This work is closely linked to JHPIEGO's other work with the Zambia Defense Force (ZDF), strengthening integrated HIV prevention, care, and treatment services and systems (#9087, #9089, #9090, #9091), and with the work of Project Concern International (PCI) supporting Counseling and Testing (CT) (#8785) and Palliative Care (#8787), as well as JHPIEGO's work on integrating diagnostic CT into TB and STI services for mobile populations (#9035).

JHPIEGO is supporting the ZDF to improve overall clinical prevention, care, and treatment services throughout the three branches of military service, Zambia Army, Zambia Air Force and Zambia National Service around the country. The overall aim of the activity is to ensure that the ZDF is equipped and enabled to provide quality HIV/AIDS services to all its personnel, as well as to the civilian personnel who access their health system. This includes strengthening the management and planning systems to support PMTCT and HIV/AIDS care and treatment services, with the appropriate integration, linkages, referrals, and safeguards to minimize medical transmission of HIV. JHPIEGO, as an important partner to the Ministry of Health (MOH) HIV/AIDS PMTCT, ART, palliative care, HIV-TB and injection safety programs, supports the ZDF in gaining access to materials, systems, and commodities funded by the U.S. Government, other donors, and numerous technical partners who work with the MOH, and to harmonize services and maximize efficiencies between ZDF and MOH facilities and programs.

The Defense Force Medical Services (DFMS) supports health facilities at 54 of the 68 ZDF sites with the remaining sites relying on Medical Assistants and outreach support. These health services are spread out, many in hard-to-reach areas, around the country, and serve both ZDF and local civilian populations. In addition, given the mobile nature of the ZDF, it is often the first responder to medical emergencies and disasters throughout the country. Unfortunately, the ZDF has not benefited from many initiatives that have been on-going in the MOH public sector mainly because the ZDF has its own heath system running independently from the national one. While these links are improving, there are continued opportunities to improve harmonization and maximize the efficiency between the MOH and ZDF health services. While the number of patients within the ZDF receiving PMTCT services has expanded dramatically, the majority of services are provided at only a few outlets. The standardization of systems and services needs continued strengthening. Continued expansion requires support for remote sites, where services are needed most. But, by their very location and nature, the cost effectiveness of delivering services to them is reduced; this burden is compounded by the complexities of working with the ZDF and each of the three individual ZDF branches, each with their own authority and chain of command.

In FY 2005 and FY 2006, JHPIEGO and other cooperating partners such as PCI supported the ZDF in key facilities to provide higher quality, comprehensive HIV/AIDS prevention, care, and treatment services, integrating CT and PMTCT with HIV/AIDS care and support, and integrating HIV more strongly into sexually transmitted infections (STI) and tuberculosis (TB) services. The initial FY 2005 and FY 2006 sites are the model sites that have been the focus of implementing comprehensive HIV/AIDS care, treatment, and support services. In addition to the model sites, service providers from many of the other DFMS sites have been included in service provider training and have received supportive supervision visits at their sites.

During FY 2006, JHPIEGO played an integral part in reopening of the Maternal and Child Health department at Maina Soko Military Hospital (MSMH), which enabled them to begin providing PMTCT services. This department had been closed for the previous four years leaving a large gap in the services provided, given that MSMH is the only military referral hospital. Through JHPIEGO's support to the ZDF in FY 2005 and FY 2006, in addition to training PMTCT service providers and establishing quality PMTCT services at eight model facilities, the ZDFMS training capacity was strengthened with the training of 16 PMTCT staff as trainers. These trainers worked with JHPIEGO staff to co-train at least 187 service providers in PMTCT. The benefit of JHPIEGO support will not be limited to the model sites as staff from many other sites will be included in orientations and trainings. By the end of FY 2006 JHPIEGO was working with eight model sites in seven of the nine provinces of Zambia. The two remaining provinces will have model sites by the end of FY 2007.

In FY 2007, JHPIEGO will support quality integrated PMTCT services at 12 model ZDF

sites, including the eight sites developed in FY 2005 and FY 2006 and expanding to four additional sites: 1. Zambia Army, L85 Barracks in Lusaka, Lusaka Province; 2. Zambia National Service, Luamfumu Barracks in Mansa, Luapula Province; 3. Zambia Army, Luena Barracks in Kaoma, Western Province; and 4. Zambia Air Force, Mumbwa, Central Province.

