This activity relates to activities in MTCT ZEBS (#8784)

In an effort to support the Zambia national framework as well as build up capacity of the national health system to provide sustainable HIV/AIDS services, the United States Government through CDC will directly support the Southern Provincial Health Office (SPHO) in its plan to better coordinate and oversee prevention of mother to child transmission of HIV (PMTCT) services to provide training, and expand PMTCT services to health centers currently not covered by Zambia Exclusive Breastfeeding Services (ZEBS) program. ZEBS will continue to provide PMTCT services in districts where they currently work but with the coordination and leadership of the SPHO to ensure uniformity and standardization of the PMTCT services. In order to create a sustainable PMTCT program, the PHO will take a key role in ensuring that supportive supervision is provided to these districts and will coordinate all PMTCT services and implementing partner (ZEBS) to ensure optimal resource utilization.

Southern Province has 11 districts and all districts are providing PMTCT services thanks to Academy of Educational Development and ZEBS. Out of 217 maternal and child health centers, the USG in FY 2006 supported 80 while the PHO supported 19. A total of 309 health workers and community health cadres have been trained in the provision of the services. The sites that provide PMTCT also provide antiretroviral (ART), tuberculosis (TB), and palliative care services to which the women are also referred.

In FY 2007, this activity will supplement PMTCT training in districts with few trained providers and number of PMTCT sites like Gwembe, Kalomo, Sinazongwe, and Mazabuka. The SPHO will train 150 health workers through this activity. The SPHO and ZEBS, working in collaboration, will ensure through the provision of technical assistance that additional sites establish the PMTCT services and the targets for the number of women accessing counseling and testing and ARV prophylaxis will be reported by ZEBS to avoid double counting. The SPHO will report on the number of health workers trained from their funding. Other activities to be implemented 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 standardization of PMTCT services. The SPHO'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 a key role in the continued delivery of PMTCT services.

In FY 2007, in joint collaboration with ZEBS, the SPHO will spearhead the scale-up of PMTCT services in Southern Province in line with the national expansion plan. This support will enable key technical staff from SPHO to coordinate, plan, and integrate services with ZEBS. This activity will include expanding and linking PMTCT services with other HIV services in the districts in the province through mapping of services during the performance audits spearheaded by the PHO every quarter and creation of a referral system for HIV/AIDS services.

In FY07, a plus up request ($100,000) and a reprogramming request ($75,000) are requested for this activity; the total amount requested for this activity is $350,000. The plus-up funds will be used to strengthen PMTCT services in the Southern 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 Southern 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 relates to activities in counseling and testing activity, laboratory infrastructure, palliative care: basic health support activity, and HVTB activities (#8992 and #8819).

Southern Province has an HIV prevalence of 16.2% and a reported Tuberculosis (TB) incidence rate of 415/100,000 at the end of 2005. Southern Province ranks third behind Lusaka and the Copperbelt provinces in terms of HIV and TB burden in Zambia. Livingstone district, which includes the Provincial capital of Southern province, reports extremely high HIV prevalence (30.8%) and TB notified cases for the province was 5,41 in 2005. The smear positive rate is reported at 24% with a cure rate of 77.2% for this area. Local statistics from the Livingstone General Hospital, Maramba Clinic,and Dambwa Clinic suggest that over 70% of TB patients are HIV infected.

In FY 2004, a pilot program was developed, with US Government (USG) support, in Livingstone district to pilot the implementation of counseling and testing for TB patients as part of routine management. From September 2004 to March 2006 68.6% of the TB patients notified in the hospital were counseled for HIV, 50.6% were tested for HIV and 42% of those testing positive were referred for ART. The pilot program therefore demonstrated that providing counseling and testing in TB clinics was feasible and highlighted issues around the availability of counselors to provide the service. Based on the successful implementation of the pilot activities, in FY 2005, the USG provided funds directly to the Southern Province Health Office (SoHO) for the scaling-p of TB/HIV activities in all 11 districts in the province. Providing this support directly to the SPHO provided opportunity to strengthen the capacity for a more rapid scale-p of activities and ensure sustainability of the program by enhancing local ownership. The SoPHO provided training in TB/HIV integration to 130 health care workers in all the 11 districts in the province, enabling the districts to begin implementation of these activities in 19 sites.

By the end of FY 2006, building on the initial progress made in FY 2005, the SoPHO will have trained an estimated 100 health workers in Diagnostic Counseling and Testing using the national training manual and 170 health care workers in TB/HIV integration. In order to increase community participation in this program area, the SPHO will train 200 community members as lay counselors. Based on the experience gained in FY 2005, the Province will provide funds directly to the districts for the implementation of training activities. It is estimated that at the end of FY 2006, the number of health centers providing DCT for TB patients will have increased to 93 sites covering all 11 districts. Other activities supported with the funding have been the strengthening of referral links between the TB and HIV treatment program to ensure that all HIV-infected TB patients are referred for ART and all HIV-infected patients are screened for TB. The SoPHO implementation team includes the CDC Field Office manager and the Clinical Care Specialist employed through HSSP.

