This activity relates to activities in MTCT (#9002).

In an effort to support the Zambia national framework and build capacity of the national system to provide sustainable HIV/AIDS services, the United States Government through CDC aims to provide direct support to Western Provincial Health Office (WPHO) to build its capacity to coordinate and oversee prevention of mother to child transmission of HIV (PMTCT) services in the province, provide training, and expand PMTCT trainings to health centers currently not covered by Center for Infectious Disease Research Zambia (CIDRZ). CIDRZ will continue to provide PMTCT services in districts where they currently work but with the coordination and leadership of the WPHO to ensure uniformity and standardization to the PMTCT services being provided in the province. In order to create a sustainable PMTCT program, the PHO will take a key role in ensuring that supportive supervision is provided to these districts and will coordinate all PMTCT services and implementing partners (CIDRZ) to ensure maximal resource utilization.

Western Province has seven districts of which four currently have PMTCT services provided through CIDRZ. The sites that provide PMTCT also provide antiretroviral (ART), tuberculosis (TB), and palliative care services to which the women are referred. As of March 2006, CIDRZ and JPHIEGO had trained 22 health care providers in the minimum package of PMTCT services and supported 33 PMTCT sites.

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

In FY 2007, in joint collaboration with CIDRZ, the WPHO will spearhead the scale-up of PMTCT services in Western Province in line with the national expansion plan. This support will enable key technical staff from WPHO to coordinate, plan, and integrate services with CIDRZ. In addition, other activities will include expanding and linking PMTCT services with other HIV services in target districts throughout the province. This will be achieved through the mapping of services during the services performance audits led by the PHO every quarter.

Direct funding for PMTCT service delivery and technical assistance at the provincial level will complement and enhance referrals to other services like ART, TB/HIV and palliative care.

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

This activity is linked with the other activities for the Western Province Health Office including counseling and testing (#9047) and the CDC new activity for WPHO in ARV services (#9769).

Mongu District in Western Province has a very high HIV prevalence of 28.2% and syphilis prevalence of 11.7% (Antenatal Clinic ANC Sentinel Surveillance, 2004) among pregnant women aged 15-44 years. Adolescents contribute considerably to the high prevalence and 17.0% of women in Mongu aged 15-19 years were found HIV positive during the 2004 ANC sentinel surveillance. To serve the youth better in Mongu district, the concept of Youth Friendly Corner services is an important component. This is where a room at a health facility is reserved specifically and conveniently for adolescent peer educators and trained service providers in which youth friendly services are provided to adolescents.

Youth Friendly Corners act as the entry and exit points for all youth clients presenting with STIs, HIV, or TB infection, and for those wanting to discuss reproductive health issues. This activity will support the Youth Friendly Corner program of Mongu district through the Provincial Health Office (PHO) in FY 2007. The support will be utilized to strengthen the eight existing sites and allow expansion to ten additional sites. Here, youth friendly services will be offered as well as on sensitization and behavior change sessions in high-risk areas and during events.

Some of the activities planned and implemented in these corners are: Peer education, which involves community sensitization through drama, group meetings and the peer counseling activities which includes one to one counseling and referring appropriate clients to trained health workers for further management. The corners also provide an opportunity for dissemination of condoms to sexually active mature youth when appropriate. In FY 2007, eight targeted condom outlets will be established to provide condoms for at-risk youth. To achieve quality results in these corners, trained health personnel with a sincere desire to work with youth are posted nearby to the site to provide knowledge, skills, and guidance to the youth. Youth who express interest in being tested for HIV are referred to the nearest clinic where they can receive counseling and testing for HIV.

The district has thirty health facilities and only eight of these currently offer youth friendly services. The main challenges that have been experienced in the implementation and expansion of services in the district are: 1) inadequate funds to run the services and 2) lack of transport to coordinate the activities at both the district and health centre levels resulting in these services being confined to urban and peri-urban areas only. There is also poor and inadequate building infrastructure at health facility levels to accommodate the health services. There is also a lack of knowledge among youth and to some extent health facility staff about the services available, which also contributes to sub-optimal provision of youth friendly services.

