This activity links to HTXS (#9182) and HVCT (#9181), to CRS HKID (# 8852), to RAPIDS HBHC (#8946), and AIHA HBHC (#8809).

The CRS SUCCESS II Project is a newly awarded follow-on to the first SUCCESS Project. In FY 2007, CRS will provide quality, community-based palliative pare (PC) services through seven Catholic Diocese home-based care programs and ten faith-based hospices in seven provinces. SUCCESS is the leading USG partner in community-based palliative care in Zambia.

In terms of prior year achievements, in FY 2005, SUCCESS reached 31,365 PLWHA with home-based and hospice care. SUCCESS exceeded its FY 2005 target by 15%, scaled-up home-based care (HBC) programs from four to six provinces, and supported ten faith- and community-based hospices. In FY 2007, the SUCCESS II project will operate in seven provinces and support 10 hospices serving 32,520 PLWHA in 44 districts (providing geographic coverage to roughly 66% of all districts in Zambia) at an average cost of about $92 per client. SUCCESS has developed an M&E system that enables it to account for individual clients, analyze data effectively, and use data for program management and planning.

SUCCESS II will link to other PEPFAR-funded projects, such as AIDSRelief, CIDRZ, and ZPCT, and to GRZ services, for treatment of OIs, STIs, and for ART. To reach more HIV+ infants, children, and pregnant women with Palliative Care (PC), SUCCESS II will strengthen referral linkages to and from PMTCT, and offer integrated CT in its service areas. SUCCESS II is a leader in supporting hospice care in Zambia. It leverages the nationwide health care infrastructure of the Catholic Church and its volunteer caregivers to reach underserved, rural areas. SUCCESS II collaborates with RAPIDS, an HBC project serving urban PLWHA, and refers clients to government health facilities for clinical care and ARV treatment.

SUCCESS II provides a standardized package of high quality and holistic palliative care and services in-line with international guidelines and emerging national standards. The HBC service package includes home visits, basic nursing care, pastoral and psychosocial support, malaria prevention (ITNs and education), nutrition counseling, targeted nutritional supplements (when available) for malnourished PLWHA, household safe water products to reduce diarrheal disease, DOTS for PLWHA co-infected with TB, and clinical referral for OIs, including TB. The program will increase its focus on identifying HIV-positive infants and children in need of palliative care, nutritional support, and/or referral for pediatric ART.

SUCCESS II has established three care categories to provide a better match between care needs and caregiver support: (1) newly infected but asymptomatic; (2). house- or bed-bound with advanced illness; or (3) recovering activity levels on ART with adherence support. The SUCCESS II innovative family-based CT model will identify newly infected clients earlier. The project will establish stronger linkages and more effective referrals to ART sites to provide a more complete continuum of care. SUCCESS II will support and extend the outreach of ART, sharing the load of patient follow-on monitoring and care. It will promote better adherence to ART as well as positive living.

SUCCESS II will continue to support hospices to improve the quality of in-patient care for terminally ill PLWHA and to provide CT and family support including day-care for children of in-patients, or the newly orphaned. Hospice clients who receive ART often recuperate and return home with follow-on support, although evidence of this at present is anecdotal. SUCCESS II awards block grants to qualifying hospices to help them attain and maintain acceptable standards of care and support. Block grants pay for medical equipment, training, staff/patient transport, and quality improvement to attain higher standards of care. SUCCESS II works with the AIHA Twinning Center to support the Palliative Care Association of Zambia (PCAZ), a national membership association of PC providers. PCAZ facilitates training and develops policy. It provides sustainable leadership in Zambia, including state-of-the-art training for caregivers and technical assistance to the GRZ in designing national PC guidelines and standards.

SUCCESS II will continue to refine the quality of palliative care services of its HBC and hospice partners. It will focus on basic nursing, symptom and pain control, patient and

family education, linkages with OVC program sites, and a standard quality training package for HBC volunteers and staff. It will also train for local partners in financial management, program development, monitoring and evaluation, logistics, report writing, and performance planning. It will increase referrals to P-ART where available, provide pediatric HBC, and refer presumed HIV positive infants/children for clinical care and treatment, to help reduce the high mortality rate in HIV infants. SUCCESS II will procure basic medications and supplies for PC as needed, using private matching funds. SUCCESS II leverages non-PEPFAR sources to ensure availability of basic medications for HBC programs in a sustainable manner.

