The third component, increasing access to CD4 testing services, links PMTCT to ART services. ZPCT will continue to support the linkage between PMTCT and clinical care ART services by offering expanded access to CD4 tests for HIV-positive pregnant women. In FY 2007, ZPCT will continue to fund transport of laboratory samples for CD4 testing from ZPCT-supported facilities to sites with CD4 machines to ensure PMTCT and ART services are more accessible.

In the fourth component, ZPCT will continue strengthening systems for follow-up of HIV-infected mothers and their infants after delivery. Working through the under-five clinics, ZPCT will establish a system to provide support and to ensure that infants of HIV-infected women are tested for HIV at nine and 18-months as per the revised National PMTCT and ART Protocol Guidelines. A Polymerase Chain Reaction (PCR) machine located at Arthur Davison Children's Hospital in Ndola (Copperbelt Province) will support the process of early diagnosis of HIV-infected infants, and will be coordinated with the PCR activities supported by the Centers for Disease Control and Prevention (CDC) (8993). Support will also include linking women with community groups that provide nutritional, legal, and psychosocial support.

In the fifth component, ZPCT will continue providing technical assistance to the national HIV/AIDS PMTCT Technical Working Group in scale-up of PMTCT services and support for the development, revision, and dissemination of PMTCT training materials, protocols, standard operating procedures, and policies.

ZPCT will also work closely with other partners [e.g., community based organizations, non-governmental organizations, faith-based organizations, United Nations Population Fund, and other USG partners, including: Health Communications Partnership (HCP) (8901), Catholic Relief Services/SUCCESS (9182), and RAPIDS (8948)] to collaborate at the community level for mobilizing activities that promote increased uptake of PMTCT services. ZPCT will collaborate with church networks to encourage pregnant women to access PMTCT services and to establish support groups. Traditional leaders and male church leaders will be enlisted to encourage partners and discordant couples to be involved in couples counseling and testing for PMTCT. The reduction of stigma and discrimination, as well as equity of access to PMTCT and related HIV/AIDS services, will be issues discussed and addressed with partners within a culturally-sensitive context.

In the final component, increasing program sustainability with the GRZ, ZPCT will work with Provincial Health Offices (PHOs) and District Health Management Teams (DHMTs) to build on the quality assurance activities started in FY 2006. With GRZ, ZPCT will identify two districts in each of the five provinces that are now providing consistent quality services and will only need limited technical support from ZPCT in FY 2007. The PHOs and DHMTs will assume responsibility for the selected districts by providing all supervision and monitoring activities in these districts in order to better sustain program activities.

By working directly with GRZ facilities, ZPCT is able to establish a sustainable program through training health care workers, developing standard treatment protocols, strengthening physical and equipment infrastructures, implementing facility-level quality assurance/quality improvement programs, improving laboratory equipment and systems, and developing and strengthening health information systems.

This activity links with the Zambia Prevention, Care, and Treatment Partnership (ZPCT) PMTCT (#8886), ART (#8885), CT (#8883), TB/HIV (#8888), and Laboratory Support (#8887) activities as well as with the Government of the Republic of Zambia (GRZ) and other US Government (USG) partners. This activity will strengthen and expand clinical palliative care services in Central, Copperbelt, and the more remote Luapula, Northern, and North-Western provinces. The total geographic coverage of ZPCT support to clinical palliative care services is 69% of the population in the five provinces. In FY 2006, ZPCT will reach 48,535 clients with clinical palliative care services, exceeding the 18-month target, and reaching 38% percent of expected clinical palliative care needs in the five provinces through support to 87 facilities. In FY 2006, 150 ART providers will be trained in pediatric ART, including opportunistic infection (OI) management for children, 50 new providers will be trained in the ART/OI curriculum, and 50 more will receive refresher training. In addition, ZPCT initiated a comprehensive quality assurance/quality improvement program to monitor and improve service provision in all 87 facilities. Other FY 2006 achievements are outlined in the component descriptions below. In FY 2007, 66,690 clients will receive palliative care services in 100 ZPCT supported facilities.