Special reproductive health services focusing on youth is a key activity to reduce STI and HIV transmission among adolescents. Mongu district has started prevention and counseling and testing programs for this age group. In collaboration with Adolescent Reproductive Health Advocates (ARHA), the District Health Management Team (DHMT) has set up several Youth Friendly Corners in eight of the thirty urban and peri-urban health centers. Mongu DHMT will strengthen the Youth Friendly Corner services as well as expand the concept to ten additional health centers. By the end of FY 2007, eighten of the thirty health centers in Mongu district will have established Youth Friendly Corners. To achieve this, the district will need to address the transportation problem to facilitate the coordination. There is also a need to build capacity among the youth and health care workers in appropriate services, to renovate existing spaces, and to procure furniture for the youth services at health centers. Another key activity is the production of information, education, and communication materials to be used for advocacy and education among the youths and the communities.

The program relies heavily on volunteers and the turn-over rate is high as the trained youth go for further training or become employed full-time. To ensure adequate numbers of peer counselors and peer educators, ongoing training of new peer counselors and educators is required. In FY 2007, forty individuals will be trained to provide HIV/AIDS prevention programs that are not exclusively focused on abstinence and/or being faithful.

An important component of the Youth Friendly Corner approach is conducting sensitization sessions within certain high-risk communities. The success in use of non-monetary incentives to reduce turn-over of volunteers will be assessed. In FY 2007, 1,500 individuals will be reached through community outreach HIV/AIDS prevention programs that are not focused exclusively on abstinence and/or being faithful.

To ensure sustainability, the Government of the Republic of Zambia through the DHMT and health centers will include the youth friendly services in the annual health plans. In the following years the PHO plans to scale up the Youth Friendly Corner approach to the other health centers in Mongu district and other districts in Western province.

This activity relates to activities in counseling and testing, laboratory infrastructure, palliative care: basic health support activity, and TBHV activities (#8992 and #9037).

Western Province is a predominately rural province with an HIV prevalence of 13.1% and a reported tuberculosis (TB) incidence rate of 481/100,000 in 2004. Outside the provincial capital of Mongu, which has an HIV prevalence of 22% and TB notification rate of 881/100,000 in 2004, access to health care facilities and services are limited. Many TB patients have to travel 20-25 km to the nearest health facility. External funding and support to this province has traditionally been low.

In FY 2006, the US Government (USG) provided funds directly to the Western Provincial Health Office (WPHO) to scale up TB/HIV activities in the province. Prior to applying for funds from the USG, TB/HIV activities were only taking place in 2 of the 7 districts in the province. Initial data from the two districts based on the HIV testing of TB patients, showed that the HIV seroprevalence rate in TB patients was 70%. Yet only 50% of the TB patients received counseling and testing in the 5 existing sites in the 2 districts. Recent data (second quarter 2006) from the province indicates that HIV screening of TB patients is taking place in 5 districts though the coverage ranges from 12% to 50% of all TB patients notified. The funding provided in FY 2006 will enable the province to expand the number of sites providing TB/HIV services to 20 covering 6 districts and train 110 health workers in TB/HIV collaborative activities by the end of the budget period. This expansion will enable up to 900 people living with HIV to receive palliative care, including treatment for TB, and result in TB screening for up to 1000 HIV infected individuals in 6 districts. The Provincial Health Team, which includes the Clinical Care Specialist assigned by HSSP and a Field Office Manager to be appointed by CDC, will implement the programs and ensure that all activities are in line with the National strategic Health Plan and the 5-year PEPFAR strategy.

In FY 2007, the Provincial Health Office will be funded to expand and support the TB/HIV integration activities in all 7 districts in the Western Province; Mongu, Senanga, Kalabo, Sesheke, Kaoma, Lukulu, and Shangombo. The funding will enable the province to increase TB/HIV services to an additional 20 sites, bringing the total number of site in the province to 40. The PHO will support the formation of a Provincial TB/HIV Coordinating Committee that will be tasked with the strategic direction and supervision of the TB/HIV integration activities throughout the province. Membership on this committee will include representation from the TB Program, Clinical Care Unit (which oversees HIV/AIDS care), the ART Programs, community care and advocacy groups, and HIV counseling/testing partners. Committee meetings will be held on a quarterly basis. An assessment of the existing infrastructure will be carried out to identify sites that require minor renovations and refurbishment in order to ensure the availability of appropriate infrastructure to provide the counseling and testing for TB patients.

Limited human resources, coupled with an expected increase in patient-load as a result of TB/HIV integration, are barriers to implementing and maintaining TB/HIV integration. This human resource shortage negatively impacts morale, supervision, and technical support and is compounded in the more rural districts, where retention of staff is always difficult. To address this, the PHO will recruit staff in remote health centers in three districts to ensure availability of counseling and testing for TB patients. Future support may be identified for TB/HIV coordinators to be placed at the district levels, particularly those identified to have a high TB/HIV burden.

In order to ensure that all health workers providing care and treatment to TB patients have the necessary skills to offer counseling and testing for HIV, a training of trainers' model currently being implemented in other provinces will be adopted and implemented. The training will be based on the national Diagnostic Counseling and Testing (DCT) manual adapted by JHPIEGO with support from the USG in FY 2006. A core group of trainers was trained in the province in FY 2006 through CDC support to JHPIEGO (see activity 9032). These trainers will be used by the PHO to provide training in 4 districts to 96 health care workers. The training will also include TB/HIV integration and management of TB, HIV and TB/HIV patients. In addition, two staff from each of four districts will be trained in TB microscopy in order to enhance the diagnosis of TB in HIV positive individuals. In addition light microscopes will be purchased for health centers.

An additional activity to be funded through this mechanism will be strengthening the referral links between the TB and HIV treatment program to ensure that all HIV infected TB patients receive the appropriate treatment. This will link to the support provided by the USG to the PHO for counseling and testing (#9047), ART (ref #9769) and laboratory support and for ARV services through CIDRZ (activity #9000). Additional links will be developed with USG partners (see activity #9180, #8946) and other partners providing basic health care and support in a palliative care setting in the province. The direct support provided to the PHO to coordinate all TB/HIV services in the province, supervise the activities, and increase its capacity to also provide the services in the province will ensure sustainability of the program.

All activities and trainings will be linked by the PHO with activities that are supported by recent district-level funding from the Global Fund against TB, HIV, and Malaria (GFATM). The GFATM has directly funded these districts to scale up TB control by strengthening the directly observed treatment strategy (DOTS) and TB/HIV integration and care. Technical support and guidance for the use of this funding will be provided by the PHO. Due to the limited access to health care facilities and limited availability of facility-based health-care staff in Western Province, special emphasis will be placed on the use of community volunteers to provide TB/HIV integrated care. To foster standardization and sustainability of the integration of TB/HIV services as part of the PHO's integral of health services, CIDRZ will work closely with the PHO to provide technical assistance to build their capacity to be able to effectively implement, manage, report, and scale up services in all the districts.

As a result of this support, each year, of an estimated 3000 TB patients in the 7 districts, 80% (2400) will receive counseling and testing over 12 months. With an estimated 70% HIV prevalence in TB patients this will result in 1772 HIV infected individuals receiving treatment for TB. Those found to be co-infected with TB/HIV will be referred for appropriate HIV care, including ART.

Links between the TB programs and other USG funded home based care programs will be established in order to ensure a continuum of care for the HIV infected TB patient. Regular review meetings will be linked to TB DOTS review meetings and co-funded by the Global Fund supported TB DOTS program.

In FY07, a plus up request ($40,000) and a reprogramming request ($50,000) are requested for this activity; the total amount requested for this activity is $240,000.

Related activities: This activity is linked to WPHO HTXS (#9769), WPHO HVTB (#9046), HVCT Mobile TBD (#9742)

Western Province has 11 hospitals and 136 rural health centers. The vastness of the province, geographic terrain (rivers, valleys, and flood plains), and low population density create a great challenge to make services accessible to the population.

In Western Province, the estimated HIV prevalence rate among adults aged 15-49 years is 13.1%. The provincial tuberculosis (TB) notification rate in 2004 was 486/100,000 of the population. The prevalence rate for syphilis among adults is estimated to be 23.1/1000, which is higher than the national average of 14.2/1000.

