Zambia is currently one of the leading countries in terms of integrating Male Circumcision (MC) into the compendium of HIV/AIDS prevention activities. JHPIEGO has been supporting the male circumcision program in Zambia for several years, beginning in 2004 when they teamed up with the government to begin work on small scale efforts to strengthen existing male circumcision services to meet existing demand. This early work in Zambia has informed the international efforts of WHO and UNAIDS, and the training package that JHPIEGO developed with the Ministry of Health in Zambia formed much of the basis for the new international WHO/UNAIDS/JHPIEGO training package. Likewise, assessment tools used in Zambia also provided background for the WHO toolkit. The Government of the Republic of Zambia (GRZ) has established an MC Task Force under the Ministry of Health (MOH) and the Prevention Technical Working Group of the National AIDS Council, of which JHPIEGO plays a key role. Zambia's 2007 COP included a limited amount of funding to examine the feasibility of male circumcision services in different sectors, or to develop and test tools that would strengthen the Information, Education and Communication (IEC) efforts for male circumcision. With these additional plus-up funds, JHPIEGO intends to expand the service delivery of MC by adding additional private and socially marketed service sites, as well as to provide significant support the GRZ to accelerate their efforts to develop clear message delivery guidelines, and develop and initiate an implementation plan to scale-up MC services that includes an IEC plan. Initial implementation support will include mass media messaging to begin to get correct and consistent information to the public quickly on the benefits and risks of circumcision. JHPIEGO's focus for this activity will be on working with the MOH and other partners to build a strong AB message as part of the MC service package, which includes the development of counseling guidelines for men undergoing MC. AB messages will play a key role in the pre and post circumcision counseling that men go through in Zambia. The funds will be used to work with the MOH to identify culturally relevant strategies surrounding AB and MC, and to implement them into the HIV prevention and education messages as part of the comprehensive MC service package. Funds will be used to: (1) support the development and testing of messages and implementing the effective messages as part of the national prevention strategy; (2) develop take home brochures, radio, and TV spots emphasizing AB as integral part of MC education; and (3) support the development of counseling protocols that include AB messages during MC service delivery, and train counselors on the importance of AB messaging within this service.

Targets

Target Target Value Not Applicable Number of individuals reached through community outreach that 20
promotes HIV/AIDS prevention through abstinence (a subset of total reached with AB) Number of individuals reached through community outreach that 6,000
promotes HIV/AIDS prevention through abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention 12
programs through abstinence and/or being faithful

Table 3.3.02:

Members of the military are at particularly high risk of HIV and STIs. These populations are away from their families for extended periods. They often have multiple concurrent sexual partners, placing them at high risk of infection with HIV or other STIs. Access to health services among these populations is often limited, meaning that men and women who do suspect they have an STI or who have symptoms of TB may not receive treatment in a timely way, increasing the chance of passing the infection on to others, and while we know that there is a high rate of co-infection of TB and HIV and the role of STIs in HIV transmission, TB and STI services have not routinely and effectively offered HIV counseling and testing until recently. At the same time, the Zambia Defense Forces (ZDF) have not benefited from the same level of investment as in the public Ministry of Health (MOH) system. JHPIEGO, as a key partner to MOH in a number of HIV/AIDS technical programs, aims to help bridge this gap. In addition, ZDF sites are spread throughout Zambia in all nine provinces and are often located in very remote and hard to reach locations presenting further logistical challenges in service provision. Data coming from the Defense Force Health facilities from June 2005 to November 2006 shows a high burden of sexually transmitted infections. A tour of Lusaka based ZDF health care facilities supported by DFMS and PCI revealed that there was: • shortage of manpower trained in Syndromic Management of STIs; • non availability of Treatment Guidelines for Syndromic management of STIs; • Lack of STI specific IEC materials; • shortage of Drugs used for the treatment of STIs• Lack of light sources, vaginal speculums and examination couches, screens; • weak health information systems (eg. Medical record keeping, mainatenance of and registers); • Lack of community engagement in prevention and control of STIs. In fiscal year (FY) 2005, JHPIEGO began work with mobile populations of sugar cane workers in Mazabuka and the ZDF Medical Services in 4 sites to strengthen the integration of diagnostic HIV counseling and testing (DCT) into TB and STI services (activity ID # 9035) and increased access to and utilization of HIV prevention, care, and treatment services. JHPIEGO has been supporting the ZDF in integration of CT into TB and STI services with over 90% of TB patients accepting HIV CT and subsequent referral to ART for those testing positive. In FY05 25 ZDF providers and 54 community lay counselors from the initial 4 sites were trained in appropriate counseling and testing skills. In the second year (2006), 25 health providers and 120 community lay counselors from 4 additional sites were trained. In order to expand integration of CT in TB and STI services, in FY07, DCT training will be provided to an additional 40 health care providers from Zambia sugar and from up to eight additional ZDF facilities. JHPIEGO will also collaborate with partners such as PCI and KARA to strengthen the community outreach around the target facilities, to improve the continuity of care and the uptake of services, including training 80 community workers in counseling and testing, group education on HIV/AIDS, recognition and referral for STI, TB or HIV care services. With the additional funding in 2007, JHPIEGO will work to strengthen training of healthcare workers within the defense forces and the Zambia sugar in the management of STIs and make available copies of the Zambia National STI case Management Guidelines. These guidleines are not readily available in for use by the clinicians caring for these high risk populations. Training will emphasize the Syndromic approach to STI management, risk assessment and risk reduction counseling. The standard available training materials will be used for these trainings. Targeted interventions contribute to the overall goal of reducing STI prevalence and slowing HIV transmission. In order to expand and sustain quality STI services and considering the negative effects of the prevailing high staff turnover in the ZDF facilities, JHPIEGO will carry out the following activities: • Make available the MOH National STI Syndromic Case Management Guidelines for Zambia; • Training 150 ZDF healthcare workers in the management of STIs by conducting 7 five day provider training workshops.The activities will enable ZDF to expand and sustain quality STIs services in order that more patients seen at military clinics can access timely and appropriate care.

