The following activity is newly proposed for FY 2008.

In March 2005, Columbia began activities in Zambia with the aim of supporting the design, implementation,

and evaluation of Pediatric and Family Centers of Excellence (PCOE) throughout the country in partnership

and close collaboration with the Department of Pediatrics and Child Health at the UTH. Target sites include

UTH in Lusaka Province and the Livingstone General Hospital in Southern Province. The PCOEs serve as:

1) model facilities to provide state-of-the art comprehensive pediatric/adolescent HIV care and treatment

services, 2) referral centers for district clinics, and 3) training/dissemination centers for Zambia. Columbia

supports the PCOEs design and implementation by serving as a technical assistance provider, supporting

capacity building activities (including training and staff augmentation), and procuring targeted commodities.

In FY 2008, an additional area that Columbia University will address is pediatric tuberculosis (TB).

Diagnosis and treatment of tuberculosis is a global challenge, particularly in children. Tuberculosis and HIV

co-infection rates range from 11 - 64% in Sub-Saharan Africa. A postmortem study in Zambia showed that

among HIV positive children over 12 months of age, TB accounted for 32% of deaths and contributed as the

third most common cause of death in these children. It is estimated that the TB rate in the first 4 years of

life in children born to HIV-infected mothers is ten times higher than that in non-HIV infected mothers and 30

times higher in HIV-infected than uninfected children.

ICAP proposes to provide technical support in the area of pediatric tuberculosis, through technical support,

capacity building, clinical mentorship and training. ICAP will work with the Centers of Excellences as well

as several additional hospitals within the Southern Province to enhance diagnosis and treatment of TB in

HIV infected and exposed children and families receiving care at the centers. ICAP will also work directly

with the Provincial Health Office in the Southern Province to establish algorithms and protocols to enhance

diagnosis and management of HIV exposed children in households of adults with TB/HIV. Finally, ICAP will

support South-to-South exchanges and learning opportunities with pediatric HIV TB experts from South

Africa to foster improved radiographic and diagnostic capacity of providers and program managers

responsible for caring for children with HIV and TB in Zambia.

TB Diagnosis and Management at the Centers for Excellence

Currently through PEPFAR support all children admitted to the hospital wards in the Departments of

Pediatrics at the UTH and Livingstone General Hospital are routinely offered HIV counseling and testing

with same day results. ICAP would like to use the opportunity to provide routine tuberculosis screening to

all children and their families, particularly those who test HIV positive and all those negative but under the

age of 5 years. A screening algorithm will be adapted to include history of tuberculosis related symptoms,

clinical indicators, and history of TB contact within the household. The use of Tuberculin Skin Testing (TST)

testing will be explored to establish the feasibility and efficacy to determine TB infection status in this

population. All children without evidence of active TB disease (based on history, examination and a

negative TST response) will be considered for a 6 month course of Isoniazid prophylaxis against

tuberculosis based on national TB program recommendations.

Most children are exposed to TB through adult caregivers within the household/childcare setting. For this

reason, a routine TB screening questionnaire will be administered to the adult caregivers of all children

testing HIV positive. This questionnaire is used routinely for TB screening in a number of ICAP-supported

adult care and treatment programs and has been demonstrated to be an effective way to identify HIV

infected adults at high risk for TB disease. Adults with a positive screening questionnaire will be referred for

further evaluation. All pediatric household members will be screened for both HIV and TB.

ICAP will work with the multidisciplinary teams at the COEs to establish routine systematic TB screening for

all HIV infected children followed in care and treatment at the centers. This will include a routine periodic

assessment of clinical and historical findings indicative of TB as well as queries about new household

contacts recently diagnosed with TB. The adult screening questionnaire will be adapted for pediatric use.

Furthermore, the feasibility of TST will be assessed in the group of children who are immunologically

reconstituted and stable on HAART. Children in the outpatient department in whom TB has been excluded

will also be eligible for a course of INH prophylaxis.

ICAP will provide technical support to the COE to enhance the diagnosis of TB in children with HIV

infection. This will be accomplished through direct technical and clinical support and mentoring on site,

through the development of TB/HIV specific training and further exchanges with experts in TB/HIV in South

Africa. See below for further description.

Provincial Health Office in the Southern Province

ICAP will work with the PHO in the Southern Province to strengthen pediatric HIV/TB activities within the

region. Activities will focus on enhancing the diagnosis and management of TB in children infected with and

exposed to HIV at several large facilities as described above. In addition, ICAP will expand upon work

currently focusing on adults to include infants, children and adolescents. ICAP will explore the feasibility of

instituting the following activities:

All children and adults diagnosed with TB are currently routinely counseled and tested for HIV. ICAP will

work with the National TB program to help strengthen the implementation of the routine testing in follow up

care of children with TB

Institution of contact tracing for pediatric family members in households of adults with HIV/TB. All children

will be assessed for TB risk (as described above) and those less than 5 years of age without evidence of TB

will receive INH prophylaxis. Routine counseling and HIV testing will be offered to all children and

household members of adults with HIV/TB.

