This activity is directly linked to Population Services International/Society for Family Health (SFH), Health Communications Partnership (HCP), JHPIEGO, and Partnership for Supply Chain Systems (SCMS) male circumcision activities (MC) as well as indirectly to Ministry of Health (MOH), National AIDS Council (NAC), and USG implementing partner AB activities.

In partnership with JHPIEGO, MOH, and NAC and through private funds, SFH has already begun implementing a socially-marketed MC pilot project in Lusaka. The objectives of this project are to assist in meeting current demand for MC services and to develop lessons learned regarding cost-effective, sustainable MC service delivery models to rapidly scale-up MC services nationwide. This project is operating in four sites: University Teaching Hospital urology clinic, two private clinics, and an SFH New Start-branded counseling and testing center. With plus-up funding, SFH will expand the pilot project to two additional sites in peri-urban settings; selection will be determined by their suitability and commitment to the project, as indicated through the use of MC site assessment materials developed by JHPIEGO. These additional sites will provide richer data regarding the feasibility of implementing cost-effective, sustainable MC models in various locales through different modalities. More specifically, three components comprise this MC service delivery package: provision of the male circumcision procedure; counseling and communications on HIV prevention (including AB messages) and testing, STI evaluation and treatment, men's general reproductive health; and linkages to other reproductive health and HIV/AIDS services. Additionally, in conjunction with the national MC task force, these results will be used to further develop appropriate training and service delivery packages to increase access to safe MC services in a variety of settings. More specifically, based on the technical manual produced by WHO and UNAIDS, a training manual/program will be developed in collaboration with JHPIEGO, MOH, and NAC. Contents of the training will include: pre-operation assessment; assessment of instruments and supplies; sterilization techniques; patient informed consent and necessary documentation; proper patient preparation; surgical procedures; pain management; post-op care; counseling for wound care; counseling about HIV/AIDS and prevention (including AB messages), reproductive health and healthy gender relations; recognition and treatment of adverse effects; and referral to tertiary centers if appropriate. Previous trainings developed by SFH (focusing on CT client counseling) and JHPIEGO (MC counseling and service provision) will serve as starting points and be revised and expanded as determined by the oversight committee. All doctors, clinical officers, nurses, and counselors involved in MC service delivery will be required to have successfully completed this training course which includes training in provision of AB messages. Moreover, frequent monitoring of service providers will promote high-quality services; service providers will be required to maintain the highest quality of service in order to remain in the MC service provision networ, including use of client feedback and follow-up to ensure service and counseling protocols are followed. While this activity's overall emphasis is on service delivery, it will be necessary to coordinate with HCP in the development and dissemination of communication materials for related AB messages. Materials will emphasize clear information regarding the importance of AB as a key component of healthy behavior when possible. In conclusion, through this approach, Zambia will be better informed of how it can provide high quality, cost-effective MC services nationwide within a comprehensive prevention program.

Table 3.3.03: Program Planning Overview Program Area: Medical Transmission/Blood Safety Budget Code: HMBL Program Area Code: 03 Total Planned Funding for Program Area: $ 4,200,000.00

Program Area Context:

Zambia has a comprehensive national blood transfusion program aimed at ensuring equity of access to safe and affordable blood throughout the country. Blood transfusion needs in Zambia are currently estimated at 100,000 units (450 mls each) of blood per year. Since the initiation of the President's Emergency Plan for AIDS Relief (PEPFAR) funding in August 2004, mobile collection sites have increased from 9 to 21 while blood collection has increased drastically from a baseline of 8,715 units in 2004 to 18,476 units for the first quarter ending March 2006 thereby bringing the current operation to 93,000 units per year exceeding the target of 88,500 units by 6%. About 40-45% of the collected blood is transfused in children under the age of five years and 20% in complicated pregnancies. With support from PEPFAR, transfusion sites have increased from 81 to 115 in number covering all nine provinces and operating in most of the 72 districts. Not only has previous funding allowed for the expansion of collection sites, the purchase of 18 vehicles and five trailers for transporting blood it has also allowed for the acquisition of nine large blood storage refrigerators for the nine regional sites and 81 small blood storage refrigerators for the blood transfusion sites. About 595 providers have been trained on safe blood operations. There is strong collaboration between the ZNBTS and other donors such as World Bank and the Global Fund to ensure funding for blood safety are coordinated and streamlined for efficiency.

