Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 3017
Country/Region: Zambia
Year: 2008
Main Partner: Johns Hopkins University
Main Partner Program: JHPIEGO
Organizational Type: University
Funding Agency: HHS/CDC
Total Funding: $4,300,000

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $465,000

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 is linked to JHPIEGO programs in HVOP, HVCT and OPHS as well as activities being

conducted by the Health Communications Partnership (HCP) and JSI/Deliver.

Zambia is currently one of the leading countries in terms of integrating Male Circumcision (MC) into the

compendium of HIV/AIDS prevention activities. JHPIEGO has been supporting the male circumcision

program in Zambia for several years, beginning in 2004 when they teamed up with the government to begin

work on small scale efforts to strengthen existing male circumcision services to meet existing demand. This

early work in Zambia has informed the international efforts of WHO and UNAIDS, and the training package

that JHPIEGO developed with the Ministry of Health in Zambia formed much of the basis for the new

international WHO/UNAIDS/JHPIEGO training package. Likewise, assessment tools used in Zambia also

provided background for the WHO toolkit. The Government of the Republic of Zambia (GRZ) has

established an MC Task Force under the Ministry of Health (MOH) and the Prevention Technical Working

Group of the National AIDS Council, of which JHPIEGO plays a key role.

Zambia's 2007 COP included a limited amount of funding to examine the feasibility of male circumcision

services in different sectors, or to develop and test tools that would strengthen the Information, Education

and Communication (IEC) efforts for male circumcision. With these additional plus-up funds, JHPIEGO

intends to expand the service delivery of MC by adding additional private and socially marketed service

sites, as well as to provide significant support the GRZ to accelerate their efforts to develop clear message

delivery guidelines, and develop and initiate an implementation plan to scale-up MC services that includes

an IEC plan. Initial implementation support will include mass media messaging to begin to get correct and

consistent information to the public quickly on the benefits and risks of circumcision.

JHPIEGO's focus for this activity will be on working with the MOH and other partners to build a strong

abstinence/be faithful (AB) message as part of the MC service package, which includes the development

and dissemination of counseling guidelines for men undergoing MC. AB messages will play a key role in

the pre and post circumcision counseling that men go through in Zambia. The funds will be used to work

with the MOH to identify culturally relevant strategies surrounding AB and MC, and to implement them

through the MOH and in partnership with other partners working in AB into the HIV prevention and

education messages as part of the comprehensive MC service package.

In FY 2008 JHPIEGO will target reaching at least 6,000 individuals with AB messages delivered through a

various communications media that will ensure the most even coverage possible. One of the key aspects

will be the on site service providers who focus on delivering comprehensive prevention messages including

AB as well as other prevention methods resulting in clients receiving all the prevention information

necessary to make an educated decision relating to MC services.

By working with and supporting the MOH in the development of AB strategies and messages JHPIEGO will

ensure that the messages being provided are done with the voice of the GRZ and form part of the

prevention messages already developed and disseminated by the MOH and other government institutions.

This will support the sustainability of prevention message development and dissemination by providing the

MOH the framework with which to develop new messages and initiatives.

Funds will be used to: (1) support the development and testing of additional messages and implementing

the effective messages as part of the national prevention strategy; (2) develop take home brochures, radio,

and TV spots emphasizing AB as integral part of MC education; and (3) support the development of

counseling protocols that include AB messages during MC service delivery, and train counselors on the

importance of AB messaging within this service.

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

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $200,000

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 is linked closely with JHPIEGO programs funded by CDC in HVTB, HVCT and HTXS as well as

DOD funded programs in HVTB, HVOP and OHPS. This activity links to activities in HVTB and HVCT being

conducted by partners, particularly CARE, EGPAF, CRS, FHI ZPCT and TBCAP, PCI, SHARE and

Provincial Health Offices, as well as to HTXS and HBHC clinical activities (EGPAF, CRS, ZPCT, and

CHAMP).