ICAP will also work with the PHO to develop practical algorithms and guides for diagnosis of TB in pregnant

women and facilitate implantation of these algorithms. TB takes a particularly large toll in pregnant and

postpartum women with HIV where the risk for progression from latent to active TB disease is accelerated

and impacts morbidity and mortality in the woman and well as her infant. ICAP will work with the PHO to

adapt the TB screening questionnaire and pilot its use at two PMTCT programs to assess the feasibility and

efficacy of identifying TB in pregnant and postpartum women.

Activity Narrative:

Supporting Training and South-to-South Exchanges for enhanced TB/HIV care in children

ICAP will support several training and mentorship activities in the area of pediatric HIV /TB. Pediatric staff

at the COEs have already participated in the South-to-South partnership with Tygerberg Hospital at

Stellenbosch University in Cape Town South Africa. The institution is well recognized for it's expertise in

the area of pediatric TB and has been at the forefront of research in the field. ICAP is working with pediatric

TB experts at Tygerberg to develop methods to disseminate knowledge and expertise to other high

prevalence HIV/TB settings. There are several opportunities currently under discussion:

A symposium on pediatric TB was held last year at Tygerberg Hospital. Plans are underway to hold another

symposium with greater attention to issues around TB/HIV co-infection. ICAP will support participation of 3

-5 key staff from the COEs and other facilities to attend the meeting in South Africa.

Experts from South Africa will be invited to Zambia to participate in a TB/HIV symposium for approximately

15 to 20 site staff where key subject areas around diagnosis, management and treatment of TB in the

context of HIV infection will be reviewed and discussed. Special attention will be paid to enhancing skills of

practioners to read pediatric x-rays. The meeting will be designed to inform policy decisions as well as to

provide formal didactic sessions to clinical providers and program managers.

ICAP will work with experts in South Africa to develop other opportunities for exchange of expertise and

learning. Other opportunities that will be explored will include expansion of the South-2-South program to

enable at 5 pediatric HIV experts from Zambia to spend 1-2 weeks at several TB programs in Cape Town

including Brooklyn Chest where they can gain expertise in diagnosis and management of HIV/TB including

reading x-rays of children with pulmonary disease. This will be followed up with training of 30 health staff in

Zambia to transfer knowledge from the South African program.

An estimated 300 children will be reached with dual HIV and TB services at the end of FY 2008

ICAP, in conjunction with UTH and National TB program will hire a Zambian Pediatric TB/HIV advisor who

will provide technical support, training and logistics management working closely with the Ministry of Health

and the National TB Working Group. This will help build capacity in Zambia and allow for future

sustainability of program in Zambia. Funding for this activity will be used to purchase commodities including

the TST tests and accessories, Isoniazid for TB prophylaxis as a single formulation (currently only

combination formulations available), local training activities, and support to the proposed South-2-South

exchange program

Targets set for this activity cover a period ending September 30, 2009.

The funding level for this activity in FY 2008 has increased since FY 2007. Narrative changes include

updates on progress made and expansion of activities.

This activity relates to activities with laboratory strengthening, the University Teaching Hospital (UTH)

Family Support Unit (FSU), UTH Pediatrics, and UTH TB/HIV programs.

In March 2005, Columbia began activities in Zambia with the aim of supporting the design, implementation,

and evaluation of Pediatric and Family Centers of Excellence (PCOE) throughout the country in partnership

and close collaboration with the Department of Pediatrics and Child Health at the UTH. Target sites include

UTH in Lusaka Province, Livingstone General Hospital in Southern Province, and Ndola Central Hospital in

Copper belt Province. The PCOEs serve as : 1) model facilities to provide state-of-the art comprehensive

pediatric/adolescent HIV care and treatment services, 2) referral centers for district clinics, and 3)

training/dissemination centers for Zambia. Columbia supports the PCOEs design and implementation by

serving as a technical assistance provider, supporting capacity building activities (including training and staff

augmentation), and procuring targeted commodities. PCOE objectives include:

1) Increasing the capacity of the PCOEs to provide comprehensive HIV case management and pediatric

care and treatment services

2) Ensuring that key services such as clinical care, opportunistic infection prophylaxis, adherence and

nutritional counseling and psychosocial support 3) are integrated with the provision of antiretroviral therapy

3) Identifying and engaging HIV-exposed infants into follow-up services

4) Conducting early diagnostic testing of HIV-exposed infants using PCR technology

