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.

CDC-Zambia will continue providing technical assistance to the Ministry of Health (MOH), the National AIDS

Council, and implementing partners in the continued expansion of prevention of mother to child

transmission of HIV (PMTCT) services nationally. In FY 2006, direct support was provided in terms of

educational materials for the national program, job aids for health workers, an assessment on infant and

young child feeding in the context of HIV/AIDS, and national dissemination meetings for both national and

international technical updates. In FY 2007, CDC-Zambia assisted the MOH to strengthen the monitoring

and data system from facility to national level reporting using the CDC-developed PMTCT monitoring

system and the SmartCare.

In an effort to improve the national PMTCT program and provide HIV treatment to children before they

become symptomatic, the United States Government (USG) has continued to support the Government of

the Republic of Zambia from FY 2006 to evaluate an inexpensive and less complex approach for use in the

diagnosis of infant HIV-1 infection in Zambia. This public health evaluation (PHE) focuses on an

inexpensive "boosted" p24 antigen and a much simplified dried blood spot total nucleic acid (TNA)

polymerase chain reaction (PCR) assay recently developed at the CDC. Using FY 2005 funds, equipment

for two different methods of infant HIV diagnosis has been installed by CDC at the National Infant Diagnosis

Reference Laboratory at the University Teaching Hospital (UTH) in Lusaka, These methods include the

regular Roche Amplicor 1.5 deoxyribonucleic acid (DNA) PCR assay and the TNA assay which detects both

ribonucleic acid (RNA) and DNA. Both techniques have performed very well in quality assurance and

quality control evaluations at the laboratory, including on dried blood spots collected from infant heel sticks

at University Teaching Hospital (UTH). By June 2007, a number of PMTCT sites across the country had

started sending infant dried blood spots routinely to the National Infant Diagnosis Reference Laboratory in

Lusaka. Early results show that it is feasible to provide early infant testing facilities at both rural and urban

sites. Further roll-out of PCR testing on infant dried blood spots will be implemented nationwide in FY 2008

based on the courier systems piloted in FY 2007, in collaboration with the Clinton Foundation. For difficult-

to-reach rural districts, an evaluation of other potential infant diagnosis testing strategies such as the ultra-

sensitive P24 antigen assay (a simple EIA technique) and/or other newer rapid antigen assays will be

conducted. This work will be conducted in close collaboration with UTH and with the University of

Nebraska-Lincoln, and with CDC Global AIDS Program (GAP) Atlanta.

In FY 2008, the USG will continue strengthening the national PMTCT program through the procurement of

back-up (buffer) supplies in-line with the U.S. Five-Year Global HIV/AIDS Strategy. As part of this activity,

the USG will procure supplies that are vital in the provision of the national minimum package of PMTCT

without national stock-outs. CDC will support the national PMTCT program with technical assistance and

support for study tours and other relevant programmatic reviews.

This activity will support continued technical assistance to the MOH and Tropical Disease Research Center

(TDRC) in the design of a PHE of pregnant women to examine the impact of PMTCT programs on

subsequent treatment outcomes in women and children (as well as a number of other related outcomes).

This PHE will take advantage of and contribute to several activities. These activities include: PMTCT,

antiretroviral therapy (ART) treatment, infant HIV diagnosis, pediatric antiretroviral therapy (ART), continuity

of care, monitoring and evaluation of programs, outcomes, and surveillance of ART treatment and

resistance in adults and children. The Global Fund will provide partial financial support for this research

effort whilst CDC-Zambia staff will provide expertise in evaluation design and facilitate the integration of

available programs and services. Additional support focusing on malaria during pregnancy and operational

research will be provided by the Gates Foundation and the World Health Organization. These efforts

provide a timely and unique opportunity for TDRC and CDC-Zambia to leverage innovative developments in

several strategic priorities supported by the President's Emergency Plan for AIDS Relief.

PUBLIC HEALTH EVALUATION

Title:

The title of the PHE is "Assessment of HIV Infection and Related Risk Behaviors of Zambian Men Who

Have Sex With Men (MSM) in Lusaka, Zambia." FY 2008 will be year 2 of the study, which began in

September of FY 2007 and will end in FY 2008. To date, a budget of $75,000 has been received and

expended, and expected additional monies needed for completion total of $50,000, which is being

requested for FY 2008.

Co-Investigators:

The local co-investigators are: Marc Bulterys, Qualifications: MD, MPH, PhD, Director, CDC GAP- Zambia,

Victor Mukonka, MD, Director of Public Health and Research, Ministry of Health, Alwyn Mwinga, MBChB,

MSc, DTM&H MMed, Associate Director for Science, CDC GAP-Zambia and Elizabeth Onjoro Meassick,

PhD, Associate Chief for Behavioral Science Treatment, Care and Prevention, CDC, GAP-Zambia.

Purpose of the Project, Methodology and Assessment Objectives:

The Purpose of this Public Health Evaluation it to 1), assess and estimate HIV prevalence and related

sexual risk behavior among n= 433 Zambian MSM in Lusaka, including the extent of MSM sexual

interaction with the female population. Respondent-driven sampling (RDS) will be used to identify and

reach 433 MSMs. Those reached through RDS will be screened for eligibility. Those eligible will be

enrolled into the assessment. Specific objectives of the assessment include:

1.Successfully train staff in informed consent procedures, RDS methodology, behavioral assessment using

ACASI, HIV counseling and testing, referral tracking, and other procedures.

2.Identify "seeds" (initial MSM contacts), and successfully screen and enroll eligible seeds into the

assessment.

