This activity is linked to SoPHO PMTCT (#9739).

Fiscal year (FY) 2007 activities will result in: (1) increased access to quality prevention of mother to child transmission of HIV (PMTCT) services; (2) quality PMTCT services integrated into routine maternal and child health services; (3) increased use of complete course of antiretroviral (ARV) prophylaxis by HIV-positive women; (4) improved referral to ARV treatment programs as they are developed within the districts; and (5) implementation and assessment of an innovative community-based voluntary counseling and testing (VCT), and PMTCT program to rural populations not ordinarily reached through facilities-based PMTCT services.

Tulane University, through its sub-partner Boston University and local non-governmental agency Zambia Exclusive Breastfeeding Services (ZEBS), and in collaboration with the Ministry of health (Southern Province Health office) began providing PMTCT in FY 2006. Despite funding problems due to delays in setting up a funding mechanism, they were able to train more than 50 health workers in the minimum package of PMTCT and established 28 PMTCT sites in Mazabuka, Siavonga and Monze districts of Southern Province by March 2006.

In FY 2007, ZEBS will continue expanding PMTCT services in Southern Province. In collaboration with the Southern Province Health Office (SPHO) and district health management districts, ZEBS will support PMTCT services in all districts of Southern Province ensuring that at least 75% of health centers in these districts establish PMTCT services. As of March 2006, USG through its partners, Academy for Educational Development and ZEBS were supporting 80 sites out of a total of 217 maternal and child health sites in Southern province. By the end of FY 2007, ZEBS will provide direct support to 165 sites in all 11 districts and will in collaboration with the province provide technical assistance to sites that will be established by district health teams. ZEBS, in partnership with the SPHO and district teams (Government of the Republic of Zambia) will train health workers in these clinics on all components of PMTCT services and integrate these services into routine maternal and child (MCH) health services. By working in collaboration with the district health teams' capacity will be built in these teams and will help to ensure that sustainable programs are implemented. Sustainability of the PMTCT program will be achieved through the integration of PMTCT services into routine MCH activities. Health workers will be trained in the implementation of the 4 pronged approach to PMTCT in counseling, the minimum package of care of PMTCT, logistics, data management, and quality assurance. ZEBS will support district efforts to develop networks and referral systems for pregnant women to access other services offered at health centers and in the communities.

The networks are critical for linking HIV-positive pregnant women to antiretroviral therapy (ART) services and developing an approach where all HIV+ women are referred for baseline CD4 counts and women needing ART, are referred to the nearest ART center. ZEBS will also provide counseling on appropriate feeding options for infants born to HIV-positive women and those of unknown status. By the end of FY 2007, data on HIV-positive women and infants referred to ART and care services will be available as this information is currently being incorporated as indicators in the PMTCT monitoring system.

Scarce and unequal allocation of human resources for service delivery is among the biggest constraints to extending coverage of HIV/AIDS services in Zambia. A creative approach is critical to human capacity development, especially in the rural areas of Zambia, where traditional birth attendants (TBAs) play a key role in implementing effective interventions in remote and rural settings. To address the shortfall in counseling services, ZEBS developed an innovative program of community-based training of lay counselors in the provision of pre- and post-test HIV and lactation counseling. A cadre of community members and traditional birth attendants was identified and trained to perform VCT at the health posts and/or within the community. As part of their scope, the TBAs also perform real-time community-based HIV testing using whole blood or oral fluid rapid tests, or link these counseling services with same-day HIV testing at the corresponding Rural Health Center. Based on the lessons learned in implementing this approach, ZEBS will train an additional 50 community based counselors

Facility-based provision of PMTCT services does not reach many women in rural areas because of the high proportion of home deliveries. This is particularly evident in the Mazabuka District, where up to 70% of the deliveries are neither facility-based nor attended by a skilled birthing attendant or health care professional.

Boston University and ZEBS will build and continue providing leadership to the USG partners on the work piloted in FY 2006 on, involving TBAs in the provision of PMTCT services. This strategy though in its infancy has the potential to fill an important gap in the outreach of essential PMTCT services to an otherwise difficult-to-reach but majority-segment of pregnant women in rural health districts in Zambia. If successful, this approach can be implemented throughout the entire Southern Province and other rural areas in Zambia.

Masters level students, from the Department of International Health at the Boston University School of Public Health in the US, will be recruited to work with the project in Southern Province on 3 to 6 month field-based applied study projects and provision of cross-training support to health workers and managers.

The plus-up funds will be used to strengthen the entire PMTCT program with special emphasis on increasing coverage of rural based women with improved maternal and child health services; providing an effective PMTCT ART prophylaxis; improving the postnatal care for mother-child pairs to ensure that both are linked into care and follow-up; establishing infant and young child feeding support and lastly, to train TBA in the delivery of PMTCT services. With the plus up funds, BU/ZEBS will strengthen the linkages between PMTCT and ART by refering all pregnant women for a baseline CD4 count which will guide the health providers on the PMTCT regimen to provide to the woman and will improve the provision of a basic package of postnatal care interventions especially support for optimal infant feeding. These funds will used to explore a performance-based bursary for the scaling up of PMTCT services at facility level. Lastly, these funds will be used to strengthen MCH programs and efficiently integrating PMTCT services into these services.

