This activity links directly with JHPIEGO (# ) and Society for Family Health (SFH) (# ) and indirectly with USAID | DELIVER PROJECT's ARV Drug (#9520) and Partnership for Supply Chain Management Systems (SCMS) Laboratory Strengthening (#9524) and Policy Analysis/Systems Strengthening (#9525).

The purpose of this activity is to provide supply chain system support for the scale-up of male circumcision (MC) programming. Funding will be used to assist the Ministry of Health, National AIDS Council, Medical Stores Limited (MSL), and other USG implementing partners to better ensure the availability of necessary MC kits and related supplies at selected sites. Currently JHPIEGO and SFH are procuring MC commodities to assemble MC kits at chosen facilities. As the national MC program grows, demands on the supply chain systems will significantly increase; therefore, it is imperative that these systems be strengthened in the beginning stages of program expansion. To accomplish the initial phase of improving the supply chain, SCMS will: actively participate in the national MC forums to ensure that supply chain issues are addressed as the program expands; conduct at least one national MC commodity quantification/forecast to determine overall commodity requirements for expansion; assist MSL in monitoring stock status and managing the distribution system to supply health facilities on a timely basis (includes establishing the pipeline monitoring and procurement planning software system for MC commodities); price the various MC products to determine the most cost-efficient manner for procuring these supplies beginning in FY 2008.

Table 3.3.05:

This activity links directly with USAID | DELIVER PROJECT's ARV Drug activity (#9520), the Partnership for Supply Chain Management Systems' (SCMS) activities in CT (#9523), Laboratory Strengthening (#9524), and Policy Analysis/Systems Strengthening (#9525), Center for Infectious Diseases Research in Zambia (#9000), Catholic Relief Services/AIDS Relief (#8827), Churches Health Association of Zambia (CHAZ) (#8992), University Teaching Hospital (UTH) (#9042), Zambia Prevention, Care, and Treatment Partnership (ZPCT) (#8885), Global Fund for AIDS, Tuberculosis and Malaria (GFATM), the Clinton Foundation, and UNITAID.

The purpose of this activity is to develop a national forecast/procurement plan and to procure Co-trimoxazole drugs in support of the Government of the Republic of Zambia's (GRZ) national ART program. Following WHO recommended guidelines, Zambia is adopting the policy of adding Co-trimoxazole to the national ART guidelines; this commodity will be added to the national ARV ordering and reporting system to better ensure its availability for ART patients. With these plus-up funds, at least 70,000 adult patients will receive Co-trimoxazole (pediatric Co-trimoxazole is being provided by the Clinton Foundation with UNITAID funding).

Finally, it should be noted that as with USG-funded ARV drugs, the Co-trimoxazole will be placed in the GRZ's central warehouse, Medical Stores Ltd. (MSL), where all public sector and accredited NGO/FBO/CBO/work-place/private sector ART programs will have access to these critical supplies.

Table 3.3.07: Program Planning Overview Program Area: Palliative Care: TB/HIV Budget Code: HVTB Program Area Code: 07 Total Planned Funding for Program Area: $ 8,222,000.00

Program Area Context:

Tuberculosis (TB) is one of the leading causes of morbidity and mortality in people living with HIV/AIDS in Zambia. The World Health Organization (WHO) estimates that the prevalence of HIV in adults with active TB is somewhere between 60 and 70%. Because of the close opportunistic link between TB and HIV (double burden of disease), the Zambia National HIV/AIDS/STD/TB strategic plan has identified the treatment of TB as one of the key objectives in mitigating the spread, limiting the co-morbidity, and minimizing the socio-economic impact of HIV/AIDS in Zambia.

The implementation of the Government of the Republic of Zambia's (GRZ's) TB/HIV national strategy is a collaborative effort between the GRZ, the Global Fund against HIV/AIDS, TB and Malaria (Global Fund), the President's Emergency Plan for AIDS Relief (PEPFAR), and other partners. For example, funds from the Global Fund (Round One) have been and continue to support the implementation of the Directly Observed Treatment Strategy (DOTS), while PEPFAR has been and continues to support the strengthening integration of TB/HIV service delivery through the following activities: training, improvement of physical infrastructure, improvement of the information system, procurement of laboratory supplies, provision of quality assurance services, and provision of technical assistance. To improve collaboration, the US Government (USG) is represented on the National TB/HIV Coordinating Committee.