In FY 2007, this activity will continue to scale up the provision of TB/HIV services within the districts so that an additional 67 sites begin to provide these services, resulting in a coverage of 72% (160 sites) of the total number of facilities (223) in the province. This will be achieved through training an additional 300 health workers and community members in TB/HIV activities. The training will be provided based on the training of trainers' model utilizing the core group of trainers resulting for the USG supported activities of JHPIEGO in FY 2006 (activity 9032). Further training in the province will be coordinated with JHPIEGO, who will provide technical support and supervision for the trainers and train additional trainers.

The SoPHO will work with the district health offices to ensure that linkages between the TB/HIV program and existing home based care programs funded through the USG (SUCCESS and RAPIDS) and other donors are strengthened. Community based treatment supporters that are currently used to supervise directly observed treatment for TB patients will receive additional training in TB/HIV integration and adherence counseling with the potential to provide support for adherence to ART.

As a result of this support to the SoPHO, it is estimated that in FY 2007, of an estimated 6,000 TB patients, 72% will receive HIV counseling and testing over 12 months. The SPHO will use the recently revised TB registers and forms to capture this data.

In order to ensure accuracy of data and quality of care, the SoPHO and district health

offices will conduct quarterly program monitoring and supervisory visits to the health centers and provide technical support to address identified areas of weakness. As a result of this activity an estimated 3,000 HIV infected individuals will receive TB treatment according to national guidelines.

As part of the national guidelines for the implementation of TB/HIV activities, the program will ensure that all HIV infected individuals in ART and PMTCT sites receive screening for TB as part of the care provided. It is expected that 50% of all individuals testing HIV positive will receive screening for TB.

To enhance equity in coverage of TB/HIV services CIDRZ will work with the provincial health office to provide technical assistance in the integration of TB/HIV care in the regional and district hospitals.

Twelve new TB diagnostic centers will be opened in the five highest HIV/TB districts in the province (Livingstone, Monze, Mazabuka, Siavonga, and Choma) by the end of 2007 using resources from Global Fund and the USG. Additionally, treatment supporters will be trained in TB/HIV integrated management for increased community awareness on these co-infections. Lack of trained staff is an important reason for the inability to implement the activities. To this end the SoPHO will provide for the hiring of additional staff through the districts. Consideration will also be given to employing district TB/HIV coordinators in selected districts.

In FY 2007, the SPHO will continue to support the Provincial TB/HIV coordinating committee that is tasked with the strategic direction and supervision of the TB/HIV integration activities throughout the province. Membership on this committee is drawn from the TB Program, Clinical Care Unit (which oversees HIV/AIDS care), and ART Program, community care and advocacy groups, and HIV counseling/testing partners. This committee shall continue to meet on a quarterly basis.

Regular review meetings will be linked to TB directly observed treatment strategy (DOTS) review meetings and symposia and co-funded by the Global Fund supported TB DOTS program. The SoPHO will continue to support the linkage of all activities and trainings to other funded programs like the Global Fund against TB, HIV, and Malaria.

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 ($20,000) are requested for this activity; the total amount requested for this activity is $210,000.

Related activities: This activity is linked to CHAZ HVTB (#8992), SoPHO ART (#9760), SoPHO HLAB (#9797), HVTB JHPIEGO (#9032), HVCT DAPP (#8998), HVCT mobile VCT TBD (#9742), CRS HVCT (#9713)

In Southern Province, the estimated HIV prevalence rate among adults aged 15-49 years is 16.2%. The tuberculosis (TB) incidence rate in 2005 was 415/100,000 of the population while the TB notification was reported at 594/100,000. The syphilis prevalence rate among adults aged 15-59 in 2002 was 4.1%.

Building on initial support provided directly to the Southern Province Health office (SoPHO) in Fiscal Year (FY) 2005, in 2006, the United States Government (USG) provided additional support for the expansion of counseling and testing (CT) services in the 19 TB diagnostic and antiretroviral therapy (ART) centers in Southern Province with special focus on the five highest HIV/TB burden districts. By the end of FY 2006, in addition to training clinicians in HIV/ART and OI management, 20 health workers were trained in psychosocial CT and 200 community members will be trained as lay counselors. All training is based on the National standardized training packages. Funds also supported the Mosi-O-Tunya Family Support Unit (FSU) with logistics for running the FSU and salary support for counselors. Other costs of running the FSU and for the activities for the orphans and vulnerable children are supported by another USG partner, RAPIDS (activity #8947).