The Zambia National Blood Transfusion Service (ZNBTS) is the government unit responsible for ensuring safety, an adequacy, and an equitable supply of blood throughout the country. ZNBTS continues to face challenges such as (1) needing to rapidly increase blood collections to meet the estimated national demand of 100,000 units of blood per year by 2009; (2) increasing the percentage of regular repeat donors from 32% in 2005 to 85% in 2006; (3) reducing HIV discards from 8% to 1% by 2007, and; (4) stretching limited resources against increasing operations.

Funding from 2004-2006 has considerably expanded ZNBTS activities. The blood safety system in Zambia comprises the coordinating centre in Lusaka and nine regional blood transfusion centers in each of the nine provinces. Together these facilities are responsible for donor mobilization, collection, laboratory screening and distribution of blood; maintaining 81 hospital-based blood banks located in government and mission hospitals. They are also responsible for blood grouping and cross-matching and monitoring of transfusion outcomes for their respective hospitals of location. There are over 112 facilities, including government, mission, military and private facilities that are currently involved in the clinical use of blood. The existing blood transfusion infrastructure is fairly developed and equipped with the requisite equipment for blood collection, testing, distribution, and cold chain maintenance. Government, mission, military and private hospitals receive tested blood and blood products from the nine regional centers. Since its inception, additional staff have been employed, operational and financial support has been extended to all regional centers, and management has been strengthened. As a result, mobile collection teams have increased steadily from nine to nineteen in 2005 and to 21 in 2006. The main strategies applied to ensure safety and adequate supplies of blood include: recruitment and retention of voluntary non-remunerated blood donors from low risk population groups; application of strict criteria for selection of blood donors; procurement of standardized and adequate blood storage refrigerators. Updated blood screening equipment; mandatory laboratory screening of blood for HIV, Hepatitis B and C, and syphilis; promotion of appropriate clinical use of blood; appropriate staff training and capacity building; and continuous improvements in management and coordination have all contributed to the successful strategy.

The blood safety program in Zambia is a national program covering the whole country. The collection, laboratory screening, and distribution of blood is the responsibility of the nine provincial blood banks. Clinical transfusion of patients is currently conducted by 112 hospitals and clinics throughout the country, including public, private, military and faith-based facilities. The total transfusion needs in Zambia are estimated at 100,000 units per year and the current operations are at about 65%. Under the current arrangement, all blood collections and screening are done by ZNBTS, while other partners are mainly involved in the clinical use of blood. In 2005, HIV prevalence in donated blood increased from 6% to 8%,

mainly due to the rapid scale-up of blood collections (93,370 units for the first 20 months of PEPFAR support), which largely depended on first time donors. The focus is now aimed at rapidly reducing HIV prevalence among donors to 1%. The percentage of voluntary, non-remunerated blood donation currently stands at 88%. Currently, 100% of blood collected throughout the country is screened for HIV and other blood borne infections. Stock-outs of test kits in donation sites are negligible.

Currently, a national blood transfusion policy and strategic plan exist. Since mid 2005, ZNBTS has embarked on the development of an appropriate legal and regulatory framework for blood transfusion services in Zambia. In the past, the lack of an appropriate blood donor tracing system contributed to over-reliance on first time donors, instead of regular, repeat donors, which led to increased discards. However, ZNBTS has developed and is now implementing a computer-based blood donor tracing system, which will be given a special emphasis in 2007. The ZNBTS intends to assure rational use of blood and blood products through a series of activities, e.g. the updating, distribution, and dissemination of the national guidelines on the appropriate use of blood; strengthening hospital blood transfusion committees; training of clinicians and medical school students in the appropriate methods of rational use of blood; improving and expanding capacities for production of various blood components; and strengthening the systems for monitoring blood transfusion outcomes.