Working with the ZDF, JHPIEGO will seek to create linkages with other collaborating partners to ensure a synergy of efforts, and reinforcing collaboration with the MOH by harmonizing ZDF programs with MOH/National HIV/AIDS/STI/TB Council guidelines, materials and tools, and strengthening the linkage between the ZDF and other PMTCT initiatives in the public sector. JHPIEGO will continue to expand facility-based performance improvement systems and maximize the benefit to ZDF from the model sites by working with ZDF central command and DFMS, as well as base commanders, to develop a system of staff rotation and on-the-job training. Further capacity to expand and support PMTCT services will be developed, as JHPIEGO will continue to select high performing PMTCT providers and develop them as trainers and mentors. JHPIEGO will co-teach PMTCT workshops with the DFMS trainers to help them improve their training skills and address any gaps.

Building on the service linkage developed between PMTCT and ART, JHPIEGO will integrate TB and palliative care services to provide integrated support for facility-based HIV/AIDS prevention, care, and treatment. As the result of this intervention, the health care workers will have a better understanding of the need to address HIV/AIDS clinical prevention, care, and treatment in a comprehensive way to ensure that clients receive complete, quality care. To support performance improvement systems, supervision visits will continue to the eight facilities, as well as the four expansion sites. JHPIEGO will also support the DFMS to conduct workshops using the orientation package for lay workers (e.g., managers, clergy, community leaders, and caregivers) on HIV/AIDS prevention, care, and treatment. The package covers CT, PMTCT, Care, and ART as well as linkages to other services such as TB and STIs, to educate the readers on HIV/AIDS and provide them with accurate and relevant information they can disseminate to more diverse populations. This will further enhance advocacy efforts to secure sustained support for these services from both the management as well as the community and client perspective.

To ensure sustainability, JHPIEGO works within the existing ZDF structures and plans. JHPIEGO facilitates the development and dissemination of appropriate standard guidelines, protocols, and plans. JHPIEGO also assists the ZDF with the implementation of a facility-level quality improvement program. The project's goal is to leave behind quality systems to ensure continuity of services after the program concludes.

This work is closely linked to JHPIEGO's other work with the Zambia Defense Force (ZDF), strengthening integrated HIV prevention, care, and treatment services (#9088, #9089, and #9090) and Systems Strengthening (#9087) activities in logistics and planning with the ZDF. It also relates to Project Concern International (PCI)'s support to ZDF in Counseling and Testing (CT) (#8785) and is closely coordinated with the USAID-funded Injection Safety program (#8876).

JHPIEGO is supporting the ZDF to improve overall clinical prevention, care, and treatment services throughout the three branches of military service, Zambia Army, Zambia Air Force and Zambia National Service around the country. The overall aim of the activity is to ensure that the ZDF is equipped and enabled to provide quality HIV/AIDS services to all its personnel, as well as to the civilian personnel who access their health system. This includes strengthening the management and planning systems to support PMTCT and HIV/AIDS care and treatment services, with the appropriate integration, linkages, referrals, and safeguards to minimize medical transmission of HIV. JHPIEGO, as an important partner to the Ministry of Health (MOH) HIV/AIDS PMTCT, ART, palliative care, HIV-TB and injection safety programs, supports the ZDF in gaining access to materials, systems, and commodities funded by the U.S. Government, other donors, and numerous technical partners who work with the MOH, and to harmonize services and maximize efficiencies between ZDF and MOH facilities and programs.

The Defense Force Medical Services (DFMS) supports health facilities at 54 of the 68 ZDF sites with the remaining sites relying on Medical Assistants and outreach support. These health services are spread out, many in hard-to-reach areas, around the country, and serve both ZDF and local civilian populations. In addition, given the mobile nature of the ZDF, it is often the first responder to medical emergencies and disasters throughout the country. Unfortunately, the ZDF has not benefited from many initiatives that have been on-going in the MOH public sector mainly because the ZDF has its own heath system running parallel to the national one. While these links are improving, there are continued opportunities to improve harmonization and maximize the efficiency between the MOH and ZDF health services.

The transmission of HIV through unsafe medical practices, while accounting for a small percentage of transmission, is largely preventable. The major areas of concern are injection safety (IS) practices, handling and processing of sharp instruments, and handling and disposal of medical waste. Infection prevention (IP) practices in Zambia are generally weak, and Zambia continues to face the challenge of lack of application of standard IP procedures. The availability of Post Exposure Prophylaxis (PEP) for those who have a potential exposure is also limited. Contributing factors include the severe human resource constraints in the health sector, limited availability of necessary equipment, commodities and systems, and weak quality support and supervision systems. The Defense Force Medical Services (DFMS) are no exception. IP/IS have been highlighted by the management of the DFMS and by other cooperating partners as an area that needs improvement.

