This relates to activity #8827.

Tuberculosis (TB) is a major cause of morbidity and morality in people living with HIV and needs specific attention. Routine testing of TB patients for HIV is an efficient means of identifying HIV in the community. The major emphasis of this activity will be on Health Care Financing and Quality Assurance and Supportive Supervision. Other emphases will include training, community mobilization/participation and the development and strengthening of networks and referral linkages.

The following populations are targeted: health care providers, faith-based organizations, community-based organizations, and all persons affected by HIV and AIDS.

Based on the principle that all HIV positive persons in the CRS AIDSRelief program are screened for TB based on symptoms and exposure history, and all patients being prepared for ARV drugs receive TB screening, this activity will be implemented in the following components: (1) Enhancing laboratory capacity diagnose TB accurately; (2) Establish and strengthen referral linkages between CRS AIDSRelief facilities and the Zambian government TB directly observed treatment strategy (DOTS) sites to ensure timely diagnosis and treatment; and (3) Ensure accessibility to information, education, and communication (IEC) materials on the relationship between TB and HIV at health facilities as well as surrounding communities. (4) Routine screening of family members of active TB cases. The funds will expand the reach of the services to ensure that all HIV positive clients in the AIDSRelief program are screened for TB and referred for appropriate TB care and that all TB patients are screened for HIV. The funds will allow the service to be provided to an additional 1000 clients in 4 new service outlets. Plus up funds will also support the training of 68 additional health care workers in the treatment of TB in HIV infected patients.

Plus up funds will be used to provide routine tuberculosis diagnosis for all patients enrolled for HIV care at an additional 4 AIDSRelief health facilities and 16 CHAZ sites not receiving global fund and other CDC support, including building acid-fast bacilli laboratory capacity and providing access to Chest X-ray to diagnose sputum-negative cases of TB. All laboratories will be equipped to perform sputum smear to detect acid fast bacilli and will be engaged in quality assurance and quality improvement activities with nearby reference laboratories. One of the 36 AIDSRelief and CHAZ supported sites will be equipped to play the role of a referral system for TB culture. In addition funds will be used to provide training and ongoing technical assistance to laboratory staff in sputum diagnosis of TB, training all cadres of staff to identify potential TB cases and to make the diagnosis. Another critical component to address is educating providers and health care worker on diagnosing extrapulmonary TB. Large numbers of HIV+ patients with low CD4 counts are presenting with TB that is not diagnosed because it either is smear negative with a near normal CXR, or is extrapulmonary. We will develop training and algorithms to address the diagnosis of these challenging patients that have high incidence of early mortality. To facilitate Pediatric Diagnosis of TB, funds will be used to training care providers using traditional Pediatric TB screening tools including reading Chest X-ray competencies. Ensuring that patients diagnosed with TB at AIDSRelief and CHAZ facilities have access to quality care involves strengthening the capacity of all AIDSRelief and CHAZ facilities to meet the special needs of persons living with HIV/AIDS and TB. Special attention will be placed on patients who are on ARVs and anti-TB treatment simultaneously. Funding toward this component will go to supporting training of all cadres of clinical staff (doctors, nurses, counselors, treatment support specialists, community health workers, etc.) on TB management especially as it relates to the HIV positive patient, establishment of referral linkages for HIV patients diagnosed with TB at AIDSRelief and CHAZ sites on TB DOTS for community-level follow-up for care and support. These funds will be used to develop and implement joint strategies to assist with patient adherence to ARVs and anti-TB drugs by utilizing community health workers, treatment support specialists and other community support groups. Up to 100 health workers will receive specific training on TB/HIV as it relates to their job responsibilities. It is estimated that a total of 3500 persons living with HIV/AIDS will be treated for TB under AIDSRelief and CHAZ using drugs obtained through the National TB program and is

not included in this budget. All patients who are diagnosed and treated for TB under AIDSRelief and CHAZ will be entered in the Zambian Government's register with appropriate linkage of medical records between TB and HIV. Funds under the Strategic information activity will be used to implement the use of TB registers in all AIDSRelief facilities, train medical records staff, laboratory staff and clinicians on entering information on suspected cases, TB screening, diagnosis, treatment, and follow-up laboratory tests for patients seen at the health facility. In addition, the plus up funds will cover additional M&E requirements related to new AIDSRelief sites and CHAZ involvement. Education and sensitization component of the Y07 funds will be extended to health facilities targeted under this plus up funds. Funds will be directed at working with local organizations to distribute IEC materials related to TB/HIV issues to communities and AIDSRelief and CHAZ facilities, conducting educational sessions at AIDSRelief and CHAZ supported support groups and other community-based groups, training VCT and other counselors to provide information on TB/HIV to their clients during counseling sessions The training of health staff and community volunteers providing care in both urban rural mission health facilities will ensure sustainability of the program.Plus -up funds of $400,000 are requested to enable the expansion of TB/HIV activities in CRS AIDSRelief sites by targeting: health care providers, faith-based organizations, community-based organizations, and all persons affected by HIV and AIDS. In accordance with AIDSRelief sustainability plan, the funds will be used to support Churches Health Association of Zambia (CHAZ) in their TB/HIV scale-up effort.

Related activities: This activity also relates to activities in HBHC SUCCESS II (#9180), CRS HVTB (#9703), HTXS (#8829) (track 1.0), CRS HTXS (#8827), CRS HKID (#8852) and HLAB. (#8996).

Based on the Zambian national HIV/AIDS strategic plan, there has been a low uptake of voluntary counseling and testing (VCT). In FY 2007, AIDSRelief will aim to improve uptake of VCT by emphasizing the activities that support VCT. This activity will be conducted in different clinical settings including adult and pediatric antiretroviral therapy (ART), prevention of mother to child transmission (PMTCT) and tuberculosis (TB), and sexually transmitted infection (STI) clinics. The suggested form of testing would be as diagnostic routine testing with the option to opt-out. This is in conjunction with the Government of the Republic of Zambia (GRZ) plans of introducing a more comprehensive approach and increasing the number of people receiving VCT services. Most of the rural mission hospital AIDSRelief sites where AIDSRelief is currently working have TB or STI clinics where these activities will be implemented. This activity will target persons affected by HIV/AIDS, faith-based organizations (FBOs), and community health care providers. There are three main components to this activity: 1) provision of comprehensive CT services within hospital settings and in the surrounding communities; 2) training of staff to provide CT services; and 3) the strengthening and expansion of linkages to ensure continuity of care for persons who test HIV positive.

The first component of this activity, to provide comprehensive CT through integrated VCT services within hospital settings and in the surrounding communities, will involve supporting 16 hospitals to provide CT for diagnostic purposes for persons attending in-patient and out-patient services. Routine CT will be offered to the following principal target populations: pregnant women, patients diagnosed with STIs, and TB patients, as well as family members of persons living with HIV/AIDS (PLWHA) and self-referred members of the general public. To enhance patient uptake, VCT services will be offered at community outreach activities in the surrounding communities, and home testing for families of PLWHA. Funding under this activity will specifically go to support the procurement of test kits and the cost to conduct community-level testing. Through this component of the activity will provide support for 16 service outlets, provide training to 48 individuals in CT, conduct and provide CT services to an estimated 20,000 individuals.

The second component of this activity is the training of staff at the hospitals to provide CT and the training of supervisory staff at the hospital to ensure that minimum quality standard of services are met. Counselors, laboratory staff, and VCT counselors will be trained on how to conduct pre-test and post-test counseling, on the correct use of the HIV rapid test kits, on providing full and accurate information on HIV prevention, and also on how to make the appropriate referrals for patients and their families who test either positive or negative. A training of trainer concept will be used for persons involved in workshops. This component of the activity will work to train 48 individuals in CT. All VCT training activities will use the standard Zambian VCT guidelines and testing protocols.

The final component is strengthening and expanding linkages to ensure continuity of care for all persons accessing CT through AIDSRelief. Strong linkages will be formed with other CRS HIV-related activities including palliative care provided by the SUCCESS and RAPIDS projects, as well as other CRS orphans and vulnerable children projects conducted by the CHAMP and RAPIDS projects (HKID activity #8947). AIDSRelief will also work to establish linkages with other community groups to ensure social, psychological, legal support, and income generation activity is available for all patients who test positive for HIV. Funds for this component will be used to establish and strengthen referral networks between community groups and social service providers, as well as with other related projects conducted by CRS and other USG partners.

With Plus-up funds AIDSRelief plans to build on its current success in ensuring that people living with AIDS have access to ART and high quality medical care. AIDSRelief currently has over 11, 000 persons receiving antiretroviral therapy (ART) in seven provinces across Zambia and plans to scale-up to additional health facilities and provinces during Year 4 of program implementation. One of the main target areas during this year is to increase the proportion of children receiving ART at AIDSRelief facilities to between 10-12%. With the current proportion of children on ART being at only 6.5%, AIDSRelief has put in place a package of measures to increase pediatrics enrollment. It includes: on site pediatrics

training, early clinical diagnosis, linking rural under 5 clinic to ART sites. In addition, AIDSRelief will utilize funds received to strengthen this area of its program implementation by increasing the capacity of selected health facilities to rapidly increase their pediatric numbers, providing funding for DCT for Pediatrics, trainings for staff on DCT and supporting Churches Health Association of Zambia (CHAZ) in their pediatric scale-up effort.

Related activities: This activity links to AIDSRelief-Zambia (#8827).

AIDSRelief provides HIV care and services, including ART, primarily to the most marginalized populations through faith based organizations in rural areas. AIDSRelief works through the local partner treatment facility (LPTF) to provide treatment and care and builds the capacity of the treatment facility to provide this care as a means of building a sustainable care system. In the initial phases of the program, the antiretroviral drugs were purchased directly by AIDSRelief, in a system parallel to the Ministry of Health (MOH). However in the spirit of supporting the Three Ones principle and in order to ensure the development of a sustainable system, beginning in fiscal year FY 2006, AIDSRelief agreed with the MOH that new patients initiated on treatment in the AIDSRelief supported site would receive first line and second-line generic drugs through the Central Medical Stores logistics supply system. This would also enable AIDSRelief to continue to scale-up services to additional sites despite no increase in funding levels under Track One. The U.S. Government through JSI Deliver has strengthened the central logistics procurement and supply of ARVs under activity number. However, currently four private, faith-based AIDSRelief sites that are not yet accredited by the MOH to receive free drugs from Central Medical Stores. However, AIDSRelief will continue to procure and distribute ARV drugs to these facilities to meet the demand for second and first-line therapy. This will also ensure that a buffer stock is available for these facilities. The drugs that will be procured are Efavirenz, Kaletra, Stavudine, Zidovudine, Tenofovir, Truvada, Combivir, and Nevirapine, of which 10% of these drugs will be for Pediatric ART services. Churches Health Association of Zambia will continue to store and distribute ARV drugs to these four facilities and will also distribute drugs to the remaining AIDSRelief facilities, in support of the Central Medical Stores logistics supply system.

In FY 2007, AIDSRelief will provide ART for 15,000 patients at 16 faith-based hospitals and clinics, including the maintenance of 10,000 patients from 2006 and the expansion of ART to an additional 5,000 patients in 2005.

This activity relates to Catholic Relief Services (#8829).

AIDSRelief has continued to contribute to the United States Government's HIV and AIDS strategy in Zambia by activating and supporting 12 local partner treatment facilities (LPTFs) and additional satellite facilities to provide antiretroviral therapy, as well as HIV care and services. As of July 2006, AIDSRelief had 7,057 patients actively on antiretroviral therapy (ART) out of which 404 were children and 19,034 patients were receiving basic care and support.