Targets

Target Target Value Not Applicable Number of targeted condom service outlets  Number of individuals reached through community outreach that  promotes HIV/AIDS prevention through other behavior change beyond abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention 150
through other behavior change beyond abstinence and/or being faithful

Table 3.3.05:

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 the Ministry of Health (MOH), National AIDS Council (NAC), and USG implementing partner AB activities. HCP currently works with in- and out-of-school youth groups through community-based organizations, including theatre groups, to promote open discussion about decreasing risky behaviors and enhancing problem-solving skills. Through these venues, HCP will inform youth on the importance of knowing one's HIV status, engaging in healthy AB behavior, seeking MC services from a trained professional, and post procedural care. HCP's theater members will also be trained to present comprehensive messages about AB, CT, and that MC can reduce the risk of contracting HIV--with an understanding that it is not 100% protective. Traditional leaders also play a key role in all HCP community-based activities; for this reason, they will be engaged to present AB and MC messages to their communities. With additional funds, HCP will also assist MOH, NAC, and MC delivery partners in developing and implementing a national MC awareness campaign that includes messages related to AB as part of the overall national MC campaign and male reproductive health kit.

Table 3.3.05:

These activities are linked with HVCT and HVTB activities (#9035, CARE, #9018, #9021, #8819, #8892, #9037, #9006, #9046, #9047, #8888, CRS HVCT #9713, CARE HVCT #9714, and PCI HVCT #8883).

In Zambia, rates of HIV and TB co-infection are more than 60% and TB is one of the leading causes of death among PLWHA. To ensure appropriate care for TB patients HIV counseling and testing should be integrated into TB programs. Likewise, it is important that patients diagnosed with HIV are appropriately monitored, screened, and treated for TB and other opportunistic infections (OIs).

JHPIEGO is working to strengthen the integration of HIV/AIDS and TB care and treatment services in Southern and Western Provinces, through: 1.) Training for diagnostic HIV counseling and testing (DCT); 2.) On-the job training (OJT) for diagnosis and management of opportunistic infections; 3.)Training of community counselors and treatment supporters; 4.) Supportive supervision in clinical training skills.

TB patients must be effectively counseled and tested for HIV, and referred to HIV care and treatment services in a timely manner. Based on successful approaches in integrating CT into antenatal care for PMTCT, in FY 2005, JHPIEGO adapted CDC counseling protocols and training materials to incorporate DCT into TB services more effectively. In FY 2005, JHPIEGO trained 63 health care providers in DCT from 14 sites in three districts (Livingstone, Mazabuka and Mongu) of Southern and Western Provinces, who provided CT to 1,300 clients. In collaboration with the Ministry of Health (MOH), CDC, World Health Organization (WHO), Tuberculosis Control Assistance Program (TBCAP), CHAZ and CIDRZ, JHPIEGO further built capacities in DCT clinical training skills in 50 MOH TB focal point persons from all the 9 provinces of Zambia as well as in staff from other implementing partners' programs.

In FY 2006 JHPIEGO continued to work with the Southern and Western Provincial Health Offices (PHOs) to build capacity to expand the integration of HIV into TB services. Working with the local provincial trainers, by the end of FY 2006 an additional 50 health care providers from ten new sites will be trained in DCT, in addition to the provinces' own programs of training beyond this number. In FY07, JHPIEGO will train 75 service providers from ten districts in Southern and Western Provinces in DCT skills, and DCT trainers in training skills, again working to build the capacity and support the local trainers and managers. To ensure that these programs are sustainable, JHPIEGO will strengthen and expand the capacity at the provincial level in training skills, supervision and monitoring, through joint training and supervision activities in Southern and Western Provinces. JHPIEGO will support the local management and supervision teams to strengthen the implementation of a standardized clinical pathway model and patient record forms adapted/developed in FY06 for DCT within TB services. JHPIEGO will also support CARE International and Eastern Province to build capacities of trainers and supportive supervision teams.