SUCCESS II care coordinators refer clients to needed services and link clients to trained medical staff in district and provincial facilities, to ART service delivery sites, and follow up with community-based adherence support. Partners also link to local branches of PLWHA and OVC support groups and to local GRZ structures. Trained volunteer caregivers, supervised by nurses, continue to form the backbone of this model. To ease gender-based burdens in care-giving, active recruitment of male and youth caregivers helps relieve the load on the female caregivers. SUCCESS II offers its volunteers monthly support meetings, refresher trainings, tools for work, and CT services to boost retention.

In recognition of the role of food in staving off disease progression, facilitating ART, and in rehabilitating severely malnourished ART patients, SUCCESS II provides targeted nutritional supplements to malnourished PLWHA. In FY 2007, SUCCESS II will continue to provide High Energy Protein Supplements (HEPS) and Ready to Use Therapeutic Food for moderately and severely malnourished PLWHA. SUCCESS II will leverage FFP and WFP food to obtain food rations for food insecure PLWHA and families, in a wrap-around model.

For sustainability, CRS will continue to build the capacity of diocesan and faith-based hospice partners through training of providers and staff at multiple levels as well as training for trainers. CRS will support PCAZ master trainers to carry out palliative care training with diocesan HBC programs and hospices, and work with PCAZ to assist GRZ with developing national palliative care standards and guidelines as well as hospice accreditation.

SUCCESS II shares best practices and lessons learned across partners through meetings and exchange visits. SUCCESS II will continue monitoring, for data accuracy, and uses performance and service data as tools to adjust program components.

To further promote sustainability, SUCCESS II will build Catholic Diocese management capacity. Catholic Church structures in Zambia, and their significant, enduring complementary role in the GRZ health system, will outlive external funding. One advantage of SUCCESS II is the reach of Zambian Catholic structures into rural communities. CRS trains dioceses in financial management and accountability, logistics, organizational development and strategic planning, as well as staff management and policy development. Partners are encouraged to link with local government institutions and community/traditional leaders. To diversify funding, SUCCESS II supports partners in accessing other funds. In FY 2007, CRS will work to implement exit strategies and graduation plans for its partners.

This activity links to HBHC (#9180) and HTXS (#9182) and to other HBC, CT and PMTCT activities.

This CRS project, "Scaling Up Community Care to Enhance Social Safety Nets-II" (SUCCESS-II) is a new award following on the original CRS SUCCESS HBC Project. FY 2007 represents the fourth year of implementation. CRS has established a large platform for HIV service delivery in seven of nine dioceses (provinces) in Zambia. SUCCESS views CT as an integral component of high quality, community-based palliative care (PC).

SUCCESS has achieved its CT targets. In FY 2006, SUCCESS had a CT target of 6,000, and reached 8,732 clients, or 146% of its target. In FY 2007, SUCCESS will target 20,000 PLWHA in 51 of Zambia's 72 districts (geographic coverage of more than 75% of all districts) with CT services and will train 96 health workers in CT, two for each hospice and 10-15 per diocese (province). This target more than doubles the SUCCESS FY 2005 target for CT. The cost per client counseled and tested, currently projected at $49 for 2007, will likely drop as SUCCESS' partners increase the volume of counseling and testing, and become more efficient. However, as SUCCESS works in rural areas, the cost per client will likely remain higher than for CT delivered in densely populated urban and peri-urban areas. The target and cost estimate rely heavily on provision of test kits by the GRZ's District Health Management Team, which the USG is supporting through JSI/Supply Chain Management Services.

SUCCESS will support its partners to provide on-site CT services that meet national and international standards, focusing on those areas where other USG supported CT does not exist. CT, the entry point for HIV/AIDS care and treatment, enables SUCCESS to identify and refer PLWHA early in their infection for palliative care and ART. Early identification of HIV infection allows PLWHA to initiate behavior change and participate in Prevention-for-Positive programming. This reinforces USG Zambia Prevention targets. It also may help in preventing or delaying Orphan-hood for Zambian children born to couples, in which one or both partner is HIV-positive, provided that they take suitable precautions.

SUCCESS has set an indirect target of referring at least 3,150 individuals found to be HIV positive for ART, including infants and children. Assuming that there is a reliable and adequate supply of test kits, SUCCCESS' partners will scale up CT services through innovative methods, such as community CT, and to the extent possible, will share its trained counselors with government health facilities when and where they are short staffed.

Catholic Diocese partners will mobilize communities and use community participation to increase acceptance and the uptake of CT, taking CT activities directly into the communities and households. SUCCESS-II will train diocesan nurses and counselors in HIV Rapid Test technology following NAC/GRZ and international CT guidelines. This builds on the established care relationships in the communities and allows for privacy and convenience of CT in the home.