AIDSRelief has been successful in providing technical support to LPTFs by providing training and technical assistance necessary for successful program implementation. A total of 107 persons have received clinical trainings conducted by AIDSRelief, with nine trained on Pediatric ART and 201 in ARV adherence. About 45 persons have been trained in strategic information and 62 on finance and compliance issues. Additional support to partners include the initiation of a bi-monthly newsletter that addresses current clinical issues and provides medical updates, the installation and training of personnel on automated CD4 technology, and the coordination of reagent procurement and instrument maintenance.

AIDSRelief continues to support the Zambian government's HIV strategy and participates in multiple technical working groups and technical committees, including: the Medical Council Site Accreditation and Provider Certification Group; the ART Regimen Choice Meeting; the National Laboratory Instrumentation Working Group; the National Pediatric ART Regimen Choice Committee; the National Pediatric ART/OI Training Curriculum Development Group; and the working group for the harmonization of the Clinical forms for Zambia.

In keeping with its commitment to ensure that care and services continue to be delivered at a high standard, AIDSRelief has implemented a Quality Assurance/Quality Improvement (QA/QI) program at its LPTFs. This included conducting formal chart reviews at facilities that were activated in fiscal year (FY) 2004 and performing viral load measurements on 10% of patients who had been on treatment for greater than nine months. Analysis of the data is still ongoing and will evaluate viral load suppression, adherence, toxicities, switched therapy, loss-to-follow-up and causes of early mortality. It is expected that the results of this activity will inform future guidelines for ART initiation in a manner that minimizes mortality within the first few weeks of therapy. In addition to the QA/QI process, the use of electronic data has led to easier access to patient records and cross-referencing. In addition, by using the pharmacy database, partners have been able to track would-be defaulters easily and implement early interventions such as home visits and counseling. This has contributed to improved adherence. By keeping track of the attrition rates, AIDSRelief and their partners have been able to implement timely intervention at LPTFs, such as community mobilization and revision of adherence strategies.

Building on fiscal year FY 2006, AIDSRelief will provide AIDS treatment services primarily through faith-based facilities that typically treat the most marginalized populations and provide services in rural areas. The cost of providing care in these areas is usually high due to poor road infrastructures that make it difficult and costly to transport supplies. The AIDSRelief goal is to ensure that people living with AIDS have access to ART and high-quality medical care. AIDSRelief believes that care and treatment for HIV-infected individuals should be integrated in the existing health care infrastructure to promote sustainability. AIDSRelief will provide ART for 15,000 patients at 16 faith-based hospitals and clinics, including the maintenance of 10,000 patients from FY 2006 and the expansion ART to an additional 5,000 patients in FY 2007. AIDSRelief Zambia will provide HIV care to a total of 42,000 individuals throughout FY 2007.

AIDSRelief will continue to provide, on a sustainable basis, the provision of ART to the greatest number of deserving patients consistent with good medical science, national priorities and programs, and cost-effective deployment of program resources. Sustainable ART programs will be supported by a commodities management system that ensures a continuous supply of drugs to patients by mobilization of patients and communities to encourage knowledgeable, consistent adherence to treatment plans. Adherence to treatment will be ensured through linkages with home-based/palliative care programs established by CRS and other partners. These linkages are critical to monitoring the

treatment adherence and preventing possible complications as a result of non-adherence. The treatment support specialist at the clinical level will be working with community health workers and volunteers from the existing palliative care programs to ensure the proper treatment monitoring as well as the ART education of patients and their buddies. Creating satellite point of service will help further expand the reach to patients in remote and rural areas of Zambia. ART services will continue to be enhanced by twinning sites from different geographical areas. This will ensure sharing experiences and lessons learned and will enable further capacity building of LPTFS. Training centers will continue to serve as resource centers for building the capacity of medical staff from other LPTFS as well as other ART providers in country offering more sophisticated services to patients on treatment.

The activities in this proposal will complement activities in track 1 (#8829) and will enhance scale-up and consolidation of ART services in areas served by AIDSRelief. These services are critical to providing quality HIV care and treatment, and have been an integral part of the AIDSRelief program since its inception. This proposal is also contingent upon continued central funding through HRSA at existing levels.

