This activity relates to activities in MTCT (#9002), CIDRZ, Care International (#8818), and CHAZ (#9734).

Eastern Province has eight districts of which four currently has prevention of mother to child transmission of HIV (PMTCT) services supported by Center for Infectious Disease Research Zambia (CIDRZ) and CARE International. The sites that provide PMTCT also provide ART, TB, and palliative care services to which the women are also referred. As of March 2006, CIDRZ and CARE International had trained 40 health care providers in the minimum package of PMTCT services and instituted 30 PMTCT sites.

In FY 2007, in joint collaboration with CIDRZ and CARE International, EPHO will spearhead the scale-up of PMTCT services in Eastern Province in line with the national PMTCT expansion plan. This support will enable key technical staff from EPHO to coordinate, plan, and integrate services with CIDRZ and CARE International and the Churches Health Association of Zambia. In addition activities will include expanding and linking PMTCT services with other HIV services in all districts of province through mapping of services during the performance audits conducted by the Provincial Health Office (PHO) every quarter.

In an effort to support the Zambia national framework and build capacity of the national system to provide sustainable HIV/AIDS services, the United States Government through CDC aims to provide direct support to the EPHO to build its capacity to coordinate and oversee PMTCT services in the province, provide training, and expand PMTCT trainings to health centers currently not covered by CIDRZ and CARE International. CIDRZ and CARE International will continue to provide PMTCT services in districts where they currently work but with the coordination and leadership of the EPHO to ensure uniformity and standardization to the PMTCT services. In order to create a sustainable PMTCT program, the PHO will play a key role in ensuring that supportive supervision is provided to these districts and will coordinate all PMTCT services and implementing partners (CIDRZ and Care International) to ensure optimal resource utilization.

In FY 2007, this activity will supplement the PMTCT training in Chama and Mambwe districts that have not yet initiated PMTCT, and will supplement training in the other districts with few trained providers in PMTCT service delivery. A total of 100 health providers will be trained through this funding. The PHO working in collaboration with CIDRZ and CARE International will ensure through the provision of technical assistance that more sites in the province establish the PMTCT services. To avoid double counting of targets, the targets on the number of women accessing counseling and testing, and ARV prophylaxis will be reported by the implementing partner working in each respective district. The PHO will report on the number of health workers trained from their funding. Other activities to implement will include monitoring visits, training of program managers in the implementation and monitoring of the PMTCT service, dissemination of national policy and guidelines on PMTCT, and the standardization of PMTCT services provided in the province across all implementing partners. The PHO's involvement in the coordination of the program will ensure geographical coverage and coordinated planning among districts for the integration of PMTCT services into routine maternal and child health units which will lead to the development of a sustainable model where Government of the Republic of Zambia plays an active role in the continued delivery of PMTCT services.

The plus-up funds will be used to strengthen PMTCT services in the Eastern province through improving coverage of counseling and testing amongst pregnant women, improving uptake of prophylaxis among HIV+ pregnant women identified through adequately training and mentoring of health workers and community health workers. The Eastern Provincial Health Office will also coordinate training and supervision of PMTCT services through the planning of PMTCT services at district level, the integration and strengthening of PMTCT into maternal and child health. These funds will also be used to establish support systems that ensure sustainability of the PMTCT scale up such as improved PMTCT supply chain management, improving the monitoring and reporting system and strengthening the linkage to ART.

This activity is linked with the other activities for the Eastern Province Health Office (EPHO) including counseling and testing (#9005) and the CDC new activity for EPHO in ARV services (#9951).

Chipata District in Eastern Province has a very high HIV prevalence of 25.9% and syphilis prevalence of 8.8% (Antenatal Clinic sentinel surveillance, 2004) among pregnant women aged 15-44 years. Adolescents contribute considerably to the high prevalence of HIV with16.2% of women in Chipata aged 15-19 testing HIV-positive during the 2004 ANC sentinel surveillance. Special reproductive health services focusing on youth is a key activity to reduce STI and HIV transmission among adolescents. Chipata district has started prevention and counseling and testing programs for this age group and the District Health Management Team (DHMT) has begun to establish 30 Youth Friendly Corners in urban and peri-urban health centers. In FY 2007, Chipata DHMT will strengthen the Youth Friendly Corner services as well as expand the concept to include all of the 39 health centers in the district in order to reach youth with HIV prevention messages and link them to the services available in their communities. These Youth Friendly Corner services are needed to address gaps in the current services in reaching all youth and especially at-risk youth.