Providers of HIV care and treatment services need significant strengthening in the recognition, diagnosis and management of TB and other Opportunistic infections (OIs). Experience from JHPIEGO's work in FY 2005 shows that significant effort in hands-on mentoring and on-the-job training can dramatically improve care and treatment for HIV patients.

Structured on-the-job training (OJT) is a non-traditional, intensive approach to in-service training in that it involves a highly experienced clinician spending at least two weeks at a service outlet working with a team of providers in their environment. It includes daily rounds together with structured, case study reviews, allowing the teams of providers to work through diagnosis, clinical decision-making, and management of TB and other OIs, building upon the national OIs and ART training materials. During FY 2005, using clinical experts from the University of Zambia (UNZA) and University Teaching Hospital (UTH), JHPIEGO provided OJT to 30 health care providers from Livingstone General Hospital, Lewanika General Hospital and Mazabuka District Hospital along with selected staff from hospital-affiliated health centres (HAHC). By the end of FY 2006, an additional 50 health care providers working at ten different sites will be provided with on the job training. In FY07, JHPIEGO will train an additional 50 health care providers in ten sites in the province - the sites will be selected based on an assessment of need and to compensate for

attrition of the already trained staff. Relevant performance standards have been drafted and will be implemented in FY 2006 and FY07. This should improve the quality of care by providing sites with standards they can implement and monitor as well as tools for supervisors to use in monitoring and supporting clinical services.

In FY 2006 JHPIEGO hopes to formalize an arrangement with UNZA and UTH to use the pool of clinical experts from the institutions for this training program as a step towards building the capacity of those key national institutions. In addition, in FY 2006 and FY07, JHPIEGO will increasingly involve the Clinical Care Specialists from the Provincial Health Offices and the experienced clinicians from the Provincial Hospitals or other larger facilities, to build local capacity to support and expand this program from the Provincial level. Thus supervision, monitoring of the training and quality of services will increasingly be carried out by the respective Provincial Health Offices with the support of JHPIEGO and the UNZA/UTH clinical experts as needed.

Integration of HIV and TB at the level of community treatment support: Based on the TB DOTS model of community treatment support programs, HIV treatment programs are similarly developing community treatment and adherence support programs. With the high rates of TB-HIV co-infection, tremendous opportunities exist to increase the synergies in these programs and ensure that TB treatment supporters are able to refer for and support HIV services, and visa-versa. In addition, these lay counselors can be incorporated into clinical services to reduce the burden on higher-level clinicians by providing group education and counseling.

In FY 2005, 60 community counselors/ treatment supporters (CCTSs) were trained in Livingstone, Mazabuka and Mongu districts in support of the sites where DCT and OJT activities were conducted. In FY 2006, an additional 50 CCTSs are being trained in these provinces to cover ten more sites (the same sites that will be strengthened in facility DCT and management of TB/OIs in HIV patients) and increase on the number of clients reached in FY 2006. Beginning in FY 2006 and continuing in FY07, JHPIEGO will draw upon earlier-trained CCTSs and local government or NGO staff, building local capacity to expand and support these programs. In order to ensure sustainability of the program the local trainers will increasingly take the lead in training and supervision activities, supported by JHPIEGO and our local partners (Kara Counseling and Community-Based TB organization (CBTO) as needed. The aim in FY07 is to train 75 CCTSs and it is expected that these trainers will conduct their own training activities using resources from the MOH, Global Fund and other USG support, thus further expanding the pool of community resources in order to attain geographical coverage of the services.

Plus up funding will enable JHPIEGO to do the following: 1) Print DCT manual; 2) Training of Trainers (with ZDF); 3) DCT training at district and health centre level; 4) development of policy and guidelines for prevention of TB transmission in health care settings.

This activity links to activities in TBHV and HVCT (particularly JHPIEGO, CARE, EGPAF, CRS, FHI ZPCT and TBCAP, PCI, SHARE and Provincial Health Offices), as well as to HTXS and HBHC clinical activities (EGPAF, CRS, ZPCT, JHPIEGO, and CHAMP. This activity will increase access to counseling and testing, integrate diagnostic counseling and testing (DCT) into TB and STI services, and strengthen linkage to HIV/AIDS care and treatment services.

Migrant sugarcane workers and members of the military are at particularly high risk of HIV and STIs. These populations are away from their families for extended periods. They often have multiple concurrent sexual partners, placing them at a higher risk. Mobile populations are also at higher risk of TB than the general population, due to their living situation, often in crowded housing such as military barracks or migrant workers' camps. Access to health services among these populations is often limited; one effect of this limitation is that men who do suspect they have an STI or who have symptoms of TB may not receive timely treatment, which increases the chance of passing the infection on to others. While we know that there is a high rate of co-infection of TB and STIs with HIV, TB and STI services have not routinely and effectively offered HIV counseling and testing. At the same time, the Zambia Defense Forces (ZDF) and private sector health services such as those of Zambia Sugar have not benefited from the same level of investment as the public Ministry of Health (MOH) system. JHPIEGO, as a key partner to MOH in a number of HIV/AIDS technical programs, aims to help bridge this gap. In addition, ZDF sites are spread throughout Zambia in all nine provinces and are often located in very remote and hard to reach locations presenting further logistical challenges in service provision.