Through its role in helping to lead the National Infection Prevention Working Group (NIPWG), JHPIEGO has ensured the ZDF becomes an active working group member and that the ZDF benefits from strengthening of IP/IS and is harmonized with national efforts. This working group includes representatives from the MOH, National HIV/AIDS/STI/TB Council (NAC), non-governmental organizations, and private sector, Environmental Council of Zambia, Medical Council of Zambia, and General Nursing Council among others. One of the priority areas is the management and proper disposal of medical waste, which is an on-going issue throughout the country.

In FY 2005 and FY 2006, JHPIEGO's support to the ZDF was generating support for sustainable solutions in IP/IS for the entire DFMS. Response to initial work shows that DFMS personnel have underestimated the shortcomings in this area, and are enthusiastically moving forward to improve their services and standards. This has resulted in their identification of needs for whole-site training, which is essential to change IP/IS standards and practices, and they are working to supplement the training provided through this program. Through FY 2005 and FY 2006, over 450 service providers and service outlet managers from over 35 sites were trained and oriented in IP/IS practices and principles including proper health care waste management. Following training, sites

received essential commodities and supplies to ensure immediate implementation of improved IP/IS practices. To ensure that IP/IS knowledge and practices are carried forward JHPIEGO has helped build the DFMS training capacity by training IP/IS trainers and co-teaching with them to ensure quality as they conducted follow-on training. JHPIEGO and DFMS have conducted supportive supervision visits, after training, to address gaps and ensure best practices are implemented appropriately. In addition PEP protocols developed were implemented and tested at key sites.

In FY 2007, utilizing the IP/IS trainers trained, JHPIEGO will co-teach and train 200 providers from all different cadres including cleaners, medical assistants, and service providers. This training will cover the remaining 19 DFMS supported health facilities as well as those units that do not have full clinics but are served by health assistants. These workshops will be led by the DFMS IP/IS trainers with JHPIEGO staff providing support in clinical and training skills areas to ensure quality training. JHPIEGO will continue with the model of providing seed amounts of essential commodities while ensuring that future procurements by the ZDF include the necessary IP/IS commodities and supplies. JHPIEGO and ZDF staff will work together to conduct supportive supervision visits throughout the ZDF to ensure knowledge transfer and to provide "on-the-spot" training to address any gaps. Opportunities to reinforce the importance of IP/IS practices for staff from all of the ZDF facilities will be sought out and pursued, ensuring continued advocacy for support at central and base management levels.

Appropriate IP/IS practices will reduce the volume and potential harmfulness of medical waste, and thus reduce the risk of needle stick injury for cleaners and communities around the facilities. JHPIEGO will work with ZDF, the Medical Council of Zambia, and NIPWG to continue to seek and implement sustainable solutions for improved medical waste management and disposal.

JHPIEGO's approach to minimizing the transmission of HIV in the ZDF will ensure greater sustainability of IP/IS practices by focusing on the development of DFMS training and supervision capacity and the facilitation of the development, dissemination, and implementation of guidelines and protocols for IP/IS, PEP and medical waste disposal systems. JHPIEGO also seeks sustainability of the activities by working with all the stakeholders in the ZDF and DFMS including the unit commanders, service outlet managers, decision makers at the central level as well as the medical service providers, ensuring that all involved understand the importance and benefits of proper IP/IS practices and protocols.

