See activity 8829

Table 3.3.11: Program Planning Overview Program Area: HIV/AIDS Treatment/ARV Services Budget Code: HTXS Program Area Code: 11 Total Planned Funding for Program Area: $ 46,933,284.00

Program Area Context:

The Government of the Republic of Zambia (GRZ) aims to expand anti-retroviral treatment (ART) to 90,000 adults and 10,000 children by the end of 2006. By 2010, the GRZ aims to have at least 160,000 clients on ART throughout Zambia. At the end of second quarter 2006, over 65,000 patients were receiving ART—double the number on ART a year ago. Furthermore, GRZ was able to increase access to ART by issuing a policy determination that made all public sector ART services free-of-charge (this applies to refugees and non-Zambian nationals as well). In line with the US Government (USG) Five-Year Strategy for Zambia and the Emergency Plan 2-7-10 goals, USG is contributing directly to achieving these national goals and will continue to assist in rapid expansion of ART services, including quality treatment for HIV-infected children and their families.

Given the magnitude of the HIV epidemic in Zambia, USG and partners work closely with the many donors and agencies providing assistance to the national ART program. Coordinating partners include: Global Fund for AIDS, Tuberculosis, and Malaria, World Bank, World Health Organization, United Nations, Medecines Sans Frontieres, Swedish International Development Agency, Japan International Cooperation Agency, European Union, Department for International Development, and many other multi-lateral organizations and private institutions.

As of August 15, 2006, Zambia had 126 ART centers, all of which are receiving USG support, either directly in the form of technical assistance/procurements or indirectly through procurements of ARV drugs and overall national system strengthening activities. During FY 2004, the focus was on building systems, human capacity, and infrastructure necessary for widespread delivery of HIV care and treatment. In FY 2005 and FY 2006, USG's emphasis, in partnership with the GRZ, was on expanding the number of sites providing ART, improving quality of care, and increasing ART uptake, including among children and their families. The scale-up plan included public, private, and NGO/CBO/FBO facilities in all nine provinces. This rapid scale-up of HIV/AIDS treatment services was very successful, including good clinical outcomes in urban and peri-urban primary care settings. In addition, tremendous progress was made during the past 12 months in providing access to ART in many rural public sector and faith-based health care facilities. However, remote and sparsely populated areas of the country still pose a major challenge to ART scale-up. To address this challenge, USG has increased its support to developing a national network of ART outreach sites in which doctors, trained in ART case management, travel to remote health centers on selected days of the month, bringing mini-labs, to train facility staff and provide HIV/AIDS clinical services to patients who would not otherwise have access to these quality services.

The Ministry of Health (MOH) and the National AIDS Council (NAC) have embarked on updating the adult ART treatment guidelines and are developing pediatric treatment guidelines with technical, financial, and logistical support from USG and its partners. USG is also assisting in the ART site accreditation system to assess institutional capacity for delivering ART according to national guidelines and standards. USG's partners have assisted in the development of national policies, plans, and guidelines necessary for the scale-up of ART services. Technical assistance will be continually provided to the national ART program and Technical Working Groups for program planning, evaluations, and updating of national training materials, protocols, and dissemination of these materials.

In FY 2006, USG partners further strengthened health systems to support ART services, including drug management and logistics, information systems, and human resource issues. By the end of FY 2006, USG will have procured over $16 million worth of ARV drugs for the national ART program. USG also supported linkages within facilities in order to integrate ART services with other clinical care services and between facilities to support the national ART network model. In FY 2007, USG, GRZ, the World Health Organization, and other key partners will formulate and implement a national ARV drug resistance monitoring strategic plan. Moreover, USG will promote operations research and strengthen evaluation of the impact of ART and quality of services.

According to MOH, approximately 2,900 HIV-infected children received ART in public-sector facilities by the end of second quarter 2006. An important goal in FY 2007 is to increase the number of infants and children receiving comprehensive care and treatment for HIV/AIDS, as pediatric access to ART is still relatively low compared to that of adults. This will be accomplished through expanding the ART outreach model, increasing access to Polymerase Chain Reaction (PCR) testing, and training ART providers in pediatric diagnosis and case management. An example is that USG and partners will assist the University Teaching Hospital (UTH), MOH, and partner institutions to create Centers of Excellence in outpatient pediatric and comprehensive family HIV treatment in Lusaka, Livingstone, and Ndola. Roll-out of infant HIV diagnosis on dried blood spots will also greatly assist in bringing HIV-infected infants and children into treatment at a much younger age. GRZ and USG are fully committed to reaching an overall national target of 15% children among all ART clients by the end of 2007.

An Adult Center of Excellence for ART at the UTH Department of Medicine will also be fully operational by the end of 2006 through USG support. These Centers will form a core network of pediatric and adult expert providers and will build on earlier USG investments in training Zambian providers in pediatric and adult HIV counseling and testing and ART. Furthermore, these Centers will demonstrate best practices and serve as loci for on-site training and referral centers for specialized/difficult cases. The USG further plans to refurbish medical facilities and laboratories for better delivery of care in each of the nine provinces of Zambia. To address the shortage of human resources, USG will also expand renovations to essential structures, including health centers and staff housing, to increase staff retention and quality of service provision.

