The Zambia Children New Life Center (a shelter for sexually abused children in Lusaka's Linda compound) was started up in February of 2002 as a result of increasing cases of reported child sexual abuse in Lusaka as well as financial support and recognition through the rebook human rights award for young human rights activists. The main objective of the centre is to work towards prevention and protection of children against sexual abuse and promoting childrens rights by working closely with family, community and government. A number of trainings on awareness about sexual abuse in children have been conducted in Linda where the centre is located. The centre provides emergency accommodation for children at risk of harm in their current environment, psychosocial counseling, and preparation for court sessions, medical attention and more recently a link has been established with the one-stop centre for post exposure prophylaxis (PEP) at the University Teaching Hospital Department of Pediatrics. Among the achievements of the centre have been: the recognition of the centre (many of the children are referred by the police, social welfare department or NGO's and individuals); increased public awareness with resultant increase in reporting of sexual abuse cases in Lusaka, particularly in Linda compound; support from organizations like World Food Program to help feed the children; and some successful income generating activities within the community. The centre has also managed to win limited financial assistance from kindernotehilfe in Germany and Cordaid Netherlands to pay towards educational programs, income generating activities, food and rentals. On average 40 children are seen every month. Funding from PEPFAR funds in 2007 will support training in the community to raise awareness in HIV/AIDS transmission through child sexual abuse. Recognition and prevention of sexual abuse in children requires a number of key elements be taken into account and noted. These trainings are conducted in such a manner that people interacting with children are able to identify some key elements, "tell tale signs" of sexual, physical and emotional abuse. To date most of the trainings have been confined to Linda compound. Among the trained personnel are teachers, church leaders, police, parents and caregivers and other key community leaders as well as children themselves. It is hoped that by extending the trainings to other areas of Lusaka, we will be able to identify another suitable site to establish a second centre in the coming year. 10 trainings of 5 days comprising 40 participants each will be carried out to reach a target number of 400 this year. Currently there is no formal referral system between the various players who handle the complex issues around child sexual abuse. The funding will also be used to establish a formal referral system between the police, law enforcement agencies, schools, hospitals and churches.

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 400
through other behavior change beyond abstinence and/or being faithful

Table 3.3.05:

In FY 2007 this activity will be linked to the USG support for the development of the Pediatrics Centre of Excellence (#8993) and the support provided to the adult ART clinic (#9000). Some patients on ART recover with complications. Neurological complications such as paraplegia, quadriplegia, and neuritis are common in patients on ART due to OIs and HIV related malignancies. Arthritis is another common complication in AIDS patients. As part of palliative care, these patients need rehabilitation in order to recover some degree of function and have an improved quality of life. UTH, being a referral center receives a large number of such patients. The Physiotherapy department at UTH currently does what it can to actively re-habilitate these patients.

As part of our strategy to improve palliative care for AIDS patients, part of the funding requested for this activity will be used to purchase some of the needed equipment such as shortwave diathermy, interferential combo machine and electric massager. As the main referral center for rehabilitation, UTH will use the funds to bring its re-habilitation center to standard and also act as training center and build capacity through providing technical assistance to other provincial centers as the activities are scaled up in FY 2008 and outwards years. As part of FY 2007 activity, the Physiotherapy department will strengthen the referral system with the 5 Lusaka Urban Clinics so that most of the patients could be seen as close to their homes as possible. The limitation of this plan however is the inadequate facilities in the Urban Clinics for Physiotherapy. The UTH Physiotherapy department is targeting 500 HIV patients in FY 2007.

As part of our strategy to improve delivery of care to AIDS patients, the UTH Physiotherapy will conduct in-service training for its staff covering 15 physiotherapists in the latest advances in AIDS care and ART related complications and extend the training to Physiotherapists in Lusaka Urban Clinics. This activity will strengthen the referral links between the UTH departments of Medicine and Pediatrics with home-based care programs supported by USG (#8946) and other organizations so that the patients can be provided with continued home-based care upon discharge from the hospital. The activity will facilitate meetings between the UTH management and the home based care organizations in order to develop the referral system and ensure accurate and timely feedback. In FY 2007 this activity will be linked to the USG support for the development of the Pediatrics Centre of Excellence (#8993) and the support provided to the adult ART clinic (#9000). Some patients on ART recover with complications. Neurological complications such as paraplegia, quadriplegia, and neuritis are common in patients on ART. As part of palliative care, these patients need rehabilitation in order to recover some degree of function and have an improved quality of life. UTH, being a referral center receives a large number of such patients. As the main referral center for rehabilitation, UTH will use the funds to bring its re-habilitation center to standard and also act as training center and build capacity through providing technical assistance to other provincial centers as the activities are scaled up in FY 2008 and outwards years.

An additional activity under this program is to support the management of opportunistic infections, preventive therapies, micronutrient supplementation and provision of insecticide treated bed nets to vulnerable HIV positive children. This activity relates to UTH (#9043, #9044, and #9765) and HTXS (#8993). In FY 2006 and 2007, the President's Emergency Plan for AIDS Relief (PEPFAR) funding is supporting the development and operation of a Pediatric and Family Center of Excellence (COE) for HIV/ AIDS care at the University Teaching Hospital (UTH). This is a tertiary level health center and national referral hospital in Lusaka and a similar centre will be opened in the tertiary hospital for the Southern Province, the Livingstone General Hospital. Up to 75% of HIV-infected children develop symptoms in the first two years of life. They often succumb to serious infections like tuberculosis (TB), pneumonia, malaria and persistent diarrhea. Effective preventive interventions do exist but are often not available in these tertiary level health care settings. In 2007 CDC proposes to support procurement of supplies that will help prevent and treat serious infections like pneumonia, (especially Pneumocystis carinii pneumonia (PCP)), TB, malaria and persistent diarrhea, as well as provide nutritional support through micronutrient and vitamin supplementation in order to provide comprehensive care to all HIV-positive children who may not necessarily be eligible for ARV's. Cotrimoxazole prophylaxis is offered to all HIV positive children for PCP (and also has benefit in preventing malaria, and some diarrheal illnesses); however, the appropriate syrup formulation is not readily available. Intravenous cotrimoxazole makes a difference between life and death in admitted patients with severe PCP, but again this is not