New activities to be supported with FY 2007 funds include: procurement of nine new large refrigerators for nine regional sites, 34 new small refrigerators to ensure all 115 sites have adequate storage space, and 21 laptops for the management of the repeat donor tracing system on the part of the mobile blood collection teams. Use of the Continuity of Care: Patient Tracking System (CC:PTS) and the issuance of individual electronic health records will also be explored as a way to maximize donor tracing and enroll citizens in the system. Additionally, ZNBTS will more actively pursue formalized and systematic linkages with counseling and testing services.

Program Area Target: Number of service outlets carrying out blood safety activities 115 Number of individuals trained in blood safety 595

Table 3.3.03:

This activity is an integral component of a prevention and care project strategically linked to HVAB and HVCT interventions, including PSI (#8926), Central Contraceptive Procurement (#8872), HCP (#8905), IYF (#8899), JHPIEGO (#9035), RAPIDS (#8945), COH II (#8939), CHAMP, and CHANGES2 (#8851).

In FY 2007, PSI, through its local affiliate, SFH, will expand and enhance outreach activities encouraging individuals to be faithful and promoting consistent and correct condom use to specific target populations. PSI/SFH is currently covering 60% of national districts with intensive condom promotion and outreach activities; low intensity activities are being implemented in the remaining 40% of the districts, which are hard-to-reach rural areas with poor infrastructure and low density populations.

Activities will specifically target: (1) sexually active males and females—including street youth; (2) men and women engaged in concurrent sexual partnerships; (3) commercial sex workers and their partners; and (4) men and women at their workplaces. In FY 2006, PSI/SFH's provincial teams of outreach workers conducted approximately 10,000 small- and medium-size interpersonal outreach sessions reaching more than 135,000 individuals with balanced HIV prevention messages using interactive photo flipcharts. PSI/SFH will continue to target these groups with risk-reduction messaging, condoms, and promotion of counseling and testing (CT). Risk-reduction messaging will focus on partner reduction, fidelity, and consistent condom use. In FY 2007 PSI/SFH will conduct interpersonal behavior-change outreach activities in locations frequented by high risk target groups such as bars, nightclubs, filling stations, truck parks, and hair salons.

Additionally, PSI/SFH will target migrant fish camp traders in the Western, Central, and Luapula provinces with partner-reduction and condom-use messages. In FY 2006 a strategic field office was opened in a major fish trading location. Activities will be designed to promote condom use and fidelity, increase personal risk assessment skills, and identify referral facilities for CT and STI diagnosis and treatment.

Further, as strong evidence has recently emerged that circumcised males are less likely to contract HIV and STIs than uncircumcised ones, PSI/SFH will partner with JHPIEGO to assess the feasibility and cost of scaling-up existing male circumcision services ($100,000). This partnership will explore what lessons existing service providers have learned as a means to assess the capacity of existing service sites to provide more comprehensive circumcision counseling services. Topics will include: (1) consensus building; (2) informed consent; (3) how to prepare and maintain service sites; (4) quality assurance; and (5) cost efficiency.

Linking with HCP, PSI/SFH and JHPIEGO will also evaluate policy issues and barriers surrounding the provision of services. Research activities will examine the reasons men opt for circumcision and how they behave (in regard to sexual activity and condom use) after receiving the operation. PSI/SFH will conduct focus groups to better understand the psychosocial dynamics of how circumcision affects men's sexual behavior. This research will take place in public, private, and CT service providers in Lusaka, Southern, and North-western provinces.

In FY 2007, PSI/SFH will build on its youth-focused behavior change program focused on prevention among youth, initiated with PEPFAR funds in FY 2006. This program will target 18-24 year olds in tertiary and secondary institutions through a combination of small-group interpersonal outreach activities focusing on life skills through drama, role play, and debates. PSI/SFH will increase the number of institutions it works with from seven to 20 by September 2007, and will reach an estimated 14,000 young people through outreach activities alone. Four targeted VCT sessions will be held every month in educational institutions through New Start's mobile VCT units.