Through Plus Up funding, BU/ZEBS will establish a comprehensive EBF demonstration program in one urban site and in at least three rural sites. There are three specific objectives: 1) to promote and achieve high levels (> 75%) of EBF through 6 months of age among pregnant HIV-infected women booking in the antenatal clinics; 2) to promote and achieve high compliance with first line ART among HIV-infected pregnant women who qualify according to National Guidelines; 3) to discourage and minimize cessation of breastfeeding or non-EBF among women who learn their infant's negative HIV infection status through early infant diagnosis (PCR). To ensure sustainability, the program will be implemented in government facilities to build their capacity to incorporate the program into the national PMCT package of services and rapidly scale up throughout Zambia. Based on the findings of the demonstration project, Boston University/ZEBS will work with MOH, UNICEF, and all PMTCT partners in Zambia in the development of national guidance on optimal infant feeding practices.

This activity is linked to TX, Home base care activities and wrap around education activities in the areas covered.

The Play Pumps (PP) is a child's merry-go-round attached to a water pump that provides clean drinking water and public service messages to schools and communities. The PP is being proposed for parts of Lusaka, Southern, Western, and Eastern Provinces.

Lusaka is a very high population density area with close to 20 high density living compounds housing 20,000 to 60,000 thousand people in each compound. Each compound has a clinic and community school. The data currently available suggest that HIV prevalence in the compounds is higher compared to the rest of Lusaka district. Parts of Southern, Western, and Eastern are dry, rural, and very poor. Communities in these regions often lack clean and safe water as the local rivers are their major source of drinking water. CDC is proposing PP to provide water to several compounds in Lusaka, parts of Southern, Eastern, and Western provinces. Selection of the actual sites will be done in collaboration with, provincial and district health teams and provincial water and sewage companies who oversee such activities in each province. The goal is to install pumps where there is the most need, where prevalence is high, and in strategic places where social services are currently used by the community. The water pumps will be installed in community areas, schools, and clinic sites in deliberate locations where they can serve both the host facility and local community.

With a population of 1.2 million people, Lusaka province currently has about 50,000 HIV patients on treatment. Most of Lusaka residents reside in high-density compounds. In accordance with the Unites States Government (USG) and the USG Zambia Five-Year strategy, CDC is scaling up HIV services in the four southern provinces. One of the challenges in the most remote rural areas such as Shangambo district in the Southern Province is clean, safe, accessible water. Access to water will not only provide the much needed and essential clean drinking water to the community, but also enhance ability to scale up HIV services in these remote areas. Improving access and availability of safe water supplies will also increase food access and income for people living with HIV/AIDS (PLWHA) and orphans and vulnerable children (OVCs), improve public health hygiene practices, provide HIV prevention and treatment, and care information, fight stigma, provide social activity for children and a forum for OVCs to mingle, play, and feel like everyone else. As the children play on the merry-go-round, water will be pumped into a tank. The tank will also provide a place to post public service messages to schools and communities in urban and rural Zambia.

The activity will be wrapped around other PLWHA activities so the water can be used to initiate and maintain community gardens, in addition to providing clean water for taking medications. A partnership is being arranged with a private agricultural company to donate seedlings and provide technical expertise in keeping healthy productive community gardens. Great attempts will be made to provide water close to school and clinic sites to encourage school children to practice hand washing after returning from the toilets. Water will also be made available at strategic locations within hospitals/clinic facilities to encourage medical personnel and patients to practice hand washing for public health reasons.

Table 3.3.06:

This activity relates to activities in UTAP-Boston 8784, SPHO 9017, SPHO 9739 and CIDRZ 9760.

Anti-retroviral (ARV) treatment services and Prevention of Mother to Child Transmission (PMTCT) activities are being scaled-up in the Southern Province of Zambia. In FY 2007 CDC-Zambia is funding the Southern Provincial Health Office (SPHO) to collaborate with Boston University (BU) to scale-up PMTCT in the province. In addition, a pilot program on early infant HIV diagnosis will be implemented in the Southern Province in 2007. It is critical to also establish the necessary care and support services for infant and adult palliative care. Funding for this activity will be used to establish and strengthen palliative care services and linkages to support adults and children infected with and affected by HIV/AIDS.

The funding will be used to establish and strengthen palliative care support for mothers and children. Parts of the Southern Province are very rural and services are scarce and far apart from one another, and extra effort is needed to establish sustainable palliative care linkages to support treatment and PMTCT services. Palliative care support will include: infant care and follow-up support for HIV infected children and mothers including the provision of infant and adult cotrimoxazole; nutritional supplements where necessary; bed nets; and building linkages with home based care programs in the province. Funding will also be used to support training for home based care within a rural setting.

To avoid double counting for reporting purposes, this activity will not have direct targets since it will support the same individuals already counted in activities 8784, 9739 and 9017.

