This activity is linked to EPHO PMTCT (#9736, #8819, and #8784).

CARE International will implement prevention of mother to child transmission of HIV (PMTCT) services in four districts of Eastern Province. The model will be based on a rural expansion program that will use other health cadres for counseling and testing (CT) and health workers for the implementation of the service. Building on synergies created by the HIV/TB work in these districts, a comprehensive package of HIV services will be used to mainstream these services. CARE International in Eastern Province will build partnerships with Center for Infectious Disease Research Zambia (CIDRZ), JHPIEGO and the Ministry of Health to carry out this task.

To have a significant impact on reducing mother to child transmission of HIV, PMTCT services need to be provided to all maternal and child health (MCH) services. In FY 2006, a training needs assessment was conducted in the project areas to assess the capacity of health workers (midwives, nurses, and doctors) to provide basic PMTCT services according to the National Protocol Guidelines. Based on the results of the assessment, training was provided to maternal and child health (MCH) staff in CT, tuberculosis (TB) screening, administration of PMTCT prophylaxis as per national protocol and antiretroviral therapy (ART) for women that need it, midwifery, and obstetrical practices to reduce the risk of transmission, feeding practices and options for HIV positive mothers, pediatric HIV care and long term support to mothers, and monitoring procedures (e.g. how to use counseling and blood test registers). The project coordinates activities with CIDRZ and the Provincial Health Office (PHO) through the provincial maternal and child health coordinator. In FY 2006, CARE International conducted 3 PMTCT trainings in Chama, Chadiza and Lundazi districts of Eastern province. A total of 75 health workers were trained. Community health cadres were also trained in counseling and testing. A total of 15 PMTCT sites were instituted in these rural health centers.

Building from FY2006 activities, CARE International in FY 2007 will roll-out routine CT for all pregnant women to know their HIV status in the three districts were they are already providing services and establish PMTCT services in Mambwe, another rural district bringing the number of sites to 30. HIV-positive mothers will be provided with a range of information on measures to reduce HIV transmission to their babies, how to avoid potential health problems during pregnancy, HIV care and treatment options, infant care, and family planning. HIV-negative mothers will be supported with interventions that will help maintain their negative status. This program will map existing support programs at the respective district hospitals or neighboring districts for service referrals and linkages. In addition, referral procedures for CT, TB screening, family planning services, and antiretroviral therapy (ART) will be developed and strengthened.

CARE International will institute PMTCT services in four of the most underserved districts of Eastern Province where traditional birth attendants (TBAs) and other community health workers (e.g. home based care givers) play vital roles in the delivery of safe motherhood and reproductive health services. An innovative approach of incorporating TBAs in the provision of PMTCT services has been identified as an on-going activity from FY 2006 and will be rolled out in FY 2007. As part of the activity, TBAs are instrumental in delivering PMTCT services to pregnant women at community level, referral of these women to antenatal care services and in providing follow-up advice and encouragement for women at the community level. A package that encompasses all aspects of the PMTCT protocol is used for training.

This activity relates to counseling and testing, palliative care: basic health support activity, and HVTB activities (#9032, #9037, and #9006,).

Continuing from work begun in fiscal year (FY) 2006, CARE International will expand the coverage of tuberculosis (TB) and HIV activities in the districts of Chipata, Petauke, Katete, and Lundazi. These activities include the need to strengthen both the capacity (technical and physical) of health service providers and community volunteers as well as expand and institutionalize multi-level linkages between the response to TB and HIV/AIDS.

CARE International will implement a program to increase the coverage of integrated TB/HIV activities to more remote areas in the targeted districts. The focus is on testing for both TB and HIV in order to address the increasing incidence of co-infection. By the end of the budget period of FY 2006, CARE International, working with the District Health Management teams in the five districts, will have implemented TB/HIV activities in all the 117 sites in the four districts. This will be achieved through training of health workers in TB, counseling skills and training of community health workers in TB/HIV linkages. Of a total of 3,411 TB patients to date 1,595 (47%) were counseled and tested for HIV.

Linking the testing and referral services to the provision of community-based care for those found to be positive for either infection will greatly increase the uptake of testing, improve treatment adherence and consequently, reduce the incidence of onward transmission. In a way similar to the prevention of mother to child transmission (PMTCT) component, linkages to organizations, both US Government-supported (e.g., Centers for Infectious Disease Research in Zambia) and non-USG supported (e.g. Mwami Mission Hospital) will be maintained to ensure a linked and comprehensive response within the province. Specifically, CARE International proposed interventions aimed to assist the government by increasing the expertise of field-based staff and lay volunteers while building stronger referral networks so that the planned national response can reach beyond its current extent.

Strengthening community-focused responses and networks will be the platform for information, education and communication (IEC) work centered upon reducing the stigma and discrimination surrounding both TB and HIV/AIDS. Materials previously developed by CARE International, in collaboration with HIV/AIDS Alliance will be used to support the IEC work.