Members of the military are at particularly high risk of HIV and STIs. These populations are away from their

families for extended periods. They often have multiple concurrent sexual partners, placing them at high

risk of infection with HIV or other STIs. Access to health services among these populations is often limited,

meaning that men and women who do suspect they have an STI may not receive treatment in a timely way,

increasing the chance of passing the infection on to others, and while we know that there is a high risk of

HIV in STI infected persons and the role of STIs in HIV transmission, STI services have not routinely and

effectively offered HIV counseling and testing until recently. At the same time, the Zambia Defense Forces

(ZDF) have not benefited from the same level of investment as in the public Ministry of Health (MOH)

system. JHPIEGO, as a key partner to MOH in a number of HIV/AIDS technical programs, aims to help

bridge this gap. In addition, ZDF sites are spread throughout Zambia in all nine provinces and are often

located in very remote and hard to reach locations presenting further logistical challenges in service

provision.

Data coming from the Defense Force Health facilities from June 2005 to November 2006 shows a high

burden of sexually transmitted infections. A tour of Lusaka based ZDF health care facilities supported by

DFMS and PCI revealed that there was: • shortage of manpower trained in Syndromic Management of STIs;

• non availability of Treatment Guidelines for Syndromic management of STIs; • Lack of STI specific IEC

materials; • shortage of drugs used for the treatment of STIs• Lack of light sources, vaginal speculums and

examination couches, screens; • weak health information systems (e.g. medical record keeping,

maintenance of and registers); • Lack of community engagement in prevention and control of STIs.

In fiscal year (FY) 2005, JHPIEGO began work with mobile populations of sugar cane workers in Mazabuka

and the ZDF Medical Services in 4 sites to strengthen the integration of diagnostic HIV counseling and

testing (DCT) into TB and STI services (activity ID # 9035) and increased access to and utilization of HIV

prevention, care, and treatment services. JHPIEGO has been supporting the ZDF in integration of CT into

TB and STI services with over 90% of TB patients accepting HIV CT and subsequent referral to ART for

those testing positive. Between FY 2005 and FY 2007, over 80 ZDF providers and 250 community lay

counselors from the initial 12 sites were trained in appropriate counseling and testing skills.

In FY 2007, JHPIEGO used the plus -up funds to provide the National STI case management guidelines to

ZDF health facilities as well as training of 150 health care providers in Syndromic case management of

STIs.

With the additional funding in 2008, JHPIEGO will continue with the work to strengthen training of

healthcare workers within the defense forces in the management of STIs and make available copies of the

Zambia National STI case Management Guidelines. These guidelines are not readily available in for use by

the clinicians caring for these high risk populations. Training will emphasize the syndromic approach to STI

management, risk assessment and risk reduction counseling. The standard available training materials will

be used for these trainings. Targeted interventions contribute to the overall goal of reducing STI prevalence

and slowing HIV transmission. In order to expand and sustain quality STI services and considering the

negative effects of the prevailing high staff turnover in the ZDF facilities, JHPIEGO will carry out the

following activities: • Make available the MOH National STI Syndromic Case Management Guidelines for

Zambia; • Training 150 ZDF healthcare workers in the management of STIs by conducting seven, five-day

provider training workshops, site strengthening by providing basic tools and equipment required to provide

quality services and also continue offering supportive supervision to all sites and on job mentorship to at

least 50 previously trained health care workers; This will be done in conjunction with the ZDF supervisors.

The activities will enable ZDF to expand and sustain quality STIs services in order that more patients seen

at military clinics can access timely and appropriate care. The above is in addition to the 75 health care

providers to be trained under DoD- JHPIEGO activity.

The trainings planned will draw on the pool of trainers developed in the Zambia Defense Forces starting in

FY 2006 and JHPIEGO staff will co-train and observe. Using this methodology will work toward

sustainability in the continuing education initiatives that the Zambia Defense Forces will periodically need to

undertake to keep their health service providers up-to-date on the best practices in STI syndromic case

management as well as other areas of health care.