PSI/SFH will develop a weekly, youth-oriented radio program in concert with the Zambian youth organization "Trendsetters." The radio show will feature an outreach component that supports anti-AIDS clubs in secondary schools, colleges, and universities in the Copperbelt and Lusaka provinces. This radio program will include dialog among and between youth and people of influence (e.g. parents, teachers, and popular figures) and will link to youth-friendly health and psychosocial referral services and telephone hotlines. PSI/SFH will explore developing a dedicated youth hotline, possibly in partnership with the

existing HIV Talkline implemented by CHAMP with funding from HCP.

In FY 2007, PSI/SFH will develop and broadcast "Delayed Debut" radio shows and conduct school outreach activities. PSI/SFH will train lecturers, teachers, and peer educators to reinforce and promote behavior-change among youth. Further, "Delayed Debut" will teach parents how to effectively and appropriately address sexuality with their children and communicate their values and expectations regarding adolescent behavior.

In FY 2007, PSI/SFH will link this project with the CT project by supporting ongoing, cohesive, mutually-supportive Be Faithful and Condom interventions for individuals and couples during post-test counseling, including discordant and concordant positive couples. These interventions will address gender equity by contributing to the establishment of revised male norms and societal behaviors with regard to HIV/AIDS.

PSI/SFH will ensure sustainability by establishing private sector partnerships with distributors and wholesalers and by building the capacity of local Zambian staff to increase their technical and management capabilities. Additionally, ongoing condom-use training for both public and private health care workers will be provided.

With plus-up funding, SFH will expand the socially-marketed MC pilot project to two additional sites in peri-urban settings; selection will be determined by their suitability and commitment to the project, as indicated through the use of MC site assessment materials developed by JHPIEGO. These additional sites will provide richer data regarding the feasibility of implementing cost-effective, sustainable MC models in various locales through different modalities. Based on the technical manual produced by WHO and UNAIDS, a training manual/program will be developed in collaboration with JHPIEGO, MOH, and NAC. All doctors, clinical officers, nurses, and counselors involved in MC service delivery will be required to have successfully completed this training course. Moreover, frequent monitoring of service providers will promote high-quality services; service providers will be required to maintain the highest quality of service in order to remain in the MC service provision network, including use of client feedback and follow-up to ensure service and counseling protocols are followed.

While this activity's emphasis is on service delivery, it will be necessary to coordinate with HCP in the development and dissemination of communication materials. Ensuring the consistent availability of suitable supplies will be critical and these efforts will be coordinated with SCMS. In collaboration with the national MC task force and MC implementing partners, an MC kit will be developed to ensure that providers have the necessary supplies. Monitoring client flow, supplies, and communications materials will require sufficient systems and documentation to function with optimum efficiency and to mitigate waste. Relevant forms, procedures, and trainings will be developed to ensure that each service provider operates as proposed and that information is readily available for review. In collaboration with JHPIEGO and other MC partners, SFH will assist in developing national standard systems that meet the requirements as stated by the MC task force.

This activity is linked to Palliative Care: Basic health care and support interventions that include Catholic Relief Services (CRS) (#9180), CARE (#8819), and RAPIDS (#8946). Launched in 1998 with technical support from CDC and funding from USAID, Population Services International's (PSI) local affiliate, Society for Family Health (SFH), currently sells almost two million bottles of Clorin safe water home treatment solution annually. It is consistently promoted to urban and rural populations through drama and mobile video unit shows, communication sessions, radio spots, and an animated TV advertisement. Clorin is sold through a variety of channels—predominately wholesalers (37% of 2005 sales), a distributor (26%), public clinics (14%), and non-governmental organizations (NGOs) (13%). In March 2006, CDC conducted a targeted technical evaluation on Clorin. Based on the recommendations of this evaluation, production of Clorin is being outsourced to a private Zambian company using a business model that will ensure that consumer prices remain low. This evaluation also led to a redesign of the bottle cap that ensures easier and more effective use (for measuring amount of the product per amount of water). PSI/SFH will soon complete the process of outsourcing production to a private Zambian company, resulting in increased efficiency, better quality assurance, and a higher concentrated solution. PSI/SFH will thus focus on promoting and distributing the product through its regular channels.