available. Isoniazid (INH) prophylaxis for HIV positive children to prevent TB though recommended nationally, is not currently given due to non-availability of the appropriate formulation as currently only combination forms of INH with rifampicin or ethambutol are available. This activity will ensure that these drugs (isoniazid and cotrimoxazole) are available in the appropriate formulation. Studies have shown that HIV positive children are more susceptible to malaria.

Insecticide treated bed nets (ITN's) have proved very effective in preventing malaria in children living in high areas of transmission. Though the malaria program under Global fund (and soon support from Presidients Malaria fund) does support provision of ITN's the focus has been mainly on rural populations. This activity will ensure that all hospital beds have ITNs that are treated regularly and also provide ITNs to all HIV positive children attending the ARV clinic. Providing nutritional care will be another area of focus in FY 2007. Micronutrient deficiencies are common in HIV-infected and HIV exposed children. The most common deficiencies are vitamin A, iron, and zinc. Children who are weaned early as part of PMTCT intervention are also more vulnerable to deficiencies. Vitamin A supplementation is given routinely as part of the National Immunization schedule. This proposal will procure multi-vitamin and daily multiple micronutrient supplements for all HIV positive children, to include those in the malnutrition ward. On discharge from the hospital the children will be referred to RAPIDS (#8946) for continued nutritional support and home-based care in the community.

Targets

Target Target Value Not Applicable Total number of service outlets providing HIV-related palliative care 8
(excluding TB/HIV) Total number of individuals provided with HIV-related palliative care 5,300
(excluding TB/HIV) Total number of individuals trained to provide HIV-related palliative 230
care (excluding TB/HIV)

Table 3.3.06:

Related activities: UTH HVCT (#9716), NIH HLAB (#9015) and Social Marketing PSI HVCT.

The University Teaching Hospital has received funding from CDC through two co-operative agreements established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3). Though both agreements are managed by the central administrative office, the accounts are separate and the location of the two departments is physically separate . To communicate the importance of the breadth of activities and for purposes of coordination, the activities linked to the two departments have been submitted as separate narratives.

The Clinic 3 is a dermato-venereology clinic which falls under the Department of Internal Medicine within the University Teaching Hospital (UTH) in Lusaka. Clinic 3 offers tertiary level services for the Lusaka District as well as primary care services to walk-in patients with sexually transmitted infections (STIs) and skin complaints. STI clients referred to the clinic from other health centers often have complicated infections that do not respond to first-line drugs or a history of repeated STIs. STIs are a major public health problem in Zambia; the incidence has been reported at 16 per 1000 person-years. The presence of an STI can increase the likelihood of acquiring HIV by two to five times and increase the probability of HIV transmission through an increased level of viral particles in the genital secretions. Therefore, providing testing and treatment of STIs can help prevent the spread of HIV.

The presence of an STI can indicate that either the client or his/her partner have engaged in risky sexual behavior and hence are at increased risk of acquiring HIV. The incorporation of HIV counseling and testing (CT) into the routine clinical management of clients with a STI is an opportunity to reinforce behavior change messages and refer the HIV-infected individuals to the antiretroviral treatment (ART) program.

From fiscal year (FY) 2004, the United States Government (USG) has provided support to the UTH STI clinic for a number of activities including: laboratory and infrastructure support, Neisseria Gonorrhea surveillance, CT training, and the implementation of routine counseling and testing for all STIs. These activities have included clients referred from any other clinical setting within the hospital and other walk-in clients. All HIV positive clients are linked to the treatment and care program within the clinic facility. In addition to referral of all STI clients for routine CT, all HIV positive clients in the CT center or in the ART program within Clinic 3 are also screened for STIs. These services were expanded during FY 2006 to include STI screening of clients undergoing HIV testing at a stand-alone CT center that has been established by RAPIDS (#8947) in the neighborhood with support from the USG. In the first six months of the program to screen STI clients for HIV, (Dec 2005 report), 413 clients were seen, of these 34% already knew their status, 66% underwent counseling and 52% of those who were tested were HIV positive. Only ten (10%) of the clients who tested positive were commenced on ART (using largely WHO clinical criteria) as many clients could not access easily the CD4 testing service due to the cost of this test. Due to difficulty in accessing CD4 testing services, the actual number of eligible clients may be under represented. However since August 2005 the Government of the Republic of Zambia made a policy decision to provide free ARVs and with the increased support of the USG for laboratory testing, a larger number of HIV positives will be able to access treatment.

The proposed activities for FY 2007 will focus on continuing to link STI clients to HIV diagnosis, treatment and care, and screening of HIV positive clients for STIs. All STI clients (100%) will be referred for counseling and testing (unless clients already have proof of being tested within the last three months). All HIV positive STI clients who up to now had difficulty with accessing CD4 testing will be linked to the National Institutes of Health CD4 testing services (Activity # 9015) within the hospital so that clients are identified in good time for treatment. Partner tracing and treatment is part of the standard approach to management of STI clients. All STI and HIV-related services will be extended to partners of our initial STI clients including PMTCT and care services.