This activity relates to: EGPAF SI (#9001), JHPIEGO SI (#9034), Ministry of Health (MOH) (#9008), Technical Assistance - Centers for Disease Control and Prevention (CDC) (#9023), and CCPTS COMFORCE (#9691)

Futures Group leads monitoring and evaluation (M&E) for Catholic Relief Services (CRS) AIDSRelief Zambia. Using in-country networks and available technology, Futures Group is building strong patient monitoring and management systems that are used to collect data and track strategic information from the points of service (POS). Strategic information includes indicators from the President's Emergency Plan for AIDS Relief (PEPFAR), other United States Government (USG) agencies, National Ministry of Health (NMOH) in conjunction with the Ministry of Health (MOH), and AIDSRelief specific project indicators. This collective information supports the provision of high quality HIV/AIDS care and treatment, ensures drug durability, tracks patient and program progress, and provides accuracy in reporting to both the USG and NMOH (former Central Board of Health). While reporting on indicators to donors and governments is an essential secondary objective, the primary aim of collecting strategic information (SI) is to assist clinicians and clinic managers in providing high quality HIV/AIDS care and treatment, to assist in chronic disease management, to monitor viral resistance, and to ensure durable viral suppression.

AIDSRelief selected a patient monitoring and management system, CAREWare, in year one and worked with programmers to modify the domestic version to meet the needs of an international environment and the specific needs of AIDSRelief Zambia.

However, Zambia found itself with multiple incompatible systems. With the MOH establishing the Continuity of Care and Patient Tracking System (CCPTSv3) electronic medical record (EMR) application as the national standard in April of 2006, essential activities of the end of the Country Operational Plan (COP) 2006 and early fiscal year (FY) 2007 must include conversion of data and forms to the new standard. The Centers for Disease Control and Prevention (CDC) is providing technical assistance and other assistance to help with this effort. By FY 2007, all clinics will have been converted and will be in compliance with the national system, and data and reports can be merged nationwide with all other care and treatment providers. The CCPTS software also produces the required national, PEPFAR, and Health Management Information System (HMIS) reports.

A software programmer will be engaged to help with technical issues in the transitioning period (end of COP 2006). This programmer will join with the source team of programmers at CDC, Center for Infectious Disease Research in Zambia (CIDRZ), MOH to ensure all necessary feedback is inputted into the system and the field is updated on new changes by start of COP 2007 activity period. Temp hires will be engaged to input all backlogs of CareWare paper forms as quickly as possible, so that the maximal amount of patient data will be in electronic medical record (EMR) at the time of transitioning, unless this approach appears to be less efficient or unduly delays the transition. Temp hires will be used to enter data into the new CCPTS in case there will be data that will not be convertible from CAREWare that must be human processed.

In FY 2007 the SI team will focus their efforts on maintaining the standardized national M&E systems that will be used across all AIDSRelief sites. This will include the mentoring of already trained as well as training of new facilities in using the forms and software adopted at national level.

Futures Group provides training and on-site technical assistance to local partner treatment facilities (LPTFs) in order to build in-country capacity and enhance paper-based and automated HMIS. Focusing efforts on capacity building activities will ensure that LPTFs are skilled in comprehensive data management, including data collection, validation, analysis, and reporting. LPTFs will also develop an understanding of the minimum data requirements for donor purposes and high-quality clinical management. It is Futures Group's intent to ensure that accuracy in data management is understood at all levels at the LPTFs because it is an essential component of monitoring patient progress and ensuring accuracy in reporting.

AIDSRelief Zambia in compliance with government guidelines has decided to shift the patient management system from CAREWare to the CCPTS EMR. In collaboration with

AIDSRelief partners, the AIDSRelief SI Advisor, working closely with the members of the Country Technical Coordinating Team (CTCT), and LPTFs, including clinicians, medical records staff, administrators, and M&E officers will ensure that the CCPTS is in all clinics and is being properly used to collect the required data.