3.Successfully screen and enroll eligible men into the assessment who are referred through coupons from

"seeds" and previous participants. Keep track of referrals by ID number; verify coupon authenticity; ensure

allowable maximum of 3 referrals per participant.

4.Screen potential participants for eligibility over the phone, and if eligible, schedule an assessment

appointment at the office.

5.Conduct the assessment appointments including: re-screen for eligibility; process informed consent for

participation; gather behavioral data using ACASI; complete HIV counseling and testing; provide HIV

prevention, care, and treatment referral information and assessment referral coupons for other potential

participants; distribute reimbursement for participant time and travel.

6.From the data for n=433 Zambian MSM in Lusaka, determine HIV prevalence and 95% confidence

interval. Analyze for demographic, behavioral and other factors associated with HIV infection.

7.From the data for n=433 Zambian MSM in Lusaka, determine rates of sexual and substance-using risk

behavior. Analyze for demographic, psychosocial and other factors associated with sexual risk behavior.

8.Establish community and scientific advisory boards to inform the assessment during the data collection

period.

9.Appropriately disseminate findings and implications from the assessment for the purposes of improving

HIV prevention and treatment services for MSM and perhaps other populations (e.g., female partners) in

Zambia.

2), allow USG Zambia to design and develop effective and targeted prevention and treatment programs for

MSMs. According to the 2004 MSM study undertaken by Zambia Association for the Prevention of HIV and

Tuberculosis (ZAPHIT) indicates that although all the respondents that were surveyed had knowledge about

HIV/AIDS and the common modes of transmission, 70% of them were not aware that they could be infected

with the virus through anal sex.

Progress to Date:

Progress of the study includes: training of three MSMs as Voluntary counseling and testing counselors,

formation of both the community and scientific advisory boards, training of project staff on data collection

methodology Respondent-driven sampling (RDS) and use of ACASI computer program. Also, renovation of

office space with sound proof walls for privacy. Being gay is illegal in Zambia this it was necessary to

identify and renovate a space that can provide greater privacy. Purchase of project supplies including office

supplies, equipments and compute programs, and office furniture.

Information Dissemination Plan:

Information dissemination plan includes the following: Findings from the study will be packaged and shared

with the Ministry of Health and the National AIDS Council to help inform the national prevention strategy.

Dissemination will be done through sharing reports and making presentations on the research findings.

Also three stake holder meetings will be held to share findings and brainstorm on way forward including

next steps.

Planned FY 08 activities include the following:

Budget justification for FY 2008 monies: Budget requested within the overall budget is $50,000 for FY

2008. Costs will support continuation of data collection, short-term hire of data analysts for input and

analysis of data, support to stakeholder meetings with MOH, NAC, and other partners and to continue to

Activity Narrative: support the continue the monthly community and Scientific Advisory Board meetings. It is also hoped that

technical assistant will be provide to help MSM community organize an advocacy voice. Support for

appropriate dissemination is also included for print reproduction and presentation to technical working

groups or an appropriate international conference.

Salaries/fringe benefits (local contracts): $ 25,000

Equipment: NA

Supplies (paper, forms, pens etc): $. 2,000

Community and Scientific Advisory Board meetings: $. 6,000

Laboratory supplies: $ 5,000

Stake holder meetings: $ 5,000

Travel (international): $7,000

Total: $ 50,000

Additional funds are being provided for technical assistance to prevention for positive program at the

Western, Southern, Eastern and Lusaka provinces.

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.

Since 2004, the United States Government (USG) has provided support for the purchase of back-up

tuberculosis (TB), opportunistic infection (OI), and sexually transmitted infection (STI) drugs to supplement

limited supplies available in the Zambia Defense Forces (ZDF) health facilities. In FY 2006, the Centers for

Disease Control and Prevention (CDC) provided technical assistance and built capacity of the ZDF to

provide effective and comprehensive palliative care to those in the armed forces and their families. These

funds were used to provide technical assistance and treatment of OIs, TB, STIs to 1,200 patients in the

ZDF. This activity, combined with the support provided by the ZDF, has resulted in a higher quality of care

for people living with HIV/AIDS (PLWHA) within these institutions. In FY 2006, this activity supported

building capacity for five new voluntary counseling and testing (CT) sites in Lusaka and Livingstone. Funds

were used to provide technical assistance in setting-up CT sites, monitoring, and furnishing these facilities

with the necessary laboratory equipment to carry-out CT activities. In collaboration with the district health

and hospital management teams, CDC procured basic furniture and equipment to bring the new sites into a

functional state. The Ministry of Health is currently strengthening the supply chain management system for

drugs, test kits, and laboratory supplies with support from the United States Government (USG) (activity #

9524).

In FY 2007, the focus of this activity has shifted to providing technical assistance and capacity building to

both the ZDF and University Teaching Hospital (UTH) to address the wide range of OIs, including support to

the diagnosis and management of STIs and back-up drugs for TB, STIs and OIs and laboratory supplies.

The USG hopes to ensure a comprehensive and sustainable package of palliative care services to Zambian

people living with and also affected by HIV/AIDS, specifically those who are now living longer due to

antiretroviral drugs. All palliative care services and activities funded by the USG in Zambia are now

coordinated by the newly formed USG Palliative Care Forum. The forum, represented by all USG partners

was established to coordinate palliative care approaches and activities within the USG and at the national

level to work with and link closely with the Zambia Palliative Care Association tasked with the development

of a national palliative care strategy, guidelines, and standard operating procedures.