The program will continue scaling-up combined TB/HIV service in all the 117 sites in the four districts in FY 2007 by upgrading health worker skills in diagnostic counseling and testing using the national training model. The training program will be based on a "training-of-trainers" model and will include training and supervision in training skills of the trainers through collaboration with JHPIEGO and with technical support from CIDRZ. A total of 70 health care workers will be trained in collaborative TB/HIV activities in the four districts. Two hundred health workers from the ART programs will also be trained in TB/HIV and the need to screen clients on ART for TB and refer for TB treatment where necessary. An additional 185 community health workers will receive training in TB/HIV. Current work has revealed significant weaknesses in regard to data collection, management, and analysis. Some training will be specifically focused on this issue and health workers will be trained in documentation and record keeping.

Additional community members (in particular home-based care volunteers and community health advisors) will be trained in the basics of TB and HIV/AIDS, caring for those infected and working with community-level support groups and referral systems. Community volunteers will be provided with information on the available service outlets and encouraged to refer those needing care to these facilities. This will add significant capacity to the various civil society actors who, along with faith-based organizations, are providing the majority of care and support services in the province. CARE International will work with the District Health Management Teams to ensure their requisitions for laboratory reagents, testing kits, drugs for opportunistic infections and other supplies are processed through the government system early to avoid stock-outs. A total of 15 laboratories in selected clinics, based on need, will be rehabilitated in order to scale up VCT and TB diagnosis.

Of the targeted 3,500 TB patients in the district, 70 % will receive HIV counseling and

testing over the period February 2007 to February 2008 and those testing positive will be referred for HIV care and treatment. This will result in approximately 1,500 HIV infected individuals being referred for HIV care and treatment.

Supportive supervision for TB/HIV activities in the districts will be carried out in conjunction with the Provincial TB Officer and the Provincial TB/HIV officer. Regular review meetings will be linked to TB Directly Observed Treatments (DOTS) review meetings. CARE International is a member of the national TB/HIV coordinating body and this will help to ensure that all the programs implemented are in line with the national strategy for TB/HIV activities and the overall National Health Strategic Plan.

This activity is linked to EPHO HVCT (#9005), EPHO HTXS (#9951), and EPHO HLAB (#9795).

Zambia faces unique challenges in tackling the increasing convergence of tuberculosis (TB) and HIV infection. There are difficulties in achieving equitable coverage of health care services in areas of low population density with limited transport and physical infrastructure to provide services. Poor treatment seeking behavior is compounded by high levels of stigma and discrimination. Severe human resource constraints exist among health care staff, especially across all facilities within rural districts.

In fiscal year (FY) 2007, the United States Government funding through this mechanism will focus on increasing the coverage of and access to counseling and testing (CT) services in Chipata, Katete, Petauke, and Lundazi of Eastern Province. The work will focus on infrastructure rehabilitation in 30 sites and increased community mobilization to encourage uptake of voluntary counseling and testing (VCT) in the catchment area. The work will target the general population as everyone needs to know their HIV status. There will be 30 facility-based service outlets providing counseling and testing and one mobile. It is estimated that 3,000 clients will receive counseling and testing for HIV and receive their results through this funding mechanism. This activity will link closely with the EPHO HVCT (#9005) to ensure wider coverage of districts and avoid duplication. Links with treatment and care services, EPHO HTXS (#9951) and EPHO HLAB (#9795) will be established as well.

CARE's proposed intervention aims to assist the Government of the Republic of Zambia (GRZ) through increasing the expertise of field-based staff and lay volunteers in VCT while building stronger referral networks so that the planned national response can reach beyond its current capacity. Once people have been tested and are receiving antiretrovirals (ARVs), adherence becomes a crucial issue. Promoting adherence to ARVs is critical to successful treatment. CARE will therefore support training of 300 health staff and 600 community volunteers (including treatment supporters) in adherence counseling for clients on TB treatment and antiretroviral therapy. The training will include helping clients understand what adherence is and how to recognize side effects of the drugs and how to cope with those side effects among other things. Mechanisms for follow-up of clients to ensure adherence will also be developed during the training to ensure that they are culturally appropriate and feasible.

To properly support the increased need in human capacity, CARE will encourage the District Health Management Teams (DHMTs) to undertake simple infrastructure rehabilitation and equipment provision for 30 zonal VCT sites in more remote areas across four districts (Chipata, Katete, Petauke, and Lundazi). CARE will work hand-in-hand with the DHMT to carry out a survey of proposed facilities.

Mindful of the challenges for distant populations with limited transport options of accessing health care facilities, CARE will establish and run a mobile VCT service to increase access for people in need of VCT in Lundazi. Chipata, Petauke, and Katete are relatively better served by existing mobile VCT than Lundazi. Costs per client reached in such mobile VCT situations increases dramatically as transportation costs of the mobile service are high.

This piece of work is envisaged as part of a longer-term supportive partnership with GRZ in the selected districts aimed at establishing a functioning comprehensive CT network to which everyone in the general population has access and is linked to equally effective referral systems.