The Churches Health Association of Zambia (CHAZ) is an interdenominational non-governmental umbrella organization of church health facilities formed in 1970. The organization has 125 affiliates that consist of hospitals, rural health centers and community based organizations. All together these member units are responsible for 50% of formal health care service in the rural areas of Zambia and about 30% of health care in the country as a whole.

Fiscal year (FY) 2007 activities will result in: (1) increased access to quality prevention of mother to child (PMTCT) services; (2) quality PMTCT services integrated into routine maternal and child health services; (3) increased use of complete course of antiretroviral (ARV) prophylaxis by HIV-positive women; (4) improved referral to ARV treatment programs and (5) linkage creation between child health, antiretroviral (ART) and PMTCT services

With FY 2005 funds CHAZ has managed to sustain and provide PMTCT services in 5 mission sites with comprehensive services where HIV-positive pregnant women are actively referred for CD4 screening at the ART sites within the hospitals. Due to delays in setting up the funding mechanism in 2005, CHAZ did not receive any funding for the PMTCT program in FY 2006. In FY 2007, CHAZ will support its mission institutions to meet the needs of the communities they serve by building and strengthening their capacities to prevent mother to child transmission of HIV, and to ensure sound follow-up of HIV-exposed infants so that a definitive diagnosis can be made through creating linkages with the National Infant Diagnosis Reference Laboratory for infant HIV testing. This strategy will ensure that timely treatment can be provided to infants testing HIV positive. By strengthening institutional capacity, and facilitating active community involvement, CHAZ will continue to advocate for community participation and involvement in PMTCT. By this intervention, CHAZ will address issues of gender inequality by providing yet another avenue for HIV positive women to access ARV, hence improving their chances for survival and their continued ability to care for their families.

In order to ensure the full success of this activity, in FY2007, all cadres of health care providers who care for pregnant women and infants will be scheduled for training in PMTCT, and will be equipped to provide high quality counseling and care to HIV positive pregnant women with regards to testing, accessing antiretroviral drugs, and infant feeding options. CHAZ will continue to strengthen linkages between local partner health facilities and the surrounding community. Community members, including traditional birth attendants and female community leaders will take part in outreach activities that promote PMTCT awareness and develop a supportive network for HIV positive women in the post-partum period, especially as it relates to maintaining their chosen feeding option, and for encouraging infant follow-up for definitive diagnosis.

To ensure access to routine counseling and testing (CT) for pregnant women, the first component of this activity will entail that all pregnant women receive routine HIV testing with improved antenatal clinic (ANC) services at 25 sites from five sites in FY 2006. The second component, ensuring adequate intervention for mother and newborn, involves establishing referral linkages between the ANC and ART clinics so that each HIV positive pregnant woman can receive CD4 testing and be assessed to either commence triple therapy ART, or other recommended prophylaxis regimen. This referral will serve as yet another entry point into basic care and support for HIV-positive women. Counseling on infant feeding, with well articulated plans for infant follow-up will be made during the antenatal period. Referral linkages will also be strengthened between the ANC, delivery wards, and the ARV clinics in all facilities so as, to ensure appropriate care for the mother and newborn in accordance with the National Guidelines. Awareness training of local traditional birth attendants (TBAs) will also be done to ensure adequate peri-partum interventions are appropriated for the mothers and newborns where deliveries are done outside the health facilities. Activities in FY 2007 will include training antenatal staff and delivery ward staff on PMTCT interventions, training TBAs, and lastly establishing/strengthening referral linkages within the health facility and with selected trained TBAs. Further strengthening of laboratory capacity will also be undertaken to accommodate the increased numbers of CD4 tests required for pregnant women identified as HIV-positive. In addition, all cadres of health workers involved in caring for pregnant women, plus key women in the communities will be trained to offer sound counseling on infant feeding options, including offering support for exclusive breast feeding.

The third component of this mechanism, involves creating and strengthening linkages between the ANC, delivery wards and Child Health clinics, training of staff in the well-baby clinic on how to follow-up and make a definitive HIV diagnosis on HIV-exposed infants, and strengthening laboratory capacity to send samples to national infant diagnosis of HIV centers. Doctors and clinical officers will be trained also in early diagnosis and timely intervention for the HIV-exposed infant. This component will establish the necessary linkages among the health facilities and communities to ensure adequate infant follow-up, definitive HIV diagnosis, and strengthen laboratory capacity.

The final component, community mobilization, includes a targeted evaluation of male involvement and participation in the PMTCT program through community outreach activities and awareness training targeted at men. This activity will support awareness campaigns, train community men, and establish or strengthen linkages between the health facilities and the community.

This activity is related to the following activities: #9032 and #9006.

Acute human resource shortages in Zambia, particularly in rural areas, necessitate the need for innovative ways to deliver quality patient care and management. The Churches Health Association of Zambia (CHAZ) is an interdenominational non-governmental umbrella organization of church health facilities formed in 1970. The organization has 125 affiliates that consist of hospitals, rural health centers, and community-based organizations. All together these member units are responsible for 50% of formal health care service in the rural areas of Zambia and about 30% of health care in the country as a whole.