The implementation of the FY 2005 and FY 2006 PEPFAR country operational plans has been through direct collaboration between the Ministry of Health (MOH), the USG and partners implementing TB/HIV activities. The USG partners are assisting the MOH and private providers to integrate TB and HIV activities including provision of voluntary counseling and testing (VCT) to all TB patients, and referral of HIV-infected TB patients for HIV services, including ART. Currently, Livingstone District in Southern Province is running a pilot program to evaluate how well VCT is being integrated into the routine management of TB.

In FY 2006, the USG provided support to develop guidelines for the implementation of TB/HIV activities, focusing on the provision of routine opt-out HIV counseling for all TB patients, and the screening of HIV-positive clients for TB. These guidelines have been incorporated into the national TB, HIV, and counseling guidelines. The MOH has adopted the practice of Diagnostic Counseling and Testing (DCT) for TB patients. The USG adapted the CDC DCT training manual for Zambia, and is using the cascade model of training of trainers (ToT) to ensure that training is available at levels of the health care system. Training in DCT has begun in the Districts. Provision of training in DCT to front line TB staff will increase the capacity of the health system to scale-up the provision of routine counseling and testing for all TB patients.

Building on the work begun in 2002, the USG is providing direct support to the National TB program. Activities include strengthening the capacity of the national TB reference laboratory, the Chest Disease Laboratory, to provide quality-assured smear microscopy services in the country (See Lab area narrative). In FY 2005 and FY 2006, the USG provided support for the development of a regional reference laboratory to enhance the capacity to provide quality assurance and culture facilities for the monitoring of TB drug resistance.

Capturing accurate data on TB/HIV activities has been a challenge because the Health Information Management System (HMIS) which the MOH utilizes to track public health services is not equipped with tools to facilitate the function. TB forms and TB registers have also been deficient in capturing HIV data. However, with USG support, the national TB forms and registers have recently been revised by the TB/HIV Coordinating Committee to include collection of HIV data. The USG support covered the development, production, and distribution of forms and registers to the provinces and districts for use. The availability of these revised registers and patient cards will enable the national program to collect nationwide data on the implementation of the TB/HIV activities by the end of the third quarter of 2006. Information on TB status is included in the national data collection forms for the ART program.

The physical separation of TB and ART services is another challenge to the integration of TB/HIV activities. ART is provided through the public health service in all provincial hospitals, in many district hospitals, and in some health centers. Treatment is normally provided in an ART-specific clinic, which might be far from TB services. Co-infected clients are in practice referred to ART clinics to be evaluated for ART eligibility. This referral process may result in a loss to follow-up of the TB patient. In order to lessen the burden for clients with co-morbidity, the USG has and will continue to strengthen the links between the TB program and HIV services, including ART, to ensure effective cross referrals between the two programs. Initiatives will include the training of staff in TB/HIV surveillance, with emphasis on the necessity for cross referrals and the use of reflex CD4 counts and treatment of TB in ART centers for patients receiving both ART and TB treatment. In addition, staff will be trained on the need to provide cotrimoxazole for HIV infected TB patients (in consonance with the national guidelines).

In FY 2007, USG in collaboration with the MOH and other donors will continue to build on and expand the scope of the programs implemented in FY 2005 and FY 2006. FY 2007 activities aim at substantially increasing the proportion of TB patients who are tested for HIV and referred to ART and other HIV prevention and care services.

All the above activities have been, and will continue, to promote sustainability after the project has ended. The strategies for sustainability include: development and distribution of training materials; empowering health care staff with the ability to continue in-house training on HIV/TB collaboration without outside assistance; community sensitization and participation; involvement of managers in issues of TB/HIV collaboration; and support to the Provincial Health Offices in helping to scale-up the implementation of TB/HIV integration. The USG will directly fund four provinces to improve the human resource base, infrastructure, and space for VCT within the facilities. The activities will compliment Global Fund supported activities to strengthen DOTS implementation. In addition, USG partners will participate in strengthening and expanding TB/HIV integration in all the nine provinces. Activities in three provinces will receive additional support for strengthening TB/HIV activities and DOTS from the CSH funds through the TB Country Assistance Plan. Support for the implementation of TB/HIV activities will be extended to the corporate sector through support to Global Development Alliance (GDA) partners as well as to faith-based organizations. Community awareness will be increased through the development, production, and dissemination of information education and communication materials.

On the issue of commodities, the USG will support the procurement of rapid HIV test kits and laboratory supplies in support of the TB/HIV program as part of the direct laboratory support though the Partnership for Supply Chain Management for the Central Medical Stores (SCMS). Service delivery points will access supplies through the MOH logistics supply system.