Since rapid testing is not effective in infants under 18 months, they will either: a) have a drop of blood drawn for PCR analysis using Dry Blood Spot (DBS) technology (available in Lusaka only in mid-2006, with plans to extend these services to Livingstone and Ndola by 2007 to provide coverage to most of Zambia); or b) where DBS and PCR are not available, HBC volunteers will visually screen infants for signs of "growth faltering" and other symptoms associated with HIV/AIDS, and referred for presumptive clinical care until confirming diagnosis. This community CT model also provides some relief for the health care human resource crisis in Zambia, by providing additional health care providers to work in SUCCESS rural service delivery sites and allowing scarce GRZ facility CT staff to remain at their service sites to meet the increasing demand for CT services.

SUCCESS partners use a network model and create linkages to existing ART services. SUCCESS works hand in hand with their GRZ local health structures to coordinate CT services and link to other NGOs and CT providers who operate Mobile Testing services.

SUCCESS II will continue to provide training at multiple levels, such as Rapid Test Training for registered nurses and counselors, and training on finger prick blood draw with rapid

testing for the many more ‘lay' counselors. In this technical area, appropriate GRZ trainers are utilized, so as to perpetuate national protocols and guidelines.

SUCCESS II partners achieve collaboration across in numerous ways. The annual meeting brings all SUCCESS II partners together for cross-fertilization of programming ideas, issues, and lessons learned. Partners are encouraged to make exchange visits to each other's sites, affording closer observation of on-the-ground best practices and skills transfer. SUCCESS II monitoring and evaluation staff and program team continue to deepen the quality of monitoring activities, not only for data accuracy but to use their performance and service delivery data as programming tools for adjusting emphases or inputs.

SUCCESS II builds its partners' management capacity to promote sustainability. The Catholic structure in Zambia, and the significant complementary role it plays to the GRZ health system. One of the comparative advantages of SUCCESS II is the extensive reach of the Catholic structure into rural and often isolated communities. Investment in their management capacity enhances their effectiveness and sustainability. SUCCESS II trains its implementing partners in financial management and accountability, logistics and commodities distribution, organizational development and strategic planning, as well as mentoring where it is requested on staff management and policy development. The projects are strongly encouraged to link with local government structures and institutions. An example of strategic networking for sustainability is that of a Catholic Bishop sitting on the Board of Directors of a provincial government hospital. Key networking also takes place at the integral community level, where local traditional leaders are involved in parish HBC coordinating committees.

Diversification of funding support is also a key factor in sustainability. CRS management capacity building also supports partners in accessing other funds when possible, and partners are in a better position to attract other funds with their project management ability enhanced through SUCCESS II.

This activity is linked to HBHC (#9180) and HVCT (#9181) as well as to other ART adherence and EP-funded palliative care projects.

The CRS SUCCESS II Project is a new follow-on award that builds on and expands successful efforts between CRS and health structures in seven Catholic dioceses. In FY 2006, its first year of Adherence Support, SUCCESS targeted 2,500 PLWHA, located in the vicinity of ART sites, for a combination of Adherence Support and Nutritional Supplementation. As of mid-year FY 2006, SUCCESS had added an Adherence Support component, wherein program coordinators, volunteer caregivers, and hospice staff were trained in ART and Adherence Support, relevant to their provider level. In addition, SUCCESS formalized referral linkages between its diocesan partners and AIDSRelief, CIDRZ, and ZPCT ART sites in eight Provinces so far; 1,400 HBC clients receive ART through CIDRZ in Western province alone, as well as many other ZPCT-supported GRZ clinical sites. These back and forth referrals - from HBC to ART and back to HBC for Adherence support - weave a strong continuum of care.

In FY 2007, SUCCESS II will continue to promote and support the rapid scale up of ART for Zambian people living with HIV/AIDS (PLWHA) through its major diocesan partners. SUCCESS II will refine and expand its HBC Client Referral to ART mechanism, and expand its ART Literacy and Adherence Support programming within HBHC. SUCCESS II will refer as many of its HBC clients and post-test HIV positive people to USG-supported ART sites as possible, and educate community members about ART facts. SUCCESS II has set a target of providing Adherence Support for 4,550 PLWHA who will receive ART from the network model.

SUCCESS II will provide support to community based ART, transporting ART clients who live far from ART sites to the clinic for care or for ARV re-supply, as a means to boost adherence, and to minimize the difficulty of reaching ART sites for PLWHA who live in remote areas.

