This activity relates to activity #9037.

Lusaka province has four districts, with the largest district being the capital city, Lusaka. The other districts are Kafue, Chongwe and Luangwa, the latter two districts being predominantly rural districts. Lusaka Province notifies over 30% of the total tuberculosis (TB) cases nationwide, though Lusaka district accounts for the largest proportion of these cases. Outside of the provincial capital of Lusaka, access to health care facilities and services, especially in Chongwe and Luangwa are limited, with many TB patients traveling 20-25 km to the nearest health facility. The implementation of TB/HIV activities in these three districts has lagged behind that of Lusaka and currently there are only 13 sites providing TB/HIV services. In the second quarter of 2006, of a total of 309 TB patients notified, 146 (47%) received counseling and testing for HIV. Lusaka district is well served with health services and has received considerable support for the implementation of programs through USG support to Centers for Infectious Diseases research in Zambia (CIDRZ).

In FY 2007 the USG will directly support the Provincial Health Office (PHO) to expand and support the TB/HIV integration activities in the three districts of Kafue, Chongwe and Luangwa. This will expand upon the TB/HIV integration activities that the USG has supported in Lusaka district through EGPAFG/CIDRZ and will result in the development of an additional 14 sites, bringing the total number of sites in the three districts to 27. The PHO will support the formation of a Provincial TB/HIV coordinating committee that will be tasked with the strategic direction and supervision of the TB/HIV integration activities throughout the province. Membership on this committee will include representation from the TB Program, Clinical Care Unit (which oversees HIV/AIDS care), antiretroviral therapy program, community care and advocacy groups, and HIV counseling/testing partners. Technical assistance for the implementation of the program will be provided by CIDRZ.

Limited human resources, coupled with an expected increase in patient-load as a result of TB/HIV integration, are a barrier to implementing and maintaining TB/HIV integration. This human resource shortage negatively impacts morale, supervision, and technical support. To address this, the PHO will support a TB/HIV coordinating officer that will be placed within the PHO. This officer will be responsible for coordinating TB/HIV activities, supervision, trainings, surveillance, and program monitoring and evaluation and will work closely with the Provincial TB/HIV committee, and the provincial TB officer to coordinate TB/HIV activities in the province and provide joint supportive supervision. Coordination of activities will be achieved through regular meetings with other partners funded by the USG for TB/HIV activities, such as Center for Infectious Disease Research in Zambia and JHPIEGO. Future support may be identified for TB/HIV coordinators to be placed at the district levels. Integrated TB/HIV training will be carried out in selected districts by the PHO, in consultation with JHPIEGO.

A training of trainers (TOT) program will be developed to provide trainers in all districts based on the national training curriculum. These trainings will focus on providing the skills for routine HIV counseling and testing of TB patients and management of TB, HIV, and TB/HIV patients. The training will also include TB screening for all clients testing positive for HIV in settings such as ART services, Prevention of Mother to Child Transmission (PMTCT) and Sexually Transmitted Infections (STI) clinics. Training will be provided to 93 health workers in TB/HIV integration and 207 community treatment supporters will be trained in TB/HIV links. Support will be provided for minor infrastructure renovations to improve the physical infrastructure in selected health centers to provide integrated TB/HIV activities.

All activities and trainings will be linked by the PHO with activities that are supported by recent district-level funding from the Global Fund to fight AIDS TB, and Malaria (GFATM). The GFATM has directly funded these districts to scale up TB control by strengthening DOTS and TB/HIV integration and care. Technical support and guidance for the use of this funding will be provided by the PHO. As a result of this support, TB patients will be tested for HIV in these three districts. Those found to be HIV positive will be referred for appropriate HIV care. TB screening of HIV -infected patients will be a key component of these TB/HIV integration activities. Links between the TB programs and other USG funded home based care programs will be established in order to ensure a continuum of care for the HIV infected TB patients. Regular review meetings will be linked to TB directly

observed treatment strategy (DOTS) review meetings and co-funded by the Global Fund supported TB DOTS program.

Of an estimated 1,600 TB patients in the three districts, 75% (1200) will receive counseling and testing over 12 month and approximately 840 (70%) will test HIV positive and be referred for HIV care and treatment. Of the 68,000 patients receiving HIV services 70% will receive routine screening for TB disease at least once

Links will be strengthened between the TB and ART services in order to ensure that all HIV infected TB patients are referred for ART, with screening to be based on the national guidelines. In order to ensure a continuum of care, the districts will develop links with USG funded and other organizations providing palliative care in a home based care setting.

To ensure sustainability, the trained staff will continue to provide the skills and knowledge. The activities will be enshrined in the GRZ district health plans.

This activity is linked to TB/HIV activity in LPHO, activities #8996 and #8991.

This activity will provide local support to Lusaka for implementation of the UTH national PMTCT and VCT quality assurance program within the districts of this province. Some major limiting factors for implementation, support and sustainability laboratory programs outside of the capital city are due to; 1) travel distances; 2) lack of transport for onsite supervision and feedback; and 3) lack of funds at the provincial and district levels. Although supervisory travel visits to Lusaka districts outside of the city can be done on a day trip, time and number of technical experts available are divided by the need to visit other sites throughout the country. The goal of this activity is to build capacity and sustainability at the local level by training and providing support for activities to be conducted by local staff within the province for PMTCT and VCT as well as care and treatment support. The goal will be to reach the six laboratories within rural Lusaka districts.

Lusaka is the largest province in Zambia. As such, access to services can be difficult due to distance and transport challenges. Availability of laboratory services in districts out side of Lusaka is limited due to several factors, which include technical human resources, lack of suitable infrastructure and services such as a source of power, geography, and increasing numbers of persons participating in prevention of mother to child transmission (PMTCT) and voluntary counseling and testing programs at local levels. Antiretroviral laboratory care and treatment services are limited. Sample preparation and transport support can alleviate the lack of services due to laboratory infrastructure and technical limitations. In FY 2007, onsite training and technical support for existing personnel in basic laboratory testing and transport will be assessed and provided. Laboratory quality assurance programs for rapid HIV testing currently performed in the VCT and PMTCT will be supervised and supported by the national HIV reference laboratory (UTH). An integrated program laboratory data management, and onsite quality assurance will assist in improving and equalizing antiretroviral therapy laboratory services to People Living with HIV and AIDS (PLWHA) in these areas. Support will be provided for basic infrastructure improvements and the provision of alternate sources of power such as solar panels at all laboratories currently lacking this infrastructure. This activity will support and complement the UTH National quality assurance program for PMTCT and VCT as well as other care and treatment support within the rural districts of this province.

Chongwe is the main source for HIV care anfd treatment in the district but the laboratory infrastructure does not support this capacity. Support has been provided through courier from Lusaka due to lack of infrastructure but the population demand is higher than can be provided by courier. Provisions for a new laboratory has been provided by a donor and CDC TA and equipment support for setting up the new lab is required. The Chainama laboratory is very small and the training laboratory is also in need of renovation to accommodate the patient care needs for the clinic and mental health institution. The facility provides training for Clinical Officers and provides rural health services for Zambia and a good training facility and clinical laboratory renovation is needed to strengthen training and direct service to the community.