Program Area Target: Number of service outlets providing treatment for tuberculosis (TB) to 657 HIV-infected individuals (diagnosed or presumed) in a palliative care setting Number of HIV-infected clients attending HIV care/treatment services that are 27,798 receiving treatment for TB disease Number of HIV-infected clients given TB preventive therapy 0 Number of individuals trained to provide treatment for TB to HIV-infected 3,888 individuals (diagnosed or presumed)

Table 3.3.07:

This activity links directly with Project TBD's activities in Counseling and Testing (CT) (#9522), the Partnership for Supply Chain Management Systems' activities in ARV Drug (#9196), Laboratory Strengthening (9524), and Policy Analysis/Systems Strengthening (#9525), Center for Infectious Disease Research in Zambia (CIDRZ) (#9000), Catholic Relief Services/AIDS Relief (#8827), Churches Health Association of Zambia (#8992), University Teaching Hospital (#9042), Zambia Prevention, Care, and Treatment Partnership (ZPCT) (#8885), Society for Family Health (SFH) (#8926), Catholic Relief Services/SUCCESS (#9181), Zambia VCT Services, Global Fund for AIDS, Tuberculosis and Malaria (GFATM), and the Clinton Foundation.

The purpose of this activity is to procure HIV test kits in support of the Government of the Republic of Zambia's (GRZ) CT, prevention of mother to child transmission (PMTCT), and National Blood Transfusion programs. In FY 2006, JSI/DELIVER provided support in strengthening the national HIV test kit forecasting, quantification, and procurement systems. With their support, the U.S. government (USG) purchased $1 million worth of HIV test kits for the national program in accordance with GRZ and USG rules and regulations.

In FY 2007, USG will continue its strong collaboration with GRZ, GFATM, Japan International Cooperative Agency (JICA), and the Clinton Foundation to assist the national HIV testing programs in fulfilling demand for these services. On behalf of the USG, SCMS will purchase three types of test kits for various testing procedures based on the GRZ's 2006 revised HIV testing algorithm: screening (Determine), confirmatory (currently Genie II, switching to Unigold), and tie-breaker (currently Bionor, switching to Bioline). All three tests are rapids and non-cold chain, therefore enhancing the overall accessibility and availability of HIV testing in Zambia. Furthermore, USG-funded HIV test kits will be placed in the GRZ's central warehouse, Medical Stores Ltd. (MSL), where all the public sector and accredited NGO/FBO/CBO HIV testing programs will have access to these critical supplies. USG's HIV test kit contribution will represent approximately 1,616,952 tests or 50 percent of all HIV tests conducted in FY 2007 (this includes confirmatory, tie-breaker, and tests performed by the National Blood Transfusion Services). In collaboration with the aforementioned partners, approximately 286,696 persons will be tested nationally in FY 2007. The FY 2007 plus up funds will result in an additional 1,500,000 tests.

This activity links directly with Project TBD's ARV Drug activity (#9520), the Partnership for Supply Chain Management Systems' (SCMS) activities 9n CT (#9523), Laboratory Strengthening (#9524), and Policy Analysis/Systems Strengthening (#9525), Center for Infectious Diseases Research in Zambia (#9000), Catholic Relief Services/AIDS Relief (#8827), Churches Health Association of Zambia (CHAZ) (#8992), University Teaching Hospital (UTH) (#9042), Zambia Prevention, Care and Treatment Partnership (ZPCT) (#8885), Global Fund for AIDS, Tuberculosis and Malaria (GFATM), and the Clinton Foundation.

The purpose of this activity is to procure ARV drugs in support of the Government of the Republic of Zambia's (GRZ) national ART program. In FY 2006, JSI/DELIVER provided assistance in strengthening the national ARV drug forecasting, quantification, and procurement systems. With their support, the US Government (USG) purchased $14 million worth of ARV drugs for the national program in accordance with GRZ and USG rules and regulations.

In FY 2007, USG will continue its strong collaboration with GRZ, GFATM, and the Clinton Foundation to assist the national ART programs in fulfilling demand for ART services. On behalf of the USG, SCMS will purchase the following drugs: 3TC, AZT syrup, LPV/r syrup, AZT/3TC, ddI 200mg, ddI 25mg, EFV 50mg, EFV 600mg, LPV/r133/33 caps, NVP 200mg, and Tenofovir. Purchases may change as additional ARV drugs become approved by the Food and Drug Administration (FDA) and registered in Zambia, as GFATM and Clinton Foundation ARV drug donations become solidified, and when GRZ changes the national ARV treatment protocols. It is estimated that approximately one percent of the total budget will be used to procure pediatric ARV drugs; this figure is based on the Clinton Foundation's commitment to provide all required pediatric first line formulations during this time period.