In all activities nationwide, USG and partners foster local ownership of the ART programs for increased acceptance and uptake of ART services by local communities. To enhance sustainability, MOH, Provincial Health Offices, and District Health Management Teams are supported to lead increased access of ART. This goal is being achieved through coordinating ART services with Neighborhood Health Committees, Community Support Groups, and other local organizations to deliver health communication messages and strengthen community support for pediatric and adult ART. Improved linkages and well-functioning referral systems among tuberculosis, prevention of mother to child transmission, ante-natal care, STI, ART, and home-based care services have been essential to rapidly scaling-up ART services.

Program Area Target: Number of service outlets providing antiretroviral therapy 319 Number of individuals who ever received antiretroviral therapy by the end of 143,278 the reporting period Number of individuals receiving antiretroviral therapy by the end of the 110,840 reporting period Number of individuals newly initiating antiretroviral therapy during the 46,920 reporting period Total number of health workers trained to deliver ART services, according to 1,769 national and/or international standards

Table 3.3.11:

This activity relates to CRS (#8827).

AIDSRelief has continued to contribute to the United States Government's HIV and AIDS strategy in Zambia by activating and supporting 12 local partner treatment facilities (LPTFs) and additional satellite facilities to provide antiretroviral therapy, as well as HIV care and services to the greatest number of needy patients. As of July 2006, AIDSRelief had 7,057 patients actively ART out of which 404 were children and 19,034 patients are receiving basic care and support.

AIDSRelief has been successful in providing technical support to LPTFs by providing the training and technical assistance necessary for successful program implementation. A total of 107 persons have received clinical trainings conducted by AIDSRelief, with nine trained on Pediatric ART and 201 in ARV adherence. About 45 persons have been trained in SI and 62 on finance and compliance issues. Additional support to partners include the initiation of a bi-monthly newsletter that addresses current clinical issues and provide medical updates, the installation and training of personnel on automated CD4 technology, and the coordination of reagent procurement and instrument maintenance.

AIDSRelief continues to support the Zambian Government's HIV strategy and participates in multiple technical working groups and technical committees, including: the Medical Council Site Accreditation and Provider Certification Group; the ART Regimen Choice Meeting; the National Laboratory Instrumentation Working Group; the National Pediatric ART Regimen Choice Committee; the National Pediatric ART/OI Training Curriculum Development Group; and the working group for the harmonization of the Clinical forms for Zambia.

In keeping with its commitment to ensure that care and services continue to be delivered at a high standard, AIDSRelief has implemented a Quality Assurance/Quality Improvement (QA/QI) program at its LPTFs. This included conducting formal chart reviews at facilities that were activated in Year 1 and performing viral load measurements on 10% of patients who had been on treatment for greater than nine months. Analysis of the data is still ongoing and will evaluate viral load suppression, adherence, toxicities, switched therapy, loss-to-follow-up and causes of early mortality. It is expected that the results of this activity will inform future guidelines for ART initiation in a manner that minimizes mortality within the first few weeks of therapy.

In addition to the QA/QI process, the use of electronic data has led to easier access to patient records and cross-referencing. In addition, by using the pharmacy database, partners have been able to track would-be defaulters easily and implement early interventions such as home visits and counseling. This has contributed to improved adherence. By keeping track of the attrition rates, AIDSRelief and their partners have been able to implement timely intervention at LPTFs, such as community mobilization and revision of adherence strategies.

Building on fiscal year FY 2006, AIDSRelief will provide AIDS treatment services primarily through faith-based facilities that typically treat the most marginalized populations and provide services in rural areas. The cost of providing care in these areas is usually high due to poor road infrastructures that make it difficult and costly to transport supplies. The AIDSRelief goal is to ensure that people living with AIDS have access to ART and high-quality medical care. AIDSRelief believes that care and treatment for HIV-infected individuals should be integrated in the existing health care infrastructure to promote sustainability. AIDSRelief will provide ART for 15,000 patients at 16 faith-based hospitals and clinics, including the maintenance of 10,000 patients from FY 2006 and the expansion ART to an additional 5,000 patients in FY 2007. AIDSRelief Zambia will provide HIV care to a total of 42,000 individuals throughout FY 2007.

AIDSRelief will continue to provide, on a sustainable basis, the provision of ART to the greatest number of deserving patients consistent with good medical science, national priorities and programs, and cost-effective deployment of program resources. Sustainable ART programs will be supported by a commodities management system that ensures a continuous supply of drugs to patients by mobilization of patients and communities to encourage knowledgeable, consistent adherence to treatment plans. Adherence to treatment will be ensured through linkages with home-based/palliative care programs

established by CRS and other partners. These linkages are critical to monitoring the treatment adherence and preventing possible complications as a result of non-adherence. The treatment support specialist at the clinical level will be working with community health workers and volunteers from the existing palliative care programs to ensure the proper treatment monitoring as well as the ART education of patients and their buddies. Creating satellite point of service will help further expand the reach to patients in remote and rural areas of Zambia. ART services will continue to be enhanced by twinning sites from different geographical areas. This will ensure sharing experiences and lessons learned and will enable further capacity building of LPTFS. Training centers will continue to serve as resource centers for building the capacity of medical staff from other LPTFS as well as other ART providers in country offering more sophisticated services to patients on treatment.

These services are critical to providing quality HIV care and treatment, and have been an integral part of the AIDSRelief program since its inception. The targets for this activity are in CRS entry #8827.

See activity 8829

Table 3.3.11: