abject poverty. Adolescent girls are another high-risk group, as females aged 15-24 years are nearly twice as likely to be HIV positive as males in the same age group, in part due to older men seeking younger women as casual sex partners.
The Zambian response to the AIDS epidemic has been hampered in large part by human resource shortages and limited local capacity. Efforts over the past six years have focused on increasing the numbers of trained providers – in both clinical and community settings – while identifying and supporting nascent local groups. Previous activities like the U.S.- U.K. announcement on supporting health systems and the naming of Zambia as an “International Health Partnership” country are examples of efforts to build enduring capacity.
Scaling-up the number of people receiving antiretroviral treatment and increasing costs due to changes in treatment regimens has raised overall costs for providing life-prolonging drugs. Preventing new infections, addressing human and financial resource gaps, along with building sustainable local public and civil society entities will be a focus of the next five years of the PEPFAR Zambia program.

Greater Emphasis on Prevention and Sustainability:

1. Community Compacts: In an effort to strengthen the prevention portfolio and further build capacity, PEPFAR Zambia will explore the use of “community compacts,” or agreements directly with communities that provide incentive rewards for effective prevention programs. The overall goal of the Community Compacts program will be to reduce HIV transmission within communities by incentivizing negative HIV status. This program will help the Zambia develop, implement, and scale-up community based agreements to decrease HIV incidence in Zambian households. Local partners will be encouraged to utilize a range of approaches at the local level aimed at increasing HIV awareness and preventive behaviors resulting in an invigorated community environment where risk of HIV acquisition is clearly understood at all levels. This should result in real behavior change. Such measures will also be criteria for evaluations of sustainability that the U.S. Mission in Zambia will use to judge the readiness of provinces and districts for “graduation” from assistance. The Embassy will pilot such community-based incentives through HIV-prevention projects funded through PEPFAR prevention Small Grants and cooperative agreements by CDC and USAID. Specific milestones/objectives of the Community Compact program will include:


  • Identifying target communities and develop partnership activities for HIV prevention interventions.

  • Transferring skills to communities through Zambian partners (including the GRZ) to launch and sustain HIV prevention activities.

  • Developing and implementing measurement frameworks to track progress of community prevention activities.

2. Capacity Building: PEPFAR Zambia programs will build capacity of Zambian institutions human, scientific, technological, organizational, and institutional capabilities. This will ultimately enhance the ability of Zambia to evaluate and address the crucial questions related to HIV/AIDS programming. PEPFAR Zambia will focus on institutional development, including community participation (of women in particular); and organizational development, especially the elaboration of management structures, processes and procedures, not only within organizations but also the management of relationships between the different organizations and sectors (public, private and community).

In order to sustain activities initiated with PEPFAR funding, program implementation will focus on fulfilling present and future needs of the Zambian community by ensuring that Zambians, (including the government) own the programs, fund them, and embrace them as their own. Hence, PEPFAR Zambia’s programs will be meeting the needs of people at present without compromising the ability of future generations to meet their own needs.

3. Partnership Framework Development: The GRZ, through the National AIDS Council (NAC) is currently developing its next National AIDS Strategic Framework (NASF). This provides Mission Lusaka with an opportunity to align Partnership Framework (PF) development with the development of the NASF. An essential mechanism for capacity building for FY 2010 is preparation of the Partnership Framework. The PF will continue to support GRZ’s overall goal to “prevent, halt, and begin to reverse the spread and impact” of HIV/AIDS. To this end, several meetings have been held with senior GRZ counterparts on aligning the PF with the next NASF. The PF will also contribute to achieving PEPFAR’s new goals (3 million on treatment, 12 million on care and support, and 12 million infections prevented) and support Embassy Lusaka’s mission statement of “promoting peace, health, and development through partnerships with the Zambian people.”
The PF will emphasize key policies that promote effective HIV/AIDS programs. It will emphasize overall accountability for resources, responsible fiscal management, and appropriate budgeting. Based on the level of resources, a goal will be increased financial contributions by GRZ to the program. Certain policy reforms are key to effective HIV/AIDS responses, and the PF offers an important new opportunity to engage GRZ in these areas. The NASF process provides an opportunity for PEPFAR Zambia to work with GRZ to track more closely HIV/AIDS and overall health financing through National Health Accounts (NHA), National AIDS Spending Assessments (NASA), and other financial monitoring and reporting systems. Working towards a costed national HIV/AIDS strategy will be an important priority for the PF. Through the PF, PEPFAR Zambia will seek to:


  • Implement the national HIV prevention policy, including targeting at-risk populations for risk reduction, and integrating prevention into other health services by focusing more on MCP, MC, alcohol abuse reduction, and increased condom use among others.;

  • Ensure that prevention policies utilize positive incentives to avoid new infections; and

  • Strive for equity in access to treatment and care by emphasizing underserved groups as well as fostering greater male participation and standardized care across all facilities.

The PF will strengthen mutual accountability between USG and GRZ. To track progress toward goals, the USG and the GRZ will establish intermediate benchmarks for PF goals in line with governments’ plans and reporting requirements. The benchmarks will ensure that the milestones and mechanisms align with those of the GRZ and of other stakeholders and that reports will contribute to the national M&E system.




Programmatic Focus

PEPFAR funding for FY 2010 will be focused on the following programmatic areas to achieve the 3-12-12 goals:


1. Prevention: The current HIV prevention program, based on the abstinence, fidelity to one sexual partner, and regular and correct use of condoms (ABC) model, has brought about an increase in the age of sexual debut, a reduction in the number of sexual partners, and an increase in the number of people using condoms. Despite such gains, the HIV prevalence rate remains high (14 percent) and the annual number of new infections remains constant, requiring intensified efforts to reduce new infections and measures to halt further spread of the pandemic. For FY 2010, PEPFAR Zambia will focus on achieving prevention impact through implementation of new and different preventive interventions and improving the effectiveness of ongoing interventions. This entails enhancing HIV prevention across the PEPFAR portfolio. Exploring the use of “community compacts” or agreements directly with communities to provide incentive rewards for effective prevention programs is one approach that will be implemented under this program area. The overall goal of the Community Compacts program will be to reduce HIV transmission within communities by incentivizing negative HIV status. Such an approach recognizes that for this effort to be successful, a comprehensive response which entails various components is necessary. Prevention activities for FY 2010 in Zambia include increasing access to quality prevention of mother-to-child transmission (PMTCT) services and mobilizing moral and traditional authorities, including religious leaders and local chiefs to lead on HIV prevention. FY 2010 activities will urge political leadership to produce a broad, national consensus on reinforcing approaches to HIV prevention. Specifically, the goals of the FY 2010 Prevention plan include:


  • Expansion of STI prevention efforts;

  • Addressing alcohol abuse;

  • Expansion of couples counseling and testing efforts;

  • Integration of  HIV prevention messaging and counseling into other HIV and health services (such as HIV Testing and Counseling services and Family Planning, Antenatal clinics, Under five clinics and specialized clinics like Diabetic clinics); and

  • Better  targeting of at risk populations with more practical and focused messages; and

  • Development of strategies/linkages with community groups to insure follow-up and continued contact with negatives.

  • Prevention with PLWHA by:

    • PLWHA support groups formation in communities

    • Discordant couple counseling regarding the need for prevention, correct and consistent use of condoms etc.

  • Mainstreaming prevention and TC by building capacity in health care providers

  • Expansion of Male Circumcision availability

PEPFAR Zambia’s FY 2010 strategy will assertively promote healthier behavior and increased male engagement. Activities will focus on societal norms and attitudes on multiple concurrent partnerships (MCP) and age-disparate partnering, while promoting male circumcision as an HIV preventive intervention. Engagements will also emphasize the positive, protective role of men in the Zambian family and their community responsibilities. Furthermore, PEPFAR Zambia will continue to improve the quality of existing PMTCT programs by ensuring accelerated roll-out of more efficacious drug regimens for HIV positive pregnant women and fostering increased access to PMTCT services, uptake for PMTCT prophylaxis, and postnatal follow-up of HIV-exposed infants. FY 2010 activities will strengthen the counseling referral system, community involvement, male involvement, and early infant HIV diagnosis. In addition, Embassy Lusaka will intensify prevention efforts with messages targeting youth, military, law enforcement, prisoners, and refugees. The U.S. Mission will improve the quality of HIV counseling and testing services, placing high priority on effective networks and referral linkages to other care and treatment services.


Recognized as important to the overall reduction of new infections, additionally, Zambia’s new emphasis will seek ways to better address the needs of negative persons and their ability to stay negative. This will be accomplished, at points of contact for example, by reinforcing the counseling of persons testing negative, at the time of testing, and ensuring that they can be referred to and linked with support groups in the community who will help them to stay negative. Additionally, more focused and broadly dispersed messaging aimed at persons who have or have not yet tested and are negative will focus on gaining and keeping the attention and seek to influence the behaviors of such persons to keep them negative.
Since sero-discordance is a major driver of HIV/AIDS in Zambia’s generalized heterosexual epidemic, Embassy Lusaka will continue encouraging Zambians to: “Know your status, know your partners’ status, know it often”. Couples counseling will be a prime program as it allows individuals to make informed decisions to protect themselves and their loved ones.
During FY 2010, PEPFAR will work with the Women’s Justice and Empowerment Initiative (WJEI) under the US Department of Justice (DOJ) to establish DNA testing capacity of local authorities. This initiative is designed to better enable law enforcement in the prosecution of gender-based violence (GBV) cases, thus deterring GBV- a significant driver of (contributor to) new HIV infections.  The current capabilities of Zambia are limited in this area and therefore requires, additional training of human resources to carry out forensic examination and analysis, improvements to facilities, and further education regarding human rights and victims’ services to the general public. PEPFAR Zambia support will assist law enforcement in the acquisition of new equipment and training of police officers and forensic scientists to build capacity.
2. Care and Support: Care and Support activities in Zambia include provision of basic health care and support for adults and children, delivery of integrated TB/HIV services, and extensive OVC programs.
In FY 2010, Embassy Lusaka’s support for OVCs will continue at the same level as FY 2009. PEPFAR support will provide OVCs with improved access to educational opportunities, food and shelter, psychosocial support, health care, livelihood training, access to microfinance, and trained caregivers. Palliative care activities will reach over 211,000 HIV-positive individuals at clinical and community service delivery sites by providing nursing/medical care, treatment of opportunistic infections, pain relief, nutritional supplements, psycho-social support, referral to ART and ART adherence programs, and pediatric and family support. Tens of thousands of trained volunteer caregivers, as well as clinical service providers, will conduct these activities. The MOH says it will continue to implement the SmartCare electronic health record, increasingly in rural clinics, however unless the GRZ or other donors provide funding to take SmartCare nationally, the USG will not continue funding it in FY 2011. To address the high proportion of TB and HIV co-infection, Mission Zambia will continue to enhance the linkage between TB and HIV services.
To support Zambia in building health worker capacity, the USG in conjunction with GRZ will increase the number and improve the expertise of health and social workers. Activities in FY 2010 will continue to support the Zambian Health Worker Retention Scheme. A total of 119 health care workers will receive support and incentives, including housing renovations, through FY 2010. However, under the Partnership Framework, the USG will transfer these costs to the GRZ in FY 2011 and beyond as the USG will not continue funding it. Embassy Lusaka will continue to work with the MOH to disseminate human resource planning and projection guidelines. FY 2010 will see continued support to provincial health offices to assess district-level human resource needs and facilitate the development of the districts’ human resource plans. Importantly, PEPFAR Zambia will support health worker training institutions to ensure inclusion of state of the art HIV prevention, care and treatment information in pre-service and in-service training curricula.
3. Treatment: As of March 31, 2009, Zambia had 250 ART centers receiving U.S. support, either directly in the form of technical assistance or indirectly through procurement of ARV drugs and strengthening of the overall national logistic system. By the end of 2009 167,545 individuals were benefiting from ART through the support of PEPFAR. The Mission will continue to collaborate with the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) to coordinate the purchase of antiretroviral drugs (ARVs) for the public sector. Through this collaboration, PEPFAR Zambia will only procure second line ARVs (Zidovudine, Lamivudine, and Ritonavir boosted Loprinavir), pediatric formulations, and one first line drug.
In FY 2010, PEPFAR Zambia will continue to provide comprehensive adult and pediatric ART services to public and private sector hospitals, clinic sites, and provincial and district public sector facilities at FY 2009 funding levels. In addition to ART procurement, Embassy Lusaka will support comprehensive care and treatment services for infants and children; train health care providers on provision of quality ART services; strengthen effective service delivery networks and linkages; strengthen laboratory, logistics, and health information management systems; and promote adherence to ART. FY 2010 activities will support the MOH with human resource planning and management, recruitment, and seconding key technical staff to provide HIV/AIDS service, training and mentoring in order to address Zambia’s human resource crisis.

4. Other Programs: To promote sustainability, PEPFAR funding will also support strategic information, health systems strengthening, and U.S. Mission management and staffing. FY 2010 funds will strengthen local health management information systems, expand use of quality program data for policy development and program management, upgrade quality assurance procedures, provide training and support, and build local partner capacity to launch and sustain programs. Activities in FY 2010 will further provide technical assistance to develop sustainable monitoring and evaluation systems, information, and adopt modern communication technology.

In FY 2010, PEPFAR funds will be used to meet the Human Resources for Health goal by training more health care and Para-social workers in order for the country to sustain the gains recorded over the years. These new health workers will provide the necessary services needed, i.e., prevention, care and treatment. Some of the activities to be undertaken will include, increasing the capacity of training institutions, building the capacity of tutors and expanding facilities, i.e., laboratories, libraries and other such facilities that have a direct influence on quantity and quality.

Redacted.


Other Donors, Global Fund Activities, Coordination Mechanisms
Zambia is the Global Fund’s third largest recipient of assistance, with over $810 million in grant applications.  Of this, $478 million has been approved through Rounds One, Four and Seven for all diseases across the four Principal Recipients; the country awaits signature of a major Round Eight HIV and systems strengthening proposal.   Of the $810 million, $619 million is for HIV.  Redacted.  Nearly half of the funds go to the MOH for public sector services. Other major donors in HIV/AIDS are the Department for International Development (DFID), World Bank, UNAIDS, UNICEF, DANIDA, SIDA, the Irish AID and the Clinton Foundation HIV/AIDS Initiative.  
The U.S. Mission in Zambia has one of two donor seats on the Global Fund Country Coordinating Mechanism and participates in various national sector coordinating committees, national technical HIV/AIDS working groups, the UNAIDS Expanded Theme Group, and the GRZ Partnership Forum. The U.S. Mission in Zambia, DFID and UNAIDS currently serve as lead donors and co-chairs of the UNAIDS Cooperating Partners on HIV/AIDS Group.

Other major donors working in the HIV/AIDS sector are UNAIDS, the World Bank and UNICEF, as well as DFID, which supports PMTCT, workplace prevention and treatment programs, condoms, and sexually transmitted infection drug procurement.


Program Contact: Kristie Mikus, PEPFAR Coordinator (Kristie.mikus@hhs.gov)
Time Frame: October 2010 to September 2011

Population and HIV Statistics

Population and HIV Statistics




Additional Sources

Value

Year

Source

Value

Year

Source

Adults 15+ living with HIV



















Adults 15-49 HIV Prevalence Rate



















Children 0-14 living with HIV



















Deaths due to HIV/AIDS



















Estimated new HIV infections among adults



















Estimated new HIV infections among adults and children



















Estimated number of pregnant women in the last 12 months



















Estimated number of pregnant women living with HIV needing ART for PMTCT



















Number of people living with HIV/AIDS



















Orphans 0-17 due to HIV/AIDS



















The estimated number of adults and children with advanced HIV infection (in need of ART)



















Women 15+ living with HIV




















Partnership Framework (PF)/Strategy - Goals and Objectives

(No data provided.)



Engagement with Global Fund, Multilateral Organizations, and Host Government Agencies
Redacted


Public-Private Partnership(s)

Partnership

Related Mechanism

Private-Sector Partner(s)

PEPFAR USD Planned Funds

Private-Sector USD Planned Funds

PPP Description

Becton Dickinson Lab Strengthening




Becton Dickinson







A more recent PPP opportunity has been leveraged with Becton Dickenson to provide training and services to medical technicians and health care workers in the areas of phlebotomy, post-exposure prophylaxis, and strengthening for policies, guidelines and standard operating procedures. This partnership will work at both the national level in the aforementioned policy areas, as well as at the provincial level to support refresher trainings and improved surveillance around occupational needle stick injuries.

Pink Ribbon Red Ribbon













PRRR is an innovative partnership to leverage public and private investments in global health to combat cervical and breast cancer. The PPP has the goals : Reduce deaths from cervical cancer by 25% among women; significantly increase access to breast and cervical cancer prevention, screening and treatment.

Public Private Partnership for HIV Prevention, Care, and Support













Within the mining and agriculture sectors, a group of companies have come together to expand clinical services beyond their immediate employee populations to support the surrounding communities. These clinical facilities have been opened up to the general population to provide HIV testing and counseling as well as anti-retroviral therapy (ART). Participating companies have also developed and implemented workplace programs to help ensure staff have the information they need to make safe and informed choices to prevent HIV infection.

Tourism HIV/AIDS Public Private Partnership







300,000

100,000

In FY2010, SHARe will continue working with the Tourism HIV/AIDS Public Private Partnership (PPP) to implement workplace HIV/AIDS programs. The partnership, which is in the final year of implementation through SHARe, was established 2006 in order to enhance and expand HIV/AIDS workplace programs within private sector tourism businesses, and through the workplace programs, to increase the sector’s HIV/AIDS social responsibility and social mobilization responses in the local communities. The partnership leverages resources from the tourism private sector and from the USG to support partners’ workplace HIV/AIDS programs. In FY2010, a key focus of the partnership will be on ensuring sustainability of partners’ workplace programs, including through strengthening HIV/AIDS mainstreaming through the Livingstone Tourism Association (LTA). The Tourism HIV/AIDS PPP private sector contribution through in-kind and direct funding for FY2010 is $100,000.


Surveillance and Survey Activities

Name

Type of Activity

Target Population

Stage

AIDS Indicator Survey

Population-based Behavioral Surveys

General Population

Planning

Antenatal Clinic Sentinel Surveillance (ANC)

Sentinel Surveillance (e.g. ANC Surveys)

Pregnant Women

Planning

Demographic and Health Survey

Population-based Behavioral Surveys

General Population

Development

Sample Vital Registration with Verbal Autopsy

HIV-mortality surveillance

General Population

Planning

Surveillance among MARPs

Population size estimates

Female Commercial Sex Workers

Planning


Budget Summary Reports

Summary of Planned Funding by Agency and Funding Source

Agency

Funding Source

Total

Central GHCS (State)

GAP

GHCS (State)

GHCS (USAID)

DOD







10,055,000




10,055,000

HHS/CDC

15,764,509

2,914,000

67,867,000




86,545,509

HHS/HRSA

4,355,513




10,180,000




14,535,513

HHS/NIH







830,000




830,000

HHS/OGHA







125,000




125,000

PC







1,946,200




1,946,200

State







773,947




773,947

State/AF







700,000




700,000

State/PRM







250,000




250,000

USAID







160,933,462




160,933,462

Total

20,120,022

2,914,000

253,660,609

0

276,694,631


Summary of Planned Funding by Budget Code and Agency

Budget Code

Agency

Total

State

DOD

HHS/CDC

HHS/HRSA

HHS/NIH

PC

USAID

AllOther

CIRC




350,000

1,750,000










2,790,000




4,890,000

HBHC




650,000

5,800,000

5,767,000




30,000

12,729,279




24,976,279

HKID



















18,559,893

300,000

18,859,893

HLAB




1,800,000

4,420,000




310,000




13,120,000




19,650,000

HMBL







2,300,000
















2,300,000

HTXD



















32,164,913




32,164,913

HTXS




200,000

15,484,858

4,332,449







6,773,702




26,791,009

HVAB







1,944,000







20,000

14,158,628

215,000

16,337,628

HVCT




400,000

6,435,000

440,000







15,038,737

106,000

22,419,737

HVMS

773,947

555,000

5,775,000







1,896,200

4,301,845

125,000

13,426,992

HVOP




800,000

3,050,000

200,000







10,779,137

229,000

15,058,137

HVSI




300,000

12,915,000

360,000







2,400,000




15,975,000

HVTB




250,000

5,973,000

1,243,000







2,600,000




10,066,000

MTCT




2,600,000

13,198,000










9,500,000




25,298,000

OHSS




1,950,000

1,050,000

300,000

240,000




11,914,428

100,000

15,554,428

PDCS







2,210,000

892,414

280,000




2,108,900




5,491,314

PDTX




200,000

4,240,651

1,000,650







1,994,000




7,435,301




773,947

10,055,000

86,545,509

14,535,513

830,000

1,946,200

160,933,462

1,075,000

276,694,631


Budgetary Requirements Worksheet

(No data provided.)



National Level Indicators

National Level Indicators and Targets

Redacted
Policy Tracking Table



(No data provided.)

Technical Areas

Technical Area Summary
Technical Area: Adult Care and Treatment

Budget Code

Budget Code Planned Amount

On Hold Amount

HBHC

24,976,279




HTXS

26,791,009




Total Technical Area Planned Funding:

51,767,288

0


Summary:

Context and BackgroundThis Technical Area Narrative (TAN) represents the combined Adult Care and Treatment program area, comprising Adult Care and Support (HBHC) and Adult Treatment (HTXS). The combination of these two areas signals integration of PEPFAR Zambia clinical and community service delivery efforts, in line with the Zambian Ministry of Health (MOH) treatment and care delivery principles. Context: In line with resource availability, and Government of the Republic of Zambia (GRZ) leadership, strategy, and policy, USG Zambia helps achieve national Anti-Retroviral Treatment (ART) and care goals. In keeping with increasing GRZ commitment and leadership, USG Zambia will continue to help expand, consolidate, and sustain adult ART and care services. Community and home-based care (HBC) adheres to national minimum standards for HBC established by GRZ. USG efforts operate under standard national guidance and participate in the Treatment, Care and Support (TCS) technical working group established by the National HIV/AIDS/STI/TB Council (NAC) Technical Working Group (TWG). PEPFAR Zambia actively participates in development of care and treatment guidelines and training manuals. Ongoing work to update care guidelines will incorporate prevention for positives (PWP) as part of standard of care. The National HIV/AIDS Strategic Framework (NASF) outlines the level of priority, structure, and the extent of ART and care services. By policy, ART has been free in Zambia since 2005. Combined with massive donor investment, this has resulted in a rapid, nationwide scale-up of ART. In FY 2007, MOH and NAC guidelines for first line adult ART regimens changed from Stavudine or Zidovudine based to Tenofovir based combinations. All new ART patients start treatment based on the new guidelines. Those on the original combination continue receiving the old regimen until treatment failure occurs or toxicity develops. The U.S. Mission continues to assist the Zambian ART site accreditation system to assess capacity to deliver ART according to national standards. In FY2009, Medical Council of Zambia accredited 82 sites to provide ART and the process is ongoing.PEPFAR Zambia and other donors assist with national ART, care, and support. Coordinating partners include: the Global Fund for HIV/AIDS, Tuberculosis, and Malaria (Global Fund), World Bank, World Health Organization, United Nations agencies, Swedish International Development Agency, Japan International Cooperation Agency, European Union, U.K. Department for International Development, and the Clinton Foundation. Global Fund support from Rounds 1 and 4 has leveraged U.S. investment, in adult ART services, supporting the purchase of first line drugs and ART by the GRZ as well as the Church Health Association of Zambia (CHAZ). USG Zambia is the largest donor, joined by the Global Fund, UNAIDS, World Bank, Ireland, Netherlands, and Germany. Major changes for FY 2010 include: 1) strengthened prevention activities (e.g. PWP); 2) more efficacious PMTCT, including HAART for pregnant women; and 3) stronger linkages between community and facility based activities. Zambia launched a new National Prevention Strategy in 2009. FY 2010 activities will include more effective HIV prevention strategies, including PWP activities in community and facility settings. Also included are: increased partner and couples testing; reinforcement of prevention messages during care and treatment clinic visits and in community settings; and training of health workers and community volunteers in effective PWP. A focus on retention of “pre-ART patients” in care will begin with immediate referrals from CT to care for long-term follow-up; increase adult prophylactic use of cotrimoxazole (CTX); promote behavior change; and ensure adequate condom supplies. Pregnant women will increasingly be referred to ART sites in a more timely way to assess eligibility for HAART and to initiate it. Improved linkages between community and facility-based activities will optimize quality of life for HIV-positive individuals and include clinical, psychological, social, spiritual, and prevention services. Fewer AIDS patients are bedridden; in 2009, only 8% of clients were deemed bedridden. PEPFAR Zambia is reorienting home-based care and hospice activities towards a more community-based approach. Overall, care and treatment budgets will decrease approximately 5% to cover increases in ARV costs and prevention activities. Other changes in 2009-2010 include the end of many major ART and care projects, transitioning to new projects. The USG will ensure a smooth transition especially for ART clients. New projects will be encouraged to absorb clients and staff/ volunteers trained by their predecessors to ensure continuity and reduce start up time.Adult care and treatment comprises facility and home/community-based activities for HIV-infected adults and their families. It includes ART services, prevention, care and treatment of opportunistic infections (OI). They can be extended with non-PEPFAR funding to include related activities such as family planning and safe motherhood.PEPFAR Zambia’s adult preventive care package addresses prevention of common diseases, such as malaria and diarrhea, with commodities/services such as: pharmaceuticals (for TB and prophylactic CTX); insecticide treated nets; safe water interventions; condoms; and nutritional assessment, counseling, and food/micronutrient supplements. Psychological and spiritual support delivered in community settings include group/individual counseling, improved mental health services, end-of-life and bereavement support. Large-scale community mobilization for care has proven effective; volunteers provide the bulk of care and support. Social support includes vocational training, income-generating activities, legal protection, training, and support of caregivers. Microfinancing is available on a limited scale however it has not produced sustainable income gains, and requires technical expertise for redesign.The supply chain for HIV care-and-treatment related commodities is described in the HTXD TAN. The GRZ does not provide home-based care kits. Most U.S. partners rely on donations or private funds to procure care kits and basic drugs; a few use PEPFAR funds to purchase kits. Zambia still lacks effective supply chain management for pain relief drugs; their use is restricted mainly to hospices, and other tertiary care hospitals. A pilot on morphine supply is underway with funding from a U.K. partner.Some U.S. partners provide differentiated adult care and support services, including hospice and “traditional” home-based care, early-initiation care/support packages for asymptomatic new clients; and “maintenance” care for ART clients in good health. U.S. partners emphasize quality care, and some document it using tools such as SmartCare (a standard medical record system). USG partners follow Zambian national minimum standards for home-based care. National standards for palliative/hospice care remain under development. Care partners have supportive supervision structures. Studies of care and support have demonstrated its effectiveness in improving quality of life and reducing illness.As adult ART provision expands, the GRZ is prioritizing pharmacovigilance in ART for providers to recognize, track adverse events and side effects, and monitor efficacy of ARVs; these programs are still under development. Nutrition is important to PMTCT, ART, and OVC clients. However, PEPFAR Zambia approaches to food and nutrition approved in 2004 were both diverse and geographically dispersed; until recently, they lacked a common methodology. In line with emerging research and OGAC nutrition guidance, USG Zambia agencies have now agreed to adopt a “food by prescription” approach, and allocate around 2% of funds for food and nutrition for PMTCT/OVC clients and the malnourished. Accomplishment sinc e last COPPEPFAR Zambia increasingly emphasizes: early identification of HIV-infected persons; linkages to and retention in care; reduction in HIV-related morbidity and mortality; improved quality of life; and reduction in transmission of HIV. Zambia has integrated cross-cutting considerations like alcohol and gender; tighter linkage of facility-community; improvement of quality in health systems and individual projects/services; as well as monitoring/evaluation. Treatment and care coverage has increased. The GRZ reports that HTXS services exist in all 72 districts of Zambia. PEPFAR Zambia supports HBHC in 70 districts (97%). As of 2009 SAPR, USG served 295,955 unique adult care clients (57% women, 43% men) at 866 service sites operating in all provinces. Efforts are underway to address an ongoing gender disparity; far more women than men access care and treatment in Zambia. Due to efforts to increase male participation as caregivers, men now represent 30% of volunteers. Furthers increases in male participation will help reduce the burden of care on women.Around 198,590 patients were on ART; of these, 178,525 (90%) were adults. The rapid scale-up of HIV/AIDS treatment services has succeeded, with good clinical outcomes in urban, peri-urban, and rural primary care settings. Efforts to increase ART access at rural public and faith-based health facilities include USG Zambia support for a national network of ART outreach sites served by mobile services. As of March 2009 (SAPR Results), the USG has supported training of 1,243 health workers to deliver ART services countrywide. A national ARV drug resistance monitoring strategic plan was developed in FY 2008. Pilot monitoring of HIV drug resistance has begun in two sites in Lusaka. This initiative will help prevent the emergence of HIV drug resistance.The GRZ endorsed SmartCare in 2007. With GRZ and USG Zambia support, SmartCare serves over 450 ART treatment and care sites. It improves continuity of care and collection of outcome statistics such as patients’ survival, mortality, transfers and CD4 changes over time. However, it’s important to note that PEPFAR Zambia will not support SmartCare program unless the GRZ or other partners provide funding for its national wide scale up. The GRZ does not have national targets for adult care and support. The MOH accepted a Palliative Care Advisor from a USG project in early FY 2009; increasing MOH capacity and leadership in HIV care and support policy and standards, including the authorization of hospices to provide narcotic drugs for pain relief.In FY 2009, patients with HIV-related cancers, e.g., lymphoma, cervical cancer, and Kaposi’s sarcoma (KS), began receiving care at the new Cancer Center in Lusaka. The USG does not support this site, and given funding limits, is unlikely to extend support.Goals and strategies for the coming yearIn 2010, the top priority of USG Zambia is prevention, including PWP. Adult care and treatment includes the purchase, distribution, and management of OI drugs (excluding TB drugs). GRZ-USG Zambia adult ART priorities are to consolidate ART service delivery and improve quality of care. Increase in ART uptake will be slower and focus on eligible pregnant women and children. PEPFAR Zambia will continue to provide technical assistance to the national ART program in 2010 to update training materials and protocols, and disseminate them. In adult care, PEPFAR Zambia will put increased emphasis on: 1) Shifts in adult care and support, from care that begins near the end-of life to care initiated at the time of HIV diagnosis, and on community vs. home care; 2) Stronger prevention focus (more PWP) on care packages that extend and improve quality of life; 3) stronger linkages between adult care and support and ART; and 4) increased collaboration with GRZ on pain management, prophylactic CTX, and food and nutrition support. Zambia has over 30,000 trained volunteer community caregivers who ca n encourage their clients to return to clinic appointments and adhere to ART. PEPFAR Zambia will emphasize integration of ART and adult care services with other clinical care services, including ANC, MCH for women and TB/HIV services. The USG will strengthen evaluation of the impact of ART and quality of services as well as laboratory capacity to diagnose and monitor patients on ART, and to provide support for CD4 count and blood chemistries. GRZ and the USG will work to standardize adult care training, update care policies and protocols, strengthen infrastructure through selective construction and renovation, continue facility accreditation and establish a hospice accreditation system, implement facility-based quality assurance/ improvement programs, and develop and strengthen care and support information. U.S. Mission at Zambia will continue to strengthen the Palliative Care Association of Zambia (PCAZ), and work to build the capacity of GRZ, faith-based and community providers to continue after PEPFAR ends.Launch of a bilateral nutrition support project is expected in 2010. It will target PMTCT clients and their HIV exposed infants for nutrition support, as well as expand food by prescription, primarily for ART clients. US partners may also target HIV positive adults with micronutrient supplements.PEPFAR Zambia will support expansion of PWP following recommendations of an interagency PWP TDY in 2009. The USG will also increase its focus on alcohol and substance abuse and gender based violence as HIV risk factors. Efforts to enhance the sustainability of the MOH, Provincial Health Offices, and District Health Management Teams, as well as to make adult ART and care more sustainable are supported. These efforts include reducing costs per client and seeking economies of scale, as well as encouraging the GRZ to absorb a larger share of the ongoing costs. Training costs are likely to reduce over time once an adequate pool of trained workers and volunteers exists. PEPFAR Zambia will continue to build the adult care and ART capacity of the GRZ, and faith- and community-based organizations. Significant private support will also help leverage and boost U.S. funded efforts. Costing of Care and Treatment ProgramsPEPFAR Zambia will continue to support and strengthen the adult treatment costing and modeling exercise to better inform cost of service delivery, resulting in cost efficiencies. New care and support initiatives will begin with access to a large cadre of trained health workers and volunteer caregivers and consequently quicker start up and reduced costs. Additionally, the expansion of ART has reduced the need for frequent, individual home visits. Costing studies by partners have helped to identify efficiencies in the delivery of services. The cost of ART at higher volume sites may have half the per-patient cost of lower volume ART facilities. Combining the M&E efforts of USG partners could also help reduce costs.

Technical Area: ARV Drugs

Budget Code

Budget Code Planned Amount

On Hold Amount

HTXD

32,164,913




Total Technical Area Planned Funding:

32,164,913

0


Summary:

Context and BackgroundAnti-retroviral therapy (ART) scale-up was a prime objective of the U.S. government (USG) and Zambian government in PEPFAR’s first phase, with emphasis on ARV (anti-retroviral) drug procurement and enhancing the capacity of the supply chain management systems. The Government of the Republic of Zambia (GRZ), with the help of PEPFAR, the Global Fund for AIDS Tuberculosis and Malaria (Global Fund), Clinton Foundation and other cooperating partners, met this objective by scaling-up antiretroviral therapy to 219,000 patients as of December 2008. By end of the first quarter of 2009, the USG reported 198,599 people on treatment, a figure that accounts for approximately 91% of patients on ARV nationwide, due to counting patients receiving both full and partial support. In FY 2009, PEPFAR Zambia obligated $24 million in ARV drug procurement, which later in the year increased to $26.7 million. The initial $24 million accounted for approximately 34% of the annual ARV supply costs. With about one million Zambians living with HIV/AIDS and about 30% of these requiring treatment the GRZ has prioritized making ART available to all Zambians in need of therapy. Efforts to achieve this objective were enhanced by the August 2005 Zambian government policy decision rendering all public sector ART services free of charge. The Zambia National antiretroviral therapy guidelines stipulate that all patients with a CD4+ count below 200 are eligible for treatment. There are no immediate plans to raise the CD4+ count cut off point due to limited financing as this would increase the number of patients eligible for treatment thereby increasing cost of treatment. In FY 2006, the USAID|DELIVER Project, with support from PEPFAR Zambia, established an ARV supply chain for unified procurement and supply of ARV drugs. In FY 2007, USAID|DELIVER focused on supporting the MOH in coordinating ARV drug forecasting and procurement planning capacity at the central level; quantifying required ARV drugs; reinforcing the standardization of ARV drug inventory control procedures at delivery sites; and developing and installing a software tool for ART sites to collect and order ARV drugs. This greatly improved procurement and supply of ARV drugs resulted in virtual elimination of country stock outs.In FY 2007, the MOH changed the first line ART regimen in Zambia for new patients commencing ART to Tenofovir + Emtricitabine/Lamivudine (FTC/3TC )+ Efavirenz or Nevirapine. Patients on previous recommended first line therapy have continued on the old regimen until either treatment failure or toxicities occur. The switch to Tenofovir based or second line therapy is mainly based on clinical parameters, as only 2 laboratories perform a limited number of viral load tests in country. Zambia has not expanded provision of viral load tests due to high costs involved with performing these tests. The decision to change followed concerns regarding toxicities such as peripheral neuropathy, lipodystrophy and suspected lactic acidosis and was made after broad consultation on best practices by the National ART treatment working group. Anemia was also commonly associated with AZT in Zambian patients. As a result of the occurrence of these toxicities, patient adherence to ART was negatively affected and suspected deaths due to lactic acidosis occurred. Converting to a Tenofovir based regimen has led to better adherence due to decreased toxicities and reduced dosage frequency. However, one disadvantage of implementing the Tenofovir based regimen is its higher cost which has led to increased costs associated with ARV drug therapy in FY 2008 and FY 2009. The expenditure has however lessened with the decrease in price of Tenofovir and Efavirenz. Cost efficiencies are further achieved by substituting FTC for the less expensive 3TC with similar efficacy. Accomplishments since last COPGreat progress has been made in improving the availability of ARV dru gs at the national level, and as of March 31, 2009 there were over 198,000 people on treatment supported by the PEPFAR Zambia. Building on the improvements made to the ARV supply chain, USAID|DELIVER continued its strong role in coordinating and addressing ARV logistics system issues in FY 2009. A contributing factor in these achievements was the lead taken by the USG and USAID|DELIVER, in close collaboration with GRZ, to facilitate development of multi-year ARV drug forecasts and quantifications. These are now updated on a quarterly basis and have contributed to elimination of ARV drug stock outs at country level. The process included development of the first national, long-term (through 2015) ARV drug procurement plan, encompassing procurements made by USG, GRZ, Global Fund Principal Recipients [Ministry of Health (MOH) and Churches Health Association of Zambia (CHAZ)], and Clinton Foundation. By FY 2009, the ARV drug forecasting and procurement planning capacity development significantly reduced the time and effort required for ordering and reporting ARV drug stocks. All drugs, regardless of which organization procured them, are pooled in the MOH central warehouse, Medical Stores Ltd. (MSL), for distribution through regular GRZ distribution channels to all accredited governmental and non-governmental ART sites. The strengthened logistics system in Zambia has benefited many institutions such as the Zambia Defense Force Medical Services who are benefiting from this system and have continued accessing drugs through the Medical Stores. ART has scaled-up to 322 ART sites in Zambia and 251 of these are supported by USG. Despite nearly level drug procurement funding, increasing cost efficiencies continue to allow scale-up of ART sites, with greater emphasis on ART provision to pregnant mothers as part of the emphasis on prevention of HIV transmission. Goals and Strategies for the coming yearIn FY 2010, PEPFAR Zambia will allocate $ 27,764,913 toward ARV drugs, an increase of $900,000 over the reprogrammed FY 2009 budget. This amount covers approximately 37% of the 2010 drug supply needs (overall needs have decreased slightly for FY 2010 because a GF principal recipient actually over budgeted for its ARV requirements and can make ARVs available for the general population). For 2010, the latest available estimate conducted before PEPFAR reprogramming, shows a total ARV requirement of $62.7 million, with the GRZ contributing 8%, the Clinton Foundation/UNITAID 10%, the USG 37% and the GF 44%. The long-term situation is affected by several uncertainties. First, calculations include a substantial and increasing contribution from the GRZ. Given the current economic situation, such contributions are in no way certain. Second, the Clinton Foundation has announced its intention to phase out of ARV procurement, with contributions disappearing by 2012. Third, Global Fund contributions phase out in 2011. Success of future proposals cannot be guaranteed.Tenofovir + Emtricitabine (FTC)/3TC + Efavirenz or Nevirapine combination will be procured for first line combination as per national guidelines and Zidovudine/Stavudine, Lamivudine and ritonavir boosted Lopinavir for second line combination as an increased number of patients are anticipated to start converting to second line therapy due to failure of first line. PEPFAR Zambia will work closely with MOH to strengthen monitoring of prescribing habits during MOH and USG site supervisory visits to ensure that switch to Tenofovir based and second line regimens strictly adhere to national ART guidelines. This activity will also be strengthened as a function of the internal quality control units.By FY 2009, all drug distribution was consolidated through the MSL and this will continue in FY 2010. All partners will continue receiving their drugs from MSL through the GRZ system, a significant achievement made possible by USG support. In the upcoming fiscal year, PEPFAR Zambia will emphasize consolidating and begin tra nsferring the ARV drug forecasting, logistics and procurement system to local institutions as part of transitioning the process to Zambian institutions for delivery of services. Through the ARV drug procurements and development of the national ARV drug logistics system, it is anticipated that these activities will assist in achieving a sustainable national ART program following intensive PEPFAR support.Costing of ART Programs In FY2008, through cost modeling and forecasting of ARV drug needs, Zambia anticipated an ARV drug procurement gap in FY2009 and FY 2010. This anticipated gap arose due to a combination of factors such as the continued rise in demand for ARV drugs while the budget remained static and the GRZ’s decision to revise the treatment guidelines in 2007 to a more efficacious but expensive Tenofovir based combination. Informed by the cost modeling and forecasting exercise USG identified and reprogrammed funds from other program areas to meet the need without affecting those program areas. Forecasting and cost modeling exercises will continue in FY 2010. PEPFAR Zambia will continue to search for cost efficiencies in ART service delivery, which will be substantiated through further modeling and forecasting exercises. As the demand for ART continues and the funding gap remains, Zambia will search for solutions to its need for ARV procurement. Potential solutions include increasing GRZ contributions, further Global Fund grants, other donors, drug price reductions and cost efficiencies. While GRZ budgeted for substantial increases in ARV procurement in 2009, the devaluation of the Kwacha has reduced the extent of this contribution. Zambia will continue to explore measures such as task shifting in ART service delivery to less expensive non-physician health providers in order to achieve cost savings. We also hope to see reduced demand in pediatric ART with the strengthening and expansion of prevention of mother to child HIV transmission services. This is expected to lead to reduced transmission of HIV to infants and therefore reduced numbers of children requiring life long ART.USG partners have ongoing costing models, examining all costs of care and potential efficiencies. While ARVs contribute to the majority of treatment costs, high volume sites demonstrate substantially lower overall costs per patient. Patients who remain on ART also demonstrate reduced inpatient costs, but it is unknown whether cost savings in the national program will be translated into sustained support for more PLHIV on ART. For ethical reasons, GRZ policy remains to provide ART for all who meet eligibility criteria; capping the number of ART patients is not on the table for GRZ discussion. Seeking efficiencies and cost savings in treatment and improving prevention efforts remain the focus of both USG and GRZ efforts.

Technical Area: Biomedical Prevention

Budget Code

Budget Code Planned Amount

On Hold Amount

CIRC

4,890,000




HMBL

2,300,000




Total Technical Area Planned Funding:

7,190,000

0


Summary:

BLOOD SAFETYZambia has a comprehensive national blood transfusion program aimed at ensuring equity of access to safe and affordable blood throughout the country. Blood Safety is the most effective strategy for the prevention of transfusion transmissible infections (TTIs), including HIV, viral hepatitis, and syphilis. Blood transfusion needs in Zambia are currently estimated at 120,000 units (450 mls each) of blood or 10 units per 1,000 population. Although Zambia exceeded its set target, collecting 90,049 units last year, this still represents only 75% of the country’s estimated blood needs. The Zambia National Blood Transfusion Service (ZNBTS) is the only institution in Zambia mandated to ensure an efficient and effective implementation of the national blood transfusion supply. The ZNBTS is comprised of the national coordination office in Lusaka and nine provincial blood transfusion centers, which are responsible for blood collections, laboratory screening and processing, and supplying of safe blood and blood products to all hospitals/transfusion outlets using WHO and the International Federation of the Red Cross and Red Crescent Societies (Red Cross) protocols. Individual hospital blood banks, based at the various transfusion outlets are not authorized to conduct laboratory screening and processing of blood, and are restricted to the following functions: storage and accounting for tested blood received from the respective regional transfusion centers; cross-matching and compatibility testing for their respective transfusion outlets; and monitoring and reporting on transfusion outcomes and blood use for their respective hospitals. The total number of health facilities that are currently receiving supplies of safe blood and blood products from the ZNBTS facilities has increased by two sites since last year to a total of 130,. . The Zambian donor recruitment and blood collection process includes: motivation outreach talks; brief medical history and physical examination; pre-donation counseling; blood donation, and post-donation counseling with a ZNBTS counselor. The USG President’s Emergency Plan for AIDS Relief (PEPFAR) has provided financial and technical support to the ZNBTS to improve blood safety since August 2004 and will continue with similar support in FY 2010. Blood safety objectives for FY 2010 will include increasing annual blood collections from 90,049 to 100,000 units in 2009/10; reducing the total discards attributable to TTIs from 12.6% in 2008/09 to 6%, and HIV discards from 3.4% to 2.5%, respectively. To achieve these objectives, the ZNBTS will strengthen blood donor management and retention by rolling-out the newly developed SmartDonor electronic blood donor database management and retention system; implement the pledge 25 blood donor club strategy in all the ZNBTS sites, and conduct the planned knowledge, attitudes, and practices study to explore blood donor attitudes toward the service. Zambia does not have an approved policy and comprehensive legal framework for blood transfusion. With funding from the MOH/Global Fund, Zambia is developing a blood transfusion policy and legislative framework to be completed in 2009 and implemented from 2010. PEPFAR will support Zambia’s plan to renovate and equip the nine regional blood centers to comply with international Good Laboratory Practice (GLP) and Good Manufacturing Practice (GMP) to enhance the country’s program capacity to meet the projected national blood transfusion needs. The ZNBTS has experienced challenges with equipment due to ageing technologies and inadequate capacity for laboratory screening, blood components preparation, the cold chain, and logistics for transportation and storage of blood and blood products. FY 2010 funds will be used to upgrade equipment for laboratory screening and the cold-chain for distribution and storage of blood and blood products Over the past four years, PEPFAR has procured 19 motor vehicles and 10 trailers to support the ZNBTS blood safety outreach activities that allows for mobile outreach for blood collections which accounts for 80% of all blood collections. In 2008, the MOH/Global fund procured 10 more vehicles, bringing the total fleet to 29 vehicles. Mandatory laboratory testing of blood for HIV, HBV and HCV using ELISA method, and syphilis using RPR kits, has continued to be the standard requirement for all donated blood at all nine regional blood transfusion centers. The equipment, test kits, reagents, and consumables used have been standardized and are procured centrally. The algorithms used for testing donated blood for TTIs are also standardized and based on the national and WHO guidelines. The existing algorithm for blood testing and confirmation requires the following steps: all blood samples undergo mandatory testing for HIV, HBV, HCV, and syphilis; and all reactive samples undergo repeat testing, in duplicate. Confirmed reactive samples are disposed of in accordance with the existing disposal procedures for biological waste, through incineration. The USG will use FY 2010 funding to procure additional laboratory equipment, particularly the automated Elisa and Architect systems, to enhance laboratory capacity and blood screening standards. Quality assurance (QA) is a critical component of the ZNBTS blood safety program and has three separate QA procedures in place: 1) Standard protocols and operating procedures for donor services, blood screening and processing, storage and transportation at ZNBTS facilities; 2) Internal quality assurance within each testing center at regional level; and 3) External quality assurance assessments by international institutions in Australia and South Africa. QA activities will continue in FY 2010 Most of the blood collected is used as whole blood, with approximately only 10% as blood components. Component preparation is still not fully developed in Zambia and is mainly done in Lusaka. The ZNBTS has been training clinicians to use blood and blood products appropriately since 2007. The program is intended to improve the clinicians’ appreciation of blood safety and engage them in implementing systems aimed at promoting appropriate use of blood and blood products. In FY 2010, PEPFAR will support the ZNBTS to: 1) establish provincial transfusion committees, 2) host regular scheduled meetings between ZNBTS and the Provincial and Hospital Directors, 3) sensitize and/or train clinicians in appropriate use of blood and blood products. Staff training and capacity building continues to be a priority for the ZNBTS. Training and capacity building has been focused on: 1) local in-house programs, 2) trainings by manufacturers/suppliers of products, and 3) regional and international trainings. In FY 2010, training will continue to focus on staff involved with donor and laboratory services. The ZNBTS has its own internal systems for monitoring performance and is also subject to monitoring and evaluation (M&E) by key stakeholders, namely the MOH, CDC/PEPFAR, WHO, and Global Fund. In FY 2010, the ZNBTS will continue to provide reports to the Government of the Republic of Zambia (GRZ) and various donors and also complete the piloting and fully implement the new SmartDonor management and retention system. National performance review meetings/workshops will be held on a quarterly - semi-annual basis. Sustainability of blood safety services in Zambia is a major goal of the ZNBTS. In order to accomplish this goal, the 1) MOH will mainstream the ZNBTS into the MOH and develop appropriate organizational and staff structures 2) ZNBTS will lobby for increased funding from MOH and the Expanded Basket donor funds, and 3) ZNBTS will continue the promotion of blood safety/donations to develop a culture of donating blood, which will contribute to long-term sustainability of blood safety.Apart from the core blood safety activities, the ZNBTS will develop linkages with other programs that will be beneficial to all organizations involved. Such activities include: male circumcision programs; injection safety; voluntary counseling and testing programs; and linkages with the National Malaria Program (See the Mechanism Narrative budget codes for more description on these linkages). MALE CIRCUMCISIONZambia has been implementing male circumcision (MC) as an HIV prevention intervention at a low scale since 2007. MC has been implemented in very few sites mainly through donor support, which has included the USG and the Bill and Melinda Gates Foundation. On July 30, 2009, the GRZ formally included MC into a comprehensive package of interventions to prevent sexual transmission of HIV/AIDS following advocacy from government officials, the USG, other donors, stakeholders and the World Health Organization (WHO). The GRZ has also collaborated with the USG, WHO, and other donors to develop and implement an MC strategic plan which aims to increase the number of individuals circumcised from the current 10,000 per year to 100, 000 in 2010 and to 300,000 per year by the end of 2014. In FY 2008, EGPAF through its sub-partner CIDRZ began a pilot study to look closer at the acceptability and methodology of neonatal circumcision in Zambia. Results are anticipated in FY 2011, which will help inform the GRZ for future neonatal circumcision. Through 17 USG implementing partners, PEPFAR is the major contributor to the 10,000 individuals circumcised in Zambia annually. USG partners have scaled-up their MC activities since 2007. The number of service outlets has increased from under 10 in 2007 to over 20 in 2009. The number of individuals provided with MC has also been increasing from below 50 per month in 2007 to approximately 1,000 per month from March, 2009 (USG partners have circumcised 6,000 individuals since March 2009). The USG also provides technical assistance to the national MC technical working group through activities such as participation in the development of the MC strategy and the MC implementation plan. In FY 2010, the main goal of PEPFAR MC assistance to Zambia will be to contribute to Zambia’s goal of increasing the number of individuals circumcised from 10,000 to 100,000 by the end of 2010. PEPFAR will implement a comprehensive package of MC services, including onsite testing and counseling (T&C) for HIV, MC surgery and post surgical care, and referral of clients to appropriate service providers for incidental disorders discovered during the provision of MC services. MC services will be provided across the entire country, targeting HIV-negative males between the ages of 15 and 49 years, including those deemed to be most at risk such as those in multiple concurrent sexual partnerships and HIV-negative men with HIV-infected sexual partners.The USG will increase awareness and utilization of MC services through the following activities: 1) linking up USG partners providing MC services with other USG partners providing other HIV services to promote cross referrals, 2) promoting MC using existing communication strategies and materials developed in collaboration with other donors and the GRZ and 3) developing additional materials to promote MC, and 4) promoting community involvement and participation in the promoting MC. PEPFAR will increase its capacity to deliver MC services through the following: 1) establishing additional MC service delivery sites, 2) increasing MC outreach services through mobile services, 3) setting up field theatres for MC using special tents, 4) forging stronger partnerships with the GRZ so that government infrastructure can be used to provide more MC services, 5) providing standard MC training to health care workers within PEPFAR partnership and between other donors and the GRZ, and 6) improving and harmonizing the supply chain for MC commodities. The USG through its Department of Defense (DOD) program will work closely with its partners and the Zambia Defense Forces Medical Services to implement and scale up MC services i n the health institutions and facilities run by the uniformed services. This will be done by building on work started in FY 2008 and FY 2009. Opportunities such as recruitment centers will be looked into to enable the military offer MC services to capture a larger group of new entrants.Sustainability of MC services to circumcise 80% of males is a major goal of the PEPFAR MC partners in Zambia. Approaches to promote sustainability will include: 1) USG partners working under the direction of the MOH, 2) USG partners providing MC services in government infrastructure, 3) USG partners providing training to host country nationals, and 4) USG partners promoting linkages between MC and other HIV services as well as MC and other health services. The USG will provide MC services in 103 service delivery sites, circumcise 42,100 individuals, reach 16,405 individuals with MC-related information, and train 417 in MC. INJECTION SAFETYPrevention of medical transmission of HIV is a priority to the Ministry of Health (MOH) and the USG. As part of the President’s Emergency Plan for AIDS Relief (PEPFAR) program, the U.S.G has supported the MOH to implement a medical injection safety project (MISP) aimed at reducing and/or preventing medical transmission of HIV due to poor injection safety (IS) and infection prevention (IP) practices in healthcare settings from 2004 to 2009.Since 2004, the MISP has achieved the following:1) trained 1,068 out of the a target of 1,080 healthcare workers, 2) collaborated with the MOH and other stakeholders to develop a standard list of essential IS/IP commodities, 3) procured IS/IP commodities to support 67 districts, 4) participated in finalizing the Zambia healthcare waste management guidelines, 5) served as the secretariat for the national IP technical working group, 6) facilitated the formation of active IS/IP committees at district and facility levels, and 7) worked with the provincial and district health management teams to incorporate IS/IP activities into their routine planning, budgeting and supervision activities. In FY 2010, PEPFAR will not implement injection safety as a stand alone activity as the Ministry of Health is effectively incorporating these practices and policies. PEPFAR will implement Injection Safety as an integral part of other HIV clinical service activities supported by PEPFAR, including PMTCT, testing and counseling, care and treatment and laboratory activities.INJECTING and NON-INJECTING DRUG USEAt this time, injection drug use appears to be a very small problem in Zambia and not a significant factor in the spread of HIV. Prevention efforts related to alcohol and drug use are integrated into Other Prevention programs.

Technical Area: Counseling and Testing

Budget Code

Budget Code Planned Amount

On Hold Amount

HVCT

22,419,737




Total Technical Area Planned Funding:

22,419,737

0


Summary:

Context and Background HIV testing and counseling (TC) remains an essential component to Zambia’s HIV prevention program. TC has increased steadily since the 2001 Demographic Health Survey (DHS) when only 9.4% women and 13.8 % men had ever been tested. According to the 2007 DHS 35% women and 20% men have now been tested. Access to TC in Zambia is not universal and coverage of services remains low in rural and hard to reach areas. Ensuring widespread access to TC services is central to Zambia’s response to HIV/AIDS. Significant progress has been made in scaling-up TC services in Zambia. In March 2006 the GRZ issued the national HIV TC guidelines calling for routine, opt-out HIV testing and use of finger-prick tests when appropriate in all clinical and community-based health service settings where HIV is prevalent and where anti-retroviral therapy (ART) is available. The Ministry of Health (MOH), in August 2007, gave directive to all health centers to begin providing routine HIV counseling and testing (PITC) for all patients, especially children, admitted into the facilities. In order to further strengthen the TC drive the GRZ in 2006 declared June 30 National Voluntary Counseling and Testing Day. In addition a new HIV Rapid Test training curriculum was developed in 2007. In Zambia all TC activities are coordinated through the National HIV/AIDS/STI/TB (NAC) TC working group. These include those conducted by the government, non-governmental organizations (NGOs), faith-based organizations, and coordinating bodies such as Provincial AIDS Task Forces (PATFs), District AIDS Task Forces (DATFs), Community AIDS Task Forces (CATFs) and the private sector. The U.S. Embassy in Zambia collaborates with the Global Fund for AIDS, Tuberculosis and Malaria (Global Fund), Japan International Cooperation Agency (JICA), the Clinton Foundation/UNITAID, United Nations Children’s Fund (UNICEF), and the Zambia National AIDS Response (ZANARA) in supporting training, technical assistance, procurement of HIV test kits and GRZs task shifting efforts.Accomplishments since the last COPU.S. partners contributed toward reaching the National HIV/AIDS Strategic Framework goals of TC (1,000,000 persons) and treatment (160,000 persons), by supporting 701 TC sites and reaching 611,043 persons with TC services by the end of FY 2008. As of March 2009, USG supported approximately 1,350 TC sites working in 69 of the 72 districts in Zambia. During the same period, USG partners provided TC to 423,504 individuals working towards meeting the annual target of 1,300,000. A national training of 23 trainers for HIV rapid testing was conducted with USG assistance during the last COP period; participants were drawn from MOH, USG and other partners involved in HIV testing. The USG also participated in carrying out the roll-out training of testers across the country.With support from USG, the U.K. Department for International Development (DFID), various United Nations agencies, and the National Aids Council (NAC) developed the National Strategy for the Prevention of HIV and STIs. The Prevention Strategy articulates the importance of HIV prevention and provides guidance on how partners can optimally prevent new infections. Furthermore, it acknowledges the fundamental role that TC plays as part of a comprehensive prevention strategy and in providing both a forum for counseling of those not infected to prevent infection, but also in identifying those already infected as an entry point for treatment and a forum for prevention with positives. In FY 2009 the USG provided support in strengthening the national HIV test kit forecasting, quantification, and procurement systems. The USG purchased $2 million worth of HIV test kits for the national program in accordance with GRZ and USG rules and regulations. In FY 2010, the USG will continue to procure HIV test kits in support of the GRZ testing and counseling (TC), prevention of mother to child transmission (PMTCT), a nd diagnostic testing programs.Goals and strategies for the coming yearThe USG will work with GRZ partners to put in place a Partnership Framework. Zambia’s National HIV/AIDS Strategic Framework plan ends in 2010 and plans are underway to draw up the next five year plan that will tie in with the development of the Partnership Framework in Zambia. In order to maximize the prevention potential of TC, mobile services will be used focusing on traditional client and provider initiated TC. Patients served by the health care system will be offered TC as part of the medical encounter and referred to care and treatment as needed. Community-based services will include mobile and home based, door- to-door TC services, which adopts a family centered approach to TC. The family centered approach to testing and follow-up care and treatment helps with disclosure within households, improves adherence and support between partners and within families as well as saves time and money for the family when all members are seen on the same day. In FY 2010, greater attention will be paid to the quality of training and monitoring of the quality of testing and counselling services being provided by community lay counselors.U.S. partners will focus on couples TC, including encouraging partner notification, disclosure between couples, and addressing gender based violence (GBV). Couples TC has been shown to reduce transmission in sero-discordant couples and encourage partner reduction and fidelity for partners who learn they are concordant negative. For those couples that are discordant, emphasis will be placed on prevention with positives. The USG will continue to support the following activities: treatment adherence counseling, client referral for appropriate follow-on services, and information, education, and communication materials distribution. TC activities will be intensified in locations that have populations with the highest disease prevalence/burden and communities characterized by highly mobile populations, including sex workers, truckers, traders, customs officials and other uniformed personnel. TC will be provided in ways that will continue to make the service convenient and accessible through the use of mobile facilities, using shipping containers strategically placed near the border crossings and truck parking areas, to provide TC services to sex workers, truck drivers, and others who congregate or are obliged to spend time at these locations. U.S. partners will seek creative ways to engage and connect communities to TC through community sensitization and mobile TC at traditional ceremonies and other social mobilization events (e.g. World AIDS day and Voluntary Counseling and Testing Day). Emphasis will be placed on working with government officials, politicians, traditional leaders, heads of industry and young influential Zambians (musicians, artists, youth leaders) to promote and advocate for increased TC uptake within communities. Additional focus will be placed on increasing male involvement in TC.The US Embassy Zambia will continue to provide TC services in private and public sector workplaces and will work with partners to provide TC to employees and identified outreach communities. Programs will strengthen and expand workplace programs by including quality assurance/ quality improvement and supportive supervision to trained TC providers offering on-site and mobile TC and linkages with other TC service providers. Focus will be placed on supporting community members that are HIV negative to help them maintain their status. Direct referrals to services for those who test positive will be provided as well as linkages to care and treatment services. The USG partners will continue to form strong linkages with other implementing partners, as well as public and private sector services to ensure patients are linked to PMTCT, ART, palliative care, TB, orphans and vulnerable children and male circumcision services.TC will form an integral part of the Private Se ctor Social Marketing Program and will be implemented in close collaboration with other HIV prevention, care, support, and treatment activities implemented by USG partners, the GRZ, and other donors. TC services will target females and males between the ages of 15 and 49 years, including individuals in multiple concurrent sexual partnerships, discordant couples, people living with HIV/AIDS (PLWHA), and commercial sex workers. Reproductive health activities such as family planning (FP) counseling and distribution of FP products will be integrated into TC services. USG will maintain its strong collaboration with GRZ, GFATM, and the Clinton Foundation/UNITAID to assist the national HIV testing programs in fulfilling increasing demand for tests kits and supplies. Additionally, USG will continue to purchase three types of test kits for various testing procedures based on the GRZ’s 2006 revised HIV testing algorithm: screening (Determine), confirmatory (Unigold), and tie-breaker (Bioline). All three tests are non-cold chain HIV rapid tests that enhance the overall accessibility and availability of HIV testing in Zambia. Priority will be placed on rapid test kits which will be placed in the GRZ’s central warehouse, Medical Stores Limited (MSL), where all the public sector and accredited NGO/FBO/CBO HIV testing programs will have access to these critical supplies. The USG will enhance commodity management and provide quality TC services; ensure same day test results; provide technical assistance to community/faith–based organizations to expand access to TC via mobile services; strengthen linkages to ART and promote routine, targeted TC with maternal child health, PMTCT, family planning (FP), tuberculosis (TB), sexually transmitted infections (STI), MC and ante-natal care services; promote couple, child and youth T&C; expand and strengthen inter-facility and community referral systems; promote follow-up services for negative clients; address gender disparities and violence that hinder access to TC services; and, support the DHMTs in quality assurance for eventual program graduation.In FY 2010, PEPFAR Zambia will continue activities to support training of health care workers and lay counselors. Health care workers and lay counselors will be trained and mentored to increase quality assurance, and improve data quality and systems for tracking patient flow. Additional emphasis will be on integrating TC with other services such as sexually transmitted infections (STIs) maternal and child health (MCH), tuberculosis (TB), and inpatient/outpatient services. TC providers will link HIV positive clients to ART and palliative care services in their respective communities to ensure continuity of care. Community TC will link with other USG programs including insecticide –treated bed nets for malaria and safe water. The USG partners will reinforce linkages with partners through the district referral networks in an effort to increase the number of people reached with TC and avoid duplication of services. Working in communities surrounding the TC sites, USG will take steps to increase demand and acceptance of services. At the national level, USG will continue providing technical assistance to the national Testing and Counseling Technical Working Group to develop, revise, and disseminate training materials, protocols, and policies.In July 2009, during the bi-annual child health week, a pilot to integrate HIV TC services was carried out in three districts of Zambia. Over a thousand PCR tests were done and close to 1,500 rapid tests performed. The success of this initiative will be replicated in future Child Health Week activities and with USG support, scaled up to cover more districts. The Zambian Pediatric counselling and testing guidelines are currently being developed and the USG will continue to support development/revision of guidelines and protocols. With an enhanced focus on strategic TC interventions -- including increasing the number of TC providers, procuring HIV tes t kits, ensuring the quality and reliability of HIV testing, expanding mobile TC services for hard-to-reach populations, engaging local communities, and strengthening referral networks for prevention, treatment, and care services-- the U.S. Mission in Zambia is well positioned to contribute to the Emergency Plan’s global 3-12-12 goals and to achieve the U.S. Mission in Zambia’s objectives.

Technical Area: Health Systems Strengthening

Budget Code

Budget Code Planned Amount

On Hold Amount

OHSS

15,554,428




Total Technical Area Planned Funding:

15,554,428

0


Summary:

Context and BackgroundThe U.S. Government (USG) and Zambian Government (GRZ), in accordance with the major overarching country themes of prevention and developing capacity to address HIV/AIDS, pursue myriad activities across the six health system building blocks. These efforts support public and private sector Zambian institutions response to the HIV/AIDS epidemic. Since 2004, significant progress has been achieved through these efforts across the health system building blocks. Selected examples of progress include:• Service delivery: Enhanced health worker retention plan that increases service delivery in remote areas for HIV and other health conditions; technical training to allow introduction of HIV services across the country; introduction of biomedical prevention interventions; renovated health facilities, staff housing and laboratories facilitating high quality service delivery across the country;• Human resources: Improved curricula used in pre- and in-service training efforts; training efforts that significantly bolster Zambian capacity to monitor and evaluate the response to the epidemic; improved training facilities, increasing the competency of graduates; a 2009 joint U.S. /U.K. assessment of Zambia’s human capacity development environment (further human resources for health assessments are planned); policy engagement on issues such as task shifting;• Information: Advanced electronic medical record systems that allow comprehensive patient monitoring; use of data collection instruments such as the Demographic and Health Survey (DHS), Antenatal Sentinel Surveillance and Behavioral Sentinel Survey which allow for a comprehensive understanding of the dynamics of the HIV epidemic;• Medical commodities and technologies: A very effective HIV commodity supply chain system; efficient, GRZ-led commodity forecasting and procurement planning for HIV commodities including all public sector and most mission health care facilities; using HIV funding to leverage USG family planning (FP), child survival and malaria funding and co-funding from the World Bank for an improved and integrated essential drugs commodity distribution system;• Finance: Direct contributions and cooperative agreements with GRZ entities to build systemic capacity across technical areas; several complementary costing exercises to detail costs of providing ART and the associated commodity supply chain;• Leadership and Governance: Engagement of leadership at all levels; fostering increasingly conducive policy and regulatory environments; enhancing coordination and collaborative efforts among the GRZ, bilateral and multi-lateral cooperating partners, faith-based organizations, the private sector, and civil society.The impact of these USG systems strengthening interventions, and others too numerous to summarize, will outlast PEPFAR funding, enhancing Zambia’s capacity to mount an effective and sustainable response to the HIV epidemic. Other health systems strengthening activities: Other organizations are also major contributors to the health systems strengthening agenda in Zambia. Most donors in the country provide assistance directly to the government, either through the Ministry of Finance as general budget support or to the Ministry of Health (MOH) as sector budget support. Donor staff representing pooled funders and project funders such as the USG collaborate equally with Zambian government staff through participation on technical working groups and in the MOH’s and National HIV/AIDS/STI/TB Council’s (NAC) annual planning processes. Beyond pooled funding, other donors continue with small project-based activities. Six senior technical advisors to the MOH, including those for the Permanent Secretary and drug supply/procurement, are funded by Sweden. The British Department for International Development supports maternal health interventions and is currently devising plans for an enhanced human resources informati on system. Japan, France, UNAIDS and WHO support advisors to NAC for various technical areas. The Clinton Foundation is a major supporter of human capacity development activities, centering on the human resources technical working group and planning for improvements to the training institute renovation and expansion. Other systems strengthening PEPFAR ZAMBIA activities include FP commodity procurement, training and storage facility renovation for indoor spraying for malaria, and facilitative technical assistance for disease outbreak investigations.As part of its Round 8 Global Fund grant for HIV, the MOH and Churches Health Association of Zambia (CHAZ) plan to implement health systems strengthening activities with several objectives: renovating ten health worker training institutions, improving staff accommodation in rural areas, developing a community health worker strategy and community health information system, and improving the health care waste management system.However, the MOH is currently working through an instance of significant funds misappropriation by some of its staff. While no PEPFAR Zambia funds were involved, the situation has led to Sweden, the Netherlands, Canada and the Global Fund delaying further disbursements pending the outcome of investigations and audits and the Zambian government’s response. While only one of the four Zambian Global Fund principal recipients is affected, the MOH is central to nearly all health systems strengthening activities. Thus the program is essentially on hold and the health sector as a whole must manage with reduced resources for at least the near future.Major USG health systems strengthening interventions not covered in other technical areas: The U.S. Mission at Zambia supports a range of activities in the health systems building blocks of commodity and procurement systems support, leadership/governance and finance. • Commodity systems: The USG places major emphasis on supply chains and procurement for HIV-related commodities, using a single procurement agent—the Supply Chain Management System—for nearly all commodity purchases. These activities provide an opportunity for targeted leveraging, with some efforts (the essential drug distribution system) explicitly co-funded with DFID funding administered by the World Bank. PEPFAR Zambia procurement and supply chain partners facilitate a GRZ-led process that identifies HIV commodity requirements and the most cost-effective method of meeting the needs. The GRZ convenes an annual planning meeting supplemented by quarterly review meetings to ensure timely procurement of ARVs, opportunistic infection and STI drugs and laboratory commodities. Attendees include Global Fund grantees, USG partners, multilateral agencies and other GRZ entities. Commodities, regardless of the purchaser, are pooled into the central drug warehouse from which the distribution system is integrated into the routine GRZ drug distribution system. The information system that allows accurate stocking at facilities is separate from the overall GRZ drug information system (currently functioning sub-optimally). However, using lessons learned from implementing an effective ARV, test kit and laboratory commodity information system, a major pilot of changes to the routine system is currently underway. Once successful, and assuming suitable domestic funding (all options in the pilot were explicitly designed to maximize scalability within a reasonable GRZ resource envelope) the targeted leveraging will result in a rarity for a developing country: a successful, integrated essential drugs supply chain system.• Leadership/Governance: In the past, the USG has implemented numerous interventions to increase Zambian capacity to lead and govern the health system. Such support will continue and expand. PEPFAR Zambia, in collaboration with other donors, will support development on the next phase of Zambia’s development planning, including the Sixth National Development Plan, the National Heal th Strategic Plan 2011-2016 and the National AIDS Strategic Framework. These plans will provide a framework for program implementation through the remainder of the PEPFAR authorization. Policy work in specific technical areas will continue, building on work performed to date. The USG will support capacity building of provincial and district bodies that coordinate the response to HIV. Management skills development will be a focal area of a new award, leveraging non-HIV funds. Local partner capacity building is a focus of a dedicated USG award as well as an intentional spillover effect of work conducted by numerous other implementing partners. PEPFAR Zambia partners continue to engage private sector actors on HIV/AIDS issues, building their institutional capacity and the country’s capability to manage the epidemic. Leadership and governance interventions will be a major component of the Partnership Framework.• Finance: The financial health systems building block has received a great deal of support from other donors in terms of understanding resource flows and their allocation. USG activities have assisted to generate some of this information. Yet given Zambia’s overwhelming preference for budget support and policy of free medical services including ARVs, comprehensive financial systems programming remains elusive. PEPFAR Zambia has supported cost analysis studies of HIV service provision and will use the results to engage the GRZ on sustainability planning. Goals and Strategies for the coming yearAreas on which PEPFAR Zambia focuses: The USG implements various interventions to strengthen health systems and the building blocks of these systems across the structures that comprise the entire health system, including the military health system. Engagement will build on accomplishments from the first phase of PEPFAR, with increased emphasis on prevention and sustainable programming in continuing activities. Few entirely new health systems strengthening activities are proposed; rather existing activities will revamp and reorient their interventions to provide greater focus on sustainability. USG health systems strengthening interventions include:• Service delivery: USG partnerships with the private sector will continue to facilitate HIV/AIDS service provision. (Systems strengthening activities are also described in other technical areas relevant to service delivery.)• Human resources: The USG will continue to work with the GRZ to support task shifting efforts, such as enabling trained lay workers to do rapid HIV testing and counseling as part of PMTCT; enabling trained nurse practitioners to manage and prescribe for HIV positive patients; increasing the number of adherence support workers; and increasing access to pain management drugs. Support for the Zambian Health Worker Retention Scheme will continue, an effective GRZ-led plan that increases the number of health workers in rural areas and in key posts in training institutions. Additionally, the USG will work with the MOH to disseminate human resource planning and projection guidelines, and support provincial health offices to assess the districts’ human resource needs and facilitate the development of the districts’ human resource plans. Importantly, the USG will maintain working relationships with health worker training institutions to ensure inclusion of state of the art HIV care and treatment information in pre-service and in-service training curricula. The USG is investigating the possibility of constructing lecture theatres to increase quality of pre-service education. The host institution, the School of Medicine, would be responsible for maintaining any facilities constructed. In addition, DOD has a longstanding partnership with the Zambia Defense Force (ZDF) to strengthen its prevention, care and treatment programs. These activities will continue in FY 2010 with a focus on strengthening systems through infrastructure improvements. • Commodities and Proc urement: PEPFAR Zambia partners will continue to assist national procurement efforts and make improvements to HIV-specific and broader essential drugs logistics systems, with a continued eye toward enhancing sustainability. The USG will maintain support of the expansion of laboratory and other health information technology and cater to the equipment needs in targeted provincial and district health facilities. In collaboration, with GRZ, NAC, MOH, and other key stakeholders, such as the CHAZ and Clinton Foundation, the USG will continue to support the national HIV/AIDS Commodity Security Strategic Plan. The USG will offer support to military health services by supporting the procurement and logistics management system within those services and enhance sustainability by facilitating their linkage to the broader MOH systems. • Information: PEPFAR Zambia will continue to strengthen coordination, monitoring, and evaluation through NAC. In addition, the USG will offer assistance to successful programs at the University of Zambia’s Department of Social Development and School of Community Medicine to build institutional and individual planning, research, monitoring, evaluation, and information technology capacity for HIV/AIDS. In the Department of Social Development, PEPFAR Zambia will support a short course on planning, monitoring, and evaluation for working and new professionals. Similarly, building research capacity in public health at the School of Community Medicine and the curriculum in biomedical research is a priority. Support for continued development and improved use of the national electronic medical record system (SmartCare) is described in other technical areas, however unless the GRZ or other donors provide funding to expand SmartCare nationwide, we will eliminate funding for it in FY 2011. • Finance: The USG will continue to support cost analysis studies of ART to better enable sustainability planning. Upon completion of the audits and investigations into the GRZ funds misappropriation and better problem definition, the USG may provide technical assistance and support for improvement of financial management systems in the MOH.• Leadership and Governance: PEPFAR Zambia will continue to build capacity of provincial and district bodies that form the local implementation and coordination bodies for funding from NAC and other channels. This support is implemented both through partner technical assistance and a small amount of direct funding through the Joint Financing Arrangement with NAC. USG partners will continue to facilitate and strengthen district and provincial capabilities to provide supportive supervision for the health care providers in their purview. These and other activities will continue to increase the ability of the Zambian health system to respond to the health needs of the Zambian people.

Technical Area: Laboratory Infrastructure

Budget Code

Budget Code Planned Amount

On Hold Amount

HLAB

19,650,000




Total Technical Area Planned Funding:

19,650,000

0


Summary:

Context and BackgroundQuality laboratory services play a crucial role in public health in both developed and developing countries by providing reliable, reproducible, and accurate results, for disease detection, diagnosis, and follow-up of treatment. Reliable laboratory results continue to be critical for the prevention, care and treatment of HIV/AIDS, TB, and opportunistic infections (OIs) in patients seeking healthcare services. Quality laboratory services require comprehensive, coordinated support programs to establish, maintain, and document ongoing testing procedures, which include effective systematic mechanisms for monitoring, collecting, and evaluating information. Providing accurate and reliable results to ensure proper patient diagnosis and monitoring involves more than just the testing component. It also includes Good Laboratory Practices (GLP) which requires: adequate facilities, infrastructure, skills, human resources, management supervision, maintained working equipment, sufficient lab commodities, waste management, and a user-friendly system of data recording and reporting. Zambia has a national laboratory network. At the central level, there is a Laboratory Services Unit attached to the Directorate of Clinical Care and Diagnosis, Ministry of Health (MOH). The laboratory network consists of 211 laboratories in 72 districts. Eight provincial hospital laboratories support district and rural health center laboratories.Accomplishments since last COPThe U.S. Mission in Zambia began providing laboratory support to the Government of the Republic of Zambia (GRZ) in 2002 in support of anti-retroviral therapy for HIV/AIDS patients to rapidly expand laboratory services in Zambia. In PEPFAR I, the USG supported 1) the provision of automated laboratory equipment testing systems throughout the country, 2) establishment of three laboratories to provide early infant diagnosis (EID), 3) the national TB laboratory network, 4) bacteriology laboratory services in 6 hospitals, 5) the provision of laboratory supplies, and 6) strengthening of the national QA plan for laboratory testing. During FY 2009, PEPFAR Zambia has focused on identifying gaps and addressing issues to improve the quality of laboratory testing services in Zambia. Within the last 12 months, the USG has accomplished the following in several key technical areas: 1. Quality Assurance (QA) Management Systems:National QA program for HIV rapid testing: In September 2008, the USG identified a need to improve the quality of HIV rapid testing in Zambia. In response, direct technical assistance was organized and provided to the MOH, UTH HIV reference laboratory, and other partners to address the issues since that time. Utilizing a phased approach, the national QA program for rapid HIV testing was established. Noted below are the outcomes of the MOH/USG/partners collaboration through the national MOH QA committee to date.Endorsed by the MOH, a revised and standardized HIV rapid test training package was developed within the last 12 months and put into use by NGOs, partners, and MOH staff for training. Twenty-six Zambian trainers (MOH and partners staff) were trained. Over 300 health workers from all nine provinces received first-time/ refresher training course for HIV rapid testing according to the standardized curriculum. Follow-up visits were made 2-3 months after training to evaluate the trainees’ performance. The testers were from facility-based (PMTCT/VCT), home-based, and mobile voluntary counseling and testing (VCT) sites. In addition, appropriate tools (timers, job aids, and national algorithm) were provided to testers to conduct rapid HIV testing according to the protocols.For sustainability purposes, technical skill was transferred to the UTH HIV reference laboratory staff. HIV proficiency testing panels were prepared in-country by Zambian laboratory staff using dried-tubes specimen techniques. Over 500 HIV proficiency testin g panels were prepared and distributed to sites for the National External Quality Assessment Scheme (NEQAS) to assess the proficiency of testers during refresher training courses. The first round of NEQAS for rapid HIV testing was conducted at the national level; over 200 sites participated. Overall results will be disseminated by the MOH at the end of 2009. Supervisory visits are being made to sites that did not receive scores of 100% in order to assess areas for improvement and troubleshoot problems.In strengthening the TB laboratory network and national TB EQA process for TB smear microscopy the USG has provided support to the National Chest Diseases Laboratory (CDL) and two regional TB reference laboratories. These three institutions provide TB lab services in culture, drug susceptibility testing, TB Acid Fast Bacilli (AFB) smear microscopy, and support the national QA program for TB AFB smear diagnosis to the Zambia TB laboratory network of 156 diagnostic centers. Earlier in 2009, the USG initiated formation of a TB laboratory working group consisting of the three institutions and other partners working in TB laboratory services in an effort to share information, better monitor and evaluate TB lab services. Short-term technical assistance was provided to the CDL and UTH TB laboratories to serve their needs. Gaps from both the laboratory network and the national TB EQA microscopy were identified and work plans developed to meet the needs. 2. Training: With regard to staff retention and career development, the USG directly supported Zambian laboratory personnel to attend training courses and workshops (for example in: bio-safety, TB lab diagnosis, HIV rapid tests, EID, LIS, national strategic plan, and international grant management). Under the COAG with the HIV reference lab- national HIV QA program, two staff attended an international course in GCLP. PEPFAR Zambia also supported a biomedical society professional meeting for career development and promotion.3. Equipment maintenance systems: To ensure uninterrupted laboratory services, a national database of laboratory equipment was developed. Equipment maintenance service contracts were supported to maintain automated equipment. Over the coming year, the USG will begin to work with the MOH to fund such contracts in future.4. Supply Chain Management Systems: The USG has been providing laboratory reagents and supplies to PEPFAR-supported laboratories since inception of the PEPFAR program. SCMS forecasts, procures, and forwards laboratory commodities to the national (MOH) Medical Stores Limited that store and distributes to its laboratory network. A national laboratory logistics system to track laboratory stock, inventory, and the use of laboratory testing records was introduced in FY 2007- 2008. It was piloted and evaluated in three provinces in 2009. A national roll-out is now beginning.5. Laboratory Information System: In September 2009, funds were awarded to the MOH to develop a computerized LIS that is appropriate for Zambia and that can interface with the established SmartCare system. Since this process is time-consuming, a paper-based laboratory registers was developed in advance in 2008 by the MOH QA committee which CDC staff are members. It will be used as a supportive tool to develop a LIS. 6. Sample Referral System: The USG-supported transportation of dried blood spots specimens from peripheral health centers to early infant diagnosis laboratories. 7. Policies: PEPFAR Zambia has supported revision and printing of the MOH laboratory policy documents including Standard Operating Procedures (SOPs) for the national laboratory network, lab safety manuals, and national HIV testing algorithm. These documents are disseminated to all levels of the laboratory network in Zambia. Through USG support, MOH senior laboratory staff attended a national strategic planning workshop. The MOH is currently developing its 5-year national laboratory strategic plan.In addition to the seven key areas, the USG also supported the following three activities: 8. Energy Program: The acquisition of reliable and affordable power poses a challenge to many health facilities in developing countries, including Zambia. In February 2009, two USG energy specialists conducted an energy assessment in Zambia. Seventeen health facilities in three provinces (Eastern, Southern, and Copperbelt) were assessed. Three crucial activities were recommended 1) training 2) the provision of technical assistance to the MOH and 3) the retrofitting of facilities with an efficient cost-effective energy system (solar panels, inverters, and generators); a report was prepared and submitted to the USG and MOH. Presently, a work plan is being developed and implementation will start in October 2009. 9. Early Infant Diagnosis: Currently there are three PCR laboratories providing early infant diagnosis in Zambia. Two laboratories are located in Lusaka and the third at the Arthur Davison Children’s hospital which serves the northern region of the country. In FY 2009, to better serve military and populations in the south, the USG provided technical assistance to the Department of Defense (DoD) and the MOH to set up the fourth and fifth PCR laboratories at a military hospital in Lusaka (Maina Soko) and at the Livingstone General Hospital, Pediatric Center of Excellence, in the Southern Province. Currently, the two laboratories are being renovated and equipment procured.10. Assistance to the MOH: At the central level, the USG assisted the MOH in several activities including: a) outbreak investigations (by providing TA, procuring reagents, assisting with specimen transportation to reference laboratories outside Zambia, and coordination) b) participation in the National QA Lab Committee c) coordination and support of workshops and d) provision of TA when needed. PEPFAR Zambia also provides support to the MOH at the provincial level; all nine provincial health offices receive assistance.Goals and Strategies for the coming year: The goals and strategies of the PEPFAR Zambia Laboratory Infrastructure program remain unchanged which is to improve the quality of laboratory services provided in country. The key areas QA, training, LIS, supply chain, equipment maintenance, specimen referral systems, and policies exist in our previous COP with the addition of three activities. In FY 2010, the USG will continue to support all 10 activities as described above as well as new activities to further strengthen the lab program in Zambia in four key areas. Key Area # 1 (Quality Management systems): These new activities will be to:1.1. Support the establishment of a national QA laboratory at Chainama College of Health Sciences, Lusaka. This activity is proposed by the Central Laboratory Services Unit of the MOH, to set-up an operational QA laboratory since the MOH has a mandate to oversee the quality of laboratory testing services in Zambia. Rooms were allocated to the MOH to perform this function independently from the hospital diagnostic services. Start-up funds were requested to furnish and equip the laboratory. Currently, Zambia has no national QA laboratory and the QA program for HIV rapid testing is being managed from within the UTH Virology department. This laboratory also provides HIV diagnostic services to patients.1.2. Support the MOH and local partners to establish laboratory accreditation systems in Zambia. The USG and its partner Clinical Laboratories Standards Institution (CLSI) will work closely with the MOH Central Laboratory Unit to start the process. Planning, assessment, training, and implementation phases will be carried out with the MOH.1.3. Expand the QA program to include CD4, blood chemistry, and hematology. This work will start at the UTH laboratory with a plan to transfer activities to the national QA laboratory at Chainama in the future.1.4. Further strengthen the national TB laboratory network and its EQA program to operate systemat ically and to cover all TB diagnostic facilities (provincial, district, and rural health centers). Currently, only 96 of the 156 provincial and district TB diagnostic labs are enrolled with the national TB EQA program. Quality of service gaps were identified at the TB reference laboratories that have called-for the need to provide continuous technical assistance. PEPFAR Zambia, therefore, will provide this direct technical assistance to the national and regional TB reference laboratories to meet their needs.Key area # 2 (Training): PEPFAR Zambia also supports building local human capacity by providing professional training of laboratory personnel at pre-service levels by pairing the University of Zambia (UNZA) with the University of Nebraska to improve knowledge and skills of new biomedical science graduates in Zambia. The curriculum will be revised; faculty staff will be trained; and there will be a student exchange program. Through linkages with UNZA under Health System Strengthening, lecture rooms and training facilities will be upgraded. A new lecturer will be hired and more visiting lecturers will be invited to teach at UNZA. Key area # 3 (Sample referral system): In FY 2010, PEPFAR Zambia will establish linkages between the Laboratory Infrastructure and Biomedical Injection program areas. Through a public-private partnership with Beckton Dickinson and the MOH; USG support will: a) establish specimen referral systems from peripheral health facilities where there is no CD4 testing facility to central laboratories by using CD4 stabilized tubes; and b) improve quality of blood specimen collection. In addition, the USG supports Provincial Health Offices (PHOs) and partners to coordinate setting up logistics system within each province to send specimens (including CD4, dried blood spots, and sputum) to provincial/ district laboratories and how to receive test results in a timely manner. Key area # 4 (Policies): PEPFAR Zambia supports the MOH to develop: 1) annual national laboratory operational plans aligned with the national five year strategic plan. In addition, the USG will support the MOH in prevention of occupational exposure; strengthen safe injection, and development of policies and guidelines. Preventive Health Care (PHC) Centers will be built where there is a constraint in providing comprehensive services, under the supervision of the DOD PEPFAR office in collaboration with the Zambia Defense Force (ZDF). Finally, PEPFAR Zambia continues to coordinate activities and share information with other donors to avoid duplication of resources and effort. With a focus on the strategic laboratory infrastructure interventions, the USG is in an excellent position to further improve the quality and sustainability of laboratory services in Zambia.

Technical Area: Management and Operations

Budget Code

Budget Code Planned Amount

On Hold Amount

HVMS

13,426,952




Total Technical Area Planned Funding:

13,426,952

0


Summary:

(No data provided.)



Technical Area: OVC

Budget Code

Budget Code Planned Amount

On Hold Amount

HKID

18,859,893




Total Technical Area Planned Funding:

18,859,893

0


Summary:

Context and BackgroundThe Government of the Republic of Zambia (GRZ) estimates that there are 1.2 million orphans, of which approximately 800,000 are AIDS orphans. The 2007 Zambia Demographic and Health Survey (ZDHS 2007) show that children under the age of 15 make up 50% of the entire population of about 12.2 million. The ZDHS 2007 further shows that of children under the age of 18, approximately 19% are orphans and vulnerable children (OVC). Provision of social services to vulnerable households is very inadequate as the Ministry of Community Development and Social Services (MCDSS), which has a mandate for social protection, is one of the least funded ministries. Coordination of OVC interventions remain a challenge due to inadequate resources. Further confounding the effort is a lack of clarity and understanding of the roles and responsibilities between the Ministry of Sport, Youth and Child Development (MSYCD) and that of the MCDSS, as both ministries perform similar functions. The Zambia Council for Children (ZCC) bill was drafted over a year ago. The bill has since been presented to the Cabinet, awaiting its approval. Once established, the ZCC will coordinate, mobilize resources, and perform monitoring and evaluation duties of interventions geared toward children. The MCDSS has social protection implementing structures at the national level down to the community level. GRZ has been providing public welfare assistance (PWAS) in selected districts through the MCDSS structures. These structures however have not been very effective in implementing OVC services as they are inadequately funded and have insufficient manpower. In addition, the ministry lacks adequate infrastructure, policy guidance and clearly documented implementation strategies. The GRZ, with technical and financial support from PEPFAR Zambia and UNICEF, has finalized the draft National Plan of Action (NPA) which is expected to be introduced in late 2009. The NPA was largely informed by the Fifth National Development Plan (FNDP), the National Strategic Framework for HIV/STI/TB for 2006-2010 as well as the National Child Policy and the Child Health Policy. The government of Zambia through the MCDSS and MYSCD has embarked on skills training for out of school youth and children on the street. While the training program has been successful, linking youths to job opportunities has been challenging. The PEPFAR Zambia is the largest contributor to OVC support in the country. Provision of OVC efforts are carried out in collaboration with other donors, some of which include: the Development Corporation of Ireland, U.K. Department for International Development, Swedish International Development Cooperation Agency, GTZ and the World Bank’s small grant mechanism. The team has been instrumental in strengthening the capacity of the government, local organizations, communities, schools, workplaces, and families to provide care and support to OVC, facilitating policy changes and leveraging private sector resources. U.S. Mission support for OVC is implemented and managed across several sectors through numerous government agencies including: the NAC; Ministry of Education (MOE); MSYCD; Ministry of Health (MOH); and the MCDSS. In addition, several non-governmental organizations serve as prime or sub-partners. The U.S. Mission in Zambia has been working with a number of umbrella organizations and networks that fund and build the capacity of local OVC programs. Accomplishments since last COPBy the end of FY 2008, PEPFAR Zambia had reached 422,118 (208,954 girls and 213,164 boys) OVC against the set target of 378,000, with different interventions as per the six plus 1 core interventions. 232,964 received more than three core services while 189,152 received less than three services. In addition 28,753 care givers were trained. In FY 2009, the U.S. Mission in Zambia continued to scale-up support to OVC. For the first half reporting period (October 2008 to March 2009), the PEPFAR Zambia reached 343,150 OVC and trained a total of 15,063 care givers. Scholarship activity by mid FY 2009 has supported more than 24,000 students with PEPFAR funded scholarships, of which 6,000 of these students have matriculated to the university. The scholarships pay for school expenses but also ensure that students are living in secure homes and are protected from dangerous situations that may expose them to the possibility of contracting HIV.PEPFAR Zambia OVC activities are coordinated through the OVC Forum, which meets monthly. The OVC Forum developed a USG 2009 joint strategic plan for OVC which detailed partners’ annual plans according to specific priority areas. This provided an opportunity for synergistic relationships and avoided duplication of efforts by partners. The OVC forum also held a retreat to look at ways in which the Child Status Index (CSI) tool can be used for assessment and monitoring. Partners have since written work plans to further test the CSI tool.Partners had challenges providing OVC services to children under the age of 5. PEPFAR Zambia overcame this by developing an under 5 OVC strategy which is being implemented by all partners. In addition the USG developed a tool for psychosocial support for children aged between 3 and 6 years for use by care givers and ECCD teachers. Goals and strategies for the coming yearThe goal of this program area is to enhance the sustainable provision of quality care to orphans and vulnerable children (OVC) through strengthened systems for coordination, planning and implementation. The program will work to provide comprehensive and quality OVC services through enhancing the policy environment and building effective systems. By strengthening already existing structures at the community, district, provincial, and national levels, the expected outcome is easy identification and targeting of highly vulnerable OVC for effective monitoring. The program aims to secure prevention, care, and support strengthening the continuum of care. Additionally, the integration of services, improving upon efficiencies, sustainability, and capacity building of the country to respond to OVC HIV/AIDS needs is priority. These efforts will include engagement with the private sector. The strategy will utilize the provision of the core services for OVC as articulated in the National Plan of Action for children (NPA) and as per PEPFAR OVC guidelines. The program also aligns with the National AIDS Strategic Plan for 2006-2010.Priority ActionsThe OVC program prioritizes both family centered and community based interventions for OVC care. It also seeks to develop synergy and maintain linkages with other cooperating partners operating within the OVC arena and work with GRZ to strengthen national social welfare systems, with a focus on care and protection of OVC. Strengthened referrals between the community and health centers for OVC will ensure that the health needs of OVC are met. The program will continue to aid OVC in acquiring basic education through educational support such as scholarships and provision of educational materials. Community school teachers will be provided with training which enables them to have necessary competencies sufficient for teaching. The Ambassador’s small grants will prioritize the rural areas while the Education Support Initiative, a scholarship program for both boys and girls, will give priority to females. Working with other partners to promote protection of OVC from abuse and exploitation, the program will provide referrals to one stop centers for management of sexual abuse if identified. OVC suffer from extreme emotions due to loss of parent(s), as well as stigma and discrimination. The provision of psychosocial support to OVC, including the OVC under the age of 6 will be maintained. OVC Food and Nutrition Support will follow Zambian national nutrition guidelines, and w ill adhere to OGAC Food and Nutrition guidance. OVC nutrition support will prioritize at-risk infants starting as young as six months, up to five years. Food supplements will be provided through a community driven sustainable means. This will be done through encouraging the establishment of community based agricultural activities. The program will build on previous programs to provide decent shelter for OVC and connect with public-private partnerships for entrepreneurial skills training, employment and access to markets for income generating activities.Information will be used for evidence-based strategic planning gathered from surveys, basic program evaluation and public health assessments, as will data be obtained from the data base. However, due to many competing priorities, government commitment has not been fully realized. In collaboration with other key stakeholders, standards of implementation for OVC will be developed which will establish a set of quality dimensions for interventions. The OVC program is expected to improve and promote coordination of OVC care at multiple levels. Direct service delivery will continue through the provision of core services in almost all districts of Zambia. The program will aim to address policy issues surrounding OVC (e.g. the OVC policy, OVC strategic plan, etc.) in order to ensure that OVC programs stand out and feed into GRZ national plans and financing systems. The program will aim to build the capability of relevant line ministries such as the MCDSS and MOE to ensure provision of quality services to children. This is essential to strengthening the government social protection system and developing the MCDSS OVC response structures as well as informal contributions made by communities. Furthermore, extending the capacity of community OVC response committees and working with political, church and community leaders as it relates to community care for OVC will aid in ensuring local ownership of OVC intervention programs. The PEPFAR Zambia support of income generating activities will provide a platform/vehicle by which vulnerable households and OVC can be weaned off external support programs thereby enhancing economic resilience. A platform will be provided for vulnerable households to have economic resilience through income generating activities so as to have the OVC weaned off the external support programs. It is expected that through this initiative OVC programs will become more integrated within existing district structures. Both government and NGOs are obliged to contribute toward building the capacity of these structures to ensure sustainability beyond the life of this program. The program will also contribute to sustainability of the HIV/AIDS OVC response in its work to solidify and reinforce critical networks through public-private partnerships.