In FY 2008, the CDC will work closely with the UTH Pediatric Centre of Excellence (Activity # 12230) to

support the creation of a mobile pediatric clinic. Children living in many disadvantaged remote communities

of Lusaka are unable to access basic health care services mainly due to abject poverty. The set-up of this

mobile pediatric clinic will entail the purchase of a fully equipped mobile health unit and provision of

comprehensive primary health care services to children as close to their homes as possible. The team will

work with the local community leaders in order to ensure that the community is aware of the schedule of

visits by the mobile team. The services will include regular growth and development monitoring,

immunizations, health education, clinics for the sick, psychosocial and HIV counseling services, as well as

linkages with local community initiatives that will positively impact children's health care. The success of this

mobile initiative will determine the scale-up of similar activities in the coming years to areas outside the

Lusaka District, especially if this demonstrates a better coverage of children in HIV/AIDS treatment and care

programs

CDC Zambia will provide technical support to the Department of Pediatrics and Child Health at the

University Teaching Hospital in the set up of mobile pediatric clinics in the peri urban communities of

Lusaka. These will be comprehensive clinics that will provide primary health servies including HIV

counseling and testing services for children in peri urban Lusaka.

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 in counseling and testing, laboratory infrastructure, palliative care: basic

health support activity, and HVTB. Provision for the following activities in support of the national

implementation of TB/HIV activities is being requested: 1) technical assistance for development and

evaluation of surveillance system for TB/HIV implementation; 2.) Provide supportive technical supervision to

the Southern, Western, Eastern and Lusaka provinces; 3) inclusion of TB/HIV data elements in the

SmartCare Electronic Health Records to improve patient care.

In FY 2007, the US Government (USG) provided support to the Ministry of Health (MOH) in the national

integration of Tuberculosis (TB) and HIV services by providing support to a variety of areas at the national

and local level, including support of TB policy processes, adaptation of guidelines and materials, and

preparation of TB clinical decision support systems. A National level TB/HIV coordinating body within the

MOH with the following membership; staff from the TB, HIV, counseling and testing (CT) units in MOH;

multilateral organizations; research groups; faith-based organizations; non-governmental organizations; and

community representatives.

This body was tasked with developing and implementing a single, coherent TB/HIV strategy, policy, and

communication message based on the best existing evidence. As a result national guidelines for the

implementation of TB/HIV activities were developed based on the World Health Organization (WHO) Interim

Guidelines for TB/HIV collaboration. Additional support was provided for the revision of TB data collection

forms and registers, based on WHO forms that incorporate the collection of HIV data. The USG produced

the revised patient treatment form, identification card, and registers that have been distributed to all

provinces and districts. Technical support was provided for the orientation of health staff in the new forms.

In addition the USG co-funded, with the MOH, WHO, and JHPIEGO, a training of trainers session for an

initial group of 25 trainers in diagnostic counseling and testing using the national training module adapted by

JHPIEGO (#9032).

In FY 2007, the USG provided technical support to the Ministry of Health for the evaluation of surveillance

systems for TB/HIV implementation. A pilot evaluation of the revised TB/HIV reporting and recording system

in Southern (21 health facilities) and Copperbelt provinces (17 health facilities) was conducted. The findings

showed that the recording and reporting systems needed strengthening and there was need to conduct a

country wide evaluation. The USG will directly fund the NTP to conduct a National TB/HIV surveillance

system in all the provinces in FY 2008. The findings of this national evaluation will bring out the strengths

and weaknesses of the program and will facilitate proper planning to make the NTP achieve better out

comes in TB/HIV activities. Technical assistance for this evaluation will be provided by the USG.

In FY 2008 the USG will provide supportive technical assistance to the NTP through supervision to the

provinces, districts and health facilities in Southern, Western, Eastern and Lusaka provinces. During these

visits, on the job training will be conducted to the staff. It is expected that 100 health care providers will

receive on the job training. The supervision will be combined with the National TB program staff.

To sustain policy and clinical decision-making for future expansion of national TB activities, CDC has

assisted the MOH in establishing an Electronic Health Record (EHR) standard that now includes TB data as

well as HIV and other opportunistic infections (OI's) data. In the last year, this EHR, now called SmartCare

(previously called CCPTS), was established as the national standard software for use in any clinic that

could support a computer. This remarkable consensus achievement by the MOH is being followed by

national training and deployment at the same time as there is ongoing development of the out patient

department (OPD) module that will include TB care planned for release in 2007. The SmartCare already

addresses TB care in the context of antiretroviral (ART) services, but the pending OPD module will establish

a bidirectional link between OPD TB services and ART TB services provided either by a patient-carried

smart card or via a periodic facility-by-facility database ‘merge'.

The EHR system and smart card carries a longitudinal record of a client's medical history, including prior

illness, physical findings, lab results, symptoms, problem list with diagnoses, and treatment plan for all

these services. A paper and electronic copy of patient information is maintained at all clinics visited, and

paper records are still used for primary data capture in most settings. Accessible and integrated information

provides one basis for improved TB care, and this will become available in the higher density settings in

2007. As the core element of the SmartCare system, the electronic record provides: 1) more fully informed

local decision support; 2) reminder reports to staff to help keep patients from "falling through the cracks" (to

assure adherence and minimize resistance); and 3) improved management of general facility operations

(such as drug utilization) by automating key management elements of local monitoring and evaluation and

logistics support.

During May and June 2007, with strong USG support, the MOH held a series of three national trainings for

180 district and provincial leaders from all 72 provinces, as part of scaling up the SmartCare deployment.