The Youth Friendly Corners are critically needed to address existing gaps in current services; youth are not able to be reached, especially at-risk youth. These corners are rooms reserved specifically and conveniently for adolescent peer educators and trained health providers in which youth friendly services are provided to adolescents. It has been observed in some studies by non-governmental organizations and the district health management teams that: 1) youth found it difficult to access health services from health institutions because of age differences with health providers and that the health services were not satisfying the needs of young people, and 2) Youth Friendly Corners act as the entry and exit points for all youth clients presenting with STIs, HIV,TB infections and for those seeking safe reproductive health options. Cases requiring further attention of health workers are referred to the appropriate services for follow-up.

Other activities carried out in these corners are peer counseling, community mobilization through drama, focus group discussions, door-to-door campaigns, health education talks, and recreational activities (sporting activities and educational modeling). The Corners also provide an opportunity for dissemination of condoms to sexually active mature youth when appropriate. Youth who express interest in being tested for HIV are referred to the nearest clinic where they can receive counseling and testing for HIV.

To ensure quality services for the youth, a trained health worker at each Youth Friendly Corner who has a sincere desire to work with youth provides knowledge and skills to them. The program relies heavily on youth volunteers and the turn-over rate is high as the youth access further training or become employed. To ensure adequate numbers of peer counselors and peer educators, ongoing training of new peer counselors and educators is required. In FY 2007, 40 new staff will be trained to provide HIV/AIDS prevention programs that are not exclusively focused on abstinence and/or being faithful. An important component of the Youth Friendly Corner approach is to conduct sensitization sessions within certain high-risk communities. In FY 2007, 1,000 individuals will be reached through community outreach HIV/AIDS prevention programs that are not exclusively focused on abstinence and/or being faithful.

This activity will support the Youth Friendly Corner program of Chipata district through the Provincial Health Office by strengthening the 30 sites that have already been established and expanding to open nine more sites where youth friendly services will be offered. In addition, all sites will strengthen their sensitization activities in the community and behavior change sessions in high-risk areas and events. Increased awareness on the issue of integrated reproductive health among the youths will be created through reorientation of all health care staff.

In future years, the EPHO plans to scale up the Youth Friendly Corner approach to the seven other districts within Eastern Province. Activities to strengthen the Youth Friendly Services will be included in the annual district and health centre health plans in order to ensure sustainability of the programs.

This activity relates to activities #9032 and #8819.

Eastern Province, with 8 districts, is predominately a rural province with an overall HIV prevalence of 13.2% and a reported 2004 tuberculosis (TB) incidence rate of 259/100,000. Outside of Chipata, the provincial head quarters (which has an HIV prevalence of 26.3% and TB notification rate in 2004 of 380/100,000), access to health-care facilities and services are limited. TB/HIV integration activities were initiated by CARE International using USG funds in FY 2005 and 93 health-care workers, from the 3 highest population districts (Chipata, Katete, and Petauke) were provided with some level of TB/HIV integration training. The largest barriers to implementing and maintaining TB/HIV integration were due to limited human resources, coupled with an expected increase in patient-load. To address the staffing issues, by the end of budget period 2006, the USG will support the Provincial Health Office (PHO) to employ a TB/HIV coordinating officer who will be based in the provincial health office and will be responsible for coordinating TB/HIV activities, supervision, trainings, surveillance, and program monitoring and evaluation. This TB/HIV coordinator will work closely with the Provincial TB/HIV committee and Provincial TB officer to coordinate activities in the province and provide joint supportive supervision.

In addition, by the end of FY 2006, the Provincial Health Office will have trained 100 personnel in TB/HIV integration from the TB diagnostic centers in addition to those from various HIV care centers and community-based programs in Chama, Nyimba, Mambwe, and Chadiza districts. The training will focus on providing the skills for routine HIV counseling and testing to TB patients and management of TB, HIV, and TB/HIV patients.

Other than the USG support, the districts have been receiving support from the global fund to scale up TB control by strengthening directly observed treatment strategy (DOTS). Another key partner is CARE International (#8819), which also previously supported TB control activities in the area for the past three years. Due to the limited access to health care facilities and acute shortage of facility-based healthcare staff in Eastern Province, special emphasis was placed on the development and support of community volunteers to provide TB/HIV integrated care.