Palliative care activities include four components: 1) strengthening palliative care services within health facilities; 2) increasing referral linkages within and between health facilities and communities working through local community leaders and organizations; 3) participating in and assisting the National Palliative Care Task Force to develop a strategy, guidelines, and standard operating procedures; and 4) increasing program sustainability with the GRZ.

In the first component, strengthening palliative care services within health facilities, ZPCT will continue assistance to 87 health facilities and expand to 13 new facilities in five new districts: one district in each of the five provinces, including Nchelenge District in Luapula Province (facilities are transitioning from Medecines Sans Frontieres support to GRZ responsibility with ZPCT assistance). Technical assistance and training will be provided to 100 health care workers (HCWs), using GRZ's two-week ART/OI curriculum which focuses on clinical palliative care for HIV/AIDS and treatment of OIs. HCWs will also be trained, using GRZ-approved curriculum, to provide cotrimoxazole prophylaxis, symptom and pain assessment and management, patient and family education and counseling, management of pediatric HIV in the home setting, and provision of basic nursing services as part of the overall package of palliative care services. Moreover, pharmacy staff will be trained in data collection/reporting and ordering, tracking, and forecasting HIV-related commodities thereby better ensuring the availability of critical medical supplies and drugs. ZPCT will also liaise closely with Project TBD (9520) and Partnership for Supply Chain Management Systems (SCMS) (9196) on forecasting drug supply requirements.

In the second component, increasing referral linkages within and between health facilities and communities, ZPCT will build on Zambia's long history of working with Faith-Based Organizations (FBOs) and Community-Based Organizations (CBOs) that provide home-based care for people living with HIV/AIDS (PLWHAs). These organizations serve as critical partners for facility-based programs supported by GRZ and USG. Therefore, as in FY 2006, ZPCT will work closely with these established entities to strengthen referral networks linking clinical palliative care services with community-based programs. For example, ZPCT through its sub-partner Churches Health Association of Zambia (CHAZ), is providing on-going technical assistance and training in clinical palliative care and linking those services to local home-based care programs. ZPCT is also coordinating with Catholic Relief Services (CRS)/SUCCESS (9180), RAPIDS (8946), and Peace Corps (9629) to better link clinical services to related community programs.

Community mobilization activities, implemented by ZPCT and partners, are another approach to strengthen referrals in palliative care within and between health facilities and communities. ZPCT will work with existing community groups, such as Neighborhood Health Committees, for activities related to stigma reduction and promotion of clinical palliative care and support services. ZPCT will also work with community-based care givers, traditional healers, and other key community leaders to increase community involvement, build community volunteers' capacity, and involve PLWHAs in palliative care services at the community level to reduce stigma and discrimination and thereby improve the quality and efficiency of these services. ZPCT uses materials developed by or adapted from materials produced by the Health Communication Partnership (HCP) (#8902).

In the third component, ZPCT will continue its participation in and provision of assistance to the USG Palliative Care Forum as well as coordinate with the Palliative Care Association of Zambia to develop a national palliative care strategy, guidelines, and standard operating procedures. Through these efforts, ZPCT aims to improve access to quality clinical palliative care services, promote use of evidence-based practices, share lessons learned in project implementation, and support the revision of national palliative care guidelines and protocols in accordance with GRZ policies.

In the final component, increasing program sustainability with the GRZ, ZPCT will work with Provincial Health Offices (PHOs) and District Health Management Teams (DHMTs) to build on the quality assurance activities started in FY 2006. With the GRZ, ZPCT will identify two districts in each of the five provinces that are now providing consistent quality services and will only need limited technical support from ZPCT in FY 2007. The PHOs and DHMTs will assume responsibility for the selected districts by providing all supervision and monitoring activities in these districts in order to better sustain program activities.

By working with GRZ facilities, ZPCT is able to establish a sustainable program through training health care workers, developing standard treatment protocols, strengthening physical and equipment infrastructures, implementing facility-level quality assurance/quality improvement programs, improving laboratory equipment and systems, and developing and strengthening the health information systems.