Furthermore, USG-funded ARV drugs will be placed in the GRZ's central warehouse, Medical Stores Ltd. (MSL), where all public sector and accredited NGO/FBO/CBO/work-place/private sector ART programs will have access to these critical supplies. It is estimated that USG procurements, in combination with GFATM and Clinton Foundation purchases, will enable Zambia to place 130,000 patients on ART by mid-2008. Cost per patient is estimated at $37/month (based on the new national treatment protocols, to be enacted in mid-2007).

This activity links with the Partnership for Supply Chain Management Systems' (SCMS) activities in ARV Drug procurement (9196), Counseling and Testing (CT) (9523), and Policy Analysis/Systems Strengthening (9525); USAID / DELIVER activities in ARV Drugs (9520) and CT (9522); Centers for Disease Control and Prevention; Center for Infectious Diseases Research in Zambia (9000); Catholic Relief Services/AIDS Relief (8827); Churches Health Association of Zambia (8992), Zambia Prevention, Care, and Treatment Partnership (8885), Government of the Republic of Zambia (GRZ), the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM), and the Clinton Foundation.

The purpose of this activity is to procure essential HIV/AIDS laboratory commodities in support of the national ART program and to ensure that US Government (USG), GFATM, GRZ, and other partners' HIV/AIDS laboratory commodity procurements are in sufficient supply and available at service delivery sites through an efficient and accountable HIV/AIDS laboratory logistics supply chain system.

In FY 2006, the USG and the World Bank provided funding for the procurement of laboratory reagents to support the rapid scale-up of treatment and care for persons living with HIV/AIDS in Zambia. Also in FY 2006, the Ministry of Health (MOH), with support from USG, Clinton Foundation, and JSI/DELIVER, developed the first national HIV/AIDS laboratory strategic plan and provided technical assistance to GFATM Principal Recipients in developing proposals to include laboratory commodity procurements. Key issues identified during these exercises were weaknesses in the overall laboratory procurement and logistics supply chain management systems. To address these challenges, USG was able to leverage SCMS project core funds to conduct the first national HIV/AIDS laboratory commodity forecast and quantification exercise. Based on this information, it is anticipated that the FY 2007 USG laboratory commodity procurement will include the following: CD4 reagents [Beckman Coulter Epics XL, Becton Dickinson FACSCalibur, Becton Dickinson FACSCount, Guava Easy CD4 System (PCA)]; hematology reagents (BX Pentra 60C+, ABX Micros 60, Sysmex pocH-100i); chemistry reagents (Cobas Integra 400, Ortho Vitros DT60, Olympus AU400, Human Humalyzer 2000, Nova Biomedical Stat Profile pHOx Plus); and various consumables (e.g., EDTA vacutainer tubes 5ml, needles 21G, disposable gloves, pipette tips). The FY 2007 Plus-up funds will support the procurement of addtional laboratory commodities to provide an estimated 400,000 more tests as well as funding for limited maintenance/service agreements for the testing equipment.

To better ensure that these valuable commodities will be available in the correct condition, quantity, location, and time, SCMS is working to improve the national HIV/AIDS laboratory logistics system. For example, in FY 2006, using project core funds, SCMS is providing assistance in the following areas: assessing the status of the national HIV/AIDS laboratory logistics system, coordinating national procurements of laboratory commodities, conducting the first national HIV/AIDS laboratory supply chain design workshop, and initiating the first national training of trainers to begin implementation of the newly designed HIV/AIDS laboratory logistics system. In FY 2007, SCMS will continue its efforts to strengthen and to expand the national HIV/AIDS laboratory logistics system in at least 112 laboratories through the following activities:1) Quantifying and procuring USG-funded HIV/AIDS laboratory commodities consistent with resources and policies for rapidly scaling-up HIV/AIDS clinical services;2) Coordinating and developing HIV/AIDS laboratory commodity forecasting and procurement planning capacity at central, provincial, district, and service delivery levels;3) Standardizing HIV/AIDS laboratory commodity inventory control procedures at central, provincial, district, and service delivery levels;4) Developing and implementing an HIV/AIDS laboratory logistics management information system (LMIS) for all levels of the health care system, including adapting a logistics software program currently in use by JSI/DELIVER and the Ministry of Health (MOH);5) Standardizing, documenting, and disseminating HIV/AIDS laboratory commodity logistics policies and procedures; and 6) Monitoring and evaluating the HIV/AIDS laboratory supply chain and making improvements as needed.To complete these activities, SCMS, in collaboration with GRZ, GFATM Principal Recipients, and other partners, will train up to 500 key personnel in the new national HIV/AIDS laboratory logistics management system. Moreover, at the central level, SCMS will coordinate multi-year national HIV/AIDS laboratory commodity forecasts and procurement plans with all key partners, including GRZ and donors. SCMS will also be a key member of national technical working groups, such as the Ministry of Health's Procurement Technical Working Group and the HIV/AIDS Laboratory Committee.Finally, in