In fiscal year (FY) 2005, JHPIEGO received United States Government (USG) support to begin work with mobile populations of sugar cane workers in Mazabuka and the ZDF Medical Services in four sites to strengthen the integration of diagnostic HIV counseling and testing (DCT) into TB and STI services and increase access to and utilization of HIV prevention, care, and treatment services. JHPIEGO also worked to strengthen training of healthcare workers in areas where these people work in the management of STIs. Training emphasized the syndromic approach to STI management, risk assessment, and risk reduction counseling. The four ZDF model sites for comprehensive HIV/AIDS care include: Zambia Air force (ZAF) Livingstone, Lusaka's Maina Soko Military hospital, Tug Argan Barracks Ndola and Kitwe, and Zambia National Service (ZNS). In FY 2005 31 health care providers were trained in appropriate counseling and testing skills using the standardized national training and within 4 months 250 individuals were counseled and tested. Based on a subset of available data, 98% of eligible clients coming into TB and STI clinics who were offered DCT accepted HIV testing, and 76% of those clients tested positive for HIV with 92% being effectively referred for HIV care and treatment services.

In addition, 70 community lay counselors were trained. The community counselors are a link between the community and health care services and are involved in providing group education and counseling and testing both at community and facility level. Another aspect of ensuring increased continuous availability of trained counselors at the service delivery sites is the "task-shifting" strategy by making greater use of lay counselors.

In the second year of USG support (FY 2006), JHPIEGO continued to work with the private agribusiness industry and the ZDF, in conjunction with other collaborating partners, to strengthen and improve the integration of TB, STI, and HIV/AIDS services. A total of 40 additional health workers are being trained in appropriate DCT skills, with continued support for Zambia Sugar, PCI and the initial ZDF sites plus expanding to four additional ZDF sites. These expansion sites, selected in consultation with the ZDF Medical Services, are Gonda barrack, Chipata (Eastern province), ZAF Mbala (Northern province), Chindwin Barracks Kabwe (Central province) and ZNS Kamitonte, Solwezi ( North-western province). An additional 80 community lay counselors are to be trained in 2006 to increase the capacity of and strengthen the facility-based DCT services. In order to ensure that the Counseling and Testing, STI, and HIV/AIDS services at the designated sites are of the highest quality, JHPIEGO is working with local stakeholders including the designated Provincial Health Offices and District Health Management Teams, Zambia Defense Forces Medical Unit, Zambia Sugar, PCI and relevant other relevant groups. In addition to building their capacity to support and expand these DCT services, increasing emphasis in 2006 is being placed on performance standards that outline the essential elements of quality STI, CT, and HIV/AIDS services. These standards form part of the monitoring plan

for the project, and will also be used by the clinic staff themselves, as well as their supervisors, to monitor and improve their performance.

In FY 2007, JHPIEGO will continue to build local capacity in supporting and expanding DCT services. By ensuring that the existing management and supervisory teams take the lead in both training and supervision activities, with JHPIEGO's support, their ability to sustain and expand these programs will be enhanced. JHPIEGO will work with the existing management and supervisory teams (e.g., from PHO, ZDF, DHMT, etc.) to provide supportive supervision and quality assurance to programs strengthened during FY 2005 and FY 2006. Supportive supervision will include visits to service providers and sites previously trained in DCT to provide on-the-spot training to update staff and address gaps. In addition quality assurance exercises will take place using a variety of methodologies (i.e., client exit interview, mystery client, chart reviews, etc.) In order to expand services, training will be provided to an additional 40 health workers as well as designated adjunct personnel (e.g., lay counselors) from Zambia sugar and from up to eight additional ZDF facilities to be selected in consultation with ZDF. The goal is to update their clinical skills in STI and HIV/AIDS care and to train them in CT services. Post-training follow-up supportive supervision visits will be conducted with ZDF and Zambia Sugar staff to bolster skills learned in training and to address any perceived gaps. JHPIEGO will also collaborate with partners such as PCI, SHARE, GDA, CHAMP, and Kara Counseling to strengthen the community outreach around the target facilities, to improve the continuity of care and the uptake of services, including training 80 community workers in counseling and testing, group education on HIV/AIDS, recognition and referral for STI, or HIV care services, treatment support and adherence support. Approximately 1300 individuals are expected to receive counseling and testing as a result of these efforts.Other partners report targets generated from this activity thus will not be included here to avoid duplication.

