This work is linked to JHPIEGO's other work with the Zambia Defense Force (ZDF), strengthening

integrated HIV prevention, care, and treatment services and systems and with the work of Project Concern

International (PCI) supporting Counseling and Testing and Palliative Care Basic Health Care (HBHC) and

support as well as JHPIEGO's work on integrating diagnostic CT into tuberculosis (TB) and sexually

transmitted infections (STI) services for mobile populations.

JHPIEGO is supporting the ZDF to improve overall clinical prevention, care, and treatment services

throughout the Zambia Army, Zambia Air Force and Zambia National Service around the country. The goal

is to ensure that the ZDF is able to provide quality HIV/AIDS services to all its personnel, as well as to the

civilian personnel who access their health system, including pediatric patients. This includes strengthening

the management and planning systems to support prevention of mother to child transmission (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) PMTCT, antiretroviral (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 MOH public sector mainly because the ZDF has its own heath system running

independently from the national one. 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. 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, FY 2006 and FY 2007, JHPIEGO and other cooperating partners such as PCI supported the

ZDF in model sites 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 STI and TB 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. In addition to training PMTCT service

providers and establishing quality PMTCT services at eight model facilities, the DFMS 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 Zambia National PMTCT training package covers the

following topics: community support for PMTCT; primary prevention of HIV/AIDS; family planning; infection

prevention; counseling; HIV testing; ARV drugs for PMTCT; maternal and child nutrition in PMTCT; PMTCT

in antenatal care, labor and delivery, and postnatal care for women and infants/children; and record-

keeping/logistics management. 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 2007 JHPIEGO was working with model

sites in all nine provinces.

JHPIEGO has supported quality integrated PMTCT services at 12 model ZDF sites, and will expand to an

additional four model sites in FY 2008. JHPIEGO will train at least 80 service providers in PMTCT to

expand service provision and to fill gaps left by service providers deployed for operations. Following the

training supervision visits will be conducted to the service providers and sites. These service providers will

be trained between September 2008 and September 31, 2009.

JHPIEGO has continued to expand facility-based performance improvement systems 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. The facility-based performance improvement system follows the JHPIEGO Standards Based

Management and Recognition (SBM-R) methodology.

Building on the service linkage developed between PMTCT and ART, JHPIEGO has integrated 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 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, supportive

supervision visits will continue to the 12 facilities, as well as the four FY 2008 expansion sites.

JHPIEGO has also supported the DFMS to conduct workshops using the orientation package for lay

workers on HIV/AIDS prevention, care, and treatment covering CT, PMTCT, Care, and ART as well as

linkages to other services such as TB and STIs. It is designed to educate the readers on HIV/AIDS and

provide them with accurate and relevant information they can disseminate to more diverse populations. In

FY 2008 an additional 30 lay workers will be trained using this package. This has enhanced advocacy

efforts to secure sustained support for these services from both the management as well as the community

and client perspective.

Sustainability is at the core of the support JHPIEGO is providing the DFMS. DFMS training capacity has

been improved through the training of trainers. JHPIEGO has co-taught PMTCT workshops with the DFMS

trainers to help them improve their training skills and address any gaps. DFMS management and

supervision capacity has been improved by providing them with the knowledge and tools they need to

support service outlets and to assess performance in a standardize way. JHPIEGO has worked to close the

divide between initiatives in the MOH and DFMS by making sure DFMS is represented and considered in

Activity Narrative: the planning and execution of national plans, including logistics management information systems,

electronic medical record systems, and the dissemination of national guidelines, protocols and plans. In

addition JHPIEGO is working to ensure sustainability in the DFMS training institutions through curricula

development and the improvement of existing training facilities.

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 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) and is closely coordinated with the USAID-funded Injection Safety program.

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

prevention of mother to child transmission (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) PMTCT, antiretroviral therapy (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 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. 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 (ECZ), Medical Council of Zambia (MCZ), 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, FY 2006 and FY 2007, 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. Between FY 2005 and FY 2007, over 600 service providers and service outlet

managers from over 50 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.

JHPIEGO has continued to expand facility-based performance improvement systems 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. The facility-based performance improvement system follows the JHPIEGO Standards Based

Management and Recognition (SBM-R) methodology.

In FY 2008, utilizing the IP/IS trainers trained, JHPIEGO will co-teach and train 150 providers from all

different cadres including cleaners, medical assistants, and service providers. These workshops will be led

by the DFMS IP/IS trainers with JHPIEGO staff providing support 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 jointly conduct supportive supervision visits throughout the ZDF to ensure knowledge transfer and to

provide "on-the-spot" training to address any gaps. Facility-based performance improvement systems will

continue to measure change in IP/IS standards. The training of the service providers will take place

between September 1, 2008 and September 30, 2009.

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, ECZ, 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 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

Activity Narrative: stakeholders in the ZDF 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.

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 Other Prevention, HIV/TB and Counseling and Testing.