Military personnel are subject to high risk of both STIs and HIV, as a result of the housing and social situations they find themselves in due to the nature of their work. It is important to take a "no lost opportunities" approach to prevention of STIs and HIV and service providers must take advantage of each interaction they have with clients and patients to provide counseling in risk reduction. This is essential in clients presenting with an STI as they are at higher risk of HIV infection. The Zambia Defense Force (ZDF) have not benefited from the same level of investment as the pubic health system under the Ministry of Health (MOH), though they are now receiving some essential medical commodities directly from the MOH and are being incorporated in more activities (trainings, assessments, etc.). This is particularly true in the area of STI programs, though it also extends to HIV/AIDS care and treatment. Patients need to be counseled on prevention and risk reduction strategies to both provide accurate information and reinforce prevention methods. STI patients must be effectively counseled and tested for HIV with those testing negative provided with post test risk reduction counseling and those testing positive referred to HIV care and treatment services in a timely manner. Based on successful approaches in integrating CT into antenatal care for PMTCT, JHPIEGO adapted Centers for Disease Controls counseling protocols and training materials to incorporate diagnostic testing and counseling into TB services more effectively. In consultation with various partners and the Ministry of Health, these materials were adopted as the national DTC training package. JHPIEGO will use this package as the basis for integrating counseling and testing into STI services providing prevention counseling and linking patients with HIV care and treatment services. JHPIEGO will focus on strengthening service providers' knowledge and skills in STI and HIV prevention counseling working with the ZDF Medical Services to better integrate counseling and testing (CT) into STI services integrating a "no lost opportunities" approach to prevention counseling as well as care for HIV infected clients to better STI services. This will be done using group-based training for skills and knowledge targeting 50 ZDF STI service providers. These training activities will be conducted by ZDF trainers with co-teaching and supportive supervision provided by JHPIEGO. Follow-up supportive supervision to the service outlets will be conducted to ensure that the skills and knowledge are being correctly applied and to provide on the spot guidance addressing any gaps. This funding will got towards reproducing materials and training ZDF personnel in Syndromic management of STIs The sustainability of this effort is a major focus of the work and is reinforced through using training capacity already developed within the ZDF Medical Services. This training capacity will be strengthened through co-teaching and supportive supervision provided by JHPIEGO. This program builds on, and links closely, with JHPIEGO's DOD funded work in HIV/TB, ART and HBHC as well as CDC funded work in HIV/TB and Counseling and Testing.

Military personnel are subject to high risk of both STIs and HIV, as a result of the housing and social situations they find themselves in due to the nature of their work. While the effort to expand access to and utilization of antiretroviral therapy (ART) services has resulted in a growing number of HIV infected individuals receiving ART, there has been a lag in emphasizing the care for those same patients when it comes to diagnosis and treatment of STIs and other opportunistic infections. The Zambia Defense Force (ZDF) have not benefited from the same level of investment as the pubic health system under the Ministry of Health (MOH), though they are now receiving some essential medical commodities directly from the MOH and are being incorporated in more activities (trainings, assessments, etc.). This is particularly true in the area of STI programs, though it also extends to HIV/AIDS care and treatment.

STI 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, JHPIEGO adapted Centers for Disease Controls counseling protocols and training materials to incorporate diagnostic testing and counseling into TB services more effectively. In consultation with various partners and the Ministry of Health, these materials were adopted as the national DTC training package. JHPIEGO will use this package as the basis for integrating counseling and testing into STI services linking patient with HIV care and treatment services.

JHPIEGO will focus on strengthening service providers' knowledge and skills in STI diagnosis and care in STI clinics / outpatient services addressing basic knowledge with more advanced skills and knowledge for STI care in HIV patients. At the same time JHPIEGO will work with the ZDF Medical Services to better integrate counseling and testing (CT) into STI services linking care for HIV infected clients to better STI services. This will be done using different approaches including group-based training for basic skills and knowledge targeting 50 service providers followed by on-the-job training (OJT) working onsite with service provider teams using a mentoring / case-based practical approach targeting 50 service providers. These training activities will be conducted by ZDF trainers with co-teaching and supportive supervision provided by JHPIEGO. Follow-up supportive supervision to the service outlets will be conducted to ensure that the skills and knowledge are being correctly applied and to provide on the spot guidance addressing any gaps.

The sustainability of this effort is a major focus of the work and is reinforced through using training capacity already developed within the ZDF Medical Services. This training capacity will be strengthened through co-teaching and supportive supervision provided by JHPIEGO. This program will build upon, and links closely with, JHPIEGO's DOD funded work in TB/HIV and ART as well as CDC funded work in TB/HIV and Counseling and Testing.

This work is closely linked to JHPIEGO's other work with the Zambia Defense Force (ZDF), strengthening integrated HIV prevention, care, and treatment services and systems (#9087, #9088, #9089, #9091), and with the work of Project Concern International (PCI) supporting Counseling and Testing (CT) (#8785) and palliative care (#8787), as well as JHPIEGO's work on integrating diagnostic CT into TB and STI services for mobile populations (#9035).

JHPIEGO is supporting the ZDF to improve overall clinical prevention, care, and treatment services throughout the three branches of military service, Zambia Army, Zambia Air Force and Zambia National Service around the country. The overall aim of the activity is to ensure that the ZDF is equipped and enabled to provide quality HIV/AIDS services to all its personnel, as well as to the civilian personnel who access their health system. This includes strengthening the management and planning systems to support PMTCT and HIV/AIDS care and treatment services, with the appropriate integration, linkages, referrals, and safeguards to minimize medical transmission of HIV. JHPIEGO, as an important partner to the Ministry of Health (MOH) HIV/AIDS PMTCT, ART, palliative care, HIV-TB and injection safety programs, supports the ZDF in gaining access to materials, systems, and commodities funded by the U.S. Government, other donors, and numerous technical partners who work with the MOH, and to harmonize services and maximize efficiencies between ZDF and MOH facilities and programs.