Capacities will be strengthened in the ZDF and Zambia Sugar structures, and the MOH public health structures (PHO/DHMT) as appropriate, so that structured mentoring site visits and supportive supervision follow-up visits will be conducted by Zambia Sugar/ZDF trainers/ mentors to reinforce knowledge transfer and address any gaps. By strengthening the ZDF/Zambia Sugar training capacity, JHPIEGO will ensure the long term sustainability of the in service training and continuing education among ZDF/Zambia Sugar staff and service providers. The standards developed during FY 2005 and whose implementation started in FY 2006 will continue to be used by the staff and their supervisors to monitor and improve their performance.

Zambia is currently one of the leading countries in terms of integrating Male Circumcision (MC) into the compendium of HIV/AIDS prevention activities. JHPIEGO has been supporting the male circumcision program in Zambia for several years, beginning in 2004 when they teamed up with the government to begin work on small scale efforts to strengthen existing male circumcision services to meet existing demand. This early work in Zambia has informed the international efforts of WHO and UNAIDS, and the training package that JHPIEGO developed with the Ministry of Health in Zambia formed much of the basis for the new international WHO/UNAIDS/JHPIEGO training package. Likewise, assessment tools used in Zambia also provided background for the WHO toolkit. The Government of the Republic of Zambia (GRZ) has established an MC Task Force under the Ministry of Health (MOH) and the Prevention Technical Working Group of the National AIDS Council, of which JHPIEGO plays a key role. JHPIEGO will be expanding MC services at additional sites around Zambia. These model sites will become future training sites for the government's effort to expand MC services and make them available as part of the basic health care package. Target institutions will likely include Ministry of Health and Zambia Defense Forces sites, and possibly Churches Health Association of Zambia sites depending on the finalization of site selection criteria and outcome of the assessment of preparedness outlined in the Policy/Systems support activities. WHO recommends MC be promoted primarily to HIV negative males in areas of high HIV prevalence. Since knowing one's HIV statues is critical to making informed decisions regarding MC and other sexual health needs, it is critical that counseling and testing be integrated into all aspects MC service provision. JHPIEGO will implement CT at all the five sites it will expand MC service delivery to and VCT will be offered to all men who seek MC services and are above the legal age for CT in Zambia. It is expected that approximately 3,000 men will be reached for MC services. With these plus-up funds, JHPIEGO intends to: (1) develop a strong counseling and testing component to support the MC services; (2) integrate VCT as integral part of the MC services; and (3) training additional VCT counselors and clinicians.

Targets

Target Target Value Not Applicable Number of service outlets providing counseling and testing 6
according to national and international standards Number of individuals who received counseling and testing for HIV 1,500
and received their test results (including TB) Number of individuals trained in counseling and testing according to  national and international standards

Table 3.3.09:

This activity relates to all activities in this section and palliative care (HBHC and TB/HIV) and antiretroviral therapy (ART) projects funded by CDC, Department of Defense, and the United States Agency for International Development, and works to address information on quality of care and fill gaps identified through strategic information (SI) initiatives.

In Zambia the scale-up of HIV/AIDS care and treatment has rapidly expanded the numbers of sites and health care workers providing HIV/AIDS treatment services with over 100 facilities and hundreds of health workers providing ART services. HIV care and treatment programs require frequent modifications based on changes in technical knowledge in the field, standards of care and information gathered from the services themselves. As a result, providers who have had basic training need continuing opportunities to update their knowledge and skills, as well as assistance in evaluating programs critically to identify gaps and solutions toward improving their performance. This is critical not only to the provision of quality services, but contributes greatly to job satisfaction, motivation, and retention of health workers. Guidelines and training materials need to stay current and creative best practices must be established for replication in other program areas.

In FY 2006, JHPIEGO assisted the MOH and NAC to update clinical training materials, and trainers, on the recently revised clinical care guidelines. In FY 2007, JHPIEGO will assist the government, particularly the Ministry of Health (MOH) and National AIDS Council, to adapt the revised clinical care guidelines and training materials into more useful electronic formats accessible to providers through a variety of appropriate technologies (e.g., CD Rom, web-based, handheld devices). This will be done in close collaboration with other implementing partners and technical specialists working on ART programs, and will ensure consistency and standardization of materials, messages, and approaches to maximize the efficiency and success of HIV/AIDS clinical care and ART scale-up activities in Zambia. JHPIEGO will also work with MOH and Zambia Defense Forces along with other collaborating partners to develop and test different technologies available to make the clinical guidelines and resources available and accessible for HIV/AIDS care and treatment providers.