In FY 2008, emphases will be on refinement of the TB service within the OPD module, addition of suitable

decision support cross-referencing other health conditions and potentially interacting medications, and

primarily scaling-up of this service increasing numbers of clinics nationwide. Building on previous year's

successes in HIV and antenatal clinic/prevention of mother to child transmission/CT services, SmartCare is

now supporting around 90,000 PLWHA. This year's funding will increasingly focus on building the capacity

of the MOH and collaborators within Zambia to implement and scale-up the TB/HIV module of the

SmartCare for purposes of sustainability, and to operationalize automatic links between increasing numbers

of SmartCare service modules in order to better care for TB-HIV patients with these concurrent illnesses

and OI's. Together with the related activities, these funds help assure that the OPD TB to HIV services link

spreads throughout the country with this same deployment effort.

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

The funding level for this activity in FY 2008 will remain the same as in FY 2007. Only minor narrative

updates have been made to highlight progress and achievements.

This activity will link to activity. The following activities are being requested:

1) Printing of the Participants manual for training TB/HIV treatment supporters. 2) Printing of TB/HIV news

letter. 3) Support for attending International seminars and conferences.

Tuberculosis remains a major health problem in the health care delivery in Zambia. The incidence and

prevalence rates continue to increase from 1985 due to HIV/AIDS. The burden of TB has risen more than

five fold since HIV/AIDS was first diagnosed in Zambia. The increase in the number of HIV/AIDS related

diseases has made it difficult for the health care system to accommodate all the chronically sick and TB

patients in hospital wards. Many of these patients are therefore discharged or referred to be managed in

their homes by the community health care providers with technical support from the trained health staff. The

Ministry of health has also been highly burdened by the attrition of trained health staff through resignations,

deaths, retirements and other reasons. Many health centers are managed by one or two trained staff.

Others are managed by non health trained staff.

Community initiatives implemented in Ndola by World Health Organization (WHO) in 1998 and Monze by

the Catholic Church showed better results in terms of case holding and better TB out comes. These

community initiatives demonstrated that effective community participation is key for successful Stop TB

strategy.

The Ministry of Health through Central Board of Health endorsed the integrated community based DOTS

approach in order to strengthen TB control in the district hospitals and health centers. This new approach

aims to provide a quality integrated TB services to the people by means of standardized diagnosis, care,

support and community based treatment.

In order to expand the community based Stop TB strategy, health workers and community volunteers

needed standardized knowledge and skills.

In 2005, the USG supported the development and printing of a Facilitators Manual for training TB treatment

supporters. This manual was developed in collaboration with the Ministry of Health, the USG, various

community based organizations and the TB committee of Care and Treatment working Group. This manual

is widely used by the Ministry of Health institutions, Non governmental organizations, community based

organizations and faith based organizations when training the TB treatment supporters.

Despite the availability of this facilitators manual for training TB treatment supporters, a gap still exist in

terms of material for the community volunteers to refer to after the training.

In FY 2008, the USG will develop and produce a reference hand-book for the treatment supporters. This

hand book will be in line with the materials in the Facilitators manual for the training of TB treatment

supporters. It is hoped that every volunteer to be trained in the country will be given a copy of the

Participant's hand book for training TB/HIV treatment supporters.

TB/HIV co-infection has presented a lot of challenges in the management of these diseases such as; the

diagnosis, care, support and treatment (fixed TB drug combination and the co-treatment with ART),

mobilization of communities, incentives for the volunteers and patient involvement; screening, counseling

and testing of TB patients for HIV; and screening of HIV infected patients for TB. Other issues include

development of linkages and referral of patients between the\ different service areas; the recording and

reporting of TB/HIV information on the data collecting and reporting tools and challenges to do with infection

control in TB/HIV settings, patient, family and community education.

Some of these challenges are handled some what different from place to place depending upon the

knowledge and skills the health care workers and the community volunteers have and the different

administrative support given. There is therefore a need to ensure that experiences in implementation of

TB/HIV activities indifferent provinces and districts are shared.

In FY 2008, the USG working in close collaboration with the Ministry of Health National TB program will

solicit for articles on TB/HIV from the Provincial Health Offices, districts and the communities and other

partners in order to share knowledge, skills and other experiences in the management of the challenges in

TB/HIV programming. Using these materials a quarterly TB/HIV news letter will be produced and

distributed to all stake holders. It is hoped that this news letter will go a long way in providing technical

support to the different players in TB/HIV by applying positive strategies used else where to implement

activities which were challenging.

In FY 2008, international seminars and conferences will be attended to sharpen knowledge and skills and

share experiences with other players in TB/HIV programs.

Additional support will be provided for the TB/HIV international expert hired through the Comforce

mechanism (see Activity #)

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

Reprogramming: 10.08: Funds are being requested to be reprogrammed to an implementing partner,

NASTAD, to support the cost of the model finalization, publication, and associated travel costs for the

consultant to disseminate the information.

The title of the PHE is "The role of supportive services in the provision of ART." This is a continuation of a

targeted evaluation in FY 2007. FY 2008 will be year 2 of the study, which began in FY 2007 and will end in

FY 2008. To date, a budget of $60,000 has been received and expected additional monies needed for

completion total $100,000, which is being requested for FY 2008.

Lead Investigator: John T. Grove, MA CDC-Zambia Staff

Proposed co-Investigator: Dr. Jack Homer, Independent Consultant

Local co-investigator: Lungowe Mwenda Mwapela, CDC Staff, MOH TBD, NAC TBD, USG Partner TBD as

required

The study represents collaboration among the Government of the Republic of Zambia and USG

implementing partners providing HIV/AIDS ARV services and technical support in Zambia through a

technical committee.