JHPIEGO is supporting the Zambia Defence Forces (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 prevention of mother to child transmission (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,

antiretroviral therapy (ART), palliative care, HIV-TB, other prevention 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.

Military personnel are subject to high risk of both sexually transmitted infections (STIs) and HIV, as a result

of the housing and social situations they find themselves 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 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

linking into the logistics management information system (LMIS) for ARV drugs and HIV test kits, as well as

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 messages and 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 CDC's counseling

protocols and training materials to incorporate diagnostic testing and counseling (DTC) into TB and STI

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 75 ZDF STI service providers. These training activities will be conducted by ZDF trainers with co-

teaching and supportive supervision provided by JHPIEGO. The training does not end at the conclusion of

a workshop. Follow-up supportive supervision to the service outlets will be conducted jointly with DFMS

supervisors to ensure that the skills and knowledge are being correctly applied and to provide on the spot

guidance addressing any gaps. This funding will go towards reproducing materials and training ZDF

personnel in Syndromic management of STIs. The training of the service providers will take place between

September 1, 2008 and September 30, 2009.

JHPIEGO has continued to expand facility-based performance improvement systems 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. The facility-based performance improvement system follows the JHPIEGO Standards Based

Management and Recognition (SBM-R) methodology.

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. Sustainability is also being addressed through

the implementation of standards for various services and a system for measuring whether or not standards

are being met. With a focus on building local organization capacity JHPIEGO has work with DFMS staff at

every step to develop the supervision tools and skills and in FY 2008 will encourage DFMS staff to take the

lead in conducting assessments of services and addressing gaps.

Sustainability is at the core of the support JHPIEGO is providing the DFMS. DFMS training capacity has

been improved through the training of trainers. JHPIEGO has co-taught workshops with the DFMS trainers

to help them improve their training skills and address any gaps. DFMS management and supervision

capacity has been improved by providing them with the knowledge and tools they need to support service

outlets and to assess performance in a standardize way. JHPIEGO has worked to close the divide between

initiatives in the MOH and DFMS by making sure DFMS is represented and considered in the planning and

execution of national plans, including logistics management information systems, electronic medical record

systems, and the dissemination of national guidelines, protocols and plans. In addition JHPIEGO is working

to ensure sustainability in the DFMS training institutions through curricula development and the

improvement of existing training facilities.

This program will build upon, and links closely with, JHPIEGO's DOD funded work in Other Prevention,

TB/HIV and ART as well as CDC funded work in TB/HIV and Counseling and Testing.

JHPIEGO is supporting the Zambia Defence Forces (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 prevention of mother to child transmission (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) PMTCT,

antiretroviral therapy (ART), palliative care, HIV-TB, other prevention 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.

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 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 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 linking into the logistics management information system

(LMIS) for ARV drugs and HIV test kits, as well as 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 (DTC) into TB and STI 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

training of the service providers will take place between September 1, 2008 and September 30, 2009.

JHPIEGO has continued to expand facility-based performance improvement systems 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. The facility-based performance improvement system follows the JHPIEGO Standards Based

Management and Recognition (SBM-R) methodology.

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. Sustainability is also being addressed through

the implementation of standards for various services and a system for measuring whether or not standards

are being met. With a focus on building local organization capacity JHPIEGO has work with DFMS staff at

every step to develop the supervision tools and skills and in FY 2008 will encourage DFMS staff to take the

lead in conducting assessments of services using the (SBM-R) tool and addressing gaps.

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 and with the work of Project Concern

International (PCI) supporting Counseling and Testing (CT) and palliative care, as well as JHPIEGO's work

on integrating diagnostic CT into TB and STI services for mobile populations.

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, including pediatric patients. This includes strengthening the management and

planning systems to support prevention of mother to child transmission (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) PMTCT,

antiretroviral (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 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 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 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 MOH 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 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 2007 JHPIEGO was working with model sites in all

nine provinces.

In FY 2008, JHPIEGO will support 16 model ZDF sites (initial 12 model sites plus four additional sites in FY

2008) providing comprehensive and integrated HIV/AIDS prevention, care and treatment programs,

including timely diagnosis and care for TB and other opportunistic infections.

This work will utilize and build on the experience, tools and methodologies developed in the larger public

sector MOH 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 supporting the training of 80 service providers in TB diagnosis and

management using ZDF training capacity developed in FY 2006 and FY 2007. 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. These service providers will be trained

between September 2008 and September 31, 2009.

To support performance improvement systems and quality HIV care, supportive supervision visits will

continue in all16 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

Activity Narrative: 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.

JHPIEGO will continue to strengthen and expand facility-based performance improvement systems, this

time by taking a low profile and allowing the mentored staff from model sites take a lead role in the

supervision and mentorship programs and only provide technical assistance where need be. To ensure

sustainability of quality work force JHPIEGO will work with the ZDF to identify one capable institution in

order to institutionalize the human capacity building. This institution will be developed to provide continued

in-service training on the various programs undertaken by JHPIEGO during the past years of work with

ZDF.