Technical Area: Pediatric Care and Treatment

Budget Code

Budget Code Planned Amount

On Hold Amount

PDCS

5,491,314




PDTX

7,435,301




Total Technical Area Planned Funding:

12,926,615

0


Summary:

Context and BackgroundThis Technical Area Narrative (TAN) represents the combined Pediatric Care and Treatment Program Area, comprising Pediatric Care and Support (PDCS) as well as Pediatric Treatment (PDTX). Pediatric care, support, and treatment encompass health services for HIV-exposed and HIV-infected children. The combination of these two areas signals greater integration of pediatric clinical and community service delivery efforts by PEPFAR Zambia in an effort to promote HIV free infant survival. Since 2007, pediatric care, support and treatment has expanded significantly across Zambia The combined efforts of the USG and Government of Zambia (GRZ) have included: appointment of two Pediatric ART (P-ART) program officers at the Ministry of Health (MOH) with support from the Clinton HIV/AIDS Initiative (CHAI)l; Zambia National P-ART guidelines; development of Zambian Pediatric Training Manual and Mentorship guidelines, followed by a series of ongoing trainings for health care workers; Issuance of guidance, by the MOH, on routine provider-initiated testing and counseling (PITC) for all children in health care settings; revision of Integrated Management of Childhood Illnesses (IMCI) guidelines to include diagnosis and management of HIV; Improved availability of pediatric formulations at district level hospitals; and USG support for three Polymerase Chain Reaction (PCR) referral laboratories and training for collection of dried blood spot (DBS). Expanded links between PMTCT and pediatric care, support and treatment services have resulted in early initiation of P-ART to reduce infant mortality. Despite efforts to improve PMTCT program, links between PMTCT and pediatric care, support and treatment still need strengthening. Opportunities include linking mothers from clinical PMTCT to community-based care and support for people living with HIV/AIDS (PLWHA) and linking their infants to OVC care and support to promote long-term HIV-free survival. Changes for FY 2010 include: 1) the relationship of the TAN to the Partnership Framework for Zambia; 2) emergence of prevention as a top priority of PEPFAR; 3) a new National Prevention Strategy for Zambia which includes prevention of mother to child transmission (PMTCT) and other pediatric prevention measures; 4) new data on the Zambia HIV/AIDS epidemic from the 2007 Demographic Health Survey (DHS); 5) stronger pediatric clinic-community linkages, referrals, and retention in care; 6) increased access to Pediatric- Antiretroviral Therapy (P-ART ) for HIV-infected infants and children; 7) better monitoring and support of the growth and nutritional status of HIV-exposed infants; 9) improved P-ART adherence support; 10) improved treatment and prevention of opportunistic infections (OIs); 11) linkages to child survival interventions including strategic links to programs caring for orphans and vulnerable children (OVC); and 12) greater emphasis and efforts to improve the “quality of life” (i.e., improving the emotional and physical well-being of children born with or exposed to a terminal illness of HIV–exposed and HIV-positive infants and children.(Just to clarify further, studies have shown higher morbidity and mortality in children exposed to HIV (not just the infected ones), by virtue of having an ill mom/parents or being orphaned).The USG is working with government partners on a Partnership Framework. The GRZ has welcomed the concept and work on the document is in progress. Zambia’s National HIV/AIDS Strategic Framework (NASF) ends in 2010. Plans are underway to draw up the next five year NASF, which will tie in with the Partnership Framework. In FY 2009-2010 many major USG supported P-ART and care projects will end and new projects begin. PEPFAR Zambia will ensure a smooth transition without interruption in services. The challenge will be to maintain both the level and quality of client services. New projects will incorporate more emphasis on sustainability and building capacity of local partners including GRZ.The efforts of PEPFAR and other donor programs in past years have had a positive impact on the health of children in Zambia. The 2007 Zambia Demographic Health Survey (ZDH) showed improved indicators (compared with 2001 ZDHS) in child health, nutrition and HIV, including: • Infant mortality rate decreased from 95/1000 to 70/1000 in 2007• Under five mortality rate decreased from 168/1000 to 115/1000 • Basic Immunization coverage increased from 77% to 84% • Children under six months exclusively breast fed increased from 40% to 61% • Percentage of under-weight children under five decreased from 28 to 18% Current gaps include: inadequate long-term follow-up after delivery; lack of support for exclusive breast feeding and other health care for HIV negative but exposed children; and counselors inadequately trained to deal with the specific needs of children and adolescents. Prior year problems with shortages of P-ART drugs have been addressed (See HTXD TAN).USG Zambia has supported increased efforts in the Lusaka area, and elsewhere in Zambia, to improve infant and young child feeding training and guidance, though improvements are still needed. Of particular concern are infants whose mothers die or are incapacitated by HIV-related illness. Safe replacement feeding options for these infants, with adequate support for those responsible for feeding the infants, need to be designed, established, and monitored. Greater support for under 5 health interventions is needed to support long-term survival of HIV-positive and HIV-exposed children. These children require greater assistance with basic health needs. Stronger, earlier linking of these children from PMTCT to OVC care and support and other child health services will help ensure that they benefit from the full range of essential services for child survival. Poor male health seeking behavior ties into lack of adequate male involvement in health care and in the promotion of healthy pregnancies and births. One strategy for USG is to promote stronger health seeking behavior by men overall, with specific focus in the areas of pediatric support. Accomplishments since last COPChildren on treatment by the end of 2008 reached over half the estimated need -18,000 (out of an estimated 35,000). Cotrimoxazole prophylaxis and PCR testing for exposed infants at 6 weeks increased from 17% (2007) to 29% (2008) and 9% (2007) to 23% (2008), respectively. Improving upon the links and follow up between PMTCT and pediatric services, both the mothers’ antenatal cards and the children’s clinic cards (U5C) have been revised to include mother’s HIV status and follow up DNA PCR results on the U5C; revised cards have been distributed country-wide. In FY 2008, Zambia adopted WHOs recommendation to treat all infants below 12 months confirmed HIV positive. This has been followed by a second adoption (after much stakeholder consultation) resulting in the use of boosted Protease Inhibitor (PI) based regimens for infants exposed to Nevirapine (NVP) through PMTCT programs. Links between PMTCT and P-ART were strengthened in various ways. Partners are using pediatric peer educators to facilitate referrals and “escort” patients between services. Reduction in turn-around time for PCR results using innovative strategies have improved efficiencies, while protecting patient confidentiality. The Zambia National Food and Nutrition Commission, in conjunction with the MOH, USG partners, and others, have drafted guidance on “food by prescription” for clinically malnourished pediatric Pre- ART and ART patients. Revision of national Infant and Young Child Feeding (IYCF) clinical guidelines are near completion and work is underway on community IYCF guidelines. This will include more routine clinical monitoring of growth and nutrition status. (See OVC TAN for further description of activities).Trauma -Focused, Cognitive Based Therapy (TF-CBT) is a research-based method of assessing child counseling needs and providing targeted mental health services to HIV-positive children. In 2008-9, 40 counselors have been trained in TF-CBT They are focal points for referral of cases, serve as a pool of trainers, and provide therapy to clients in a TFCBT pilot now underway. Early reports indicate needs for pediatric mental health services exceed initial expectations. Another mental health initiative, Interpersonal Therapy in Group (IPT-G) focuses on depression in adolescence. Pilot efforts indicate 20% or more of HIV-infected or –affected adolescents may be depressed. Results of both these initiatives are expected in December 2009.Training in improved pediatric counseling is now available in Zambia, and supports communication between volunteer caregivers and parents with HIV positive children. Participants in TF-CBT are selected from among trained pediatric counselors. Such pediatric psychosocial support measures are required to support improved quality of life for pediatric clients, who experience a wide range of health and social challenges. The Palliative Care Association of Zambia has made headway in addressing pain management and use of morphine in hospices, including for children. In October 2008, the MOH authorized hospices to stock and dispense morphine. The needs for HIV positive physically disabled children have also been addressed through community based initiatives that provide palliative physiotherapy as close to home as possible and encourages community participation, learning and ownership. In July 2009, a pilot to integrate HIV testing and counselling services was carried out in three districts of Zambia. Over a thousand PCR tests were done and close to 1,500 rapid tests performed. The success of this initiative will be replicated in future Child Health Week activities and scaled-up to cover more districts.To date, Zambia has only developed general counselling and testing guidelines. In 2009, the Counseling and Testing technical working group (CT TWG) representing numerous stakeholders, has embarked upon developing specific child counselling and testing guidelines (incorporates adolescent). The USG, among other stakeholders, is participating in the process of creating these guidelines.Successful models for adolescent programs have been set up at major centers across Zambia. These are being replicated with more emphasis being placed on child friendly services at district hospitals. The preventive care package , designed to help prevent opportunistic infections in HIV positive infants and children, includes safe water through provision of chlorine and education on water treatment, safe storage and basic hygiene education. Other interventions include wrapping around the President’s Malaria Initiative (PMI) and National Malaria Center in the ongoing residual spraying program and supply of insecticide treated bed-nets (ITNs) for all pregnant women, their exposed babies and infected children. This has contributed to a national reduction in cases of malaria.(Again to clarify, Chlorine tends to help disinfect water, but in HIV infected individuals has the additional benefit of preventing Opportunistic diarrheal illnesses. Malaria and HIV has been debated and evidence that HIV infected individuals more prone to Malaria and complication related)Goals and Strategies for coming yearWith a strong Pediatric ART program (P-ART), Zambia now has large numbers of HIV positive children who have grown into their adolescent years. HIV prevention programs for this group are now a priority for many partners in FY 2010 plans. More efforts are also needed to prevent new infections among sexually active youth/adolescents. Improved efforts will be required to support pediatric adherence, for both the pediatric client and his/her family members and caregivers. Many partners have included infrastructure support to accommodate the needs of children/adolescents. The family support unit (FSU) model has been scaled up to encourage family based counselling and testing with greater involvement of fathers/men. In FY 2010, strategies will be employed to improve male involvement in the care of their children and families with more attention paid to prevention counseling in the context of the family, couple and individual. Roughly 30% of volunteer community caregivers are men, indicating that men can be persuaded to participate, if they are actively encouraged and supported to do so. In FY 2010, the MOH in partnership with stakeholders will revise the current pediatric treatment guidelines to reflect changes in the protocols first printed in 2007. Key changes will include guidance on DBS testing, treatment for all infants confirmed positive (<12 months) and boosted protease inhibitor based regimes for NVP exposed infants. In FY 2010, two additional PCR laboratories will be set at the Maina Soko Military Hospital and the PCOE in Livingstone General Hospital. These will serve the country’s military population, alleviate some logistical problems with transport to central laboratories and further expand national coverage.The USG will support a number of prevention messaging programs highlighting pediatric specific issues. These will also include job aids and flip charts for health care workers to provide basic package of care. In FY 2010, many more partners have recognized the need to address and expand programs to prevent child sexual abuse, including community sensitization, engaging leadership, teaching children their rights and access to early and effective post-exposure prophylaxis for abused children. Another area that was successfully started in FY 2009 and will be expanded in FY 2010 is the community-led integrated management of childhood illnesses. This equips community health workers with skills for early identification and management of childhood illnesses and appropriate referral to counselling, testing and ART services.

Technical Area: PMTCT

Budget Code

Budget Code Planned Amount

On Hold Amount

MTCT

25,298,000




Total Technical Area Planned Funding:

25,298,000

0


Summary:

Context and BackgroundThe goal of prevention of mother to child transmission of HIV (PMTCT) is to achieve HIV-free survival of children through quality, comprehensive services including: universal testing and counseling of pregnant women and their partners; the timely use of efficacious antiretroviral drug (ARV) regimens for HIV infected women and their infants; identification of discordant couples to prevent family transmission of HIV and prevention messages for negative mothers and couples; appropriate feeding practices for infants; and quality care for mothers during pregnancy, childbirth, lactation and linkages to reproductive health and HIV care and treatment services for mother and baby. Early infant diagnosis is part of this critical package but is discussed in the pediatric care and treatment section. The United States Government (USG) in partnership with the Government of the Republic of Zambia (GRZ) will in FY 2010 focus on strengthening the entire PMTCT program to ensure that optimal implementation of the PMTCT protocol guidelines and strategy. By 2009, 933 of the 1,281 antenatal clinics nationally provide PMTCT services; in the FY 2008 APR 785 of these sites (84%) were supported by PEPFAR through implementing partners or direct support to GRZ. In FY 2008, 386,031 pregnant women received testing and counseling services with support from PEPFAR, which represents 80% of an estimated 483,000 antenatal clinic (ANC) attendees nationally.The core activities implemented by PEPFAR Zambia partners for PMTCT are: antenatal care with routine ‘opt out’ HIV testing; provision of ARVs for PMTCT as per updated national GRZ protocols guidelines of a more efficacious regimen comprising Zidovudine, Nevirapine and a Lamivudine tail; increase male involvement in PMTCT; couples counseling; work with mother support groups; malaria in pregnancy interventions (working with the President’s Malaria Initiative (PMI) program); labor and delivery management, post-natal mother and baby follow-up with early infant HIV diagnosis; linkages to care and support for both mother and baby; family planning; infant and young child feeding counseling; community support including male involvement in PMTCT; infection prevention for health workers; and, reporting and data collection activities. Some partners piloted the provision of performance-based financing directly to selected districts, as a means to increase district health office ownership of the program. Despite high rates of testing nationally, only about 10% of partners/couples are tested. The National PMTCT Policy recommends retesting of pregnant women after 3 months prenatally and postpartum; although national data are not available, there is a high incidence of HIV infection in women during pregnancy and lactation and this contributes substantially to PMTCT failures. Partner testing, especially among couples, has been promoted, but few facilities have had great success. Luapula Province has been the exception, with rates of partner testing reaching 66% in the second quarter of 2009, mainly because the strategies employed utilize traditional chiefs and community leadership as well as scaling up the men taking action tool kit; isolated clinics in Western Province have achieved over 80% partner testing but only 14% of partners are tested in the province. Community leadership to make partner and couples testing a social norm and standard of care seems a critical ingredient to this success. Training of trainers in couples counseling has been completed in all provinces during 2009. In FY 2010 PEPFAR Zambia will intensify efforts through community approaches and facility practices to ensure near universal testing of pregnant women attending ANC and high rates of partner testing. The USG plans to establish community compacts that provide additional support and incentivize success in reaching 95% testing in pregnant women and 80% partner testing.Antenatal sentinel surveillance in 22 selected site s has demonstrated a decline in the HIV infection rate in pregnant women, from a peak of 20% in 1994, 19% in 2004, and 17% in 2008. These declines have been greatest in younger women, suggesting modest success in prevention programs in these age groups. The number of HIV infected women who received ARV for PMTCT at PEPFAR-supported sites was 42,869 in FY 2008. The DHS 2007 estimates that of those mothers who gave birth in the last twelve months preceding the survey, HIV prevalence was 18 – 19% in the 25-29 and 30-34 age groups respectively. About one-third of eligible pregnant women do not receive ARV. For HIV infected women, Zambia adopted a policy of initiating high active antiretroviral therapy (HAART) for pregnant women with CD4 counts below 350, with two drugs for those with higher CD4 counts, however about 40% of pregnant women still receive single dose Nevirapine, either due to lack of staff to perform clinical assessment, lack of timely access to CD4 measurement, or because women come in very late in pregnancy. Most sites refer pregnant women to a registered ART site for assessment to initiate HAART, and many women do not complete the referral. Some implementing partners have piloted bringing ART clinicians to ANCs or other mobile services. Nurse midwives, though experienced in PMTCT, require additional training and certification by the Zambia Medical Council so they can prescribe HAART. An objective of PEPFAR support for FY 2010 is to strengthen these systems to provide access to timely HAART to at least 20% of all HIV infected pregnant women (approximately 30% are eligible based on CD4<350) and to reduce the number of sites that are offering only single dose nevirapine to less than 10%. In effect, PMTCT sites need to be adjunct ART sites, since referral of pregnant women to distant sites will not result in prompt initiation of HAART. Delivering CD4 results to the antenatal clinic will require improvements in the laboratory logistics and information systems. A courier system is in place to link ANCs with the 131 laboratories with CD4 capacity, but this has not succeeded in providing timely results on a consistent basis. The use of specimen tubes with fixative to allow stable CD4 measurement for 7 days rather than the current 2 days is being validated at this time in Zambia. This will allow the expansion and improvement of the courier system for centralized testing, in order to provide CD4 services to the most remote ANCs. Laboratory manpower is limited in rural facilities and the capital and maintenance costs of equipment and the human resource training and deployment costs of expanding CD4 capability at rural sites would likely be prohibitive and unsustainable. Centralized testing will maintain quality at lower cost; a central laboratory with high output in Lusaka provides nearly 200,000 CD4 per year at a comprehensive program cost of less than $3 per test.New international guidance is expected regarding ARV use for mother and baby in the postnatal period. We anticipate that Zambia policy will quickly adopt best practices, as it has in the past. Working with the MOH leadership, the Churches Health Association of Zambia (CHAZ) and the National PMTCT technical working group, the PEPFAR Zambia team will seek to support rapid implementation of regimen modifications through ARV procurement and training. Continuity of care for HIV infected women through pregnancy, childbirth and lactation requires strengthened systems and linkages between ANC, maternity units, and maternal and child health (MCH) clinics within existing PMTCT facilities and with ART facilities for ongoing care and treatment of infected mothers and infants. Prevention of unwanted pregnancies among HIV-positive women is a key goal of the national program. In FY 2010, PEPFAR Zambia will strengthen wrap-around activities with safe motherhood, family planning services and the safe water program. More specific maternal focused clinical services in the MCH clinic will also help and a continuity of medica l record is important for quality of care of HIV infected mothers. Zambia introduced a standardized, national electronic or paper medical record (SmartCare); while it covers the majority of those attending ART clinics, it has not expanded to as many PMTCT sites. In FY2010, the SmartCare modules for ANC and MCH will be modified to capture new regimens and rolled out to additional clinics and other monitoring systems will be merged with SmartCare. Continuity and portability of medical information for mothers and infants will allow better linkages to care and treatment programs while this system can also better capture national data, particularly regarding ARTs and outcomes, in addition to improving quality of data. However, SmartCare will not be funded in FY 2011 unless the GRZ or other donors come forward to support the system nationwide.. The early infant diagnosis (EID) program uses three central laboratories for polymerase chain reaction (PCR) testing and postal services to deliver dried blood spot specimens for testing. Expansion of coverage so that more infants are tested is discussed in the pediatric care and treatment program. A significant proportion, possibly one-fourth, of current infant infections comes from women who become infected during pregnancy and lactation. The reasons for this are complex and not fully understood. Physiologic vulnerability during pregnancy and the peripartum period contributes to HIV transmission. With low levels of partner testing, discordant couples are not identified. Better understanding of sexual practices during pregnancy and the barriers to partner/couples testing will assist program improvement; an evaluation of these issues will be proposed in FY 2010. Couples testing presents as an opportunity to provide HIV prevention messages for the reduction of multiple partners, the use of condoms during pregnancy to protect against HIV and other STIs, and most of all to identify discordant couples. Lack of partner testing may also contribute to women being non-adherent to ARVs prescribed during pregnancy. Without disclosure of HIV status, family support is lacking for women taking ARVs to protect their fetus and infant. Therefore the overall effectiveness of PMTCT may be significantly limited by the lack of a family and community approach. A community compact approach is being developed to work with communities to reduce incidence of HIV in geographic communities and organizations. This approach will engage community leaders to change social norms and will incentivize successful reduction in incidence with beneficial community programs. A key starting point will be high rates of testing of individuals and especially couples in these communities, and high rates of retesting to identify new HIV infection. One type of community is represented by pregnant women and their families attending an ANC. The high incidence in pregnancy and lactation makes this a natural high risk group where regular testing is the standard of medical care. Women who test negative during pregnancy are retested every 3 months; identifying discordant couples would help to prevent such incidence, not just detect it. Facility incentives, such as priority for electrification, staff housing improvements or other community strengthening projects would provide a double benefit, in addition to lowering the burden of HIV in both the children and adults.In FY 2010, the PEPFAR Zambia and its partners will work intensively to link PMTCT, OVC, both adult and pediatric care and support activities more closely in order to facilitate the early identification, care and treatment of HIV positive infants and children. Clinic-based programs like PMTCT will refer clients to community-based programs such as OVC and care and support, so that trained community caregivers can follow up and screen HIV exposed infants for potential danger signs such as growth faltering, and refer them for pediatric testing. Community caregivers may also be linked directly to the pediatric te sting initiative once the GRZ authorizes them to collect dried blood spots (DBS) for analysis. These strengthened community-to-clinic links will facilitate improved child survival outcomes for HIV-exposed and HIV positive children under five. As part of the increased clinic-community linkages, PEPFAR Zambia will support implementation of the revised national Infant and Young Child Feeding (IYCF) guidelines. Since few mothers meet acceptable, feasible, affordable, sustainable and safe (AFASS) criteria for replacement feeding, promotion of exclusive breast feeding to six months is the safest alternative for the majority of infants. Improved training for health workers and community volunteers will enable them to counsel mothers more effectively and support mothers’ decisions to breast feed. Teaching mothers the proper preparation and use of complementary feedings will reduce the harm done by abrupt weaning without sufficient establishment of alternative feeding. Two infant feeding issues of particular concern are: 1) HIV mothers whose infants test HIV negative at six weeks apparently have been shifting to replacement feeding out of fear of infecting their infants; and 2) infants of mothers who have died or been incapacitated through HIV/AIDS require access to safe replacement feeding options. Therefore, some form of reliable external support for safe feeding in cases of maternal death or incapacity is required. In addition to developing the Partnership Framework agreement and ongoing collaboration with the Ministry of Health, USG will continue to work with the Global Fund for AIDS, TB and Malaria, the United Nations Children’s Fund (UNICEF), World Health Organization, World Bank, UK Department for International Development (DFID), Japan International Cooperation Agency (JICA), Irish Aid, World Food Program (WFP) and Medecin sans Frontieres and other partners to provide technical and financial support. As Zambia develops its Partnership Framework and designs new 5-year HIV/AIDS and Health strategic plans in 2010, there will be expanded opportunities for successful partnership to reduce mother to child HIV transmission and to achieve HIV-free survival in children.

Technical Area: Sexual Prevention

Budget Code

Budget Code Planned Amount

On Hold Amount

HVAB

16,337,628




HVOP

15,058,137




Total Technical Area Planned Funding:

31,395,765

0


Summary:

Context and BackgroundZambia faces a generalized HIV/AIDS epidemic with about one in seven adults infected (14.3% - 2007 Zambia Demographic Health Survey) and women disproportionately impacted at 16.1%, compared to 12.3% of men. According to a June 2009 joint National AIDS Council (NAC)/UNAIDS report (Zambia HIV Prevention Response and Modes of Transmission Analysis), the following represents the state of the epidemic in Zambia:Despite significant decreases in some populations and geographic areas, Zambia‘s HIV epidemic has stabilized at high levels. Overall adult prevalence is 14%, and 1.6% of the adult population becomes newly infected each year. In 2009, that will mean approximately 82,681 new adult infections. More effective prevention is imperative and essential for achieving and sustaining high rates of access to ARV treatment. Using the UNAIDS/NAC incidence model, 71 of 100 new HIV infections are estimated to occur through sex with non-regular partners, including being, or having a partner that has another sexual partner. Substantial percentages (21%) of new infections are estimated to occur in people who report that they have only one sexual partner. This signals significant HIV risk even for those who are faithful, given large numbers of couples in which one person is HIV-positive. Low levels of male circumcision, inadequate condom use, and a range of social norms increase risk and help drive Zambia’s varied epidemic. This conclusion is supported by evidence which suggests that while HIV prevalence levels have decreased, the number of absolute new infections has not decreased due to Zambian population growth. In light of Zambia’s HIV/AIDS epidemic and the need to decrease new HIV cases, USG began supporting the NACs efforts to develop a National HIV Prevention Strategy in 2008. The strategy served to kick-start a reorientation of the PEPFAR portfolio continuing through 2009, with a large scale refocusing to intensify prevention efforts and strengthen linkages between prevention and other key, high-impact interventions. PEPFAR program initiatives are aligned with both the National Prevention Strategy and the overarching Zambia National AIDS Strategic Framework (NASF) for 2006-2010. The USG utilized a series of internal and partner-driven focus groups bolstered with expertise from OGAC, USAID and CDC across a broad range of topic areas. The main foci of these were to: • Identify missed opportunities for greater linkages between prevention and other HIV and health activities;• Recommend ways to balance USG prevention, treatment, and care efforts; • Identify themes for positive behavioral change messages for reaching wide audiences; and, • Suggest ways to reflect a greater focus on prevention into the Partnership Framework In late FY 2009, Embassy Lusaka initiated discussions with the Government of the Republic of Zambia (GRZ) for development of a Partnership Framework and Implementation Plan (PF and PFIP respectively). The focus has evolved to support the design of the 2011-2015 National AIDS Strategic Framework. As such, the GRZ NASF will serve as the basis for the USGs PFIP and will encompass a concerted and enhanced focus on HIV prevention. The current NASF and PEPFAR Zambia Strategy jointly prioritize: a comprehensive, combination prevention strategy promoting abstinence, partner reduction, and mutual fidelity among young people aged 10-25 and adult men and women; counseling and testing and follow-up for discordant married couples; increasing the availability of condoms; addressing male norms, gender and sexual violence; improving timeliness and effectiveness of STI treatment; promoting behavior change communication (BCC) and education; promoting post-exposure prophylaxis (PEP); substance abuse prevention and treatment; scaling up male circumcision; and creating linkages to other HIV/AIDS services. Additional Context and BackgroundZambia’s epidemic trends highlight the need to intensify prevention to mediate sexual transmission combining biomedical, behavioral, and structural interventions to address factors at multiple levels. The 2007 Demographic Health Survey outlined the extent to which particular factors at the individual/couple, community, and population levels increase risk and drive Zambia’s varied epidemic. Noted factors at the individual/couple level include: • Extensive multiple and/or concurrent partnerships (MCPs): 14% of men reported MCPs in 2007, though studies suggest under-reporting of these partnerships;• Low condom use: 27% of men reported using condoms in MCPs, with lower proportions in other types of relationships; and,• Low levels of male circumcision (MC): While high levels of MC occur in two provinces that traditionally practice circumcision (Northwestern: 71% and Western: 40%), reported MC across Zambia remains low (13%).Factors at the community level include harmful cultural practices (e.g., dry sex, sexual inheritance, sexual cleansing), age/wealth disparate and other transactional relationships, gender-based violence, and alcohol abuse. Factors at the population level include migration for temporary and seasonal employment and effects of gender-based discrimination.As the largest international donor of HIV and family planning commodities, the USG has supported Zambia in ensuring the availability of male and female condoms. As a result of social marketing efforts, the USG has ordered 23 million male condoms for distribution during FY 2010, meeting 44% of Zambia’s need, inclusive of supplies as buffer stock. An additional $400,000 to purchase female condoms in FY 2010 has also been requested. The GRZ has varied laws and policies that affect MARPs and other vulnerable populations. Commercial sex and sex between men remains illegal and taboo, driving these sub-groups “underground”, consequently, the “hidden” nature of these sub-groups increases the difficulty in reaching them for surveillance purposes or prevention activities. Nonetheless, the national HIV/AIDS policy framework acknowledges the importance of addressing the needs of sex workers and MSM. The framework also supports interventions for other MARPs and vulnerable groups, such as migrant workers and military personnel. COH II has carried out interventions targeting female sex workers and long distance truck drivers in border posts and selected inland towns. These interventions have been evaluated through periodic BSS, the most recent (2009) showing that: among FSWs: consistent condom use is low; alcohol consumption is on the rise and there are gaps with regard to comprehensive knowledge of HIV transmission.Accomplishments since last COPBy September 2008, almost 1,487,350 individuals were reached with AB messages; 24,390 trained as peer educators; and 1,166,282 individuals reached with other prevention messages. Despite significant ABC prevention achievements, challenges remain with regard to limited local implementing partner capacity, high attrition of peer educators, low condom uptake, and accessing hard-to-reach populations in rural areas. In 2009, PEPFAR Zambia will reach 2,865,742 and 1,124,816 individuals with AB and A-only messages respectively, and 732,750 with other prevention activities. An estimated 330,000 female and 15,500,000 male condoms will be distributed through 2,641 outlets including social marketing entities, and private and public sector health facilities. The USG will train 5,590 and 12,039 individuals to provide other prevention and AB messages. The 2009 SAPR confirms that the US Mission is on track for meeting these targets.Goals and Strategies for the Coming YearPrevention activities meet specific needs of the target populations, integrate biomedical, behavioral, and structural interventions, and respond to key drivers of Zambia’s epidemic. They will:• Reduce MCPs by increasing targeted messaging and counseling, and engaging communit ies (e.g. community leaders, gate keepers, and facilitating “Community Conversations” on issues of MCP and HIV transmission),• Increase acceptability, availability, and correct and consistent use of male and female condoms; and,• Reduce HIV risk among sex workers, MSM, migrant workers, military personnel, and other MARPs.The GRZ has developed a legal and policy framework that supports national prevention efforts. In response, the USG has supported the GRZ to develop the National Strategy for the Prevention of HIV and AIDS 2009. This document identifies the “prevention of sexual transmission” as the top core strategy. The USG has oriented prevention activities to support implementation of this strategy through the following:• Expansion of evidence-based prevention for youth;• Expansion of STI prevention efforts;• Addressing alcohol abuse;• Expansion of couples counseling and testing efforts;• Integration of HIV prevention messaging and counseling into other HIV/health services (such as Testing and Counseling and Family Planning, and specialized clinics); • Targeting at risk populations with more accurate and focused messages;• Development of linkages with community groups to ensure follow-up and continued contact with negatives;• Prevention with PLWHA by:o PLWHA support group formation in communities o Discordant couples counseling regarding prevention and condom use; and • Building capacity of health care providers in prevention and TC by:o Providing routine Prevention messages and TC to new and/or all patients o Providing diagnostic TC for patients at risk of contracting HIV or uncertain of their HIV statuso Making HIV status part of routine History taking in patientso Expanding MC availabilityo Implementing community compactso Enhanced engagement of government leadersUSG-supported prevention efforts will also feature activities that:Intensify prevention efforts aimed at reaching men in the general population. Efforts will target sub-groups of youth (ages 15 – 24) and adults (older than 24) to meet their unique needs. Activities for all men will address sexual risks (e.g., MCPs), behavioral triggers (e.g., alcohol abuse, peer pressure), and harmful social and gender norms; those for young men aim to delay sexual debut by empowering them around their values, aspirations, and expectations. Activities for adults as well as high-risk and sexually active youth will promote secondary abstinence, mutual monogamy, partner reduction, correct and consistent condom use, and responsible alcohol consumption. Reduce transactional sex, sexual coercion, and gender-based violence. PEPFAR Zambia supports the design of interventions to reduce age/wealth disparate relationships and intimate-partner violence based on formative assessments. These will focus on targeted interventions and prevention messages to empower women with safer sex negotiation skills while ensuring that men’s values and social norms that promote trans-generational sex are addressed. During FY2010, PEPFAR will work with the Women’s Justice and Empowerment Initiative (WJEI) to establish DNA testing capacity thereby enabling law enforcement agencies in the prosecution of gender-based violence (GBV) cases, thus deterring GBV- a significant contributor to new HIV infections. PEPFAR Zambia support will provide training to law enforcement in carrying out forensic examination and analysis- building human resource capacity, improvements to facilities, and education about human rights and victims’ services to the general public. Additionally, assessments will be conducted to examine the networks of men and women in transactional sex and describe attitudes toward and determinants of these relationships. Efforts to reduce transactional sex aim to decrease HIV acquisition attributable to casual heterosexual sex, which accounts for approximately 71 % of new infections among Zambians. Direct efforts toward “bridge” sub-groups in the general population engaging in risky behaviors. Specific activities will reduce high levels of unprotected sex between sex workers and their regular clients and steady boyfriends. The USG will leverage these activities as a platform to highlight condom use for greatest impact, such as preventing HIV/STI transmission among casual sexual partners and discordant couples and unintended pregnancies among HIV-positive women.Provide a comprehensive range of HIV prevention services to MARPs and other vulnerable populations. Aligning with the national prevention strategy and building on evidence from current programs, USG efforts will provide tailored core packages of services to meet the unique needs of MARPs. Provide access to prevention of risky sexual behaviors attributable to alcohol and drug use. The USG will support prevention at the primary, secondary, and tertiary levels. Primary prevention will promote responsible alcohol consumption and deter drug abuse, encouraging behavioral change (e.g., peer outreach and education and communication campaigns highlighting the risks of alcohol/drug abuse) and create an enabling environment (e.g., enforcement of laws and social norms on alcohol sale and consumption). Secondary prevention will detect and reduce the propensity of alcohol/drug abuse, particularly those who engage in risky sexual behaviors, through screening, testing, and counseling. Tertiary prevention will entail expansion of support services for abusers of alcohol and drugs to manage their addictions.Direct efforts toward persons who test negative. HIV counseling and testing will be utilized to emphasize “prevention with negatives”. Persons who test negative will be linked to community groups in an effort to support behaviors that keep such persons negative. Focused messaging via national and regional campaigns will be designed to reinforce behaviors that keep persons negative.Mobilize moral and traditional authorities, including religious leaders and local chiefs to lead HIV prevention discussion. This includes facilitating political leadership to produce a broad, national consensus, reinforcing approaches to HIV prevention.Explore advances in prevention programming. Novel approaches include use of “community compacts,” or agreements directly with communities that reward them for meeting HIV prevention benchmarks.