JHPIEGO will also continue to provide support and national leadership in the area of performance support for HIV/AIDS care and treatment providers, to address gaps identified in ART service delivery programs. This support is critical to ensure that HIV/AIDS care and treatment services maintain an acceptable level of quality, which will help to ensure not only that new clients are encouraged to enter care but also that existing clients remain under care. To achieve this, JHPIEGO will continue to support the implementation of continuing education opportunities for HIV/AIDS clinical staff at ART centers, reinforcing their basic skills and expanding their knowledge on specific areas. In FY 2005 and FY 2006, JHPIEGO assisted the GRZ to develop and pilot continuing education programs for ART service providers and teams. These programs included a combination of distance education programs for use in low technology settings, as well as internet and e-mail based education programs from the Johns Hopkins University Center for Clinical Global Health Education. Through the end of FY 2006, initial programs will have trained 250 ART providers, including at least some staff from all hospital and large urban-clinic based ART sites. In FY 2007, JHPIEGO will continue to support these programs to reach additional clinical caregivers, while developing additional content to fill identified gaps. One such gap to be addressed will be to strengthen the use of HAART in pregnant woman for their own health (as well as to further reduce mother to child transmission of HIV), a high priority for training in FY 2007 consistent with national PMTCT and ART guidelines in Zambia. In FY 2007, these continuing education programs will be made available to all functioning ART sites in the country and are estimated to reach 150 sites and approximately 450 providers.

JHPIEGO will also work with the MOH, University of Zambia and the University Teaching Hospital partnership and the Medical Council of Zambia to adapt and apply additional tools for performance support which will be integrated into ART service provision programs such as those of Elizabeth Glazer Pediatric AIDS Foundation and Zambia HIV/AIDS Prevention, Care, and Treatment Partnership, as well as JHPIEGO's work with the Zambian Defense Forces. These tools and approaches will help not only to support the quality of HIV/AIDS care and treatment services, but enhance the sustainability of technical support. These efforts will focus on maximizing the use of tools that can be delivered onsite to reduce the

need for ongoing external technical assistance and additional manpower (e.g., trainers and supervisors). One such tool is TheraSimtm's case-base simulation program, a computer-based interactive tool which allows providers to go through a series of HIV care cases and receive feedback on their clinical decision making. This is a tool which can be used both for advanced training as well as for monitoring performance.

To ensure sustainability of the program, JHPIEGO works in close collaboration with the MOH, NAC, Medical and Nursing Councils, and University of Zambia Medical School / UTH, to build the capacity of those institutions to design, develop, and implement programs to support quality ART services. Materials developed in these programs are ‘owned' by the national program and these institutions, and are designed to be implemented through existing channels (e.g., by involving the Provincial Clinical Care Specialists to monitor and follow-up the distance education programs). By using appropriate technology, implementation and support costs are reduced over other, more traditional approaches. For example, one focus is to develop tools that can be delivered on site, requiring less movement by clinical staff, reducing costs of travel and lodging while also ensuring less disruption of services and improving the ‘immediacy' of applying training to service delivery on-site. Likewise, electronic versions of guidelines and continuing education materials can be updated, reproduced, and disseminated at much less cost than print-based materials. These approaches will assist the national program and local partner institutions to continue to support these programs with limited levels of investment (as compared to the cost of traditional group-based in-service training, for example).

Related activities: This activity links to all ART activities in Zambia.

The national antiretroviral therapy (ART) implementation evaluation published in April 2006 revealed numerous areas of need to improve the implementation of services in Zambia. For example, eighty-four percent (84%) of institutions visited, reported not having seen the national ART implementation plan with many sites having never received key policy documents and guidelines. One can proximally assume then that quality improvement and monitoring activities were few. Moreover, this evaluation did not include in-depth investigation of care quality as part of its mandate. It is clear that as ART continues to be rolled-out at a rapid pace in Zambia, quality must be assured to promote the sustainability of these services in to the future. In cooperation with JHPIEGO, CDC-Zambia began support for a cluster evaluation of ART technical and financial support in Zambia in 2006 that revealed key areas for quality improvement interventions. This evaluation activity is now an ongoing process of data collection and feedback. It is therefore critical for funding in 2007 and 2008 to implement address sustainable activities that will aim to close performance gaps identified in the ongoing evaluation process.

CDC-Zambia will enter in to a collaborative partnership with an appropriate organization working locally to implement the Zambia A-QIP (Antiretroviral - Quality Improvement Project). A-QIP will consist of four inter-related components designed to facilitate quality improvement among the Government of the Republic of Zambia (GRZ) and cooperating partners (CPs) in Zambia.

1. Collective and Routine Monitoring of Quality Cluster evaluation with participation across ART service providers in Zambia to include GRZ, major private sector companies, and CPs to include EGPAF/CIDRZ, ZPCT, AIDSRelief/CRS, University Teaching Hospital Pediatrics/Columbia University, John Snow Incorporated/DELIVER, and JHPIEGO. The cluster evaluation aims to convene GRZ and CPs to identify critical and common questions and a shared evaluation strategy related to care quality, cost, service delivery and coverage, and continuity of care. The process will require regular meetings of project directors, M&E staff, and clinical experts to identify indicators, collect and share information, and inform policy and service delivery processes in Zambia. In addition to tracking a common set of quality indicators, several special studies will be supported in areas identified by the group.