The Defense Force Medical Services (DFMS) supports health facilities at 54 of the 68 ZDF sites with the remaining sites depending on Medical Assistants and outreach support. These health services are spread out, many in hard-to-reach areas, around the country, and serve both ZDF and local civilian populations. In addition, given the mobile nature of the ZDF, it is often the first responder to medical emergencies and disasters. Unfortunately, the ZDF has not benefited from many initiatives that have been on-going in the MOH public sector mainly because the ZDF has its own heath system running independently from the national one. While these links are improving, there are continued opportunities to improve harmonization and maximize the efficiency between the MOH and ZDF health services.

While the number of HIV-infected patients receiving improved palliative care has expanded within the ZDF in the past two years, the majority of services are provided through a few outlets, and the standardization of systems and services needs continued strengthening. Continued expansion requires development and support for increasingly remote sites, where services are needed but, by their location and nature, the cost effectiveness of delivering these services is reduced, a fact which is compounded by the complexity of working with the ZDF and each of the three individual ZDF branches, each with their own authority and chain of command.

JHPIEGO will utilize and build on the experience and tools developed in the larger public sector Ministry of Health ART expansion programs and particularly the HIV-TB Working Group which JHPIEGO has extensively supported, and will continue to develop and strengthen linkages between the ZDF and MOH programs.

Tuberculosis (TB) and HIV co-infection is estimated to be as high as 70% in Zambia. Military personnel are subject to high risk of both TB and HIV, as a result of the housing and social situations they find themselves in due to the nature of their work. While the effort to expand access to and utilization of antiretroviral therapy (ART) services has resulted in a growing number of HIV infected individuals receiving ART, there has been a lag in emphasizing the care for those same patients when it comes to diagnosis and treatment of TB and other opportunistic infections (OIs). Through JHPIEGO's work on integrating HIV diagnostic counseling and testing into TB services for mobile populations, more TB patients will be able to access HIV testing and care and treatment services. The focus of this activity, building on our work in FY 2006, is to ensure that patients enrolled in HIV care are adequately screened for TB, and that caregivers are able to recognize, diagnose and manage TB and other OIs.

During FY 2006, the ZDF's local capacity was strengthened with the training of 12 ART and TB staff as trainers and mentors, who in turn were supported to train at least 160 service providers in the diagnosis of TB and other common OIs associated with HIV/AIDS. In addition, the eight ZDF model sites received intensive on-the-job training and

mentoring, which was intensive and costly but essential to address the complexities of TB and OI presentation given limitations in diagnostic skills and tools. The benefit of JHPIEGO support will not be limited to the model sites, however, as staff from many other sites will be included in orientations and trainings. By the end of FY 2006 JHPIEGO was working with model sites in seven of the nine provinces of Zambia and the two remaining provinces will have models sites established by the end of FY 2007.

In FY 2007, JHPIEGO will support 12 model ZDF sites providing comprehensive and integrated HIV/AIDS prevention, care and treatment programs, including timely diagnosis and care for TB and other opportunistic infections. This includes the initial eight model sites developed in FY 2005 and FY 2006 plus four additional sites: 1. Zambia Army, L85 Barracks in Lusaka, Lusaka Province; 2. Zambia National Service, Luamfumu Barracks in Mansa, Luapula Province; 3. Zambia Army, Luena Barracks in Kaoma, Western Province; and 4. Zambia Air Force, Mumbwa, Central Province.

This work will utilize and build on the experience, tools and methodologies developed in the larger public sector Ministry of Health TB, ART and OI management programs, which JHPIEGO has extensively supported, and will continue to develop and strengthen linkages between the ZDF and MOH programs. JHPIEGO will continue to expand the local ZDF capacity by training an additional 12 ART and TB staff as trainers and mentors to support and expand the program. While expanding and improving the diagnosis and treatment of TB and other OIs among HIV/AIDS patients, JHPIEGO will also work to strengthen the linkages between the TB services and the HIV/AIDS care and treatment services. JHPIEGO/Zambia will continue seeking opportunities to create linkages with other collaborating partners, such as PCI, and work with the ZDF to ensure a synergy of efforts.