Expansion of counseling and testing (CT) services for HIV is a key activity that will help achieve the goals of the President's Emergency Plan for AIDS Relief by identifying individuals at high-risk of being infected and linking them to care services such as PMTCT and antiretroviral therapy (ART). The districts in Western Province have already received support from the Global Fund to implement some activities in VCT.

In Fiscal Year (FY) 2006, the United States Government (USG) provided direct support to the Western Province Health Office (WPHO) to scale-up on both TB/HIV (#9046) and CT activities. Funding was made available in September 2006 and by the end of the budget period the WPHO will have trained both health workers and non-professional health staff such as Classified Daily employees (CDE), community health workers (CHW) and trained traditional birth attendants (TTBA) in counseling and testing using the national training manuals and in conjunction with Kara Counseling and Trust.

In FY 2007, the USG will support the WPHO to provide CT in the routine care of patients with TB and sexually transmitted infections (STIs), and development of linkages with the ART and PMTCT services (WPHO HTXS #9769, WPHO HLAB #9799) in the seven districts in the Western Province: Mongu, Kalabo, Senanga, Sesheke, Lukulu, Shangombo, and Kaoma. To accomplish this, the WPHO will provide regular supportive supervision to the sites. Each of the districts will identify five health care workers who will be trained in HIV counseling and rapid testing using standardized guidelines and protocols. This training of health care workers will result in the CT of HIV for a total of 6,400 individuals (voluntary counseling and testing as well as diagnostic counseling and testing for chronically ill patients). The training will also strengthen the linkages between the CT services and the STI, TB, and ART program to ensure that HIV positive patients are screened for both TB and STIs. Emphasis during training will also be made on prevention of HIV transmission among those who test positive and issues around disclosure and discordance. It is expected that 60% of all clients testing HIV positive will receive screening for TB.

Documentation of counseling activities will be done in standardized registers at each health facility and referral to care. To account for human resource shortages and to extend HIV counseling services beyond the health facility, a total of 20 community members in two remote districts (Lukulu and Kalabo) will be trained to conduct HIV counseling at the community level and refer clients to health facilities for additional CT needs. This will result in 2000 people receiving HIV CT. A recording and reporting system to document counseling activities at the community level will be established within the district reporting system. Supervision of these counselors will be provided by the District Counseling Coordinators. In order to enhance the ability of the District Coordinators to support and supervise the community counselors, two motorbikes will be provided for Lukulu and Kalabo districts. Logistics such as HIV test kits will be supported by USG through the Central Medical Stores. This activity will link with the proposal to provide mobile and boat VCT through TBD in the districts of Lukulu, Kalabo and Shangombo.

The districts will hold monthly meetings with organizations and community-based groups implementing CT activities to report on findings, share experiences, and to identify weaknesses. The Government of the Republic of Zambia structures at national, provincial, district, and community levels will ensure sustainability of the program. These activities are planned by the various districts in their action plans. Emphasis on training and incorporation of counseling and testing in all service delivery points empowers staff and ensures long term sustainability. It is hoped that Global Fund money will also be able to support these activities in future years.

The Western Province of Zambia has an HIV sero-prevalence of 13.1% in the general population of between 15-49 years (DHS 2002). The province consists of savannah woodlands in sandy plateau and plains, traversed by the Zambezi River. Deep sandy terrain and flood plains make communication and food production extremely difficult. Most areas of the province can only be reached by 4x4 vehicles all year round and some only by canoes and speed boats in the rainy season making the logistics of service delivery challenging and the cost much higher than most provinces in Zambia. The province has 11 hospitals and 134 rural health centers. The vastness of the province and low population density makes it difficult to make services easily accessible to the population, which is compounded by low staffing levels and insufficient infrastructure. Lukulu and Kalabo districts are especially limited in their efforts to scale-up HIV and tuberculosis (TB) related services due to staff shortages.

Based on the 13.1% prevalence and with a population of 871,030 the province has an estimated 114,389 HIV/AIDS cases in 2005. By the end of 2005 only 3,213 people living with HIV/AIDS were receiving antiretroviral therapy (ART). At present, the province has 10 ART sites. All districts have at least one site where ART services are offered. To make ART services more accessible to the population as well as to improve the quality of the services by decongesting some of the present ART sites, there is need to increase the number of ART sites in some of the districts.