The purposes of this Public Health Evaluation (PHE) are to: 1) evaluate the relational or non-relational

linkages between ART treatment success and affiliated supportive services in 4-6 ART provision areas in

Zambia so as to inform models for sustainable service provision; and 2) utilize emerging evaluation

approaches, in this case systems theory based, to model the availability, volume and value of supportive

services in relation to clinic-based services, so as to inform program planners, clinicians, community

workers, and policy makers on essential components of successful long-term treatment models including

task reallocation. At present, a system dynamics model which would simulate the role of supportive services

during a "surge" event such as an overburdened clinic will be developed and tested using prototypical and

real data from key sites.

Progress of the study to date includes the following: 1) administration of a comprehensive qualitative

stakeholder assessment that determined: the primary evaluation questions of interest in relation to ART

and supportive services; the pros and cons of current monitoring and evaluation approaches; the primary

obstacles or areas of concern related to using emerging evaluation approaches; 2) individual meetings

with national and USG technical experts were convened to: finalize evaluation questions and options; and

develop an evaluation scope and desired deliverables; and 3) consultation services in the area of systems

modeling were identified and training on modeling software and development of a model prototype will take

place in December 2007. Based on the above activities, an evaluation protocol is currently in development.

Lessons learned include the following: The ART scale up in Zambia has examined largely clinical success

of treatment programs in terms of the increased numbers of patients on treatment and treatment initiation.

Evaluations to date have not tended to include related supportive services as factors of success or non-

success. Stakeholder interviews indicate that it is important to begin to evaluate and document the

relationship of these services with specific respect to site "surge" capacity and possible task-shifting

approaches. It is also evident that the ability to look at the "whole picture" of HIV/AIDS care is limited by our

current planning and evaluation approaches and new methods could be used to gain greater insights

through a broad perspective on care and support.

Information dissemination plan includes the following: Findings from the study will be packaged and

disseminated to in-country SI and programmatic technical working groups, with guidelines on utilization of

quality indicators for improvement of program service delivery. Findings may also be disseminated more

widely through appropriate international conferences and journals.

Planned FY 08 activities include the following:

Budget justification for FY 2008 monies: Budget requested within the HTXS/CDC overall budget is

$100,000 for FY 2008. Costs will support travel to conduct field work, international travel for appropriate

training, consultancy services for systems modeling, short-term hire of data analysts for input and analysis

of data as required, support to stakeholder and dissemination meetings with MOH, NAC, and other

partners. It is anticipated that some of the funds requested would be reprogrammed to an organization

such as NASTAD in order to facilitate logistics and administration of required consultancies. A small lunch

allowance will be provided to participants in interviews and focus groups. Support for appropriate

dissemination is also included for print reproduction and presentation to technical working groups and

appropriate international fora.

Budget for FY 2008:

Equipment (Software):$ 3,000

Supplies (Paper, forms):$ 5,000

Travel (local, international):$15,000

Participant Incentives (lunch, teas):$ 3,000

Other (Consulting services, Planning Meetings venue):$ 70,000

Other (Dissemination Meeting):$ 4,000

Total: $100,000

Reprogramming 10.08: A reduction in the CDC/HTXS TA funds is being requested to support the Univerisity

of Zambia (UNZA) School of Medicine (SOM) to strenghthen medical training facilities and programs toward

long term improved treatment outcomes. UNZASOM is the only medical school in the country and therefore

the best implementing partner for these activities.

The funding level for this activity in FY 2008 has decreased since FY 2007. Only minor narrative updates

have been made to highlight progress and achievements.This activity links to all ART activities

Implementation of the surveillance for antiretroviral (ARV) drug resistance and procurement of equipment

for the activity is in process and technical assistance for the development of surveillance for HIV-1

antiretroviral drug mutations has been provided by the United States Government (USG).

The USG, through the Centers for Disease Control and Prevention (CDC), plans to support technical

assistance to the Government of the Republic of Zambia on: 1) surveillance of antiretroviral (ARV) drug

resistance; 2) supervisory visits to project sites in four provinces to evaluate antiretroviral therapy (ART)

service delivery and quality improvement; 3) a systems-theory-based analysis of essential services

exercise; 4) collaboration with MOH and the World Health Organization (WHO) on ARV drug resistance

surveillance; and 5) critical electronic medical record systems.

With the increased, widespread availability of ARV treatment in the public health sector, it is expected that

with time the numbers of drug resistance cases will increase. In FY 2005, in response to a specific request

from the Ministry of Health (MOH), the USG provided technical assistance to the national ART program in

developing a national plan for surveillance for HIV-1 antiretroviral drug mutations. In FY 2006 and 2007, the

USG provided support for the procurement of equipment and supplies, as well as training for laboratory staff

in testing for ARV drug resistance, in collaboration with Japan International Cooperation Agency, the

University of Nebraska-Lincoln, and the University of Alabama-Birmingham.

In FY 2008, the USG will continue to provide technical assistance to key sites to ensure ongoing monitoring

of drug resistance nationally, in close collaboration with the WHO, MOH, and all cooperating partners in

provision of ART services. ARV drug resistance testing will also become part of HIV care among children

who maintain high viral loads despite ongoing treatment at the USG-supported Center of Excellence for

Pediatric and Family HIV Care at the University Teaching Hospital Department of Pediatrics. CDC provides

technical support to the national ART program and its coordinator to include quality improvement,

monitoring and evaluation, and health management information systems. FY 2008 funds will support

technical assistance from CDC care and treatment and strategic information (SI) teams to the national

program focusing on a quality improvement initiative in coordination with SI activities such as the expansion

of the SmartCare Electronic Health Record system and an ART cluster evaluation. SmartCare was

identified as the national electronic medical record system for ART and is to be used in all sites where a

computer is used.