2. Data Use for Improved Care The Continuity of Care: Patient Tracking System (CC:PTS) has been deployed in more than 35 sites between 2005 and 2006. It is anticipated that the system will continue to be deployed where feasible in GRZ locations throughout the country in 2007. CC:PTS provides critical individual level data on health services as well as numerous opportunities to query facility-based and eventually district and provincial data. Data use from this system, in cooperation with other facility-based aggregation systems (e.g. ARTIS) and what will be a redesigned health management information system for Ministry of Health (MOH), must be maximized to inform quality improvement activities. This is a key feature and task of the A-QIP project.

3. Coordinated Quality Improvement Technical Assistance Based on findings from the cluster evaluation, key interventions for quality improvement will be elaborated and delivered. A central organization will map and help to coordinate technical support activities being delivered through GRZ and CPs. Additionally, the central organization will have capacity to actively provide quality assurance and facilitation services to improve individual and facility-level performance by providing on-the-job training (OJT) for quality improvement.

4. Creating International Networks for Learning Distance learning will reinforce a response to findings from the cluster evaluation and the OJT, opportunities for distance learning in cooperation with MOH facilities will be organized with a specific set of course work and informal sharing focused on adult and pediatric ART. Lectures from within Zambia and abroad will be taped and used in these sessions. A central organization will be required to moderate and facilitate ongoing learning through session design and execution.

This activity is linked to SOPH HTXS (#9760). As other monies under this mechanism will be sent to the JHPIEGO Zambia country office, monies for this activity will remain at Johns Hopkins University.

Few studies have assessed the care of HIV-infected children and adolescents in rural sub-Saharan Africa, particularly outside established HIV-1 research sites. The care of HIV-infected children and adolescents, and particularly the provision of antiretroviral therapy (ART), in a rural community in sub-Saharan Africa may have higher rates of treatment failure than in urban settings because of several impediments, including limitations in accessing appropriate care, reduced adherence with prescribed treatment regimens, and frequent co-infections. The aims of this activity are to: 1) measure immunologic and virologic treatment responses and survival in a cohort of HIV-infected children and adolescents receiving ART in rural Zambia; 2) identify risk factors for ART failure and death in children residing in rural Zambia, including antiretroviral drug resistance, barriers to care and status of the child's primary caregiver; and 3) assess the rate of disease progression in HIV-infected children and adolescents who are not eligible for ART in order to evaluate treatment guidelines on when to initiate ART in children and adolescents in Zambia. Findings will be used to develop strategies to improve the care of HIV-infected children and adolescents at Macha Hospital in Southern Province, with the long-term goal of developing strategies applicable to rural communities throughout sub-Saharan Africa.

In March 2005, Macha Mission Hospital began a government program to provide ART by trained health care workers under the supervision of Dr. Janneke H. van Dijk and others. As of May 2006, 31 children and adolescents were receiving ART at Macha Hospital, 12 of whom are less than five years of age, nine between the ages of five and 12 years, and 10 between 13 and 20 years. An additional 63 HIV-infected children and adolescents are cared for at Macha Mission Hospital but are not yet eligible to receive ART, 35 of whom are less than five years of age. Thus, the cohort will consist of approximately 100 HIV-infected children, with additional children eligible for enrollment as they present for care.

JHU will conduct a prospective cohort study of HIV-1-infected children cared for at Macha Hospital. The first study aim will be to assess treatment responses and survival in HIV-infected persons initiating ART. JHU will measure CD4+ T-lymphocyte cells counts and plasma HIV-1 viral loads, and a study team will actively trace defaulters to assess survival. The main outcome measures for Aim one are treatment failure and survival rates after initiation of ART. Accurate assessment of immunologic and virologic treatment failure rates will allow for the identification of risk factors for treatment failure, barriers to care, and the development of strategies to improve the effectiveness of ART for children and adolescents in rural sub-Saharan Africa. Determinants of treatment success or failure comprise a complex set of factors operating at multiple levels, and include drug availability, access to health care, prescribing practices, level of patient education, adherence, social support and stigmatization, drug resistance, frequency and type of co-infections, and the nature and severity of drug toxicities. To identify risk factors for ART failure in rural Zambia, we will focus on barriers to adherence at the level of the individual family, including the status of the child's caregiver, and the emergence of HIV-1 drug resistant mutations. Drug resistance testing will be performed in the laboratory of Dr. Deborah Persaud, whose laboratory recently developed methods for performing antiretroviral drug resistance testing on a 560 base pair region of reverse transcriptase from samples stored as dried blood spots. The cost of drug resistance testing will be paid for by a separate grant from the Elizabeth Glaser Pediatric AIDS Foundation and will not be covered under this proposal.