This activity links with the Zambia Prevention, Care, and Treatment Partnership (ZPCT) PMTCT (8886), ART (8885), CT (8883), Palliative Care (8884), and Laboratory Support (8887) activities as well as with the Government of the Republic of Zambia (GRZ), and other US Government (USG) agencies and partners as outlined below.

Approximately 62 percent of tuberculosis (TB) patients are HIV positive, and TB is the most common opportunistic infection (OI) in HIV patients. However, very few TB patients are offered HIV CT and related services. For this reason, in FY 2005, ZPCT began a partnership with and will continue to support Centers for Disease Control and Prevention (CDC) and GRZ to ensure consistency in HIV/TB training and service protocols and to improve availability of TB testing equipment and related commodities. ZPCT will also continue its support to the GRZ in strengthening and expanding TB/HIV services in Central, Copperbelt, and the more remote Luapula, Northern, and North-Western provinces. The total geographic coverage of ZPCT support to TB/HIV services is 69 percent of the population in the five provinces. In FY 2006 ZPCT began tracking TB/HIV clients; and through counseling and testing corners, ZPCT will be able over the 18 month target time frame, to provide CT to 5,000 TB clients and TB treatment to 3,961 ART clients over the 18 month target time frame will receive TB treatment. In addition, TB is included in the ART/OI training program in which 100 providers will be trained in TB/HIV treatment in FY 2006. In FY 2007, CT will be provided to 7,000 TB clients and 4,300 clients in HIV care will receive TB treatment.

This activity includes four components: 1) integration of HIV CT in TB clinics; 2) strengthening and expansion of TB services among HIV-infected individuals; 3) training for health care workers and lay counselors in cross-referral for TB/HIV and other opportunistic infections (OIs); and 4) increasing program sustainability with the GRZ.

In the first component, ZPCT will integrate HIV CT into TB clinics in the 87 ZPCT-supported facilities and will expand to nine new facilities in Nchelenge District in Luapula Province (facilities are currently transitioning from Medecines Sans Frontieres support to GRZ responsibility with ZPCT assistance) as well as 72 new facilities across all five provinces. TB clients are offered CT as part of the basic package of services within TB clinics and, if necessary, referred for further testing and support services, such as determining ART eligibility among HIV-infected TB patients. Those eligible will be offered ART on-site or referred to nearby ART facilities if ART is not available at the facility. The TB/HIV link will be further strengthened in facilities offering CT to ensure that all TB patients who are co-infected are identified and provided with appropriate care and treatment services. Furthermore, CT services will be offered to the TB patient's family, with emphasis on reducing stigma and discrimination associated with TB and HIV. In FY 2007, 7,000 TB clients will receive CT over the 12 month reporting period.

More specifically, with FY 2007 plus up funds, an additional 100 HCWs will be trained in the ART/OI curriculum in 68 new facilities serving an additional 2,152 clients.

The second component, strengthening and expanding TB services for HIV-infected individuals, involves TB diagnosis among all HIV-positive patients for reducing the incidence of TB Immune Reconstitution Syndrome and for offering appropriate TB and/or ART services. ZPCT will train 100 clinical staff in ART/OI management, including TB/HIV. Laboratory equipment, such as microscopes, will be procured to strengthen diagnosis of TB in selected ZPCT health facilities that currently have weak TB diagnostic capacity. Through these interventions, 4,300 HIV-TB co-infected persons will receive needed TB treatment over the 12 months.

In the third component, training for health care workers and lay counselors in cross-referral for TB/HIV and other OIs, ZPCT will work with GRZ facility management personnel to ensure that counselors are trained and available for TB clinics in ZPCT-supported facilities. Lay counselors will be trained and assigned to provide support in these clinics, as needed. In addition to counseling skills, health care workers (HCWs) and lay counselors will be trained in making referrals for appropriate HIV/AIDS services. Training in cross-referrals between TB and HIV/AIDS services will be included in all CT and ART/OI management training supported by ZPCT.