5) Increasing antibody testing of children >18 months of age

6) Implementing routine provider-initiated HIV testing for hospitalized pediatric and neonatal patients

7) Instituting a comprehensive patient follow-up and defaulter tracing program

8) Linking and collaborating with community and faith-based organizations to support complementary and

supportive services

9) Integrating child development and neurodevelopment assessments and interventions into routine care for

HIV exposed/infected children

10)Improve care and support for sexually abused children through close collaboration and linkage with a

multi-disciplinary team offering care to sexually abused children

11) Improve the physical and emotional well being of HIV positive children and their caregivers and families

12) Supporting comprehensive, efficient and effective monitoring and evaluation systems

13) Implementing training, supervision and capacity building in pediatric HIV/AIDS management, including

antiretroviral treatment

14) Enhancing and expanding human capacity resources to support a multidisciplinary team of HIV pediatric

and family care providers

15) Cooperating and collaborating with other HIV care and treatment activities in the respective PCOE

provinces

16) Disseminating lessons learned models and best practices to multidisciplinary teams and sites

implementing pediatric HIV/AIDS programs.

The program began implementation of activities at the UTH Department of Pediatrics in September 2005

and in Livingstone General Hospital in October 2006. Some of the system achievements to date include:

1) Recruitment of management and implementation staff to support the PCOEs,

2) Establishing data systems, logistics and referral flow between various service points,

3) Supporting ongoing and dynamic training, technical assistance and supportive supervision.

In 2006, 423 PCOE staff were trained in pediatric technical areas such as sexual abuse, palliative care,

child development, adherence, TB/HIV, and ART in pregnancy,

4) Establishment and initiation of the infant diagnostic protocols and guidelines.

In FY 2008, this program will continue to primarily provide technical support to the development and

operation of the existing PCOEs in UTH, Livingstone, and Ndola (Note: the Arthur Davison Children's

Hospital in Ndola will receive technical support in close collaboration with the USAID supported partner,

Zambia HIV/AIDS prevention, care, and treatment (ZPCT)/FHI.), and help the UTH Department of

Pediatrics with implementation of new sites in Mazabuka and Monze

Columbia will continue to support the PCOEs to offer comprehensive pediatric care and treatment by

ensuring that all exposed and infected children: 1) receive quality and continuous clinical care, 2) are

properly monitored and assessed for treatment eligibility, and 3) are continuously assessed for immunologic

response to treatment, toxicities and adverse events.

Columbia will begin to support the expansion and "down" referral of pediatric services for 2 district clinics

that filter into Livingstone and UTH PCOE (4 new sites). This will include supporting the sites by initially

supporting "satellite" clinic services by PCOE staff and in tandem building the capacity of the sites to

independently provide comprehensive pediatric care and treatment services. Columbia will do so by

supporting staff augmentation, training, task-shifting, clinic reorganization, and minor renovations.

Depending on the site needs, enhancing PMTCT services to deliver care and treatment to pregnant women

can be a focus for technical support.

Columbia will continue to expand child development by continuing the twinning relationship with Boston

University-SPARK Centre to ensure that child development and pediatric neurodevelopment

issues/approaches are integrated and applied as part of comprehensive care for the HIV infected child.

PCOE staff will continue to learn how to offer comprehensive and integrated services to address the

medical, developmental, emotional, and/or behavioral challenges of the HIV infected child via a multi-

faceted training approach.

Columbia will continue to support and expand comprehensive community outreach and patient follow-up

activities. This includes a patient follow-up and tracking program supported by teams of outreach workers

and "expert" caregivers trained in locating and supporting families of clients who have discontinued care

and treatment services. Additionally, Columbia will support PCOE community advisory boards to solicit

input from constituents to design and revise programs/services to ensure continuous quality services.

Columbia will continue to strengthen the pediatric patient tracking and monitoring system in the PCOEs by

Activity Narrative: implementing the Ministry of Health designed M&E tools and electronic data collection system on site in

addition to further enhancing local systems that track patients from inpatient testing through enrollment and

follow-up in care and treatment.

The UTH PCOE will continue to support and build National pediatric HIV/AIDS capacity by implementing a

comprehensive training program that includes onsite on-the-job training whereby staff at sites targeted to

initiate pediatric HIV/AIDS services visit UTH for rotation throughout the various PCOE clinical and

supportive services.

Capacity building will be supported by instituting a clinical fellowship program for advanced-level pediatric

infectious disease fellows. Fellows will be supported to rotate in the PCOEs where they will engage in

supporting clinical, teaching, and research activities. Each fellowship will bring specific expertise to the

PCOEs through applied study projects and cross-training activities (see prevention of mother to child

transmission activities). To promote sustainability, fellows from the US will partner with Master of Medicine

in Pediatrics fellows at the UTH to ensure exchange of knowledge and local building capacity.