Not all HIV-infected children and adolescents seeking ART are eligible for therapy. However, little is known of the characteristics of this patient population. What is their median CD4+ T-lymphocyte cell count at the time of the initial clinic visit? How rapid is their disease progression and over what time period do they meet treatment criteria? What proportion die before starting ART, particularly in rural settings? Understanding the answers to these questions will assist in evaluating the criteria to initiate ART in children and adolescents in rural Zambia and in anticipating resource needs. To address these questions, JHU will establish a second cohort of children and adolescents seeking ART at Macha Hospital but who do not meet ART treatment criteria. This cohort will be followed

every three months to assess their baseline immunologic and virologic status and to monitor disease progression and survival. The major outcome measure for Aim three is the time from the initial evaluation until the child meets ART treatment criteria. The hypothesis to be tested is that a subset of HIV-infected children and adolescents in rural sub-Saharan Africa is at risk of rapid disease progression and may benefit from earlier initiation of ART.

This activity relates to EGPAF SI (#9001), AIDSRelief - Catholic Relief Services (CRS) (#8828), Ministry of Health (MOH) (#9008), Technical Assistance/Centers for Disease Control and Prevention (CDC) (#9023), and CCPTS COMFORCE (#9691).

Building upon fiscal year (FY) 2006 activities, JHPIEGO will continue to support the scale-up and deployment of electronic patient monitoring and data management tools to enhance continuity of care. This will be provided by a) training and b) supporting the deployment and use of the growing number of modules in the Continuity of Care and Patient Tracking System (CCPTS) software. In collaboration with new district health management team (DHMT) leaders, the Ministry of Health (MOH), Centers for Disease Control and Prevention (CDC)-Zambia, and JHPIEGO, together with other collaborators including the Center for Infectious Disease Research in Zambia (CIDRZ), AIDSRelief, and Zambia Prevention Care and Treatment program (ZPCT), will support the scale-up of data entry, IT systems, and CCPTS project through training. This will include the direct hiring of technical deployment support staff.

JHPIEGO in FY 2005 and FY 2006 supported the development of the CCPTS and its pilot and scale-up in Kafue District. JHPIEGO has supported the training of 25 service providers and the orientation of nine DHMT staff to the system. In addition, JHPIEGO has identified and placed two Software Data Management Officers (SDMOs) in Kafue district to assist the DHMT in the roll out to all service outlets in the district. The SDMOs work in the district and support the District Health Information Officers (DHIOs) in the training of the service providers and provide technical support on hardware and software trouble shooting. As Kafue district is completely deployed, they will be redeployed to train other deployment specialists in a close partnership with, and under the direction of the MOH deployment plan.

In particular, JHPIEGO will support the scale-up of the CCPTS project through training, the direct hiring of four additional Software and Data Management Officers (SDMO), provision of logistical support for the deployment, and a small amount of site readiness preparation. The SDMOs will themselves be deployed strategically and dynamically in the provinces targeted for the scale up of the CCPTS system according to the MOH plan, to provide strong support for the technical side of the training. They will be expert in the use and maintenance of the CCPTS system and will ensure that quality in training and management of the CCPTS system is maintained as the number of deployed sites grows.

The SDMOs will also support the training of 250 service providers in the provinces and districts targeted during the scale up. They will co-train with the provincial and district trainers and work in conjunction with all the partners supporting the scale up of the system such as MOH, CIDRZ, ZPCT, CRS, and CDC Zambia. They will make sure that the quality of training is maintained from the Provincial Health Office (PHO) to the districts.

Increasingly, the MOH is taking the lead in CCPTS collaboration, deployment authority, and field support, and has solicited commitments for infrastructure from all major implementers. The MOH has also developed, planned and promoted its own very aggressive deployment process for the CCPTS, using an almost ‘viral' dissemination plan: a) train provincial level Trainers of Trainers at central trainings, b) send provincial technical leadership back to province to replicate training with district leadership, who then c) take the skills back to their districts for implementation. So even before the FY 2007 activity period, the efforts of these initial three CCPTS collaborators will be joined by efforts of all other HIV/AIDS care and treatment partners in Zambia, including AIDSRelief (Catholic Relief Services - CRS) and the Zambia Prevention, Care, and Treatment (ZPCT), HSSP, JHPIEGO, as well as EGPAF.

In building this collaboration around the CCPTS solution, it is clear that the Ministry is comfortable taking the initiative on this effort. The place for JHPIEGO will be to leverage its long term good relationship with MOH and established ‘trainer' role, by acquiring approximately four more strong technical staff to support the rapid national deployments and most of the rest of this activity will be in support of the training. While this developing country EMR now provides services to more than 60,000 patients, with the additional partners starting deployment before the end October, the rate of growth may increase non-linearly as the number of electronic clinics increase, provided there are no supply limitations.

In an effort to build upon FY 2006 work involving the expansion of the CCPTS system into Mazabuka, Monze, and Choma Districts, JHPIEGO will conduct on-the-job training of 250 service providers from the remainder of the districts in Southern Province, or as otherwise directed in collaboration with the MOH deployment plan. JHPIEGO will also conduct follow-up supportive supervision visits to those service outlets previously trained to ensure quality services and to identify any gaps in data entry or service provision. Data entry staff will conduct the trainings as well as the follow-up supportive supervision visits. JHPIEGO will continue to support the development and updating of training materials and user manuals.