Technical Area: Strategic Information

Budget Code

Budget Code Planned Amount

On Hold Amount

HVSI

15,975,000




Total Technical Area Planned Funding:

15,975,000

0


Summary:

Context and BackgroundStrategic Information (SI) efforts in Zambia focus on aspects of sustainability that cross all program areas: human resource capacity development, institutionalization of information systems, and establishing informatics infrastructure; all of which will remain with the country after PEPFAR. Zambia’s institutionalized information systems have developed markedly in the last five years. Notably, the Ministry of Health’s (MOH) Health Management Information System application called ‘HMIS’ has been updated and rolled out to all 72 districts of Zambia. SmartCare, the MOH electronic health record system (EHR), is integrated with the HMIS, and in 2006, the MOH identified SmartCare as the national electronic clinical information system for any clinic capable of sustaining computer equipment but provided no funds. NACMIS, the National AIDS Council’s new management information system has begun integration of inputs from 12 separate information streams, including HMIS and SmartCare. PEPFAR Zambia continues to strengthen the GRZ through the Ministry of Health, the Zambia Defense Force, the Central Statistical Office (CSO), the University of Zambia (UNZA), national laboratories, the National Blood Transfusion Service (NBTS), and the National HIV/AIDS/STI/TB Council (NAC), to integrate national systems and develop human resource capacities to collect, manage, analyze, and use data. For PEPFAR-specific purposes, ZPRS is the partner reporting system. Several enhancements are being developed that will facilitate the use of data by partners. Regular trainings on planning and reporting are conducted with a focus on data quality and utilization for program improvement. The PEPFAR Zambia SI team comprises surveillance, management information systems (MIS), and M&E experts from all five U.S. agencies working in-country: USAID, CDC, Peace Corps, DOD, and State. The SI team works as a collaborative, consensus-based team to guide all SI and SI-related activities. The team meets weekly, and there are SI representatives on each programmatic technical working group (TWG). Members of the SI team sit on GRZ TWGs for M&E, surveillance, geographical information systems (GIS), OVC, PMTCT, HMIS, and others, convened by the NAC and MOH. SI team representatives will continue to work closely and collaboratively on all national SI activities and priorities. Supported SI activities in Zambia include in general terms: improving information systems infrastructure and management; upgrading quality assurance procedures; providing essential staff training and support; and providing technical assistance in developing sustainable systems and workforce in the areas of monitoring and evaluation (M&E), epidemiology and surveillance, scientific research methods, health information systems (HIS) including electronic health records (EHR), and information and communication technology (ICT). Specifically, PEPFAR Zambia has been a key partner of the GRZ in the implementation of HIV/AIDS-related surveillance, including the 2006 and 2008 Antenatal Clinic Sentinel Surveillance (ANCSS) which included 3 UNHCR refugee camps, the Zambia Sexual Behavior Survey (ZSBS), the 2007 Demographic and Health Survey (DHS), the results from the 2005 Zambian Sexual Behavior Survey (ZSBS), two PLACE studies, and the 2005 Service Provision Assessment (SPA), in addition to the national routine information systems (HMIS, SmartCare) already mentioned. Currently, Zambia satisfies reporting requirements (including those of UNGASS and the Global Fund to Fight AIDS, Tuberculosis and Malaria) on a national level through a combination of NAC, MOH, and donor reporting systems.As Zambia is becoming a nation relatively rich in data for decision-making, human capacity development in use of such strategic information is increasingly important.Accomplishments since Last COPIn FY 2009, PEPFAR Zambia support ed implementation of the 2008 Sexual Behavior Survey, secondary analysis of the 2007 ZDHS, continued implementation of a system to monitor HIV drug resistance emerging during treatment, and further built capacity in innovative geographic mapping and spatial analysis, data management, statistical analysis, and scientific writing. SmartCare, the national EHR, has now been deployed to 520 of the largest facilities – 373 of which were done solely with the expertise, staff, and logistics support provided by the MOH. SmartCare has been deployed in one tertiary hospital by the Ministry of Defense, and seventeen clinics and hospitals by private organizations.By early 2008, SmartCare was deployed in at least one facility in all 72 districts in Zambia, following trainings for provincial and district level leadership. This was part of the implementation of a provincial led ‘training of trainers’ deployment cascade. Use of existing personnel for training and data entry has been a successful strategy for improving sustainability. Anti-Retroviral Therapy Information System (ARTIS), ‘paper system’ sites are being converted as infrastructure permits, but will continue to precede SmartCare as ARTIS first moves into more rural areas. In FY 2008, all remaining sites using CareWare were successfully converted, and Pediatric HIV specialty services were initiated. Pharmacy dispensation was enhanced to capture sufficient detail to support automated drug supply chain management linkages, which is now being piloted. Initial supportive supervision has been provided to all these facilities, but ongoing supervision is required. Other parties have contributed modest funding to deploy and supervise more sites (Global Fund, UNICEF, and WHO). Unless the GRZ or other donors provide funding to take SmartCare nationally, the USG will not continue funding it in FY 2011. PEPFAR is collaborating with WHO and other stakeholders in a number of surveillance activities including ANCSS, Zambia National Cancer Registry and HIV Drug Resistance in ANCSS among others. PEPFAR is an advocate for international standards in monitoring and evaluation through the NAC. It collaborates with partners including UNAIDS, WHO and GFATM, for instance: the implementation of the WHO Early Warning Indicator Report (EWI); and, the implementation of the UNAIDS HIV Data Security and Confidentiality Guidelines. Zambian reference labs and other supported partners finalized testing for a proportion of recent HIV infections, to estimate HIV incidence in Zambia from 1994 through 2004; completed HIV and HSV-2 incidence estimates in migrant farm workers; strengthened surveillance of AIDS-related malignancies; conducted the 2008 ANCSS; and implemented HIV drug resistance surveillance in antenatal clinics. The Central Statistics Office (CSO) expanded the Sample Vital Registration with Verbal Autopsy (SAVVY) System for monitoring mortality in selected regions in Zambia, to validate the data capture instruments, and to evaluate the SAVVY implementing process. Partners working with the MOH in Zambia provided technical assistance to build government capacity to use geographic information systems (GIS) for planning and monitoring interventions; GIS capacity is now linked to both static information (population, DHS, and ANCSS statistics) and real-time clinical care data in SmartCare. This linkage has provided easy to understand visuals to leverage the utility of the EHR system, available in over 500 locations at facility and district levels, as well as nationally.Between FY 2006 and FY 2009, over 400 Zambian student professionals and MPH students were trained in M&E skills. This has increased the overall cadre to support a number of local organizations implementing HIV programs in Zambia for improved quality of data for decision making.There were very few changes in the USG SI staff in FY2009. USAID had one movement of an SI member who left the agency, as did CDC. Goals and Strategies for th e Coming YearThe primary goals for the coming year are to: implement, integrate, and continue to institutionalize sustainable SI systems; triangulate and strengthen the use of data for programmatic decision-making and improved quality of HIV/AIDS services and activities; build infrastructure that supports effective SI systems; and train Zambian professionals to help ensure the sustainability of activities in the SI technical area. As part of the strategy to increase local capacity for systems sustainability, PEPFAR Zambia will support the training of people in SI and provide technical assistance to organizations. Through technical assistance to NAC, capacity will be developed at the national, district and community levels through focused training and mentoring visits.The Zambia Partner Reporting System (ZPRS) will be updated to ensure that it increase the capacity of partners to not only upload but also view their own and national level indicator and spatial data. Increasingly, the USG has been shifting the task of uploading data to the partners. More and more partners are beginning to use the ZPRS for deciding geographical program expansion in relation to similar PEPFAR Zambia funded activities. In FY2010 developments will be aimed at designing and enhancing features that foster sustainability. The first step will be to share ZPRS with NAC for possible adoption to enhance district level results reporting.Working together with other partners, PEPFAR Zambia will continue to provide financial and technical support of national priority surveillance activities to the MOH, Tropical Diseases Research Centre, CSO, UNZA, University Teaching Hospital, and the Zambia National Cancer Registry. Surveillance activities will include reporting of the 2008 Sentinel Surveillance and HIV Drug Resistance in Sentinel Surveillance 2008, and expansion of the Sample Vital Registration with Verbal Autopsy (SAVVY) to strengthen vital registration systems in regions of Zambia. FY 2010 funding will support plans for new HIV surveillances, including development of a population based AIDS indicator survey, and surveillance of HIV in children, and will continue to support strengthening of local capacity to collect, analyzing and report surveillance data through training and implementation of partnerships for ongoing and new surveillance activities.Support of NACMIS will emphasize M&E and data use capacity-building at the provincial, district and community levels. NAC, working together with NASTAD, SHARe and UNZA M&E program, will train community, district, provincial and national level NACMIS contributors to analyze and use data generated through NACMIS. In FY 2010 NAC will be supported to review and update the national M&E plan as the current one ends in 2010. Other related activities will include support of the collection of data during the Joint Annual Program Review. Information from this exercise is not only useful for decision making at the national level but also feeds into relevant global reports such as the UNGASS report.The MOH says it will continue to implement the SmartCare EHR, increasingly in rural clinics, and in the remaining clinical services for clinics with initial deployments, but this may not occur if MOH 2010 funding is reduced from the 2009 level. The goal for FY 2010 is to proceed at a sustainable rate to 90% of the rest of the clinics that today have electrical capacity to sustain implementations, allowing sufficient time for existing staff to build the essential computer literacy through practice with initial deployed services, and for good processes to be established. SmartCare will provide information for 75% of the applicable and required PEPFAR indicators for populations fully using the EHR - as a routine effect of the necessary documentation of preventive and clinical services. This provides an efficient means of evaluating ongoing operations of the EHR. ZPRS, NACMIS and the MOH/SmartCare systems, with increasing support for training in data use, present good opportunities for further systems integration and decision-making support.

Technical Area: TB/HIV

Budget Code

Budget Code Planned Amount

On Hold Amount

HVTB

10,066,000




Total Technical Area Planned Funding:

10,066,000

0


Summary:

Summary StatisticsTuberculosis (TB) is a major cause of morbidity and mortality in Zambia. The burden of TB has increased five fold from a case rate of 105 per population of 100,000 people in 1985 to 506 in 2007. The estimated incidence of all forms of TB in Zambia in 2007 was 60,337 (506 TB cases per population of 100,000 people). In 2007 the country notified 50,415 cases of all forms of TB (389 cases per population of 100,000 people). The estimated sputum smear positive TB cases in 2007 was 22,956 (193 cases per population of 100,000 people) and the country notified a total of 13,378 sputum-smear positive TB cases (112 cases per population of 100,000 people). TB case detection improved from 52% in 2006 to 58% in 2007 (WHO, 2009)The upsurge in TB notifications is attributed to the high prevalence of HIV, which stands at 14.3%. It is estimated that up to 70% of all TB patients are co-infected with HIV. In 2008, a total of 30,654 (65%) of all notified TB patients were counseled and tested for HIV and 20,839 (68%) were HIV positive. TB Control in ZambiaTB control in Zambia is implemented by the National TB and Leprosy Control Program (NTP), which falls under the Directorate of Public Health and Research within the Ministry of Health (MOH). The NTP has three main organizational layers namely, the national, provincial, and district levels. The national level of the NTP has three government supported staff and a TB/HIV coordinator supported by the United States Government (USG) and a data management specialist supported by the Royal Dutch Anti-Tuberculosis Association (KNCV) (using other donors’ funds). At the provincial level, TB control is overseen by a disease control specialist, who also oversees control of other communicable diseases. District level TB efforts are overseen by a district TB/Leprosy focal point person. Provincial disease control specialists and district TB/Leprosy focal point persons are employed by the MOH. The main goal of the NTP is to reduce morbidity, mortality and the socio-economic burden associated with TB (so that it would no longer be a major public health problem). The key objectives of TB control are to detect at least 70% of infectious TB cases, cure at least 85% of TB patients, and reduce the prevalence of TB by 50% by the year 2015.Partner support to the NTPNTP activities are implemented within the conceptual framework of the Zambia National Health Strategic Plan (NHSP) 2006-2010. All partners providing support to the NTP implement activities of the NHSP 2006-2010. The NTP implements TB control activities with technical and financial support from donors and cooperating partners, including Japan International Cooperation Agency (JICA), the Global Funds to Fight HIV/AIDS/TB and Malaria, the Royal Dutch Anti-Tuberculosis Association (KNCV), and the United States Government (USG) through PEPFAR and non PEPFAR funds. PEPFAR provides support in TB/HIV to the NTP at the national level and to four of the nine provinces of Zambia through. Non PEPFAR USG funds support TB control efforts in the other five provinces through the Tuberculosis Control Assistance Program (TBCAP). The MOH ensures that there is no overlap or duplicity of activities among the partners.Policy environmentThe policy environment for implementing effective management of the TB/HIV co-morbidity in Zambia is good. Zambia has developed and implemented guidelines to effectively manage the TB/HIV co-morbidity, including provider-initiated testing and counseling (C&T) for HIV for all TB patients, linking all HIV-infected TB patients to HIV treatment and care services ( including cotrimoxazole prophylaxis), and screening HIV-infected patients for TB. In FY 2009, the USG supported the MOH to 1) revise the facilitators’ manual for training TB treatment supporters and 2) develop and print national TB/HIV infection control guidelines and MDR-TB treatment guidelines. In FY 2010, the USG will provide support for the development of the Intensified TB case finding guidelines and TB infection control training materials. The USG will also support Zambia to revise TB treatment guidelines to change from an eight month to a six month regimen. Under the stewardship of the NTP, the US Mission and other donors have supported Zambia to establish TB/HIV coordinating bodies at the national, provincial, and district levels since 2006. In FY 2009 TB/HIV coordinating bodies met on a quarterly basis to review and use data to inform programming for results. In FY 2010, the USG will support the Ministry of health to strengthen the national, provincial, and district coordinating bodies and establish health center and community level coordinating bodies. With support from USG and other donors, Zambia revised TB data collecting tools to include HIV variables in 2006. Over the last three years, PEPFAR Zambia has supported the NTP to validate the TB/HIV surveillance system using revised TB data collecting tools in the Copperbelt, Southern, Eastern, Northern, Western, and Lusaka provinces. The tools were found to be effective and user-friendly and yielded valid results. The USG will continue to support the validation of these tools in FY 2010 in the other three provinces using existing Cooperative Agreements. TrainingZambia has continued to train health care workers in provider-initiated T&C to improve the management of TB/HIV co-morbidity. In FY 2008, Zambia trained 1,386 health care workers in TB, including provider-initiated T&C. PEPFAR Zambia will continue to support training in TB/HIV in FY 2010.LaboratoryZambia has 156 laboratories with the capacity to perform quality assured TB microscopy to serve approximately 1,300 health facilities. Three of these, the Chest Disease Laboratory, the University Teaching Hospital Laboratory, and the Tropical Disease Research Centre, perform culture and drug susceptibility testing. Inevitably, some facilities must transport sputum and/or prepared slides to diagnostic centers for diagnosis of TB. PEPFAR Zambia has supported the transportation of sputa and/or prepared slides through a courier system and provision of bicycles, motorcycles and automobiles. In FY 2010, the USG will continue to support the transportation of sputa and/or prepared slides. The US Mission in Zambia will also continue to support other efforts to strengthen the TB laboratory network such as training of laboratory personnel in TB smear microscopy, including sputum collection and transportation and preparation and reading of slides. The USG will also support the procurement of equipment and reagents and renovations of TB infrastructure. MDR-TBThe prevalence of multi-drug resistant TB (MDR-TB) in new patients is estimated at 1.8% and 2.3% in previously treated cases (Zambia Drug Resistance Survey, 2001). The NTP has embarked on the following road map of activities to deal with the threat of MDR-TB: 1) strengthening the TB laboratory network (including culture services) and conducting drug resistance surveys to find out the actual burden of MDR-TB, 2) development policies and guidelines for managing MDR-TB, 3) applying to the Green Light committee (GLC) to have access to second line TB drugs, and 4) developing and implementing TB infection control strategies. In FY 2010, the USG will continue to support these efforts through existing Cooperative Agreements with the MOH. Placement of staffTo supplement staff within the NTP, PEPFAR Zambia collaborated with the NTP to hire a national TB/HIV coordinator to coordinate TB/HIV activities at the national level in FY 2007. To supplement staff at the provincial level, the USG has collaborated with the NTP to hire four provincial level staff to coordinate TB/HIV activities at the provincial level. Though the provincial level position is not provided for under the current NTP personnel establishment, the NTP sees it as being useful and will continue to lobby for its inclusion onto the establ ishment. The USG also supports HIV/AIDS Counselors, data associates, and laboratory staff in selected districts. In FY 2010, PEPFAR Zambia will continue to support staff placements. TB/HIV Service integrationIn FY 2008, the USG supported the MOH in 645 sites and attended to 22,485 TB/HIV co-infected clients and contributed to increasing the proportion of TB patients testing for HIV to 49%. In FY 2010, the USG will continue to support the MOH’s goal of integrating TB and HIV services. TB service sites will provide increased HIV services, including testing and counseling for HIV, CD4 assays, and provision of prophylaxis for opportunistic infections. HIV service sites will also provide increased TB services, including sputum examination and treatment of TB. PEPFAR Zambia will link co-infected individuals to care and support services such as post test clubs, hospices, hospitals, and support groups for people living with HIV/AIDS for continued care and support. Community involvement:At 58%, Zambia is far from reaching the WHO target of case detection rate of 70%. The USG will support Zambia to implement intensified TB case finding through community involvement and participation. Approaches will include training of communities, meetings with communities, including traditional leaders, church leaders, traditional healers, and community-based organizations, and social mobilization and advocacy through drama, focus group discussions, and the media. Trained health center staff will provide technical support to community TB treatment and adherence supporters. Confirmed TB cases will be treated at health facility or community level. Routine reports will be given to the health facilities by the community volunteers on the management and follow up of confirmed cases.Prevalence survey:The MOH has not conducted a national TB prevalence survey in over thirty years. The NTP plans to conduct a TB prevalence survey in FY 2010 to assess the prevalence of smear-positive and bacteriologically positive pulmonary TB, assess the prevalence of symptoms suggestive of TB and predictive values, assess the magnitude of TB care outside the NTP, and assess the prevalence of HIV among TB patients. PEPFAR Zambia will provide financial and technical support to this activity through the existing cooperative agreements with the MOH and provincial health offices.TB Infection control:The NTP conducted the first TB infection control training for health care workers in the first half of 2009 and held the second one during the second half of 2009 with support from the USG and other partners. In FY 2010, the USG will continue to provide support to train health care providers to ensure that TB infection control is maximized at the health facility level. In addition, the USG will support the NTP to reduce TB nosocomial infections through prompt diagnosis and treatment of TB, renovations of TB infrastructure, management controls such strengthened supervision, and the use of Personal Protective Equipment (PPEs).National, Provincial and District data review meetingsThe NTP holds annually both national and quarterly provincial TB/HIV data review meetings with support from the USG and other partners. During these meetings, data is completed, validated, and analyzed to yield useful program information for all stakeholders. The USG will continue to support the MOH in conducting these meetings in FY 2010.National TB evaluation The MOH last evaluated the performance of the NTP in 2005. This review provided the MOH an opportunity to know the strengths and weaknesses of the program and guided the NTP’s strategic planning. The MOH is planning to hold another evaluation of the NTP in FY 2010. Support of this evaluation will be provided by PEPFAR Zambia through technical and financial assistance.Sustainability of activitiesSustainability of TB/HIV services is a major goal of the USG. The USG will implement the following processes to ensure that TB/HIV ser vices are sustainable: 1) TB/HIV services will be implemented within the policy framework of the host government, 2) Implementation of TB/HIV activities will occur within the host government structures and infrastructure, 3) The health care workers implementing TB/HIV activities will be employed by the host country government, and 4) The NTP will provide leadership in the implementation of TB/HIV activities.

Technical Area Summary Indicators and Targets

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