In FY 2007, the USG will continue to support the Provincial Health Office to expand TB/HIV in Chama, Chadiza, Nyimba and Mambwe districts. An additional eighty (80) health staff will be trained in diagnostic counseling and testing from the four districts. Each district has one service outlet providing clinical prophylaxis and or treatment for TB to HIV infected individuals and it is expected that three more new sites will be opened in each district in FY 2007.

An estimated 678 TB patients will be diagnosed in 2007 and 65% of these (441) will receive counseling and testing for HIV.

It is also estimated that 880 HIV positive clients will be diagnosed and 30% of these (264) will be screened for TB disease.

The four districts are remote and the health facilities are spread far apart the population though small is widely dispersed. This activity will strengthen the capacity of the district to provide support supervision for the implementation of activities. Although scaling up services in rural areas in quite challenging and more expensive compared to urban areas, strengthening the Provincial Health Office delivery system is key to ensuring services being scaled up can be sustained as part of the government health provision structure. The TB/HIV integration designed and process are being implemented as integral part of the Provincial Health Office's health activities.

To enhance equity in coverage and ensure standardization of TB/HIV services CIDRZ will work with the PHO to provide technical assistance and build its capacity in the integration of TB/HIV care in regional and district hospitals. Additional technical capacity is provided by the Clinical Care Specialist assigned by HSSP and a CDC Field Office Manager to be placed in the PHO in FY 2007.

A total of 120 lay counselors from the community will also be trained in TB/HIV collaborative activities to strengthen community support and awareness. Monthly

community sensitization meetings with Neighborhood Health Committee, church and other community leaders will be held. Monthly supportive technical supervision from the province and the districts to the service outlets will be implemented. Monthly district and quarterly provincial meetings will be held to monitor the program activities at district, health center and community levels. To increase on TB/HIV collaborative activities, all the four districts will participate in the World TB day commemorations. Linkages between the TB programs and other USG funded home-based care programs will be strengthened to ensure continuum of care for the HIV infected TB patients.

An assessment of existing infrastructure will be carried out to identify sites that require minor renovations and refurbishment in order to ensure the availability of adequate counseling and testing space for TB patients.

In FY07, a plus up request ($40,000) and a reprogramming request ($50,000) are requested for this activity; the total amount requested for this activity is $190,000. In FY 2007, the USG will train 80 personnel in Diagnostic counseling and testing from 4 districts within the province. It is estimated that 331 ( 65%) of the total TB notifications (509) will receive counseling and testing for HIV. The outlet sites will increase from 4 to 12 in 2007. Plus up funds will help the Eastern Provincial Health office expand TB/HIV services and training of health care workers in Diagnostic Counseling and testing. It is estimated that 60 more health care providers will receive training in diagnostic counseling and testing. An additional 2 sites will be opened with the new funds and 200 TB patients will access counseling and testing for HIV. In addition, it is also expected that 2 more health facilities will be renovated to create space for counseling and testing.

Related activities: This activity is linked to EPHO HVTB (#9006), EPHO HTXS (#9951), CARE HVCT (#9713) and CRS HVCT (#9714).

In Eastern Province, the estimated HIV prevalence rate among adults aged 15-49 years is 13.2%. In 2004, the HIV prevalence rates among adults aged 15-49 years in Chipata, Katete, and Petauke were 26.3%, 18.1% and 9.3% respectively. The provincial tuberculosis (TB) notification rate in 2004 was 263/100,000 population. The syphilis prevalence rate among adults aged 15-59 years is estimated to be 9.3%.

In fiscal year (FY) 2006, the United States Government (USG) is supporting a number of counseling and testing activities, at the Eastern Provincial Health Office (EPHO), including: rehabilitation and renovation of counseling and testing rooms in the four selected health facilities (Nyimba, Mambwe, Chama, and Chadiza); training 100 community lay counselors and 40 health care workers in adherence counseling; setting up appropriate referrals to health centers. In addition the district recording and reporting system will be used to document counseling activities as well as fulfill the reporting targets under President's Emergency Plan for AIDS Relief. FY 2006 funding is expected to be available in mid-September 2006 and these activities will start immediately when funding is available.