While the primary target of Clorin is households with children under five, an important secondary target is people living with HIV/AIDS (PLWHAs). Consequently, PSI/SFH intends to increase its distribution of Clorin to PLWHAs via home-based care (HBC) programs, public clinics, and through post-test Clubs nationwide. In the past, PSI/SFH has sold Clorin in bulk to organizations such as CARE, CRS, and RAPIDS for distribution in their home-based care (HBC) programs. This program will be augmented by the training of approximately 140 HBC and public clinic staff on the importance and benefits of consistently and correctly treating household drinking water. Special emphasis will be paid to correct dosing techniques using Clorin's specially-developed dosing lid. Further, 20 training coordinators running SFH's "Horizon" network of post-test clubs will be trained. In FY 2007 safe water education through these coordinators will reach an estimated 2,000 HIV-positive individuals a year in eight SFH-run "Horizon" clubs, and a further 2,000 HIV-positive individuals through "Horizon" clubs run through faith-based organizations and workplaces. Combined with communications encouraging good hygienic behavior, such as regular hand washing and proper storage, using Clorin can play a significant role in encouraging healthy lifestyles among PLWHAs.

PSI/SFH now plans to donate Clorin to these programs—rather than selling it—to increase its distribution and potential health impact. This requires, however, that the full cost of production and distribution ($0.33 per unit) be covered for this target group rather than being subsidized as it is to the commercial sector with partial cost recovery. USAID health funding will continue to support the use of Clorin as a socially marketed product for other target groups.

PSI/SFH will ensure sustainability by providing partner organizations with the necessary materials and guidance to educate PLWHAs on the benefits, techniques, and importance of water treatment. With free product available, Clorin will be more accessible to Zambian NGOs that support HBC initiatives, but cannot afford to buy Clorin for PLWHAs. Given the wide availability and high affordability of Clorin in the private sector, beneficiaries beyond the scope of this program will also benefit. Further, the transfer of Clorin production to a local, private-sector company not only establishes a unique public-private partnership model, but helps to ensure knowledge transfer and a more stable source of quality supply.

In FY 2007, PSI/SFH intends to distribute 660,000 bottles of Clorin to HBC programs. This will treat an estimated 660 million liters of water and prevent more than 1.3 million episodes of diarrhea. This amount will provide 55,000 PLWHAs and their families with a one-year supply of Clorin.

This activity is an integral component of a project linked strategically to HTXS, HVAB, and HVOP interventions, including PSI (8925), CDC (9026), Peace Corps (9629), CIDRZ (9000), CRS/AIDSRelief (8827), ZPCT(8885), CHAMP, and CARE (8818).

Since opening the first New Start voluntary counseling and testing (VCT) center in FY 2002, PSI, through its local affiliate Society for Family Health (SFH), has played a key role in promoting and providing VCT in Zambia. Over 500 VCT/ PMTCT centers exist within integrated government health delivery systems across the country, but many behavioral and resource barriers to utilization still exist. PSI/SFH augments government efforts to provide VCT to as many citizens as possible by implementing "The New Start VCT Network." New Start is a socially marketed service delivery mechanism that promotes VCT through mass media and interpersonal communication, while simultaneously supporting a franchised network of branded, high-quality VCT centers. The franchised network approach helps to develop VCT capacities, ensure quality and consistency, and boost demand for and uptake of VCT services. Coupled with increased promotion, this has led to a steady increase in VCT numbers, particularly in mobile units. Mobile units have enabled 33% of all districts to be covered nationwide. Additionally, many non-branded VCT centers reported an increase in VCT numbers potentially as a result of New Start promotion campaigns.

Since FY 2006, five fixed-site New Start Centers (two of which are PEPFAR-funded) and four mobile units (two of which are PEPFAR-funded) have been in operation. The centers in Kitwe and Lusaka are PSI/SFH-managed sites and operate as ‘centers of excellence' for the network. All others are managed through key partnerships between PSI/SFH and public and private institutions. PSI/SFH provides human and operational resources, technical assistance, monitoring and evaluation (M&E), and training to public and private VCT centers in the network. All counselors are Zambia Counseling Council certified, and the network provides group and individual supervisions and refresher courses to enhance service delivery. Centers also support mobile VCT units and post-test programs.