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

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $995,000

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 is linked to JHPIEGO programs funded by CDC in HVCT, HVAB and OPHS as well as activities

being conducted by the Health Communications Partnership (HCP) and the Partnership for Supply Chain

Management.

Zambia is currently one of the leading countries in terms of integrating Male Circumcision (MC) into the

compendium of HIV/AIDS prevention activities. JHPIEGO has been supporting the male circumcision

program in Zambia for several years, beginning in 2004 when they teamed up with the government to begin

work on small scale efforts to strengthen existing male circumcision services to meet existing demand. This

early work in Zambia has informed the international efforts of WHO and UNAIDS, and the training package

that JHPIEGO developed with the Ministry of Health in Zambia formed much of the basis for the new

international WHO/UNAIDS/JHPIEGO training package. Likewise, assessment tools used in Zambia also

provided background for the WHO toolkit. The Government of the Republic of Zambia (GRZ) has

established an MC Task Force under the Ministry of Health (MOH) and the Prevention Technical Working

Group of the National AIDS Council, of which JHPIEGO plays a key role.

The focus for this activity will be to support the six model sites developed in FY 2007 to consolidate their

MC service delivery ensuring that comprehensive services are being provided to clients including

standardized counseling, service provision and follow-up monitoring of clients. Emphasis will be placed on

developing institutional capacity to train new service providers in the comprehensive approach to MC

service provision. Within this framework, JHPIEGO will continue to strengthen the environment for scaling-

up MC services gauging suitable expansion sites for FY 2008. JHPIEGO is a member of both of the

national coordinating bodies working on male circumcision currently and will continue to support these

groups, the Male Circumcision Task Force under the Ministry of Health and the Prevention of Sexual

Transmission Working Group under the National AIDS Council.

In FY 2007, JHPIEGO worked with the model sites to ensure that they met the minimum standards to

provide quality MC services, and trained 50 clinicians to provide MC services as well as 50 counselors to

support male reproductive health and male circumcision services. Sites were supported to provide

integrated services, strengthening links to STI and family planning programs, provision of routine opt-out

HIV counseling and testing, and strong components of HIV prevention counseling and services. JHPIEGO

will continue to provide ongoing support to these sites, to ensure that they provide high quality,

comprehensive MC services, through supportive supervision using a standard-based management and

recognition approach. In addition, JHPIEGO will also continue to monitor changes in the sexual risk

behavior of clients post-procedure, to ensure that adequate, effective counseling and HIV/AIDS prevention

measures are in place and well integrated with the new MC services.

In FY 2008 JHPIEGO will identify additional sites suitable for the expansion of male circumcision services

based on demand and the maximization of service coverage. These sites will benefit from the training sites

developed in FY 2007 for the government's effort to expand MC services and make them available as part

of the basic health care package. The training institutions will allow for structured mentoring of service

providers from expansion sites. This structured mentoring will take a comprehensive approach as expose

service providers to each of the steps included in providing MC services. MC services start the moment a

client visits a service outlet and receives counseling on MC and male reproductive health and continue

through the follow-up of clients after surgery. Target institutions will include Ministry of Health and Zambia

Defense Forces sites, and possibly Churches Health Association of Zambia sites depending on the site

selection criteria and outcome of the assessment of preparedness outlined in the policy/systems support

activities.

It is expected that these model institutions will provide counseling and MC services to approximately 6,000

clients, more than tripling the current MC provision. For a new service like male circumcision, the number of

clients reached is difficult to predict and will depend on the success of IEC and mobilization programs which

will be running in parallel to the MC service scale up. This support will support: (1) training of counselors

and clinicians; (2) conduct an assessment of preparedness for male circumcision scale-up, focusing on key

target areas where MC work has not been initiated, testing and using the WHO tool kit, and working with

WHO staff to pilot test these tools in the process; (3) facilitate a thorough pilot testing of the international

WHO/UNAIDS/JHPIEGO clinical training package, in conjunction with WHO; (4) work with the Zambian

team to adapt this package, and to develop associated service delivery guidelines; and (5) develop and pilot

test performance standards for male circumcision, to standardize and enhance performance and quality

improvement and supervision of MC services.