Boston University has established a good working relationship with the Provincial Health Office as they are already working together on scaling up PMTCT services in the province, and is also implementing a breast feeding program. They are in a solid position to work with the SPHO to ensure strategic and sustainable linkages are developed and palliative care services developed are accessible to clients.

Related activities: This activity links to AIDS Quality Improvement Project (#9745).

Equity and efficiency are two important characteristics of successful and sustainable public health interventions. The Center for International Health and Development at Boston University (CIHD) and the Zambia Exclusive Breastfeeding Study (ZEBS) propose to conduct three public health evaluations (PHEs) to address each of these facets of the AIDS treatment rollout in Zambia.

Evaluation 1: Cost-Effectiveness of Models of Delivering Antiretroviral Therapy (ART) ($!50,000)

To achieve the President's Emergency Plan for AIDS Relief (PEPFAR) goals for treatment of HIV/AIDS, ART must be delivered in a wide range of settings and at multiple levels of the healthcare system. The cost per patient enrolled and cost per successful patient outcome are likely to differ widely by location (urban, periurban, rural), patient characteristics (e.g. starting CD4 count, duration on treatment), scale and scope, facility type (hospital, clinic, GP's office), provider (public sector, private sector, NGO), human resource use, and adherence support strategy. For national treatment programs to be financially sustainable, accurate information is needed about the costs of reaching different patient populations using different types of delivery models.

In South Africa, the CIHD is analyzing the cost-effectiveness of different models of delivering ART to adult patients. CIHD now proposes to conduct a similar targeted evaluation in Zambia. The evaluation will generate accurate, current information about the costs of treatment in diverse settings, identify the key cost drivers at each site, and evaluate the tradeoff between facility costs and patient costs. CIHD will aim to answer the following questions for each participating site:

1. What is the average cost to the provider over the first 12 months of ART initiation to produce a successful clinical, immunological and virological responses? 2. What is the breakdown of cost per patient, by major cost component? 3. Is there a relationship between treatment cost and recorded patient characteristics (e.g. age, sex, starting CD4 count) in the first 12 months of ART? 4. What are the costs to patients of obtaining ART at each site?

The audience for this PHE includes the Office of the Global AIDS Coordinator, other funding agencies, Zambian policy makers and program planners, NGO and private providers, and any others responsible for expanding access to treatment to as large a population as possible within a given budget, estimating resource needs, or increasing efficiency among existing providers.

Evaluation 2: Rationing of ART for HIV/AIDS: Current Practices and Potential Outcomes ($150,000)

Despite Zambia's rapid scale-up of ART for AIDS, access to treatment is still a challenge to many medically eligible patients. Access to treatment is influenced by an individual's demographic, geographic, social, and economic status, as well as medical condition. While the Government of the Republic of Zambia determines the aggregate allocation of treatment resources, there are no clear and enforceable national or sub-national guidelines for prioritizing patients. Many rationing decisions, whether implicit or explicit, are therefore being made at the level of individual clinics and clinicians.

How rationing practices develop—whether they are equitable or inequitable, efficient or inefficient, "fair" or "unfair,"—will be an important determinant of long-term national and international political support for the national treatment program, and thus of its sustainability. In two papers published in 2005, CIHD researchers described and evaluated various approaches to rationing ART in Africa. The paper has provoked much debate and recently led the organizers of the Third Seminar on Health and Development in the Portuguese Speaking Nations, sponsored by the Instituto de Higiene e Medicina Tropical of the Universidad Nova de Lisboa, to choose the rationing of ART as the theme of the conference, which was attended by Ministers of Health and other health policy makers from all the Portuguese speaking countries. CIHD now proposes to conduct a PHE to assess provider-level rationing criteria in Zambia, analyze the extent to which treatment

is being rationed on the basis of non-standard criteria, evaluate the criteria that are in use, and analyze the future implications for the treatment program of these criteria.

The audience for this PHE is similar to that for Evaluation 1 but includes community and civil society representatives as well as national and international policy makers and planners. As it will be one of the first attempts to examine the issue of rationing empirically, CIHD anticipates that it will also be of interest to health system planners throughout the region.

Evaluation 3: Qualitative Study to Identify Potential Barriers to Adherence within the ZEBS Cohort ($40,000)

The ZEBS will conduct a qualitative study to examine a local perspective on adherence to ART. Qualitative methods are used because they are designed to identify new and hitherto unknown factors, whereas quantitative methods are better suited to testing the local importance of factors already identified. This study will generate hypotheses on what encourages and hinders adherence to ARVs from the perspective of local population. A qualitative study is a critical strategy at this stage in order to identify potentially modifiable factors associated with adherence with a well-characterized population (ZEBS). A group of women from the ZEBS mother support group are already trained in qualitative interviewing and will participate in conducting this study. This initial qualitative study would generate hypotheses inform plans for future quantitative studies of need, impact, and feasible program implementation.

Data on factors perceived by local people to affect their ability to commence and adhere to HIV therapy will be generated. Based on these data, a report and recommendations will be made for assessment tools and/or programs designed to improve adherence and that would be suitable for implementation and testing. The target audience for this study is program planners and clinicians.