An additional activity that the Clinic 3 will undertake in FY 2007 is to link-up with the departments in-patient wards and provide CT services to all partners of patients admitted in the hospital. The department has applied for USG funds (Diagnostic Counseling and

Testing (DCT) (#9716) to support the recent Zambian national policy of routine diagnostic counseling and testing in the hospital setting and all in-patient adults admitted to hospital. Upon obtaining permission from the patient tested under this DCT program, partners and relatives will be encourage to attend Clinic 3 for CT .

Due to rapid staff attrition, human capacity in the clinic will need to be improved. Activities to address this need in FY 2007 include the addition of two laboratory and counseling staff positions as well as the development of continuing education opportunities and in-service training for existing staff. One of the main barriers to improving care and treatment for HIV in Zambia has been the lack of human capacity and trained health care providers. This activity will address this need. While the cost per person of CT services is greater than most programs, it is due to the additional support to the STI reference laboratory in terms of equipment, STI diagnostics and support to the staff salaries.

The activities of the Clinic 3 are part of the government-run tertiary referral and teaching hospital. All activities in this proposal are within the confines of the priorities of the UTH which strives to establish a sustainable program, by training of health care workers, developing standard treatment protocols, strengthening physical and equipment infrastructures, implementing a facility-level quality assurance/quality improvement program, improving laboratory equipment and systems and development, and strengthening health information systems. The UTH management has contributed and shared some of the costs for this program with the President's Emergency Plan for AIDS Relief funds by providing: part time staff, some of the supplies (needles, syringes, and test kits) and supportive lab services. The benefit of this shared cost approach is that in the long-term UTH will only require minimal funding once staff is trained and systems are in place.

Related activities: Linked to HTXS UTH (#9043), HTXS UTH Centre of Excellence (#9765) and OVC (#8947).

The University Teaching Hospital has received funding from CDC through two co-operative agreements established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3). Though both agreements are managed by the central administrative office, the accounts are separate and the location of the two departments is physically separate . To communicate the importance of the breadth of activities and for purposes of coordination, the activities linked to the two departments have been submitted as separate narratives.

The Family Support Unit (FSU) provides a number of activities including CT services to inpatient and outpatient children that are seen in other departments of University Teaching Hospital (UTH) and community. HIV testing is carried out onsite and enables the center to provide same-day results to their clients. Child sexual abuse cases are also counseled, tested, and given psychosocial support in the unit (#9043). Children who test HIV positive are referred to a specialized HIV clinic within the Department of Pediatrics. Adults who test positive are supported with initial CD4 (laboratory support through United States Government (USG) funds) testing and referred to appropriate antiretroviral therapy (ART) centers within the hospital (UTH Department of Medicine (NEW activity) or at the nearest district health clinic providing ART services. Once the Pediatric and Family Centre of Excellence (COE) is fully established (HTXS CEO #New), with USG support, within the Department of Pediatrics the FSU will continue to play a key role with provision of CT and ongoing psychosocial support for children and their caregivers.

The FSU also runs an outreach program focused in three sites, one at the UTH and 2 others in urban communities within the district. These outreach activities provide: community sensitization on issues around pediatric HIV testing services to orphans, follow-up on children enrolled in care and treatment services, and provisions for psychosocial support to the children living with HIV/AIDS and their care givers.

Educational and recreational activities for children within the three sites are also offered. This activity is supported by RAPIDS (#8944) Children are encouraged to express themselves in writing, drawings, and games. Play therapy involving HIV+ children is used to build confidence and reduce stigma and discrimination. RAPIDS will support non-medical services of the FSUs, linking children to ART services, and support ART adherence.

A total of 2,302 children have been enrolled in the unit in the last three years. Ongoing educational and recreational activities will be incorporated into the multi-disciplinary approach of the pediatric COE that will be established in the Department of Pediatrics with support from the USG.

The FSU is also a training center in psychosocial counseling following the Zambian National VCT training guidelines and facilitates training courses as requested by the general public. These courses are very popular; however trainees must secure their own funding for training costs. Specialized trainings in child counseling are also conducted by Kara Counseling and Training Trust, a reputable non-governmental counseling training organization. This organization was initially supported by the Norwegian Agency for Development Cooperation and works with other USG partners in VCT training programs (Biz AIDS USAID HVCT - No activity number).

The FSU activities in FY 2005 were supported by PEPFAR funds through FHI and RAPIDS (HKID #8947) and RAPIDS continues to provide support programs that encourage parents and guardians to seek CT for OVCs, provide community based support and address the specific needs of the OVCS. Beginning in FY 2006, specific support for the counseling activities, including salary support for counselors has been provided by CDC, while the OVC support has been provided by RAPIDS. In FY 2006, counseling has been provided with a greater focus on community outreach and pediatric ART adherence issues. In FY 2007 additional direct funding will be used to expand to five additional sites in the Lusaka District that will link children directly with the ART and counseling program in the peripheral clinics currently supported by the USG. The unit will also add two additional activities to increase the number of trainings devoted to child counselors and work closely

with home-based health care programs supported by the USG (RAPIDS, HKID #8947) and other partners to integrate pediatric care and support into their activities.

Related activities: HVCT UTH/ZVCT (#9718), HVCT UTH (#9042), Renal (#9756), Hepatitis B & C (#9752),and FSU (#9044)

The University Teaching Hospital has received funding from CDC through two co-operative agreements established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3). Though both agreements are managed by the central administrative office, the accounts are separate and the location of the two departments is physically separate . To communicate the importance of the breadth of activities and for purposes of coordination, the activities linked to the two departments have been submitted as separate narratives.

The University Teaching Hospital (UTH) is the only tertiary teaching hospital and the main national referral center for Zambia. The Department of Internal Medicine admits on average 1,000 patients every month. An estimated 60 - 80% of clients in the adult admission wards are HIV-infected.