National New Start promotion and advertising is implemented by PSI/SFH on behalf of all VCT centers affiliated with the network. In FY 2006, a mass communication campaign entitled "Know for Sure" was developed to regularize and destigmatize VCT among the general population. The campaign will continue in 2007.

PSI/SFH has been able to maintain this unique network through funding by the German Development Bank (KfW) and PEPFAR. In tandem, these two sources of funding have supported five New Start centers that include, in varying degrees: mobile VCT units, training and quality assurance, integrated medical services such as STI treatment and ART (provided by partners), IEC materials, promotional campaigns, and post-test services. KfW funding will end in October 2007.

To further improve access to rural and peri-urban populations, FY07 funds will continue to support the four mobile VCT units launched in FY 06, the fixed site at University Teaching Hospital, and national M&E and promotional activities. Funds will be used to scale up existing services by adding five new mobile units, bringing the total number to nine (geographic location to be determined in late FY 2006). In order to strengthen technical and management capabilities of local governmental and non-governmental partners, these units will be operationalized through sub-contracts to partnering VCT centers.

To support mobile units, community mobilization and follow-up care and support continue to be accomplished through linkages to other organizations such as ZPCT, CARE, CIDRZ, CHAMP, and CRS.

In FY 2006, a comprehensive post-test program was developed as an extension to New Start counseling and testing services. In FY07, "Horizon" post-test club will be expanded through a series of sub-grants to local FBOs and CBOs. Synergies with other NGOs offering VCT services will be utilized to expand the Horizon network to other provinces. The sub-granting model will help to build local capacity to public and private institutions. PSI/SFH will continue to provide technical assistance.

In FY07, PSI/SFH will reach 58,800 Zambians with VCT through New Start. 20% of all clients will be referred for care and treatment services during post-test counseling. At

post-test counseling, clients are also given messages on the ABC approach, and risk reduction planning. Condoms are distributed, where appropriate. Clients are also counseled on disclosure to their partners. By maintaining the sub-grant/partnership model, PSI/SFH will continue to strengthen VCT technical capabilities of Zambian organizations by: (1) improving laboratory capacity to perform HIV testing; (2) increasing human resource capacity through training; (3) developing VCT protocols and procedures; (4) increasing the availability of VCT; and (5) creating linkages to care and treatment services. The partnership model also enables a more straightforward exit strategy for PSI/SFH in the service delivery of VCT and a more sustainable transition to full service delivery by the partnering organizations.

To address the key legislative issue of gender equity, PSI/SFH will continue to run a multimedia demand-creation campaign to increase the number of people seeking VCT services. PSI/SFH will focus on increasing the number of men and couples accessing VCT and will address issues pertinent to discordant couples. Currently, 10% of PSI/SFH's clients are couples (an average of 250 couples per month).

Additionally, the key legislative issue of stigma and discrimination will be addressed. Improved access to VCT services and referral and the means to control the advancement of the disease will diminish the likelihood that Zambians will experience social discrimination as a result of myths surrounding the disease. In rural and peri-urban areas, as well as in mobile VCT programs, a decrease in stigma has led to an uptake in VCT services. Post-test programs that provide information about positive living—including legal and human rights issues—also help reduce stigma and discrimination.

PSI/SFH plans to leverage other donor funds to offer expanded services along with its stand-alone and mobile VCT units. Integrating other critically needed health services with VCT will diminish potential stigma issues in both urban and rural communities associated with attendance at an HIV-testing facility.

With plus-up funding, SFH will expand the pilot project to two additional sites in peri-urban settings; selection will be determined by their suitability and commitment to the project, as indicated through the use of MC site assessment materials developed by JHPIEGO. These additional sites will provide richer data regarding the feasibility of implementing cost-effective, sustainable MC models in various locales through different modalities. More specifically, three components comprise this MC service delivery package: provision of the male circumcision procedure; counseling and communications on HIV prevention (including AB messages) and HIV testing, STI evaluation and treatment, men's general reproductive health; and linkages to other reproductive health and HIV/AIDS services. Additionally, in conjunction with the national MC task force, these results will be used to further develop appropriate training and service delivery packages to increase access to safe MC services in a variety of settings.