In FY 2007, the SoPHO will increase the number of health workers overall who offer CT services to 35% from current proportion of less than 20%. This will be achieved by training more health workers in psychosocial counseling and additional lay counselors. This is expected to result in an increased number of people who test for HIV. The SoPHO will also offer health workers previously trained on ART and opportunistic infections (OI) management training in the following areas: ARV drug adherence counseling, prevention of HIV transmission in those who test positive (positive prevention), issues around disclosure discordance, and updates in current protocols in HIV testing and HIV management. Appropriate referral mechanisms will be established for referrals between voluntary counseling and testing (VCT)/prevention of mother to child transmission (PMTCT), TB/STI, and ART services. In addition, all HIV positive individuals will be screened for TB using a screening questionnaire and referred for appropriate management. All these areas will be covered in any new training in FY 2007.

Additional plans for SoPHO in FY 2007 include increasing access to CT for young people as a continuing strategy in the prevention of HIV infection by providing direct support to District Health Offices in the establishment and strengthening of Youth Friendly Health Services (YHFS). This activity will focus on strengthening HIV/STI prevention services and STI treatment services for youth. The activity will link sexually active youths to existing reproductive heath services currently provided by other donors, such as ____, This will be accomplished through on-site training of health providers to work with young people, training peer HIV counselors as well as creating sufficient space for the YFHS activities. By the end of FY 2007, 70% of health facilities in the province shall offer a complete package of adolescent friendly health services. The program shall target the age group 10-24 years, and reach 15,000 young people with integrated information on reproductive health, TB/HIV/AIDS, and ART services by the end of FY 2007. The YFHS will also improve young people's health seeking behaviors; thus facilitating early diagnosis and management of TB and STIs, including HIV. Linkages to TB/ART services will also be strengthened.

By strengthening the community component of CT by training community resource persons and community adherence supporters will lead to the capturing of another 20% of HIV-infected persons who can then access treatment. In addition to the 200 community HIV counselors trained in FY 2006, 300 more are targeted for training on community HIV and adherence counseling in Southern Province. This is expected to result into over 12,000 people receiving counseling and testing for HIV and receiving their results in the province by the end of FY 2007.

In order to expand the services offered and provide adequate space for counseling, resources will be allocated to renovate three CT sites in each district of the Southern Province. Direct support will continue to be provided to the Mosi-O-Tunya HIV counseling initiative at Livingstone General Hospital. As result, an additional 3,000 clients will be counseled and tested.

Expansion of CT services for HIV remains a key activity that helps achieve the goals of the President's Emergency Plan for AIDS Relief by identifying individuals at high-risk of being infected and linking them to care and support service (SoPH HTXS Activity#9760 and SPHO HLAB Activity#9797). In FY 2007, USG proposes to continue to support the PHO to provide CT in the routine care of patients with TB and sexually transmitted infections (STIs) and strengthen linkages with the ART services in 39 sites within the 11 districts in the Southern Province. To accomplish this, the PHO will provide support for a focal person who will coordinate the CT activities in the province. Regular supportive supervision will be conducted by the focal person in collaboration with the Clinical Care Specialist and the Field Office Manager at the PHO in the districts.

In each of the 39 ART sites, five health care workers will be trained on HIV adherence counseling and rapid testing using standardized guidelines and protocols at the Ministry of Health. It is hoped that this training of health care workers will result in improved adherence by TB patients on ART and improve the cure rate from 77.4 % in 2005 to 90 % in 2007. The training will continue to strengthen the linkages between the CT services and the STI, TB, and ART programs to ensure that HIV positive patients are routinely screened for TB and STIs. It is expected that 50% of all individuals testing HIV positive will receive screening for TB.

This activity, in addition to the work that JHPIEGO (#9035) will support in CT for the mobile population and agribusiness, the program to provide mobile and boat VCT in Namwala and Itezhi-Tezhi, and DAPP (#8998) will result in a significant increase in the availability of counseling services in the province. Additional support for CT in the district of Senanga will be provided through Catholic Relief Services (#9713).

To sustain this program, the districts will include the activities in the Government of the Republic of Zambia annual district health plans. 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.

This activity is linked to EGPAF (#9000, #9003) and CRS (#8827, #8829).

The Southern Province Health Office (SPHO) proposes to expand ART services in the province in FY 2007 and will work closely with partners such as the Center for Infectious Disease Research in Zambia (CIDRZ) and Catholic Relief Services in expanding and consolidating the services. There will be close communication, exchange of ideas, and experiences between the providers in the province through clinical symposia in order to continue providing improved and quality ART services.

The prevalence of HIV in Southern Province was estimated at 16.2 % at the end of 2004. With the increasing burden of HIV-positive diagnosed individuals and the government provision of free antiretroviral therapy (ART), the demand for ART services continues to increase.