ZPCT will also work at the national level with GRZ and USG partners, such as CDC, as well

as through the national TB and ART Technical Working Groups, to ensure that policies and guidelines are optimal for TB/HIV linkages at all levels of the health care system: national, provincial, district, and community. In addition, Family Health International is a partner with The Royal Netherlands Tuberculosis Foundation (KNCV), Japanese Anti-Tuberculosis Association (JATA), and World Health Organization (WHO) in the USAID Child Survival Fund's Tuberculosis Control Assistance Program (TB-CAP) and will be working with the Ministry of Health (MOH) to: 1) strengthen and expand quality DOTS programs in Central, Copperbelt, Luapula, Northern, and North-Western, provinces; 2) improve collaboration between TB and HIV partners and programs; 3) increase community involvement and awareness of TB; and 4) strengthen public/private partnerships to combat TB and HIV. ZPCT will coordinate all TB/HIV activities with the MOH and TB-CAP.

In the final component, increasing program sustainability with the GRZ, ZPCT will work with the Provincial Health Offices (PHOs) and District Health Management Teams (DHMTs) to build on the quality assurance activities started in FY 2006. With the GRZ, ZPCT will identify two districts in each of the five provinces that are now providing consistent quality services and will only need limited technical support from ZPCT in FY 2007. The PHOs and DHMTs will assume responsibility for the selected districts by providing all supervision and monitoring activities in these districts in order to better sustain these program activities.

By working with GRZ facilities, ZPCT is able to establish a sustainable program by training health care workers, developing standard treatment protocols, strengthening physical and equipment infrastructures, implementing facility-level quality assurance/quality improvement programs, improving laboratory equipment and systems, and developing and strengthening health information systems. ZPCT's goal is to leave behind quality systems to ensure continuity of quality TB/HIV services after the program concludes.

With FY 2007 plus up funds, an additional 100 HCWs will be trained in the ART/OI curriculum in 68 new facilities serving an additional 2,152 clients. With FY 2007 plus up funds, an additional 100 HCWs will be trained in the ART/OI curriculum in 68 new facilities serving an additional 2,152 clients.

This activity links to Zambia Prevention, Care, and Treatment Partnership (ZPCT) activities in ART (#8885), TB/HIV (#8888), PMTCT (#8886), Palliative Care (#8884), and Laboratory Support (#8887) as well as with the Government of the Republic of Zambia (GRZ), Japan International Cooperative Agency (JICA), and other US Government partners as outlined below. The focus is to improve CT services in the Central, Copperbelt, and the more remote Luapula, Northern, and North-Western provinces to reach 54,000 people with CT services in 99 facilities. The total geographic coverage of ZPCT support to CT services is 69% of the population in the five provinces. In FY 2006, 86 GRZ facilities were supported to provide CT services through training 272 health care workers (CWs) and lay counselors, refurbishing 86 facilities, and providing same day test results; 95% of clients receive their test results on the same day, reaching 68,000 clients in FY 2006's 18 month reporting period. Other FY 2006 achievements are outlined in the component sections below.

The targets have been revised based on an assessment of CT service utilization, facility catchment populations, community mobilization/outreach service activities, and the need to minimize any potential for double-counting of CT in other sectors (e.g., TB and STI clinics). Facilities were strategically chosen to ensure equity of access, including a strong emphasis on reaching rural populations. Five activity components include: 1) provide comprehensive assistance to facility-based CT services; 2) provide technical assistance to Neighborhood Health Committees, non-governmental organizations (NGOs), faith-based organizations (FBOs), and community-based organizations (CBOs) to expand access to CT via mobile outreach programs; 3) expand and strengthen CT referral systems; 4) provide technical assistance to the national CT technical working group; and 5) increase program sustainability with the GRZ.