A small study conducted in 2003 to determine HIV prevalence among all in-patients admitted to the medical wards, concluded that 60% of patients were infected. Approximately 99% (n = 103) of patients agreed to be tested after counseling, however, 50% of these clients never received results due to delays in obtaining the HIV test results. Even with the use of rapid tests, samples sent to the main laboratory in a large hospital lead to unnecessary delays and missed opportunities for diagnosing and identifying clients that need to be placed on antiretroviral (ARV) medications. The medical emergency and inpatient wards are also important settings for identifying HIV-infected individuals who are can be enrolled into treatment and care programs.

Since the beginning of 2006, the Department of Medicine has encouraged the medical residents to offer routine HIV testing to all patients admitted in the medical wards. In March 2006 the Zambia National Guidelines for HIV Counseling and Testing recommend routine "opt-out" testing in all clinical care settings where HIV is prevalent and where ARV treatment is available. These guidelines have helped strengthen the departments' guidelines to routinely test all patients.

Therefore in fiscal year (FY) 2007 the department will embark on an aggressive program to have facilities in place to routinely test all patients admitted in the medical wards and provide same day results. The department has six low cost wards (bed capacity of 240) and one emergency admission ward (bed capacity 42).

In order to achieve this, the department will ensure that all wards have a room dedicated to CT. This room would need minimal rehabilitation which would include obtaining furniture and cupboards to store the test kits. All the wards currently have at least one or two nurses who are trained psychosocial counselors. Due to the attrition rate of medical staff (especially nurses), UTH will train all the nurses and doctors in the department in counseling skills as well as rapid HIV testing. The Zambia VCT (ZVCT) has long experience in training (using National Guidelines) and will be consulted. As the feedback time of all results improves, increased uptake of HIV testing will occur and in turn improve the level of care provided to HIV-infected individuals because they will have been identified at an earlier stage.

Partners (spouses) and other relatives (upon obtaining permission from the client) will be contacted and encouraged to seek voluntary counseling and testing (VCT) services at the dermato-venereology clinic (#9042) , which also falls under the Department of Medicine. VCT services would include risk reduction programs and prevention of transmission among those that test positive (positive prevention). Finally parents will be encouraged to have all their at-risk children tested through the Family Support Unit in the Department of Pediatrics (#9044). Informal links already exist but this activity is currently working on formalizing this link in order to obtain referrals of HIV-infected parents from the center as well.

This activity is also related to two targeted evaluations planned in FY 2007 with the Department of Medicine. One of which is screening all HIV positive individuals for Hepatitis B and C (HTXS UTH #9752) and the other is to evaluate simple dipstick tests for renal impairment in those who are positive (HTXS UTH Renal #9756).

The activities of the Department of Internal Medicine are part of the government-run tertiary referral and teaching hospital and all activities in this proposal are within the confines of the priorities of UTH. This system strives to establish a sustainable program through training health care workers, developing standard treatment protocols, strengthening the physical and equipment infrastructures, implementing facility-level quality assurance/quality improvement program, improving laboratory equipment and systems and development, and strengthening its health information systems. The hospital management will be able to cost share with the President's Emergency Plan for AIDS Relief funds by provision of some aspects of the program these include: staff time, supplies such as needles and syringes, specimen bottles and test kits, and supportive laboratory services. The benefit of this shared cost approach is that in the long-term UTH will only require minimal funding once staff is trained and systems are in place.

Related activities: This program is linked to the development and operation of a Pediatric and Family Center of Excellence (COE) for HIV/AIDS Care (#8993) at the Department of Pediatrics at UTH in Lusaka, the Family Support Unit (#9044) and child sexual abuse (#9043) programs.

The University Teaching Hospital has received funding from CDC through two co-operative agreements established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3). Though both agreements are managed by the central administrative office, the accounts are separate and the location of the two departments is physically separate . To communicate the importance of the breadth of activities and for purposes of coordination, the activities linked to the two departments have been submitted as separate narratives.

Routine opt-out HIV testing is gaining increasing support in many parts of the world today. The World Health Organization now recommends routinely offering an HIV test if antiretroviral (ARV) treatment is available, and the United States CDC has released new guidelines aimed at making HIV testing a routine part of American health care.

Botswana was the first African country to successfully introduce routine opt-out HIV testing in 2004. Integrating HIV testing into conventional health services in Botswana increased the testing uptake from 64% in 2004 to 83% in 2005.

The 2006 Zambia National Guidelines for HIV CT recommend routine opt-out testing for all clients seen in the clinical care setting where ARV treatment is available.

The UTH Department of Pediatrics, with direct support for CDC, embarked on a program to offer routine opt-out testing to all children admitted at the UTH and their care-givers in September 2005. Since the inception of this program in fiscal year (FY) 2005, the uptake for routine testing has been over 50%. In FY 2007, the department will strengthen the uptake to at least 80 - 90%, but also extend coverage to the Livingstone General Hospital in Southern Province of Zambia where a second Pediatric and Family Center of Excellence is planned with the President's Emergency Plan for AIDS Relief (PEPFAR) funding.

The funding requested for this activity will be used to train health workers in the provision of opt-out counseling and testing services, identifying and rehabilitating appropriate space for counseling, purchase of back up supplies and reagents, and strengthening referral systems from the referral hospitals to local clinics. Initiating the program in Livingstone will require some initial start-up costs that will increase the cost per person receiving CT services.

The activities of the Department of Pediatrics and Livingstone General Hospital are part of the government-run tertiary referral and teaching hospital. All activities in this proposal are within the confines of the priorities of the two tertiary hospitals that strive to establish a sustainable program by training health care workers, developing standard treatment protocols, strengthening physical and equipment infrastructures, implementation facility-level quality assurance/quality improvement program, improving laboratory equipment and systems and development, and strengthening health information systems. The UTH management will be able to cost share with PEPFAR funds by provision of some aspects of the program, these include: staff time, supplies such as needles and syringes, specimen bottles and test kits and supportive laboratory services. The benefit of this shared cost is that in the long run, sustainability requires minimal funding once staff is trained and systems are in place.

Related activities: EPHO HVCT (#9005), SoPHO HVCT, (#9018), and WPHO HVCT (#9047).

The University Teaching Hospital has received funding from CDC through two co-operative agreements established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3). Though both agreements are managed by the central administrative office, the accounts are separate and the location of the two departments is physically separate . To communicate the importance of the breadth of activities and for purposes of coordination, the activities linked to the two departments have been submitted as separate narratives.

The ZVCT program is a Ministry of Health (MOH) initiative started in 1999 with the support from Norwegian Agency for Development (NORAD). It is also supported through the National HIV/AIDS Council (NAC). From an initial 22 sites, the program has expanded to have 550 sites throughout the country. This includes government and non-governmental organization (NGO) run centers. Through support from United States Agency for International Development (USAID), the ZVCT program has developed a voluntary counseling and testing (VCT) and preventing mother to child transmission (PMTCT) information system that is currently being used by all VCT service providers throughout the country. The program has recently attained national status and is integrated with the PMTCT program. In conjunction with NAC and through the VCT technical working group, Zambia VCT services has developed a revised HIV testing algorithm. This is in an effort to make HIV testing standard and accessible throughout the country with the most practical non-cold chain dependent rapid tests. All test kits for the counseling and testing (CT) programs are purchased through John Snow International (JSI) Deliver and other logistics for testing are supported through Japanese International Cooperation Agency (JICA).

In spite of all these achievements, the services have not yet reached many of the rural areas. VCT services are by and large urban concentrated. It is against this back drop, that the MOH and NAC through the ZVCT program would like to take the VCT services to the most rural parts of Zambia.

The ZVCT has the experience and technical knowledge of conducting CT trainings and continues to provide support to trainings conducted in Lusaka and other urban areas (will work closely with UTH Department of medicine in trainings in CT, activity HVCT UTH). However the program lacks capacity to increase coverage to rural areas due to financial constraints including lack of viable and reliable transport. The two operational vehicles purchased in 2000 have outlived their expected use with extensive use for national level coverage in all the 72 districts of Zambia.

As part of this expansion program and in an effort to provide a comprehensive and accessible VCT service to the majority of Zambians, including those in rural areas, the following needs have been identified for support from the President's Emergency Plan for AIDS Relief funds in fiscal year (FY) 2007: 1. Purchase of two vehicles 2. Technical visits to all the District Health Management Teams of the 72 districts of Zambia in order to consult and select practical centers to establish as VCT sites (four rural sites per district) 3. Hold meetings with the local leaders in the districts in order to sensitize, mobilize, and get community buy-in from the outset 4. Conduct trainings and refresher courses to would-be service providers in each district using National standards and protocols in conjunction with the Provincial Health Offices 5. Strengthen HIV testing and quality control in all testing centers, current and new, for VCT and PMTCT programs 6. Monitoring and evaluation activities 7. Procure locally appropriate information, education and communication materials

The Zambia VCT program is part of the government initiative under the MOH and works within the confines of government health facilities. It strives to establish a sustainable program, through training of health care workers, developing standard testing protocols, strengthening physical and equipment infrastructures, implementing facility level quality assurance/quality improvement program, improving laboratory equipment and systems and development, and strengthening health information systems.

This activity relates to Columbia University (#8993) and #9016.

Since fiscal year (FY) 2005, the United States Government (USG) has provided limited support to the Department of Pediatrics at the UTH to strengthen activities developed for the management and monitoring of cases of child sexual abuse. These activities included training of health care workers in the recognition and care of child sexual abuse, the provision of post exposure prophylaxis and antiretroviral therapy, development of a monitoring system, and a follow-up program for reported cases. Other activities include strengthening links between the Department of Pediatrics and the Zambia Society for Child Abuse and Neglect, development of activities to increase community awareness of child sexual abuse, and the provision of psychosocial support to sexually abused children and their families.

In the first year of operation, the integrated CSA program at University Teaching Hospital (UTH) in the capital Lusaka has attended to 1,009 cases of child sexual abuse (this includes defiled children below the age of 15 and rape cases of those above 15). Of these, 123 were started on post-exposure prophylaxis (PEP) for HIV. All children testing positive for pregnancy are referred appropriately for PMTCT intervention and those that test HIV positive at first contact are referred to the pediatric ARV program.

Child sexual abuse (CSA) has received increasing media attention since September 2003 in Zambia, when a young 11 year old girl died in the UTH in Lusaka as a result of complications of multiple sexually transmitted diseases contracted after she was raped by her step-brother. Cases of child sexual abuse are on the rise, though many cases remain unrecognized or underreported. The perpetrators are often relatives of the victim, neighbors or close friends, and often only those that develop complications like physical trauma or STI's reach the health service. One case of child sexual abuse is reported every day in Zambia and it is estimated that for every reported case there are at least ten others not reported (press release Sept 2003). One in five sexual abuse cases involve young children. Increasingly girls less than 15 years of age are testing positive for HIV which contributes to the higher prevalence of HIV among women.

Factors that contribute to the practice of CSA in the population include: misconceptions that sex with virgins will cure AIDS, or that young girls are HIV negative; traditional sexual cleansing practice with young girls; poor law enforcement strategies; lack of awareness and knowledge in the communities about victims' rights and appropriate action to take.

Funding for FY 2006 supports a continuation of current activities as well as expansion of similar services to Livingstone Hospital in Southern Province.