In FY 2007, USG will continue to support the EPHO to expand counseling and testing activities to four additional sites within these districts for a total of eight. The recent national policy of providing routine counseling and testing in health facilities that can provide antiretroviral therapy (ART) services supports the plan to train 80 health care providers in HIV/AIDS counseling and rapid HIV testing. These trainings will also include: appropriate referral of HIV positive clients to PMTCT and ART services and emphasis on prevention of transmission of HIV among those who test positive (positive prevention) as well as issues surrounding disclosure and discordance. This training program will complement the training to be provided under activity EPHO HTXS (new) and EPHO HVTB (#9006) in HIV and ARV's and OI's; TB/HIV and STI/HIV correlation and integration. The training will include TB screening using a screening questionnaire for all persons testing HIV positive and appropriate referrals to the TB service. It is expected that at least 50% of all individuals testing positive for HIV` will receive TB screening. Due to the current human resource crises in Zambia, an additional 100 lay counselors will be trained in counseling to increase HIV awareness, care, and referral of cases that need further counseling and care to health facilities. These counselors will help improve adherence among patients on ART. Training costs increase substantially when conducted in a rural setting where the districts are far apart as compared to standard costs for services provided in urban areas.

Service outlets for CT will also increase from one in each district to a minimum of two. The EPHO and the District Health Management Teams will provide technical supervision to service remote sites monthly. There will be monthly meetings for monitoring and sharing of experiences in each of the four districts. Linkages with other USG-funded programs in the area of prevention care and treatment and the Global Fund activities will be strengthened through quarterly partner meetings to share experiences and avoid overlap.

Logistics such as HIV test kits are being supported by the USG through the Central Medical Stores. The districts currently hold monthly meetings with organizations and community-based groups implementing CT activities to report on findings, share experiences, and to identify weaknesses.

The expected outcome of this activity is to provide HIVtesting services to 400 STI patients and 200 HIV/AIDS patients and approximately 1,322 clients will receive CT services from the CT outlets.

These activities will be coordinated by the EPHO and linked to the activities to be implemented by CARE (new activity HVCT) and will result in a substantial increase in access to CT in the province in all districts. Additional support for CT will be provided in faith based institutions in two districts through Catholic Relief Services HVCT (#9713).

There are established structures in terms of human resource, infrastructure, and resource mobilization through the Government of the Republic of Zambia and other donors support to ensure sustainability of the program. The activities will also be included in future

national health plans, which will secure national funding for the activities. Emphasis on training and incorporation of CT in all service delivery points empowers staff and ensures long-term sustainability. It is hoped that Global Fund money will also be able to support these activities in future years.

Related activities: This activity links to EGPAF (#9000, #9003) and CRS (#8827, 8829).

The Eastern Provincial Health Office (EPHO) intends to scale-up and consolidate provision of the antiretroviral therapy (ART) services in close linkage with Catholic Relief Services (CRS) and Center for Infectious Disease Research in Zambia (CIDRZ). The Eastern Province, with a population of 1.6 million people, has an HIV seroprevalence of 13.2% among the general population between 15 - 49 years (DHS 2002). The province has eight districts and is primarily a rural province. Currently there are nine sites offering ART in the province, based primarily at the district hospitals, with the exception of the Chadiza district which does not have a district hospital and services are provided at the health centre. The capital of the province, Chipata, has two sites offering ART. A total of 6,257 clients in the Eastern Province were receiving ART in the government program as of June 30, 2006.

Due to the large distances and poor road networks and transportation system in the province the cost of providing care is high and access to ART is limited to those with means of transportation. In order to increase access to ART for a larger section of the population, the PHO would like to expand the number of service delivery points in five of the districts by additional two sites per district. The EPHO plans to expand ART services to the hard to reach areas of the province and will develop mobile ART clinics to provide care to some of these areas. The EPHO will liaise with CIDRZ and CRS in the selection of sites to avoid duplication and to increase geographical coverage of the province with ART services. The EPHO has the advantage of having a presence and basic infrastructures in almost all corners of the province through which ART services will be provided, although additional and rehabilitation of the existing infrastructures may be required in some parts of the province.

In ongoing efforts to support national efforts, United States Government (USG), through Health and Human Services (HHS)/CDC aims to provide direct support to EPHO for supportive supervision by provincial teams of ART service delivery in districts and to enable improved linkages with the national ART program in fiscal year (FY) 2007. Activities include monitoring visits, training, policy and guideline dissemination, participation in national quality improvement efforts, and integration and scale-up of the national ART information system and the Continuity of Care: Patient Tracking System (CC:PTS).