order to create a more sustainable HIV/AIDS laboratory commodity logistics system, SCMS will continue to improve national capacity through training and skills transfer programming that is consistent with the GRZ's vision of a fully-functioning national HIV/AIDS laboratory system.

This activity links with Project TBD's activities in Counseling and Testing (CT) (#9522) and ARV Drugs (#9520), the Partnership for Supply Chain Management Systems' (SCMS) activities in CT (#9523), ARV Drug (#9196), and Laboratory Strengthening (#9524), Centre for Infectious Disease Research in Zambia (CIDRZ) (#9000), Catholic Relief Services/AIDS Relief (#8827), Churches Health Association of Zambia (CHAZ) (#8992), University Teaching Hospital (UTH) (#9042), Zambia Prevention, Care and Treatment Partnership (ZPCT) (#8885), Government of the Republic of Zambia (GRZ), Global Fund of AIDS, Tuberculosis and Malaria (GFATM), and the Clinton Foundation.

The purpose of this activity is to provide support to GRZ policy makers, National HIV/AIDS/STI/TB Council (NAC), Ministry of Health (MOH), Ministry of Finance and Planning (MOFP), and other relevant stakeholders to implement the HIV/AIDS Commodity Security Strategy which is currently being developed with assistance from SCMS and JSI/DELIVER in FY 2006.

The development and implementation of a national HIV/AIDS Commodity Security Strategy will provide GRZ policy makers, NAC, donors, and other partners with a strategic plan outlining priority interventions to better ensure a sustained, appropriate supply of essential HIV/AIDS commodities required for the continuation of the national HIV/AIDS program following intensive PEPFAR support.

More specifically, in FY 2006, the US Government (USG) leveraged SCMS project core funds to facilitate the development of a national HIV/AIDS Commodity Security Strategic Plan. This strategy is being developed in close collaboration with GRZ, NAC, Ministry of Health (MOH), and other key stakeholders, such as CHAZ and the Clinton Foundation. Additionally, SCMS is currently conducting an analysis of existing policies, procedures, guidelines, and programs to identify commodity security issues that must be addressed in order to better ensure the availability of key HIV/AIDS commodities (e.g., HIV test kits, ARV drugs, laboratory reagents). An assessment of the HIV test kit and ARV drug logistics system was completed in FY 2005 by JSI/DELIVER; this information is being used to inform the strategic plan as well. Once the analysis is complete, SCMS, in collaboration with GRZ, will host a launch event to raise awareness of and build policy-level support of the need for HIV/AIDS commodity security.

In FY 2007, an implementation plan for the HIV/AIDS Commodity Security Strategic Plan will be developed to foster local ownership and to provide monitoring and evaluation of progress towards commodity security. Furthermore, the newly formed national HIV/AIDS Commodity Security Working Group, representing 20 organizations, will ensure that activities are institutionalized and in accordance with the GRZ policies and procedures. Training will be provided to GRZ national, provincial, and district level staff, working group members, and implementing partners to increase their skills in advocacy for resources and management of essential commodities at the policy level.

Specific HIV/AIDS Commodity Security activities in FY 2007 include: 1) development of an operational plan for the HIV/AIDS Commodity Security Strategy, including specific indicators, measurable targets, and responsible parties for achieving desired outcomes; 2) continuous review, monitoring, and updating of the implementation of the HIV/AIDS Commodity Security Strategy; 3) advocacy for HIV/AIDS Commodity Security at all levels of the health care system: national, provincial, district, and community; 4) facilitate GRZ and donor coordination to harmonize various inputs into the national HIV/AIDS procurement systems; and 5) enhance GRZ's commitment to provision of these essential commodities through increased budgetary support.

The USG, GRZ, GFATM, Clinton Foundation, and other partners are committed to creating an environment that will allow for the sustained availability of these critical supplies; the implementation of the HIV/AIDS Commodity Security Strategic Plan will greatly assist in achieving this admirable goal.