In FY 2007, funds are being requested to continue current activities, strengthen and integrate networks with the law-enforcement agents and other non-governmental organizations working in the area of CSA. The other proposed activities are an extension of services to a third site at Kitwe Central Hospital in the Copperbelt Province and to intensify community sensitizations to ensure early referral of cases to the hospital as well as to strengthen post exposure prophylaxis and follow-up of abused children.

All the CSA sites are being established within the government health care setting. This will ensure long-term sustainability through staff training, systems development for quality assurance, monitoring, and referrals.

Related activities: This is activity is linked to UTH CT (#9042), EGPAF HTXS (#9000), JHPIEGO HTXS (#9033), Columbia HTXS (#8993), and new UTH - DCT (#9716), ZVCT (#9718), and Renal (#9756).

The University Teaching Hospital (UTH) has received funding from CDC through two co-operative agreements established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3). Though both agreements are managed by the central administrative office, the accounts are separate and the location of the two departments is physically separate. To communicate the importance of the breadth of activities and for purposes of coordination, the activities linked to the two departments have been submitted as separate narratives.

The UTH antiretroviral therapy (ART) program, which started as a pilot in 2002 with only 90 patients has grown into a well organized, multidisciplinary project with over 4,500 patients on ART. Through vigorous training programs, over 300 nurses, 160 doctors, and 30 clinical officers have been trained and are now instrumental in the training programs nationally. The hospital has established close links with the activities of other stakeholders such as CIDRZ, CRS, and JHPIEGO. A referral system has been developed with other hospitals nationally and the Lusaka urban health centers where stable patients on ART are referred to receive care at the community level. As the program matures, the number of complications and treatment failures have also increased creating a strong need to have a state of the art facility to deal with these challenges. A new Center of Excellence with the specific purposes of enhancing the gains we have had so far while conducting research is being built under the Department of Medicine. This center will improve the collaborations with other institutions as well as improving the understanding of care of HIV patients and ensuring sustainability of the program. The UTH is best suited for the proposed public health evaluation (PHE) for it has a well trained multidisciplinary team and support services such as radiology, pathology, and virology. The results of the PHE will ultimately lead to improved patient care and treatment outcomes.

This activity funding will be used to determine the prevalence of hepatitis B and hepatitis C virus infections in HIV-infected patients on antiretroviral (ARV) treatment in Lusaka, Zambia. Approximately 64, 000 individuals out of a total targeted population of 200,000 in Zambia are on ART. Liver dysfunction is a common side-effect of ART and severe hepatotoxicity is more common in patients with co-infection with viral hepatitis (Becker 2004). Hence, it is mandatory that patients with pre-existing liver disease receive these drugs only under strict monitoring (Sulkowski 2002, 2004).

Despite the rapid roll-out of ARVs in Zambia the prevalence of hepatitis B and C in high-risk individuals (especially HIV positive individuals) has not been documented. According to the Zambian National Blood Transfusion Services (ZNBTS) the hepatitis B and C prevalence is approximately 7% in low risk individuals. Consequently, potentially vulnerable individuals who could develop hepatotoxicity or do poorly on ARVs have not been identified. Knowing the prevalence of hepatitis B and C infections could influence the choice of ARVs which could ultimately, affect policies regarding procurement of ARVs.

This activity will involve performance of hepatitis B and C antibody and antigen testing as well as baseline and periodic monitoring for liver and kidney function tests. The objectives of this activity are to: 1) to establish the prevalence of co-morbidity of HIV and hepatitis B and/or C virus in Lusaka, Zambia; 2) to determine risk factors for hepatitis B and C co-infections in a Zambian cohort of HIV positive patients on ARVs; and 3) to ascertain the risk of drug-induced hepatitis in patients taking ARVs with co-morbid hepatitis B and C virus infections in Lusaka, Zambia. Participants are those patients who are currently enrolled on the Government of the Republic of Zambia ARV program at the UTH. Currently 4,000 adults are enrolled with an average of 100 new individuals evaluated every month. Therefore an estimated 5,000 adults will be enrolled by the time the project is underway in the 1st quarter of 2007. The timeline will be one year to allow adequate follow-up of the cohort by UTH.

Before coming in for review, all patients will have a supplementary sample of blood taken (in addition to the usual safety and monitoring labs) to test for hepatitis B & C. Arrangements will be made with ZNBTS to do the tests at UTH Zambia National Blood Bank which already has facilities to screen donated blood and is supported directly by the

President's Emergency Plan for AIDS Relief (PEPFAR) (#9049).

In addition, a questionnaire after consenting will be administered to determine risk factors for acquiring the infection as well as co-morbid conditions for developing hepatitis and chronic liver disease. There won't be an extra cost to the participant as they would already be coming in for their clinical reviews.

The activities of the Department of Internal Medicine are part of the government-run tertiary referral and teaching hospital and all activities in this proposal are within the confines of the priorities of UTH. This system strives to establish a sustainable program through training of health care workers, developing of standard treatment protocols, strengthening of the physical and equipment infrastructures, implementing facility-level quality assurance/quality improvement program, improving laboratory equipment and systems and development, and strengthening of its' health information systems. The hospital management will be able to cost share with the PEPFAR funds by provision of some aspects of the program; these include: staff time, supplies such as needles and syringes, specimen bottles and test kits, and supportive laboratory services. The benefit of this shared cost approach is that in the long-term UTH will only require minimal funding once staff is trained and systems are in place.

This activity is linked to UTH CT (#9042), EGPAF HTXS (#9000), JHPIEGO HTXS (#9033), Columbia HTXS (#8993), UTH DCT, UTH ZVCT, UTH Hepatitis B and C.