In fiscal year (FY) 2006, the Provincial Health Office (PHO) ART subcommittee in Southern Province was strengthened and continued its further gradual expansion to make ART accessible to the population, while at the same time maintaining quality standards and considering aspects of sustainability. The first priority was to complete phase three of the implementation program to provide ART services at district hospital level. At this time, Southern Province had two hospitals remaining for the introduction of ART: Kafue Gorge Hospital (Mazabuka District) and MARS Clinic (Livingstone District). A second priority was to focus on a number of health centers in underserved areas, such as Sinazongwe Health Clinic (Sinazongwe District) and Mukuni Health Clinic (Kazungula District).

In 2006, the target for Southern Province was set at a minimum of 25 ART centers and 15,000 patients on treatment. In FY 2007, the United States Government (USG) will support the PHO to increase the number of ART sites to 39 from the current 25 by opening up 14 new sites in selected health centers. Since CIDRZ proposes to open additional sites in the province, the selection of sites will be done in close consultation SPHO to avoid overlap, duplication and to increase geographical coverage within the province.

The Southern Province is a large province with several remote centers making the cost of providing ART very high. However, as mentioned for other provinces, the SOPH has the advantage of having a presence and basic infrastructures in almost all the corners of the province in which ART services will be introduced and integrated with additional funding.

There is still an enormous need of trained personnel to offer ART/OI/STI services. More training will need to be done to address the shortfall and increase the number of trained staff from 288 in FY 2006, to at least 400 in FY 2007. However, considering that HIV/AIDS management concepts are rapidly evolving, and that the clinical problems encountered with ART treated individuals continue to evolve with increasing duration on therapy, a lot more attention will be paid to the up-dating of knowledge and skills for these health workers. This will be done through increased Technical Supportive Supervision (TSS) and Technical Assistance (TA) by specialists and the holding of Clinical Symposia.

Further, with increased counseling and testing capacity, more TSS will be required to strengthen linkages between community counseling and other services to tuberculosis (TB) and ART services.

In FY 2007, further expansion will be decentralized to the district level to ensure that ART delivery becomes an integrated service in the basic health care package thereby ensuring sustainability of provision of ART service. In this case, the provincial ART sub-committee will focus on monitoring and evaluation. Aspects such as the identification of potential ART centers, the structured assessments of the identified sites and the supervision of the service will continue to be implemented by the District Health Management Teams. The health center staff will be supported to work with neighborhood health committees, Trained Birth Attendants, treatment supporters, community health workers and community leaders in increasing awareness on the availability and benefits of ART services. This is expected to result in 17,000 HIV patients enrolled on ART at the end of 2007.

In 2007, the provincial ART sub-committee will continue to coordinate the ART program.

The PHO will support the District Health Offices to conduct site assessment for the targeted 14 new ART sites, using the existing assessment format. In each of the 14 new sites, six health workers will be trained on ART / OI management totaling 84. Further training gaps will be identified from the old centres especially the hospitals in the five high HIV burden districts of Livingstone, Monze, Choma, Mazabuka, and Siavonga (9 hospitals) and at least three health workers will be trained per hospital. The provincial database of ART training needs for all districts (names and cadres) will be revised and updated on a regular basis to include changes in staffing levels.

This activity is linked to TH/HIV in SPHO, activities #8996 and #8991.

This activity will provide local support to Southern Province for implementation of the University Teaching Hospital (UTH) national prevention of mother to child transmission (PMTCT) and voluntary counseling and testing (VCT) quality assurance program within the districts of this province. Although, Southern Province is five hours by road from Lusaka where the UTH, CDC and MOH laboratory experts are located. Supervisory travel visits to Southern and other provinces must be divided by the time and number of technical experts and resources available. 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 Southern Province.

Southern Province has an HIV prevalence of 16.2% and a reported TB incidence rate of 415/100,000 at the end of 2005. This ranks Southern Province third behind Lusaka and the Copperbelt provinces in terms of HIV and TB burden in Zambia. Livingstone district, which includes the Provincial capital of Livingstone, reports extremely high HIV prevalence (30.8%) and TB notification rates for the province was at 5,941/100,000 in 2005). The smear positive rate is reported at 24% with a cure rate of 77.2%

Availability of laboratory services in most of the more rural districts is limited due to several factors including human resources, lack of suitable infrastructure and services such as a source of power, geography, and increasing numbers of persons participating in prevention of mother to child and voluntary counseling and testing (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 antiretroviral therapy laboratory services to People Living with HIV and AIDS (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 lacking this infrastructure. Supplemental funding is being provided for basic infrastructure improvement; transportation, alternative power support such as solar panel and automatic back up generators; patient sample transportation mechanisms (vehicle and motor cycle for 2 districts Kanzangula and Gwembe ). This activity will support the UTH National quality assurance program within the districts of this province.