To support performance improvement systems and quality HIV care, supportive supervision visits will continue in all the twelve model sites. JHPIEGO will also support the DFMS to conduct workshops using the orientation package for 30 lay workers (e.g. managers, clergy, community leaders, and caregivers) on HIV/AIDS prevention, care and treatment orientation package, covering CT, PMTCT, Care and ART as well as linkages to other services such as TB and STIs, to educate them on HIV/AIDS and provide them with accurate and relevant information they can disseminate to more diverse populations. This will further enhance advocacy efforts to secure sustained support for these services from both the management and the community / client perspective.

To ensure sustainability, JHPIEGO works within the existing ZDF structures and plans. JHPIEGO facilitates the development and dissemination of appropriate standard guidelines, protocols, and plans. JHPIEGO also assists the ZDF with the implementation of a facility-level quality improvement program. The goal is to leave behind quality systems to ensure continuity of services after the program concludes.

This work is closely linked to JHPIEGO's other work with the Zambia Defense Force (ZDF), strengthening integrated HIV prevention, care, and treatment services and systems (#9087, #9088, #9090, #9091), and with the work of Project Concern International (PCI) supporting Counseling and Testing (CT) (#8785) and palliative care (#8787), as well as JHPIEGO's work on integrating diagnostic CT into TB and STI services for mobile populations (#9035). It also relates to the pre-service training component of the Health Systems and Services Program/USAID (#8794), as well as various partners supporting the MOH in the area of HIV care and treatment.

JHPIEGO is supporting the ZDF to improve overall clinical prevention, care, and treatment services throughout the three branches of military service, Zambia Army, Zambia Air Force and Zambia National Service around the country. The overall aim of the activity is to ensure that the ZDF is equipped and enabled to provide quality HIV/AIDS services to all its personnel, as well as to the civilian personnel who access their health system. This includes strengthening the management and planning systems to support PMTCT and HIV/AIDS care and treatment services, with the appropriate integration, linkages, referrals, and safeguards to minimize medical transmission of HIV. JHPIEGO, as an important partner to the Ministry of Health (MOH) HIV/AIDS PMTCT, ART, palliative care, HIV-TB and injection safety programs, supports the ZDF in gaining access to materials, systems, and commodities funded by the USG, other donors, and numerous technical partners who work with the MOH, and to harmonize services and maximize efficiencies between ZDF and MOH facilities and programs.

The Defense Force Medical Services (DFMS) supports health facilities at 54 of the 68 ZDF sites with the remaining sites relying on medical assistants and outreach support. These health services are spread out, many in hard-to-reach areas, around the country, and serve both ZDF and local civilian populations. In addition, given the mobile nature of the ZDF, it is often the first responder to medical emergencies and disasters throughout the country. Unfortunately, the ZDF has not benefited from many initiatives that have been on-going in the public sector. While these links are improving, there are continued opportunities to improve harmonization and maximize the efficiency between the MOH and ZDF health services.

While the number of patients receiving ART has expanded dramatically within the ZDF, the majority of services are provided through a few outlets, and the standardization of systems and services needs continued strengthening. Continued expansion requires development and support for increasingly remote sites, where services are needed but, by their location and nature, the cost effectiveness of delivering these services is reduced, a fact which is compounded by the complexity of working with the ZDF and each of the three individual ZDF branches, each with their own authority and chain of command.

The ZDF have not benefited from the same level of investment as the pubic health system under the Ministry of Health (MOH), though they are now receiving some essential medical commodities, including antiretroviral medications (ARVs) directly from the MOH and are being incorporated in more activities (trainings, assessments, etc.). JHPIEGO will utilize and build on the experience and tools developed in the larger public sector Ministry of Health ART expansion programs, which JHPIEGO has extensively supported, and will continue to develop and strengthen linkages between the ZDF and MOH programs. Work in strengthening HIV/AIDS prevention, care and treatment too often is conducted vertically failing to produce and encourage the linkages between service areas resulting in gaps that prevent clients from receiving complete care and treatment. A more comprehensive and integrated approach to the HIV/AIDS clinical care system will facilitate the continuity of care across service areas providing clients with complete, quality care.

While focusing on comprehensive strengthening of quality HIV prevention, care and treatment services at selected model sites, JHPIEGO's support will impact these services throughout the ZDF. In FY 2005 JHPIEGO trained and retrained 120 service providers in ART and opportunistic infections management drawing providers from many service outlets including the four model sites. Through JHPIEGO's support to the ZDF in FY 2006 the ZDFMS training capacity was strengthened with the training of 12 ART and TB staff as trainers. These trainers worked with JHPIEGO staff to co-train at least 80 service providers in the provision of ART. In addition, the model sites from FY 2005 and FY 2006 received support in the procurement of essential commodities and/or the minor renovation

of service outlets to enable the provision of more comprehensive, quality services. By the end of FY 2006 JHPIEGO will be working with eight model sites in seven of the nine provinces of Zambia and the two remaining provinces will have model sites by the end of FY 2007.

In FY 2007, JHPIEGO will be supporting 12 model sites, including the eight developed in FY 2005 and FY 2006 plus four new sites which will be added in FY 2007: 1. Zambia Army, L85 Barracks in Lusaka, Lusaka Province; 2. Zambia National Service, Luamfumu Barracks in Mansa, Luapula Province; 3. Zambia Army, Luena Barracks in Kaoma, Western Province; and 4. Zambia Air Force, Mumbwa, Central Province.

Local ZDF capacity to support these sites and expand to other ZDF facilities will be further developed by training 12 ART staff as trainers and mentors and co-teach ART and OI management workshops with the DFMS trainers to shore up training skills and address any gaps. While expanding the scope and coverage of ART services, JHPIEGO will also work to strengthen the linkages between ART and other HIV/AIDS prevention, care and treatment services to ensure more comprehensive and continuous care for people living with HIV/AIDS. Linkages with other counseling and testing activities, including stand-alone services as well as those integrated into other service delivery areas (antenatal care/PMTCT services, STI services, TB services, etc.) will be strengthened so that those identified with HIV infection access the clinical care services they need in a timely fashion. JHPIEGO will seek to create linkages with other collaborating partners, such as PCI, working with the ZDF to ensure a synergy of efforts, as well as reinforcing the collaboration with the Ministry of Health by harmonizing ZDF and MOH/NAC guidelines, materials and tools and strengthening the linkage between the ZDF and national initiatives in the public sector.

To support performance improvement systems and quality ART service delivery at all 12 sites, supportive supervision visits will be continue to the initial eight facilities supported in FY 2005 and FY 2006, as well as the four expansion sites. JHPIEGO will also support the DFMS to conduct workshops using the orientation package for lay workers (e.g., managers, clergy, community leaders, and caregivers) on HIV/AIDS prevention, care and treatment orientation package, covering CT, PMTCT, Care and ART as well as linkages to other services such as TB and STIs, to educate them on HIV/AIDS and provide them with accurate and relevant information they can disseminate to more diverse populations.

To ensure sustainability, JHPIEGO works within the existing ZDF structures and plans. JHPIEGO facilitates the development and dissemination of appropriate standard guidelines, protocols, and plans. JHPIEGO also assists the ZDF with the implementation of a facility-level quality improvement program. The project's goal is to leave behind quality systems to ensure continuity of services after the program concludes.

This work is closely linked to JHPIEGO's other work with the Zambia Defense Force (ZDF), strengthening integrated HIV prevention, care, and treatment services (#9088, #9089, #9090) and on prevention of medical transmission/injection safety (#(9091), and with the work of Project Concern International (PCI) activities with the ZDF in strengthening integrated HIV prevention, care, and treatment services for the Zambian military. It also relates to the pre-service training component of the HSSSP (HSSP)/USAID (#8793). The aim of the activity is to ensure that the ZDF is equipped and enabled to provide quality HIV/AIDS services to all its personnel, as well as to the civilian personnel who access their health system. This includes strengthening the management and planning systems to support PMTCT and HIV/AIDS care and treatment services, with the appropriate integration, linkages, referrals, and safeguards to minimize medical transmission of HIV. The ZDF has a network of 54 health facilities supported by the Defense Force Medical Services (DFMS), located on bases around the country, that provide health services to personnel in the three branches as well as to civilian populations in the same areas. Because these facilities are under the Ministry of Defense (MOD), they do not always benefit from support and resources provided to the Ministry of Health (MOH), although significant efforts are ongoing to bring these related services closer together.

During FY 2007, JHPIEGO will continue to support the ZDF in strengthening support systems to address these gaps, building on experience and tools developed within the larger MOH public sector programs and strengthening appropriate linkages with MOH and other cooperating partners. ZDF has a program to train a cadre called Medical Assistants, however they have limited, or no training in HIV-related care and support. Medical Assistants form a very important part of the ZDF health services as they are often called on, due to the lack of adequate professional health staff. They are drawn from all of the defense force branches to participate in three to six month training, conducted by health personnel within the ZDF. Medical Assistant training has not been conducted in a uniform and standardized way, resulting in inconsistency in training content as they progress from one level to the next, and there has been very limited preparation of this cadre in the area of HIV/AIDS prevention, care, and treatment. To address deficiencies in Medical Assistant training highlighted by the ZDF, JHPIEGO worked with the ZDF and other collaborating partners, such as PCI, in FY 2006 to develop a system to incorporate HIV/AIDS material into training for Medical Assistants. This system was developed to address those already deployed (in-service training) as well as strengthening the basic Medical Assistants training program (pre-service training). This complemented, and was coordinated with, ongoing support for strengthening other health worker pre-service training programs (see HSSP activity #8793). A set of core competencies in HIV/AIDS prevention, care and treatment has been developed and integrated into relevant training materials for ZDF Medical Assistants. JHPIEGO supported 20 faculty/trainers, who received updates based on the revised curriculum, to train 100 deployed Medical Assistants in the core competencies. For FY 2007 JHPIEGO will support the ZDF faculty/trainers to update 100 deployed Medical Assistants at different levels. In addition, Medical Assistants trained in FY 2006 will be followed up to ensure that they have retained knowledge from the training and to address any gaps on-the-spot. With the core competencies in place and a methodology for updating them as well as trained faculty/trainers, the ZDF will be able to sustain the program of training and updating Medical Assistants in the long term. The ZDF has experienced difficulties in planning and management of health and HIV clinical prevention, care, and treatment services as well as gaps in procurement, logistics management and forecasting of medical supplies and drugs. JHPIEGO will build on experience within the MOH system to support the development of a better system for planning and managing their health and HIV clinical prevention, care, and treatment services, helping the ZDF develop tools (such as Geographic Information Systems (GIS) mapping of capacities and catchments populations). In addition, JHPIEGO will continue to work with the ZDF and in-country partners on planning, forecasting, procurement and logistic management to strengthen the medical procurement and logistics systems throughout the ZDF. John Snow, Inc (JSI/USAID) is also providing similar technical assistance to the MOH, and as such is well positioned to identify areas and means to strengthen linkages between the ZDF and MOH procurement and logistics systems. As part of the support for capacity building and strengthening of DFMS, JHPIEGO sub-contracted with JSI to assess the supply chain management systems used by the three branches of the ZDF and to collaborate with the DFMS to develop improved SCM systems. The funding under this sub-contract would allow the contractor to reach the stage of facilitating the development of an improved inventory control and logistics management information systems for ARVs

and HIV Tests through a participatory process for the medical services. As a follow-up to this process, it is imperative that the next stage be the actual implementation of a new system. In the same way in which the contractor has been supporting the MOH, the implementation would involve the following steps: Development of the standard operating procedures (SOPs) for both the ARV and the HIV Tests logistics system and then the printing of those SOPs; Development of training materials and the subsequent training of DFMS personnel in the Antiretroviral Logistics System based on the SOPs. This targets 130 service providers. The assumption is that the contractor would be able to call upon already trained MOH and partner trainers to conduct these trainings; Training of DFMS personnel in the HIV Test Kits Logistics System based on the SOPs. The ZDF, in addition to providing health care services to defense personnel and their dependants, provide services to the civilian populations living in close proximity to ZDF sites. With the transition to a new MOH supply chain system for ARVs and HIV test kits the ZDF ART sites will need to be accredited in order for them to access ARVs through local DHMTs. JHPIEGO will work with the MOH, Medical Council of Zambia and DFMS to facilitate the accreditation of all ZDF service outlets providing ART, which could reach as high as 54 sites. Following the MCZ guidelines for site accreditation team will visit the sites, which are spread throughout the country, often in hard to reach places.

These plus up funds will be used to spearhead the development of national policy of MC (in process), strategic planning and implementation of scale-up efforts. JHPIEGO is a key member of the MC Task Force and the Prevention Technical Working Group, and thus will be able to ensure that the policy being developed is well informed and complements the whole prevention process and the overall national HIV strategies in Zambia. JHPIEGO's work in policy and systems strengthening with these plus up funds will focus on: (1) providing technical assistance to finalize the existing draft policy recommendations on comprehensive male circumcision services (from neonatal to adult), translate the policy recommendations into a policy proposal and support the process to get the policy adopted; (2) work with the Zambian team to adapt and adopt this package, and to develop associated service delivery guidelines; and (3) develop and pilot test performance standards for male circumcision, to standardize and enhance performance and quality improvement and supervision of MC services.