The University Teaching Hospital (UTH) has received funding from CDC through two co-operative agreements established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3). Though both agreements are managed by the central administrative office, the accounts are separate and the location of the two departments is physically separate. To communicate the importance of the breadth of activities and for purposes of coordination, the activities linked to the two departments have been submitted as separate narratives.

This activity will consist of a cross-sectional hospital-based assessment to determine the prevalence of Chronic Kidney Disease (CKD) in a cohort of HIV positive individuals on antiretrovirals (ARVs) being followed-up by the UTH Clinic 5. The current cohort numbers are about 4,000 adults with an equal sex distribution and an average of 100 new patients enroll each month. Therefore, approximately 4,000 clients will be evaluated over a time period of one year (this is to cater for the stable patients who are on biannual reviews).

The UTH ART program, which started as a pilot in 2002 with only 90 patients has since grown into a well-organized, multidisciplinary project with over 4,500 patients on ART. Through a vigorous training program, over 300 nurses, 160, and 30 clinical officers have been trained and are now instrumental in the training programs nationally. The hospital has established close links with the activities of other stakeholders such as CIDRZ, CRS and JHPIEGO. A referral system has been developed with other hospitals nationally and the Lusaka urban health centers where stable patients on ART have been referred to receive care at community level. As the program matures, the number of complications and treatment failures has also increased and there is therefore a strong need to have a state-of-the-art facility to deal with these challenges. A new Center of Excellence with the specific purposes of enhancing the gains achieved so far while conducting research has been built under the Department of Medicine with support from the USG. This center will improve the collaborations with other institutions as well as improving the understanding of care of HIV patients and ensuring sustainability of the program. The UTH is best suited for the proposed Public Health Evaluation for it has a well-trained, multidisciplinary team and support services such as radiology, pathology and virology.

A variety of renal disorders have been described in patients with HIV-infection. These abnormalities may be associated with HIV-infection itself, opportunistic infections, antiviral medications, or unrelated primary disorders. Proteinuria may serve as an early indicator of HIV-associated nephropathy (HIVAN). Autopsy data in adults with HIV-infection or AIDS have demonstrated a prevalence of HIVAN of between one and 15%. Other cases of CKD could be due to the use of herbal medications and imprudent use over the counter (OTC) drugs.

Presence of proteinuria may indicate renal disease even with a normal serum creatinine. Renal insufficiency is the asymptomatic stage of reduced renal function with serum creatinine elevated above normal. Patients with these abnormalities have a potentially serious renal disease that might progress to renal failure. Early detection and referral may prolong life of patients with dual burden of CKD and HIV.

Detecting proteinuria could help establish a diagnosis and predict the outcome of most renal diseases. Urinalysis specifically albustix could prove to be an important simple test for detecting early renal dysfunction in patients with HIV-infection on Highly Active Antiretroviral Therapy (HAART). Microalbuminuria could also be useful as an early sero-marker of systemic infection.

The frequency of CKD, its causes, and its natural history in Zambian HIV-infected adults has not been studied, particularly in the era of ARV medications. The primary aim of this study is to determine how common HIV-infected individuals have evidence of persistent proteinuria and CKD.

The objectives of this activity are 1) to describe the prevalence of renal pathologies in patients on HAART; 2) to examine the relationship between abnormal urinalysis and renal dysfunction; and 3) to determine possible predictors for abnormal renal function in HIV

positive patients on ARVs.

Participants will be screened with a first-morning macroscopic urinalysis for the detection of proteinuria. The effectiveness of albustix as a simple low cost tool for detecting early renal dysfunction in Zambian HIV positive adults will be evaluated. Equal number of patients with evidence of renal dysfunction (glomerular filtration rate (GFR)<60ml/min) and normal renal function will be compared. Further quarterly follow-up of patients with normal GFR but abnormal urinalysis (albustix) will be followed to determine if they develop overt renal dysfunction. These results if positive could then be recommended to the national ARV program.

The activities of the Department of Internal Medicine are part of the government run tertiary referral and teaching hospital and all activities in this proposal are within the confines of the priorities of University Teaching Hospital (UTH). This system strives to establish a sustainable program through training of health care workers, developing of standard treatment protocols, strengthening of the physical and equipment infrastructures, implementing facility level quality assurance/quality improvement program, improving laboratory equipment and systems and development, and strengthening of its' health information systems. The hospital management will be able to cost share with the President's Emergency Plan for AIDS Relief funds by provision of some aspects of the program these include: staff time, supplies like needles and syringes, specimen bottles and test kits, and supportive laboratory services. The benefit of this shared cost approach is that in the long-term UTH will only require minimal funding once staff is trained and systems are in place.

This activity relates to Columbia University COE (#8993), Micronutrient supplementation, FSU (#9044), CSA (#9043), VCT (#9717), and Lab (#9798).

The University Teaching Hospital (UTH) has received funding from CDC through two co-operative agreements established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3). Though both agreements are managed by the central administrative office, the accounts are separate and the location of the two departments is physically separate. To communicate the importance of the breadth of activities and for purposes of coordination, the activities linked to the two departments have been submitted as separate narratives.

This program was first funded in fiscal year (FY) 2005 through Columbia University, is supporting the development and operation of a Pediatric and Family Center of Excellence (COE) for HIV/AIDS care at the Department of Pediatrics at UTH in Lusaka.

In close collaboration with Columbia University and CDC, the primary goals of the center are to: 1) increase the number of children engaged in care and receiving antiretroviral therapy (ART); 2) develop a regional training center for multidisciplinary teams (MDT) in pediatric HIV/AIDS care and treatment and 3) be the prime referral site for children with advanced and complicated HIV/AIDS disease. The COE will provide state-of-the-art care and demonstrate best practices for infected and exposed children, which will be disseminated through off-and on-site training activities. In addition to providing on-site training to teams of providers, the COE will also support mobile training teams to train, supervise and support MDT initiating pediatric HIV care in neighboring provinces and districts. In-patient routine opt-out testing at the Department of Pediatrics will continue to be strengthened in order to identify HIV infected and exposed children who subsequently will be enrolled into care and treatment at the COE.