In the first component, assistance to facility-based CT services, ZPCT will continue to support 86 facilities and add 13 new facilities. These new facilities will include five in Nchelenge District, Luapula Province (facilities are currently transitioning from Medecines Sans Frontieres support to GRZ responsibility with ZPCT assistance) and two facilities in each of the other four districts per the other four provinces. This assistance includes facilitating management of CT commodities (including HIV test kits), conducting moderate refurbishments, training and mentoring, increasing quality assurance mechanisms, building human capacity, and improving systems for tracking patient flow, accessibility, and acceptability of CT services. ‘Testing Corners' (minimal laboratories placed within or in close proximity to CT sites to facilitate same day test results) will be expanded to all 99 sites; this will include integrating CT into other clinical services, such as TB and STI care. Staff capacity to forecast and procure HIV test kits and supplies and to improve data entry will also be enhanced. In new service sites, ZPCT will work with the facilities and District Health Management Teams (DHMTs) to obtain CT site accreditation status of these facilities, thereby making them eligible to receive supplies from Medical Stores Ltd. In collaboration with GRZ, Project TBD (#9522) and Partnership for Supply Chain Management Systems (SCMS) (#9523), pharmacy, laboratory, and counseling staff in the supported facilities will be trained in data collection and reporting, ordering, tracking, and forecasting of CT-related commodities.

In the second component, ZPCT will work in the communities surrounding the CT sites to increase demand and acceptance of CT services, including targeting discordant couples. ZPCT will work with facilities and NGOs/FBOs/CBOs to deliver CT services through mobile teams of HCWs and lay counselors. This integrated effort of bringing together NGOs/FBOs/CBOs, Neighborhood Health Committees, community leaders, and facility health workers will greatly increase access to CT services in rural areas and will mobilize overall demand for and acceptance of CT. For example, lay counselors will lead group discussions and offer pre/post test individual counseling within communities and at facilities. HIV-infected individuals will be referred for other services, including PMTCT, ART, and palliative care.

In FY 2006, 100 HCWs received the GRZ counseling training course, 60 HCWs the counseling supervision training, and 112 lay counselors from CBOs and FBOs were trained. In FY 2007, an additional 100 HCWs will receive the GRZ training, 100 will receive refresher training, and 60 will receive counseling supervisor training. An additional 100 CBO/FBO lay counselors, including persons already working in facilities (e.g., TB treatment supporters) will be trained to support CT services in health facilities and to increase

demand for these services within communities. These community representatives will also assist health facility management and staff to make CT services more accessible and acceptable among the population they serve.

In the third component, ZPCT will work with facilities, communities, and partner organizations to establish, strengthen, and widen referral linkages. Inter- and intra-facility referrals between CT and TB, STI, ante-natal care, in-patient, and out-patient services will be expanded, and existing community-based services will be integrated into an active referral system. A ZPCT provincial referral officer works with organizations in each ZPCT-supported district and a contact person in each supported facility to strengthen the district referral networks.

In the fourth component, ZPCT will provide technical assistance to the national CT Technical Working Group on strategies for scaling up CT services and developing, revising, and disseminating training materials, protocols, and policies. Policy issues continue to include recognition of lay counselors' role in facilities, involving non-HCWs in HIV testing, and adapting CT strategies for provider-initiated protocols.

Linkages with USG and non-USG partners will increase the number of people reached with CT services and will avoid duplication of services. Through collaborative efforts with Health Communication Partnership (8901), Society for Family Health (SFH) (8926), and Peace Corps (9629), ZPCT will provide targeted IEC materials, developed in local languages for use by community groups. ZPCT will also seek opportunities to leverage resources by partnering with organizations that provide CT services, such as SFH's (8926) New Start and mobile CT network, and strengthening referral networks to ZPCT ART-supported facilities. ZPCT will continue to collaborate with projects supporting home-based care services, such as Catholic Relief Services/SUCCESS (9180) and RAPIDS (8946), to promote and expand CT services for the communities in which they work.

In the final component, increasing program sustainability with the GRZ, ZPCT will work with Provincial Health Offices (PHOs) and DHMTs to build on the quality assurance activities started in FY 2006. With GRZ, ZPCT will identify two districts in each of the five provinces that are now providing consistent quality services and will only need limited technical support from ZPCT in FY 2007. PHOs and DHMTs will assume responsibility for selected districts by providing all supervision and monitoring activities in these districts in order to better sustain the program activities.

By working with GRZ facilities, ZPCT is able to establish a sustainable program through training health care workers, developing standard treatment protocols, strengthening physical and equipment infrastructures, implementing facility-level quality assurance/quality improvement programs, improving laboratory equipment and systems, and developing and strengthening health information systems.