The activities to be supported through the proposed funding include training of 50 additional staff using the national ART training modules. Five staff will be trained per site, to provide a multidisciplinary team. This will increase the number of staff trained in ART in the province to 179. Like most provinces in Zambia, there is a shortage of physicians in the Eastern Province, the bulk of the people trained will be clinical officers (CO) and nurses who have proved to be a reliable and effective group of workers in provision of ART in a resource limited set up. The few ART trained physicians at the Provincial and District Hospitals in the province will provide supervision to the COs and nurses. Training will include adherence counseling. The additional treatment sites will result in an additional 2000 persons receiving ART. Funds will also be used for infrastructure renovations and enhancements, such as remodeling, painting and procurement of basic furniture for the existing ART sites in order to provide confidential service for the ART patients.

In FY 2007, Elizabeth Glaser Pediatric AIDS Foundation - CIDRZ will scale-up support in Chipata and other sites in Eastern Province. This support will enable key technical staff from EPHO to plan and integrate services with CIDRZ and expand and link ART services in target and harder to reach districts throughout the province.

Direct funding for ART service delivery and technical assistance will complement other support to the province such as in TB/HIV and counseling and testing and will ensure sustainability of ART services within the province. Funds will also be used for infrastructure renovations and enhancements, such as remodeling, painting and procurement of basic furniture for the existing ART sites in order to provide confidential service for the ART patients.

This activity is linked to UTH activity.

This activity will provide local support to Eastern Province for implementation of the UTH national PMTCT and VCT quality assurance program within the districts of this province. Some major limiting factors for implementation, support and sustainability of laboratory programs outside of the capital city are due to; 1) travel distances; 2) lack of transport for onsite supervision and feedback; and 3) lack of funds at the provincial and district levels. Eastern Province is seven hours by road from Lusaka where the UTH, CDC and MOH laboratory experts are located. Supervisory travel visits to Eastern and other provinces must be divided by the time and number of technical experts. The goal of this activity id to build capacity and sustainability at the local level by training and providing support for activities to be conducted by local staff within the province for PMTCT and VCT as well as care and treatment support. During this first year (2007), the goal will be to reach ten laboratories within Eastern Province.

Eastern Province is a predominately-rural province with an HIV prevalence of 13.1%. Access to health care facilities and services are limited, with an estimated 40% of the population living on a walking distance of more than 12 kilometers from the nearest health facility. Availability of laboratory services in most of the districts is limited due to several factors, which include technical human resources, lack of suitable infrastructure and services such as a source of power, geography, and increasing numbers of persons participating in PMTCT and VCT programs at local levels. Antiretroviral laboratory care and treatment services are limited. Sample preparation and transport support can alleviate the lack of services due to laboratory infrastructure and technical limitations. In FY 2007, onsite training and technical support for existing personnel in basic laboratory testing and transport will be assessed and provided. Laboratory quality assurance programs for rapid HIV testing currently performed in the VCT and PMTCT will be supervised and supported by the national HIV reference laboratory (UTH). An integrated program to include, laboratory data management, onsite quality assurance within will assist in improving and equalizing ARV laboratory services to PLWHA in these areas. Support will be provided for basic infrastructure improvements and the provision of alternate sources of power such as solar panels at all laboratories currently lucking this infrastructure.

This activity will allow the EHPO to build its capacity to take the leadership supporting its laboratory functions within the districts. Support will be provided for basic infrastructure improvements in laboratories in rural areas and districts to improve HIV/TB and opportunistic infection diagnosis. Other needs include trasnsportation mechanisms and automatic backup generators to support equipment operation for laboratory testing. It will also allow the district to draw and train the necessary laboratory personnel to provide supportive supervision within the districts.

This activity relates to Ministry of Health (MOH) (#9008), and Technical Assistance/Centers for Disease Control and Prevention (CDC) (#9023).

Eastern Province, with eight districts, is a predominately rural province with an overall HIV prevalence of 13.2% and a reported 2004 tuberculosis (TB) incidence rate of 259/100,000. Outside of the provincial capital of Chipata (which has an HIV prevalence of 26.3% and TB notification rate in 2004 of 380/100,000), access to health-care facilities and services are limited.

Proposed funding would support VSAT internet connection for the province through the Provincial Health Office (PHO) in Chipata to improve strategic information activities. Improving internet service and email communication will reduce the isolation through increased access to information. Communication flow between central level and the province will be enhanced with this service and help link the PHO and the District Health Offices. It is assumed that the availability of good internet access will also be an important motivator to retain staff as it offers them an opportunity to participate in distant learning programs and conduct research projects. Such investment in technology is a sustainable contribution to essential communications infrastructure for many years ahead. The Government of the Republic of Zambia's National Develop Plan places improved information services as a top priority, lending non-United States Government efforts for sustainable use of technology of this kind in to the future.