The comparative advantage of CHAZ is its area of operation which is mainly rural, thus heavily involved in the development and utilization of community-level volunteers to assist with TB treatment adherence and support by providing regular visits to the patient's home to directly-observe therapy and a basic check-up. The use of community-level volunteers to provide TB support is an innovative and cost-effective strategy to address the severe human capacity shortages in health care at the local level. Further, the use of community-level volunteers empowers community members and multiplies the skills and knowledge, needed to appropriately care for such patients. Results from these visits show that community-based treatment supporters have improved TB treatment adherence and outcomes.

The goal for CHAZ is to reduce the number of deaths related to TB through improved quality of TB care and increasing the cure rate through directly observed treatment strategy (DOTS) implementation. CHAZ utilizes the following strategies to achieve this goal: 1) Increase the training of health care workers in DOTS; 2) Increase training of community Treatment Supporters in DOTS; 3) Procure and create provisions to get bicycles for Treatment Supporters; 4) Procure motorbikes for Program Officers at the health facility level; 5) Procure microscopes; 6) Information, Education and Communication (IEC) on TB; and 7) Develop income generating activities (IGAs) to support TB patients and families. Using funds obtained from the Global Fund Round 1 grant to Zambia, CHAZ has strengthened TB DOTS implementation in all its institutions, including community mobilization, capacity building and provision of income generating activities (IGA) to ensure sustainability of the community response.

Despite implementing the above listed activities, CHAZ still face many challenges in TB control. Some of these challenges and gaps include lack of clear coordination mechanism between the TB and HIV programs at the health facility and community levels as well as the lack of integration between the TB services, HIV testing facilities, and HIV care services including ART at health center level. The lack of training in TB/HIV management for health care workers and lack of counseling skills among TB officers and treatment supporters are also barriers that need to be addressed. The lack of basic training for treatment supporters in TB/HIV links and care for co-infected patients, lack of IEC materials on TB/HIV link, poor infrastructure for TB/HIV diagnosis and treatment further complicated implementation of CHAZ's goals. In addition, there is still need to improve documentation of TB/HIV activities and the existing referral systems.

In FY 2005 and FY 2006 the US Government funded CHAZ to begin the implementation of TB/HIV activities at faith-based and community-based health care facilities in four provinces (Lusaka, Eastern, Southern and Western), covering 44 institutions. Due to delays in establishing the funding mechanism, release of the funds and development of national guidelines, training materials and data collection tools for TB/HIV, activities on the ground have been implemented from 2nd quarter 2006. Initial activities have included the sensitization of the central unit and inclusion of a discussion of TB/HIV during regular quarterly TB DOTS review meetings. CHAZ has conducted a training of trainers' session for five national trainers in diagnostic counseling and testing (DCT) in the faith based institutions utilizing the national DCT manual adapted by JHPIEGO in conjunction with the Ministry of Health. Following this training, 81 health staff members will soon be trained in DCT and begin implementing TB/HIV activities, immediately. To date, 51% of the TB patients notified in the four provinces received HIV counseling and testing. Additional activities to be implemented include training of community members in TB/ART support, and community sensitization. Progress in the implementation of the activities will be monitored through regular review meetings.

Building on the activities begun in FY 2006, CHAZ will continue to scale up the implementation of TB/HIV activities in the 44 faith-based institutions in the 4 Provinces. These activities will continue to focus on the following; 1.) Capacity building for health care workers in TB/HIV management and counseling including screening of HIV infected individuals for TB, 2) Training of treatment supporters in basic TB/HIV links and counseling; 3) Linking home-based TB patients to HIV counseling and testing and other care services, including treatment; 4) Producing information education communication materials including radio programs on TB/HIV; 5) Strengthening the referral, recording and reporting systems at the health facility and community levels; 6) Strengthening the monitoring and evaluation system at CHAZ secretariat and health facility level; and 7) Improving the infrastructure for TB/HIV services at health facility level. In addition, CHAZ will screen all community TB Treatment Supporters for TB.

Though all the institutions in the four provinces will have staff trained in DCT, because of the high rate of staff attrition in many facilities due to either movement of staff or illness and death, CHAZ in FY 2007 will train an additional 50 health worker in DCT and TB/HIV links in the 44 institutions. Strengthening the link between HIV and TB will be given careful attention. In addition, 200 community volunteers will be trained to provide support for TB patients, including linking home based care patients for both TB and HIV screening and will be linked to the 44 health institutions. As a result of this training it is expected that in FY 2007, with an estimated 3,576 TB patients notified, 2,500 (70%) will receive HIV counseling and testing and those testing positive will be referred for HIV care and treatment based on the national guidelines. Additionally, it is expected that at least 50% of all individuals testing HIV positive will receive screening for TB and that 1,500 HIV infected individuals will receive treatment for TB.

These activities will be coordinated with similar activities to be implemented in the five Northern provinces with funds from the Global Funds. Community involvement in TB DOTS and TB/HIV in all nine provinces in the faith-based institutions will be strengthened through funding for IGAs, Home Based Care kits and bicycles and other non-monetary incentives using funds from the Global Fund.

This geographic and programmatic expansion will be accomplished by a training of trainer model that will then be used to train community treatment supporters working with TB/HIV patients. The goal is to train 200 community-based volunteers who will monitor TB and HIV treatments and supervise TB and HIV treatment patients that are unable or unwilling to make regular visits to the health facilities. CHAZ health-facility personnel will provide ongoing technical supervision to ensure appropriate standards are being met.