Emphasis in FY 2007 will focus on trainings to increase human capacity for infant diagnosis and the care and management of opportunistic infections. UTH is one of the first sites to initiate infant diagnostic testing as part of a national level scale-up using dried blood spots. An additional activity that UTH will carry out is improved management of children who are malnourished by developing and implementing a program that will provide micronutrient supplementation. Monitoring and evaluation systems for counseling, testing, infant diagnosis and care and treatment will be developed, piloted and implemented at UTH.

In FY 2007 an additional regional COE will be launched at Livingstone General Hospital and UTH will provide technical support to this center through trainings, capacity building, and system development, in close collaboration with Columbia University.

The activities of the Department of Pediatrics and Livingstone General Hospital are part of the government run tertiary referral and teaching hospitals and all activities in this proposal are within the confines of the priorities of the two tertiary hospitals that strive to establish a sustainable program, through training of health care workers, development of standard treatment protocols, strengthening of the physical and equipment infrastructures, implementation of a facility level quality assurance/quality improvement program, improved laboratory equipment and systems and development, and strengthening of the health information systems. The two referral hospitals will be able to cost share with the President's Emergency Plan for AIDS Relief funds by provision of some aspects of the program, these include: staff time, supplies such as needles and syringes, specimen bottles and test kits, and supportive laboratory services. The benefit of this shared cost is that in the long-run, sustainability requires minimal funding once staff is trained and systems are in place.

Funding through this activity will also support the linking up and establishment of a referral system with the Lusaka District Health Centres of complicated cases to the specialist UTH PCOE and the down referral of stable children to the respective nearby centres providing pediatric ART services. Another activity will be to work closely at the community level and follow up on patients and address adherence issues through community links.

Rapid HIV laboratory testing provides evidenced-based information in prevention of mother to child (PMTCT) and voluntary counseling and testing (VCT) programs for both preventive care and treatment decisions. Recently the national algorithm for rapid HIV testing was adopted and an internal and external quality assurance plan was formulated by UTH for documentation and monitoring the quality in PMTCT and VCT programs throughout the country. Rapid HIV training will be customized for Zambia's national algorithm based on the recently published World Health Organization/CDC quality system guidelines. The UTH serves as the national reference laboratory for HIV testing. The quality assurance program will involve training on the newly changed rapid HIV algorithm for both technical and non-technical laboratory persons in PMTCT and VCT programs throughout Zambia. This activity will be supported by four new provincial health office activities listed in the PHO narratives to conduct quality assurance at the district level within Southern, Eastern, Lusaka and Western provinces. Because UTH serves as the national reference laboratory for HIV testing, guidance to the other five provinces with the support of other laboratory partners working at the provincial and districts will also be provided as resources are available.

Technical support to UTH, equipment, transport and supplies for both internal and external quality assurance will be provided to implement and assess the quality of rapid and confirmatory HIV testing services in PMTCT and VCT programs. This activity will be performed by taking quality control samples to confirm the accuracy of the test kits and the competency of testing personnel. Additionally, random statistical samples of the tests performed will be periodically rechecked to ensure accuracy of results reported in selected PMTCT and VCT programs. Feedback and onsite training will be provided when problems are detected. Ensuring the accuracy of HIV testing results is imperative to the success of diagnostic, prevention and surveillance programs.

Funding within this activity also supports the national TB program with External Quality Assurance TB Smear Microscopy which was previously supported by JICA. Responsibilities include: providing onsite supervisory support, training, panel testing of staff and random sample rechecking of smears for the laboratories performing AFB smear micrscopy in Lusaka Province. These will include both public and private labs /clinics.

Narrative Changes: In FY07, a plus up request ($250,000) and a reprogramming request ($52,000) are requested for this activity; the total amount requested for this activity is $6,502,000. Lusaka, as the capital and the largest city in Zambia has 1.5 million people and an HIV prevalence of 22%. In Lusaka alone approximately 260,000 people are HIV infected with 56,000 requiring immediate ART access and 28,000 new patients become eligible for ART each year. As a result of this large concentration of patients the growth in HIV care programs in Lusaka has been rapid and massive. As of March 2007, in Lusaka alone, there were 100,000 patients enrolled in HIV care and 33,000 patients on antiretroviral therapy. We anticipate the need for HIV care will continue to expand for the next several years. In the early stages of antiretroviral therapy roll-out in Lusaka, CIDRZ collaborated with the MOH to improve district clinic infrastructure to provide, pharmacy, chart storage facilities, counseling and clinical rooms. However as a result of the rapid increase in numbers the existing facilities in many clinics are now overwhelmed and lacking space to provide privacy, clinical care, and support needs (pharmacy, lab, and data) required to provide quality HIV care. CIDRZ continues to expand floor space in a number of clinics; for example renovations are ongoing at Matero Ref (6800 patients enrolled), Kanyama (9076 patients enrolled) and Kalingalinga (4892 patients enrolled) but there is also the need in many other clinics for expansion. We propose to expand existing clinic infrastructure in at least 5 ART sites in Lusaka including Kanyama West, Chainama, Chazanga, Matero Ref and Chelstone. This urgently needed space will allow programs to grow while at the same time maintaining quality of patient care. Additional funding is being provided to support TB laboratory infrastructure in providing air conditionors for the microbiology lab to maintain cool temperature in the laboratory and equipment operation. The funds will also be used to provide maintenance of Biosafety cabinets and reagents for TB culture, identification and drug susceptibility testing.