CDC-Zambia staff are engaged with the WHO on ART quality and guideline development for pediatric and

adult ART as well as medical information data standards. Occasional travel and local meetings are required

on these tasks. In addition, funds within this activity will also used for staffing costs needed to monitor the

scale-up of ARV services and infrastructure rehabilitation.

Reprogramming 10.08: A reprogramming of funds from CDC Lab/TA to 2 implementing partners: 1) $200K

to Lusaka Provincial Health Office to support lab renovations; 2) $200K to University Teaching Hospital to

support the Microbiology unit. See subsequent activity reprogramming sheets for further details.

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 is linked to all TB/HIV activities in Eastern, Western, Southern and Lusaka Provinces and for

the Ministry of Health, as well as the University of Nebraska, CIDRZ, and JHPIEGO.

Technical expertise, material support, and human resource capacity strengthening are critical for building a

sustainable laboratory program for diagnosing and managing treatment of HIV/AIDS, tuberculosis (TB) and

other opportunistic infections. In FY 2005, 2006, and 2007 automated chemistry, hematology, and CD4

analyzers were placed in three provincial hospitals; Livingstone, Lewanika, and Chipata General.

Automated full blood count and CD4 analyzers were placed at district sites in Southern Province. Care and

treatment support and human resource capacity was expanded in the Department of Pediatrics at University

Teaching Hospital with the implementation of automated chemistry and hematology analyzers. Instrument

validation and correlation function studies on different testing systems was a major milestone for the

implementation of the national quality assurance program. Strategic laboratory reagents and consumable

acquisitions with national maintenance and service agreement for automated systems were provided. FY

2006 and 2007 marked a period in which laboratory reagents were in continuous supply to Government of

the Republic of Zambia (GRZ) Medical Stores Facility for care and treatment support to the national

antiretroviral (ARV) program.

This activity continues to support: 1) expansion of laboratory technical expertise through training and quality

assurance (QA) to the Ministry of Health (MOH) laboratories national reference, provincial, district, urban,

and rural health centers, as well as at the University Teaching Hospital (UTH); 2) renovation and expansion

of support for CD4 staging, liver and kidney function testing, and treatment services at the training center at

Chainama College in Lusaka; 3) installation of integrated computer systems and implementation of a

laboratory information system for data management to improve the documentation of patient test results,

tracking of reagent procurement and consumption, and QA efforts; 4) strengthen the palliative care system

by improving detection and treatment of opportunistic infections commonly associated with HIV/AIDS; 5)

provide technical support for infant HIV diagnosis with dried blood spot (DBS) analysis in children at the

Arthur Davison Children's Hospital (ADH) in Ndola and other regions in Zambia; 6) support much needed

improvements in laboratory infrastructure at key district-level and rural health facilities in Eastern, Lusaka,

Southern, and Western Provinces; and 7) provide laboratory staff travel support for training and supervisory

visits to testing sites to ensure proper equipment operations, feedback, and to reinforce system

strengthening.

In FY 2007, infant HIV DBS sample collection and transport expansion to three reference laboratories within

the country with integrated sample transport twice per week pickup for both DBS and TB samples is

improving test result turn-around time. The MOH and National HIV/AIDS/STI/TB Council (NAC) recently

adopted a national algorithm for rapid HIV testing using a non-cold chain algorithm. In FY 2007, CDC with

other cooperating laboratory partners, collaborated with MOH to customize the World Health Organization

(WHO) HIV guidelines and training curriculum for counseling and testing. Implementation of the first

"master trainer of trainer "HIV workshop was held in FY 2007. A quality assurance training program will be

supported from the University Teaching Hospital (Virology) which serves as the national HIV reference

laboratory. In FY 2008, the QA program will expand to both technical and non-technical laboratory persons

in VCT, PMTCT, and integrated HIV/TB programs. National expansion of infant diagnosis utilizing

polymerase chain reaction (PCR) DBS techniques will continue in FY 2008 along with integrated specimen

transport courier systems for rapid detection of multiple and extreme resistant cases of TB.

Transferring skills to Zambian nationals currently in the field is critical, as is building capacity of clinical

personnel during training to ensure graduates going to the field are equipped with the necessary laboratory

knowledge and skills. In this regard, the USG is providing support to Chainama College in renovating the

training laboratory to improve the diagnostic studies in pre-service training for graduating clinical officers

and ART curricular for advanced diplomas for clinical officers. Once graduated, in most cases, clinical

officers are the ones who provide direct care at districts and rural clinics. This will ensure that all graduating

clinical officers in the field have adequate diagnostic laboratory skills and knowledge for providing HIV/TB

and opportunistic care. The Chainama College training center will increase opportunities to laboratory staff

and build capacity in the rural areas by training community workers in laboratory techniques, such as HIV

testing and acid fast smear microscopy for diagnosis of TB in HIV/TB programs. This is vital in addressing

opportunistic infections which are a major threat to PLWHA. Training and support will be provided to

clinicians and laboratory technologists on cost effective diagnostic testing and implementation strategies,

guidance on antibiotic utilization to prevent avoidable resistance levels, and standardization of infection

control practices in both medical and laboratory settings. This is one of the only two colleges where USG

support offers pre-service training in laboratory, HIV care, and counseling to clinical officers and nurses.

Further, the facility is the only psychiatric hospital in Zambia offering mental health treatment services to

patients diagnosed with HIV. Continued curriculum development support is in progress to improve quality

and access to training for healthcare staff working in rural areas where most of the clinical officers are

assigned. This activity will be completed by the end of FY 2008. This initiative is closely linked with HIV

care and treatment training activities supported by CIDRZ and JHPIEGO.