Additional Funds: With the additional $200,000, JHPIEGO will train 100 community counselors/treatment

supporters (CCTS) in counseling, HIV care services, treatment support and adherence support, based on

the TB DOTS model of community treatment support. In addition, JHPIEGO will print 1000 home visit

diaries for use by CCTSs to monitor patients and record vital patient information including missed drug

doses, patient activity levels, patient health status, side effects, etc.

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 and with the work of Project Concern

International (PCI) supporting Counseling and Testing and palliative care, as well as JHPIEGO's work on

integrating diagnostic CT into TB and STI services for mobile populations. It also relates to the pre-service

training component of the Health Systems and Services Program/USAID, 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 DFMS 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

Activity Narrative: 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 and on prevention of medical transmission/injection

safety 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 Health Systems and Services Program (HSSP)/USAID.

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 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 MOH, although significant

efforts are ongoing to bring these related services closer together. One area in which the ZDF is challenged

is in the overall management and planning for their health services, particularly when it comes to training

auxiliary health personnel and ensuring the reliable availability of essential commodities to serve the

patients at their various installations. During FY 2008, 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 (MAs), however they have limited, or no

training in HIV-related care and support. MAs are often called on, due to the lack of adequate professional

health staff, to work in the health centers in positions as high as that of Ward Masters, which includes

administrative and medical responsibilities. 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. There are different

levels/ranks of MAs and progression depends on the amount of training received. To attain the highest MA

level or rank can take two to three years.

To address deficiencies in MA training highlighted by the ZDF, JHPIEGO worked with the ZDF and other

collaborating partners, such as PCI, in FY 2006 and FY 2007 to develop a system to incorporate HIV/AIDS

material into training for MAs and standardize the training as MA's progress from one level to the next. This

system was developed to address those already deployed (in-service training) as well as strengthening the

basic MAs 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 MAs. JHPIEGO supported 20 faculty/trainers, who received updates

based on the revised curriculum, to train 100 deployed MAs in the core competencies.

In FY 2007 JHPIEGO supported the ZDF faculty/trainers to update 100 deployed MAs at different levels of

MA training. In FY 2008 MAs trained in FY 2006 and FY 2007 will be followed up to ensure that they have

retained knowledge from the training and to address any gaps on-the-spot while at the same time

supporting their progression through the program. JHPIEGO will also work with the ZDF and MAs just

starting the training to map out their progression and ensure that it follows the standards developed in FY

2006 leading to the training of 100 new MAs. Upon completion of training in the core competencies, MAs

will be prepared to disseminate accurate prevention information and to support the seeking of care and

adherence to treatment by HIV-infected military personnel. 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 MAs in the long term. The training of the MAs will take place between

September 1, 2008 and September 30, 2009.

The ZDF has experienced difficulties in planning and management of health and HIV clinical prevention,

care, and treatment services as well as gaps in supply chain, logistics management and client medical

records. 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 services, helping the ZDF adopt existing tools such

as the SmartCare electronic medical record system by training 20 service providers in it's use. JHPIEGO's

partner, John Snow International (JSI) Logistics Services, will assist in the area of logistics support through

supportive supervision of the 260 ZDF staff trained by JSI in FY 2007 in LMIS for ARVs and HIV test-kits

designed in FY 2007. In FY 2008 JSI will focus on developing a supply chain and LMIS for laboratory

commodities. This will build on lab assessment activities already conducted. JSI will provide dedicated

staff to provide technical assistance to DFMS and setup the already existing JSI Pipeline Software to

manage the ZDF procurement and supply situation for laboratory commodities. JSI will then conduct a

design workshop with the appropriate military personnel to develop and agree upon new logistics

management information and inventory control systems for laboratory commodities. Then JSI will work with

the ZDF to set up a unit to manage the regular reporting and ordering of laboratory commodities, including

making use of the recently revised supply chain management software developed to manage the MOH

national laboratory logistics system. JSI then train 100 ZDF staff on the LMIS and inventory control

systems. To ensure correct usage and address any gaps JSI will conduct joint ZDF and JSI monitoring

visits to the field to monitor the laboratory logistics system as well as the LMIS for ARV drugs and HIV tests.

JSI is also providing similar technical assistance to the MOH, and as such are well positioned to identify

areas and means to strengthen linkages between the ZDF and MOH procurement and logistics systems

(JSI/USAID).

These activities are nationwide throughout the ZDF, entailing extensive travel for follow-up supportive

Activity Narrative: supervision of both the Medical Assistants and the procurement and logistics systems. The core of the

activities will be conducted by ZDF and DFMS staff to ensure buy-in and sustainability of the programs, but

JHPIEGO and JSI will provide support to ensure quality and reliability. These programs will be led by the

DFMS with support form JHPIEGO and JSI. All training and systems management will be done by ZDF

staff supported by JHPIEGO and JSI to ensure that programs belong to the ZDF and are not dependant on

external management.