SUCCESS II will refer palliative care clients to the nearest ART sites and will provide ART literacy and adherence support as part of HBC. SUCCESS will refer clients as follows: in Solwezi Diocese (Northwest province), to Mukinge Mission Hospital (supported by AIDSRelief); in Kasempa District, and Solwezi General, Kabompo District, Zambezi District, and Mwinilunga District Hospitals (supported by ZPCT). In Mongu Diocese (Western Province), SUCCESS will refer HBC clients to Lewanika General Hospital (CIDRZ) (1,400 HBC clients are already linked to ART). In Mansa Diocese (Northern Province), clients are linked to Mansa General and Kawambwa District Hospitals, (ZPCT). In Mpika Diocese (Northern Province), clients are referred to Chilonga Mission Hospital (AIDSRelief) and to Mpika and Chinsali District Hospitals and Nakonde Rural HC (ZPCT). In Chipata Diocese (Eastern Province) clients will be referred to St. Francis Mission Hospital (AIDSRelief) in Petauke; in Kasama to Kasama General Hospital and Mbala District Hospital (ZPCT). Monze Diocese (Southern Province) will refer to Macha and Mutendere Mission Hospitals (AIDSRelief). AIDSRelief is developing a further site in Monze, which will link with SUCCESS II palliative care support.

Adherence support, initially made possibly by GHAI Rapid Expansion funding, will continue with the widespread training of caregivers on ART, ART literacy education, and Adherence support methodology, and the ensuing application among the patients on ARVs in the diocesan HBC programs. The partners are including PLWHA in the adherence trainings to further empower those who are closest to the need, and are also balancing the number of male and female adherence supporters. SUCCESS II will continue to provide severely malnourished ART patients with nutritional supplements either with limited direct PEPFAR funding, or through wraparound arrangements with FFP, the WFP, Global Fund or other donors.

‘Adherence vehicles,' managed by the dioceses, also supported with GHAI Rapid Expansion funding, will provide needed transport for non-ambulatory patients to often-distant ART sites, transport of test samples to labs, and transport of adherence supporters to visit distant clients in need of regular follow up. This vital support will continue and will provide a continuum of care from testing, through palliative care, through treatment, and adherence to treatment.

SUCCESS II will support ART through many, well-established referral linkages for other services outside its care and support package. SUCCESS II already has an established and effective network of trained community volunteer caregivers who carry out ART literacy education and ART adherence support; for which personal relationships and trust are cornerstones.

SUCCESS II will continue to provide training at multiple levels, for HBC volunteers and staff across all Dioceses. To build local capacity, Trainings of Trainers are held and then training is cascaded to subsequent levels of local personnel until all are trained in the programming area relevant to their role in the project. Due to the sparse population in rural Zambia, the SUCCESS II project is required to train larger numbers of caregivers than other projects, to cover the long distances between PLWHA homes and provide regular care and support.

SUCCESS II will also train by leveraging and linking partners, such as carrying out ART Literacy and Adherence Support trainings with AIDSRelief co-trainers in areas where SUCCESS II and AIDSRelief are co-located. Joint training strengthens the linking to ART, and follow on Adherence Support for compliance to treatment. Using standardized adherence support training materials will build sustainability when many practitioners provide the same level of service. A further dimension of sustainability will be achieved when HBC / ART clients return to active family and community life, as well as when PLWHA know how to manage their now-chronic illness. Many positive-living PLWHA become role models in their communities and further break down stigma as a barrier to accessing treatment for HIV.

Collaboration across SUCCESS II partners is achieved in numerous ways. Annual meetings will bring SUCCESS II partners together for cross fertilization of programming ideas, issues, and lessons learned. Partners will be encouraged to make exchange visits to each other's operational sites, affording closer observation of on-the-ground best practices and skills transfer. SUCCESS II monitoring and evaluation staff and program team will continue to deepen the quality of monitoring activities.

The second component of SUCCESS II sustainability is building management capacity. Catholic Church structures in Zambia, and leveraging the significant complementary role of the Church health structures, which will outlive external funding trends. One comparative advantage of SUCCESS II is the extensive reach of Catholic structures into rural communities. To build capacity, SUCCESS will train implementing partners in financial management and accountability, logistics and commodities distribution, organizational development and strategic planning, as well as staff management and policy development. The projects are strongly encouraged to link with local government structures and institutions. An example of strategic networking for sustainability is that of a Bishop sitting on the Board of Directors of a provincial hospital. Key networking also takes place at the integral community level, where local traditional leaders are involved in parish HBC coordinating committees.

SUCCESS II will also promote diversification of funding support as a key factor in sustainability. Management capacity building will support partners in accessing other funds. Partners will be in a better position to attract other funds with their project management ability enhanced through SUCCESS II.