Information management is also crucial to patient care, laboratory procurement and monitoring the success

of the ARV treatment programs. Laboratory computers and printers have been placed at the provincial

laboratory sites, and 35 laboratory staff members were trained on how to use the data management system,

to improve communication across geographical regions where travel is slow and limited, and to increase the

efficiency of the network of laboratories. Improved infrastructure capacity has allowed for information

technology systems to enhance maintenance services utilization of modern and efficient laboratory

equipment, with capacity for internet connectivity. These activities and laboratory management tools will

continue to strengthen the capacity of the GRZ, USG, and other laboratory partners in monitoring laboratory

data for improving services and forecasting for procurement of reagents and supplies. An electronic

laboratory information system has been developed and is currently in beta testing in several sites within the

Eastern, Western, Southern, and Lusaka Provinces. Standardization of data collection provides meaningful

Activity Narrative: managerial information in a timely manner. The MOH and USG laboratory team is working to improve data

collection and management in the laboratory.

More than 10 laboratory and medical staff have attended the six-week management Sustainable

Management in Public Health (SMDP) training course held in Atlanta and over 60 Zambians involved in

health care management have been trained through the follow-up activities in-country. In FY 2007, the first

CDC laboratory technologist attended the six week training and joined the MOH laboratory and other health

care worker alumni team to strengthen management and laboratory quality assurance curriculum

development in the Ndola College of Biomedical Sciences. In FY 2008, continued skills transition and

management activities will build sustainable systems in areas such as HIV/TB and opportunistic infection

care and treatment support. Lessons learned in FY 2007 will provide guidance for developing and

expanding laboratory capacity in district hospitals, urban and rural clinics for better care. In FY 2008, CDC

Zambian laboratory staff will travel to CDC Atlanta to work in the International Laboratory Branch to expand

knowledge and skills as train-the-trainers in both general laboratory management and PCR techniques. In

FY 2008, funding will also be used to provide technical assistance to Department of Defense laboratory

facilities in all nine of the Zambian provinces. Infrastructure support through laboratory renovations and

equipment, reagents, and consumable supplies allows technical skill and knowledge transfer to Zambians

and development of sustainable laboratory services for diagnosis, care and treatment of HIV/TB and

opportunistic infections.

The funding level for this activity in FY 2008 has decreased since FY 2007. Only minor narrative updates

have been made to highlight progress and achievements.

This activity relates to Elizabeth Glaser Pediatrics Aids Foundation (EGPAF) SI, JHPIEGO SI, AIDSRelief -

Catholic Relief Services (CRS), Ministry of Health (MOH), National AIDS Council (NAC), SI Central

Statistical Office (CSO), Tropical Diseases Research Centre (TDRC), Eastern Provincial Health Office

(EPHO), Western Provincial Health Office (WPHO), Zambia National Blood Transfusion Service (ZNBTS),

and COMFORCE.

Expanded Activities: In addition to ongoing activities from FY 2007 that will continue in FY 2008 outlined

below, funds are being requested to support an evaluation of SAVVY, and provide support to the NAC for

implementation of the data systems integration plan recently developed by United States Government

(USG). Additionally, as with all strategic information (SI) activities for FY 2008, there will be a focus on

capacity building for data analysis and utilization of data from ongoing SI activities.

Continuing work from FY 2007, CDC's SI activities provide critical support to information systems, building

sustainable monitoring and evaluation (M&E) capacity, and ensuring that essential information from sentinel

surveillance, national health surveys, clinical information systems, and targeted evaluations is obtained and

used to improve quality of care. Core systems must be institutionalized to sustain improved quality of care,

decision-making about resources, and improved service delivery mechanisms. CDC provides technical and

financial support to the MOH and the NAC at central, provincial, district levels, the CSO, TDRC, the

University Of Zambia School of Medicine, and a number of other partners. CDC Zambia is helping institute

durable systems for quality clinical health services, disease surveillance, and M&E.

Approximately $700,000 supports official CDC office locations and collocated partners in Zambia which

require one-time and on-going improvements to their information systems infrastructure. These office

locations are at the U.S. Embassy, University Teaching Hospital (UTH), Chest Diseases Laboratory (CDL),

Intercontinental Hotel in Lusaka, and a growing number of offices based at the Provincial Health Offices,

such as in Livingstone in Southern Province. This activity will fund the following: (1) procurement of IT

equipment for the new Pediatric and Family Center of Excellence at UTH to include computers for the

offices and points of service, setting-up communications systems, equipment for training and conference

facilities, integrate power supply systems for server and core equipment; (2) maintenance contracts for

printers & computers, continued network operability for remote sites, VSAT and terrestrial communication

links, and network routing hardware; (3) training for CDC and partner IT staff in networking and server

administration; (4) assistance to NAC for implementation of strategic information activities by hiring a short-

term advisor (one year contract $150,000); (5) initial consultations and design support to the ZNBTS on

linking SmartCare to the national donor retention database.

Approximately $450,000 will support M&E activities to: (1) continue technical support to the national M&E

capacity and workforce building initiative in cooperation with NAC, MOH, SHARE, Peace Corps, the

University of Zambia, and National Alliance of State & Territorial AIDS Directors to deliver performance-

based ongoing training, mentoring, and scholarships to partners, Provincial AIDS Coordinators, District

Planners, and District and Provincial AIDS Task Forces. USG support includes technical assistance and

support to national meetings and dissemination of the "One" M&E Manual and Training kit develop with

technical assistance from CDC Atlanta; (2) finalize the joint Government of the Republic of Zambia (GRZ)

and USG ART cluster evaluation initiated in 2006 and take it from an information-gathering stage to

intervention stage through the launch of the AIDS Quality Improvement Project (AQIP); (3) develop a

companion training manual and toolbox for the SmartCare to build capacity at national, provincial and

district levels to maximize data use for quality improvement by clinical staff and district, provincial, and

national teams; these will be based on current partner input and linked to standardized data quality

indicators that can be integrated into SmartCare; and (4) continue to support Zambian M&E professionals to

publish as well as present at regional and international conferences on operational and evaluation research.