This activity links with the Zambia Prevention, Care, and Treatment Partnership (ZPCT) CT (#8883), PMTCT (#8886), TB/HIV (#8888), Palliative Care (#8884), and Laboratory Support (#8887) activities as well as the Government of the Republic of Zambia (GRZ) and other US Government (USG) partners as outlined below. This activity will strengthen and expand ART services in Central, Copperbelt, and the more remote Luapula, Northern, and North-Western provinces. The total geographic coverage of ZPCT support to ART services is 69% of the population in the five provinces. In FY 2006, ZPCT will reach 37,335 (2,800 pediatric) ART clients, exceeding the 18-month target and reaching 36% and 18.6% of expected ART need in the five provinces and in Zambia respectively. All 49 ART sites have been renovated and are fully functioning. Other FY 2006 achievements are outlined in the component descriptions below. In FY 2007, 51,300 ART patients, of whom 15,600 will be new (1,560 pediatric), will be provided with ART. As of September 30, 2008, the number of persons who ever received ART will be 54,300.

The seven components are: 1) provide comprehensive support to strengthen ART facilities and services; 2) expand implementation of the ART outreach model; 3) strengthen referral linkages and increase demand for ART services; 4) participate in and support the national ART Technical Working Group; 5) assist in scaling-up pediatric ART services; 6) expand renovations to GRZ structures to assist with staff retention; and 7) increase program sustainability with the GRZ.

In the first component, provision of comprehensive support to strengthen ART facilities and services, ZPCT will continue its FY 2006 assistance to 49 ART centers and expand to nine new ART facilities, including five in Nchelenge District, Luapula Province (facilities are currently transitioning from Medecines Sans Frontieres support to GRZ responsibility with ZPCT assistance) and one district in each of the other four provinces. In FY 2006, ZPCT is training 50 health care workers (HCWs) in ART/OI management, 50 HCWs in the ART/OI refresher course, and 150 HCWs in management of pediatric ART. In FY 2007, ZPCT will train 100 HCWs in initial and refresher ART management and 50 HCWs in pediatric case management. In collaboration with the Health Services and Systems Program (HSSP) (8794), all 58 ART sites will be assisted in developing quality assurance mechanisms and supportive supervision systems to ensure implementation of standard operating procedures for ART case management, conducting minor refurbishments, providing ART-related supplies, and linking ART patients and their families to ante-natal care, PMTCT, TB, palliative care/home-based care, and other appropriate treatment and support services.

In the second component, ZPCT will expand the ART outreach model to a total of 21 sites (four to be added in FY 2007). Through this model, doctors trained in ART case management travel to non-ART health centers on selected days, bringing with them mini-labs, to train facility staff and to provide HIV/AIDS clinical services to patients who would not otherwise have access to these quality ART services.

In the third component, ZPCT will work with USG partners, such as CRS/SUCCESS (#9182), Health Communication Partnership (HCP) (#8901), RAPIDS (#8948), and Society for Family Health (SFH) (#8926) to strengthen referral linkages and community outreach efforts aimed at creating demand for ART services and supporting treatment adherence among ART patients. During FY 2006, ZPCT is collaborating with GRZ to develop, pilot, and roll out an adherence counseling training curriculum for HCWs and adherence support workers (ASWs). ASWs, many of whom are ART patients, are also being trained to work in facilities and communities with ART clients, particularly those persons initiating therapy. In FY 2006, 50 HCWs are being trained in adherence counseling and 145 ASWs in ART adherence counseling, treatment support, and community outreach. In FY 2007, an additional 25 HCWs and 25 ASWs will be trained in adherence counseling. FY 2007 support will also further reduce stigma and discrimination associated with ART by working with community leaders and key stakeholders regarding the importance of CT and availability of ART.

In the fourth component, in coordination with HSSP (#8794) and JHPIEGO (#9033), technical assistance will continue to be provided to the national ART Technical Working Group for scaling-up ART services, focusing on developing, updating, and disseminating training materials, protocols, and policies. For example, during FY 2006, ZPCT, GRZ, and other partners involved in ART programming are collaborating to revise and disseminate

the national standardized patient information tracking system.

The fifth component will provide assistance to the GRZ in scaling-up ART services and treatment for pediatric patients to serve 4,300 (1,560 new) children in FY 2007. Building on the pediatric training program mentioned above, ZPCT will provide technical assistance to GRZ in the five provinces to address limited HIV/AIDS pediatric expertise. Major challenges include building capacity in diagnosing HIV in children less than 18 months and providing adherence counseling for children and their caregivers. To meet these challenges, in FY 2006, ZPCT will procure a Polymerase Chain Reaction (PCR) machine for Arthur Davison Children's Hospital in Copperbelt Province, which will be used as a referral center for pediatric diagnosis. This activity is closely linked to the Centers for Disease Control and Prevention (CDC)/Centers of Excellence (#8993). In collaboration with CDC, ZPCT will integrate innovative approaches to pediatric ART case management, including mentoring, on-site training, and strengthening basic ART/OI pediatric management. ASWs will continue to assist families in addressing ART adherence and other challenges to effective pediatric case management. Fifty-four ART sites will be able to provide pediatric ART services in FY 2007, with the other four ART sites in Ndola District referring pediatric cases to Arthur Davison Children's Hospital.

ZPCT will also work with partners to strengthen referral networks within and between facilities and communities to expand access to pediatric HIV care, including tracking of mothers and their infants for up to 18 months through the under-five clinics. ZPCT will continue to work with churches and local community groups to reach families with information and referrals for CT and ART for children under 14 years of age.

In the sixth component, ZPCT will work with GRZ, Provincial Health Offices (PHOs), and District Health Management Teams (DHMTs) to identify essential structures (e.g., health centers, staff housing) requiring refurbishments to increase quality of life as a means for enhanced staff retention in the most remote, rural areas of Northern and North-Western provinces. In FY 2007, ZPCT will conduct an in-depth assessment of facilities/houses to improve at least 50 structures.

In the final component, increasing program sustainability with the GRZ, ZPCT will work with DHMTs and PHOs to build on quality assurance activities started in FY 2006. With the GRZ, ZPCT will identify two districts in each of the five provinces that are now providing consistent quality services and only need limited technical support from ZPCT in FY 2007. The DHMTs and PHOs will assume responsibility for the selected districts by providing supervision and monitoring in order to better sustain program activities.

By working with GRZ facilities, ZPCT is able to establish a sustainable program through training health care workers, developing standard treatment protocols, strengthening infrastructures, implementing quality assurance/quality improvement programs, improving laboratory systems, and developing/strengthening health information systems.

This activity links with the Zambia Prevention, Care, and Treatment Partnership (ZPCT) CT (#8883), PMTCT (#8886), ART (#8885), TB/HIV (#8888), and Palliative Care (#8884) activities as well as with the Government of the Republic of Zambia (GRZ) and other US Government (USG) partners as outlined below.

This activity will provide support to the GRZ for strengthening and expanding laboratory services in the delivery of HIV/AIDS care in Central, Copperbelt, and the more remote Luapula, Northern, and North-Western provinces. During FY 2006, ZPCT is improving laboratory services by training 75 laboratory technicians, renovating six laboratories (57 laboratories were renovated in FY 2005), procuring essential laboratory equipment and reagents, expanding quality assurance activities, developing and computerizing a Laboratory Management Information System to track HIV-related laboratory tests, and providing technical assistance and mentoring. In FY 2006, ZPCT also initiated a laboratory specimen referral system with 62 laboratories to transport specimens from health facilities without laboratory facilities to the central labs. This new system is greatly improving the ability of more rural facilities to provide quality HIV/AIDS services, and has led to same-day test results and an increase in new ART patients. In FY 2006 it is estimated that the number of tests performed at ZPCT-supported laboratories will be 417,679 over the 18 month target time frame.

In FY 2007, ZPCT will continue providing assistance to 63 GRZ laboratories providing CT, PMTCT, ART, and/or clinical palliative care services. ZPCT will also support five new hospital laboratories in newly selected districts for a total of 68 laboratories. Forty-one of the 68 supported facilities will have the capacity to conduct more advanced HIV laboratory tests, such as CD4 and lymphocyte tests. More specifically, laboratory support activities include: 1) strengthening laboratory infrastructure; 2) improving laboratory quality assurance mechanisms, information systems, and personnel capacity; and 3) increasing program sustainability with the GRZ. Total geographic coverage of ZPCT support to laboratory services serves 81 percent of the population in the five ZPCT-supported provinces.

In the first component, strengthening laboratory infrastructure, all sites providing ART will have access to the full complement of basic equipment for hematology and biochemistry (including total lymphocyte count and liver and renal function testing for ART patient monitoring). Equipment purchased, such as hematology and chemistry analyzers, will be in accordance with GRZ guidelines/policies. Other equipment, including autoclaves, centrifuges, microscopes, and refrigerators, will be provided as needed. ZPCT will continue to link new ART sites currently without access to CD4 testing to nearby ART facilities that have Facscount machines, and will ensure availability of transport of samples from project-supported facilities to sites with CD4 machines for proper ART patient monitoring. ZPCT will also work in close collaboration with the GRZ to ensure provision of supplies for CD4 enumeration in the hard-to-reach areas. In addition, the laboratory team will provide technical support for the utilization of the Polymerase Chain Reaction (PCR) machine located at Arthur Davison Children's Hospital in Copperbelt Province to support the process of early diagnosis of HIV-infected infants. These activities will be closely coordinated with the Centers for Disease Control and Prevention (CDC) programs/Centers of Excellence (8993). In FY 2007, the number of tests performed at ZPCT-supported laboratories will be 372,254 over a 12 month time period.

In FY 2005 and FY 2006, ZPCT provided minor refurbishment, essential furniture, and fixtures for selected laboratories to enable all facilities to provide the appropriate level of laboratory services. In FY 2007, ZPCT will expand to Nchelenge District in Luapula Province (facilities are currently transitioning from Medecines Sans Frontieres support to GRZ responsibility with ZPCT assistance) and four additional new district laboratories, one in each of the other four provinces.

In the second component, ZPCT will work with GRZ and CDC to strengthen laboratory quality assurance mechanisms, information systems, and laboratory personnel's capacity to ensure adherence to GRZ's recommended laboratory standards. In FY 2006, 75 laboratory technologists/technicians are being trained in lab-related activities and in FY 2007, another 60 persons will be trained. To improve quality assurance practices, approximately ten percent of HIV test samples will be checked by trained laboratory staff from designated National Quality Assurance Centers; samples from facilities without

laboratories will be transported to the nearest laboratory site in order to facilitate testing availability. ZPCT will also disseminate laboratory standard operating procedures to all sites to ensure that all facilities implement proper laboratory practices. Finally, laboratory staff will continue to be trained in commodity management; this particular assistance will be coordinated with Project TBD (#9520), Partnership for Supply Chain Management Systems (SCMS) (#9524), CDC, and GRZ to avoid duplication of efforts and to ensure that facility-level forecasting and procurements provide constant supplies of required laboratory commodities.

In the final component, increasing program sustainability with the GRZ, ZPCT will support the MOH laboratory quality assurance (QA) assistance plan in collaboration with CDC. ZPCT will work with GRZ to strengthen QA activities in the three Central Hospital laboratories and six General Hospital laboratories in the five ZPCT supported provinces. To maintain consistent and high quality laboratory services and improved supervisory support to the District Hospital laboratories, ZPCT will provide support to strengthen the capacity of the General Hospital laboratories. The MOH, through the Provincial Health Offices, will then assume responsibility for the monitoring of the General and District Hospital laboratories' QA program.

By working with GRZ facilities, ZPCT is able to establish a sustainable program by training health care workers, developing standard treatment protocols, strengthening physical and equipment infrastructures, implementing facility-level quality assurance/quality improvement programs, improving laboratory equipment and systems, and developing and strengthening health information systems. ZPCT's goal is to leave behind sustained systems to ensure continuity of quality laboratory support after the program concludes.