The Western Provincial Health Office (WPHO) in fiscal year 2007 proposes to expand and consolidate the ART services working closely with Center for Infectious Disease Research in Zambia, Catholic Relief Services, and other partners providing care in the province. The WPHO will target this expansion in areas where the partners do not have a presence.

In order to expand and strengthen the availability of ART services in the province, the Provincial Health Office (PHO) will introduce ART sites in Shangombo, Senanga, Mongu, and Kaoma districts. This will entail training of health centers staff, using the government model of developing treatment teams in the health centers. The centers will be supervised by ART trained physicians from the provincial and district hospitals who will visit the center at least once a month. A referral system will be developed so that patients with complicated conditions or complications arising from ART that cannot be dealt with by the local staff are referred to centers with higher ART expertise. A mobile ART clinic will be established to provide antiretroviral services at a difficult to access rural health centre in the Lukulu district that is inaccessible for six months due to flooding in the plains. The health center is situated on the western side of the Zambezi River and the mobile ART clinic is expected to serve a population of over 20,000. The staff in the health centre will be trained in counseling, testing and care, including prevention of mother to child transmission, TB/HIV services, as well as ART.

A team from the hospital consisting of a physician, a nurse, one counselor, and one lab/pharmacy (alternating) and will start visiting Mitete an out post in Lukulu District four times a quarter - monthly and for one month fortnightly - only during the month of the fortnightly visit, will new patients start ART as they need to be reviewed after two weeks. During the floods they will use a boat provided by the District Health Office to visit the post. Extra staff will be recruited for Mitete to ensure adequate capacity at the health center to deal with the increased workload.

In order to improve the quality of service for ART and enhance adherence, the WPHO will train staff in ART/opportunistic infections management, adherence counseling, and ART data management. In addition, community members will be trained in home based care.

The involvement of the WPHO in expansion of ART services to the hard to reach areas will contribute towards coordination, standardization, sustainability, and equitable access to ART in the Western Province of Zambia. In addition, funds will also be used for infrastructure renovations and enhancements, such as remodeling, painting and procurement of basic furniture for the existing ART sites in order to provide confidential service for the ART patients.

This activity is linked to WPHO ART, PMTCT, #9046, and #9047.

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

Western Province is a predominately rural province with an HIV prevalence of 13.1%. The deep sandy terrain of this area, the poor road network, and the lack of public transport systems leave only one option for the majority of the people who walk to the nearest health facility. Access to health care facilities and services are limited, with an estimated 40% of the population living more than 12 kilometers from the nearest health facility.

Availability of laboratory services in most of the districts is limited due to several factors which include technical human resources, lack of suitable infrastructure and services such as a electricity, geography, and increasing numbers of persons participating in prevention of mother to child (PMTCT) and voluntary counseling and testing (VCT) programs at local levels. Antiretroviral laboratory care and treatment services are limited. Sample preparation and transport support can alleviate the lack of services due to laboratory infrastructure and technical limitations. In FY 2007 onsite training and technical support for existing personnel in basic laboratory testing and transport will be assessed and provided. Laboratory quality assurance programs for rapid HIV testing currently performed in the VCT and PMTCT will be supervised and supported by the national HIV reference laboratory. An integrated program to include laboratory data management and onsite quality assurance will assist in improving and equalizing antiretroviral laboratory services to people living with AIDS in these areas. Support will be provided for basic infrastructure improvements and the provision of alternate sources of power such as solar panels at all laboratories currently lacking this infrastructure. This activity will support the UTH national quality assurance program within the districts of this province to sustain quality services and build staff capacity.

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

Western Province is a remote and scarcely populated province (population density: roughly seven people per sq kilometer; surface: 126,386 sq kilometers). The province consists of savannah woodlands on sandy plateau and plains, traversed by the Zambezi River, which divides the Province into East and West. Deep sandy terrain and flood plains makes communication and transport extremely difficult. Especially Kalabo, Lukulu, and Shangombo district are affected by the terrain and are very isolated.

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