For HIV/AIDS surveillance $750,000 in FY 2008 will: (1) continue technical and material support to GRZ in

its surveillance and reporting of HIV and syphilis prevalence through 27 antenatal clinic sentinel sites

(ANCSS) and refugee camps; toward the end of FY 2008 preparations for 2010 round must commence.

This activity is conducted in collaboration with the MOH, the CSO, UTH, NAC, TDRC, and United Nations

High Commission for Refugees (UNHCR); (2) support the GRZ in its surveillance of HIV incidence and

prevalence of other important viral infections over time by testing blood specimens from the antenatal clinic

sentinel surveillance (1994-2008) and the Zambia Demographic and Health Survey (ZDHS), including use

of the BED-CEIA assay developed at the CDC to test for recent HIV infections to estimate incidence; (3)

partner with the private sector in Zambia to strengthen surveillance and reporting of HIV prevalence and

incidence among workers in the agricultural and other industries; continue our partnership with a major

sugar estate to examine risk factors for HIV acquisition among migrant and non-migrant workers. FY 2008

funding will allow us to utilize the findings and to develop the methods and tools for HIV prevention, to

strengthen the continuity of HIV care for migrant workers during the work season, and to help establish

linkage to care upon their return to home regions; (4) continue to strengthen and work towards sustaining

the Zambia National Cancer Registry and the Cancer Diseases Hospital in their surveillance and reporting

of AIDS-related malignancies through technical and material assistance. Surveillance of AIDS-related

cancers is important both for GRZ planning of cancer screening, control, and treatment needs, design of

preventive interventions in the population, and for monitoring the impact of ART scale-up on the risk of AIDS

complications and survival; (5) support the CSO to expand the Sample Vital Registration with Verbal

Autopsy (SAVVY) System in selected regions in Zambia, to validate the data capture instruments, and to

evaluate the SAVVY implementing process. This activity builds upon the Feasibility Study conducted in FY

2007 by CSO in its surveillance and reporting of vital events in Zambia and will add coverage areas beyond

the pilot sites. The FY 2008 plan aims to strengthen and sustain the CSO office and expand expertise for

vital registration in Zambia; (6) collaborate with the World Health Organization to provide assistance to the

MOH in establishing a system to monitor the prevalence of transmitted HIV drug resistance (HIVDR)

observed among young women attending antenatal clinic. Such a system will strengthen the MOH HIVDR

Working Group to develop and implement its national strategy for HIVDR resistance monitoring, design and

implementation of appropriate study populations in which to monitor HIVDR, and to collect information on

behavioral and other risk factors associated with increased risk of HIVDR development, technical support to

build laboratory capacity to perform genotypic HIV drug resistance testing, management and analysis of

data on the magnitude of HIVDR in the selected study population, and the coordination of report

Activity Narrative: dissemination to the GRZ, health professionals, the public, and the scientific literature; (7) support the

surveillance of HIV/AIDS in prison populations in Zambia; (8) ensure the sustainability of HIV surveillance

activities by providing expertise and coordinating training courses to increase long-term Zambian human

resource capacity in data management, statistical analysis, data use and interpretation, scientific writing,

and preparation of manuscripts for publications in scientific literature; 9) improve Zambia's geographic data

layers and data infrastructure needed to utilize geographic information and geographic mapping to support

HIV/AIDS monitoring, evaluation, and response.

The funding level for this activity in FY 2008 will remain the same as in FY 2007. Only minor narrative

updates have been made to highlight progress and achievements.

CDC supports improved data management, dissemination, and data for decision-making in the delivery and

management of health services in national and local institutions in Zambia. Systems beyond the realm of

traditional strategic information activities require support to ensure efficient treatment and care capabilities

in all facilities. Using FY 2005 and FY 2006 funds, CDC procured 662 desktop computers and 34 laptops for

various institutions and affiliated United States Government projects focused on HIV/AIDS. In FY 2007,

CDC provided expanded support to laboratory informatics and remained responsive to equipment needs in

local health offices in targeted provinces. In FY 2008, this support will continue. For example, specific and

ongoing support to infrastructure enhancement is required for the Chest Diseases Laboratory (CDL) and the

Tropical Diseases Research Center (TDRC) tuberculosis (TB) laboratory. In addition to upgraded and new

desktop computers, the installation of network capabilities will be continued as part of this activity. These

enhancements will come in the form of servers, routers, hubs, broadband connections, wireless capabilities,

and appropriate measures for network security. Software will also be purchased. CDC will also provide

material support to targeted clinic and office facilities for provincial and district health facilities. In addition to

equipment and infrastructure costs, CDC will continue to provide technical support on installation, routine

maintenance planning, software licensing, and input on establishing relationships between assisted

organizations and technical support providers in Zambia. This will require occasional supportive

supervision visits by CDC staff to active project sites or for CDC to engage other technical support as

required. Lastly, as CDC has staff placements at increasing numbers of locations around the country

providing direct support and technical assistance (TA) at provincial health offices, there are increasing

communication costs supporting dedicated lines to the central offices, in addition to the infrastructure

support at these sites (see also CDC-TA under HVSI).