In addition, the funding will be used to integrate MC as integral part of the prevention package accompanied

by clear and effective patient education.

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

Funding for Care: TB/HIV (HVTB): $650,000

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.

These activities are linked with HVCT and HVTB activities, CARE, CRS HVCT, CARE HVCT, and PCI

HVCT and also JHPIEGO's DOD work on TB/HIV.

In Zambia, rates of HIV and TB co-infection are more than 60% and TB is one of the leading causes of

death among PLWHA. To ensure appropriate care for TB patients, HIV counseling and testing should be

integrated into TB programs. Likewise, it is important that patients diagnosed with HIV are appropriately

monitored, screened, and treated for TB and other opportunistic infections (OIs).

JHPIEGO is working to strengthen the integration of HIV/AIDS and TB care and treatment services in

Southern, Western and Eastern Provinces, through: 1.) Training for diagnostic HIV counseling and testing

(DCT); 2.) On-the-job training (OJT) for diagnosis and management of opportunistic infections; 3.)Training

of community counselors and treatment supporters; 4.) Supportive supervision in clinical training skills.

TB 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, in FY 2005, JHPIEGO adapted Centers for Disease Control and Prevention's (CDC) counseling

protocols and training materials to incorporate DCT into TB services more effectively. In FY 2005,

JHPIEGO trained 63 health care providers in DCT from 14 sites in three districts (Livingstone, Mazabuka

and Mongu) of Southern and Western Provinces, who provided CT to 1,300 clients. JHPIEGO provided

technical assistance to the Ministry of Health (MOH), CDC, World Health Organization (WHO), Tuberculosis

Control Assistance Program (TBCAP), Churches Health Association of Zambia (CHAZ) and Center for

Infectious Diseases Research in Zambia (CIDRZ), to further build capacities in DCT clinical training skills in

50 MOH TB focal point persons from all the nine provinces of Zambia as well as in staff from other

implementing partners' programs.

In FY 2006 and FY 2007 JHPIEGO continued to work with the Southern and Western Provincial Health

Offices (PHOs) to build capacity to expand the integration of HIV into TB services. Working with the local

provincial trainers in FY 2006 and FY 2007 an additional 125 health care providers from ten new sites were

trained in DCT, in addition to the provinces' own programs of training beyond this number. To ensure that

these programs are sustainable, JHPIEGO will strengthen and expand the capacity at the provincial level in

training skills, supervision and monitoring, through joint training and supervision activities in Southern and

Western Provinces. In FY 2007 JHPIEGO used plus-up funds to train a total of 216 trainers in DCT from all

the 72 districts of Zambia and developed the training capacity of the Zambia Defense Forces by holding a

DCT clinical training skills workshop for 12 ZDF trainers who went on to train 80 service providers. In FY

2008, JHIEGO will work with these trainers to conduct additional workshops targeting at least 100 ZDF

service providers from sites nationwide. This number will be in addition to the 80 ZDF health care providers

who will be trained in TB diagnosis and management under the DoD-JHPIEGO TB/HIV (activity #9090.)

JHPIEGO will also continue FY 2007 plus-up funding initiatives to develop district level DCT clinical training

skills by ensuring that in FY 2008 new trainers receive support in their first trainings by pairing them with

experienced trainers to aid in the consolidation of their training skills. JHPIEGO will also train 40 new

trainers to account for the attrition of trainers. Other support will be provided through the further

development of materials including guidelines for the prevention of transmission of TB in health care

settings, printing of training packages, guidelines, job aids, and dissemination of these guidelines at

provincial level to all the 9 provinces for the provincial managers and representatives from the DHMTs, as

well as continued support to local management and supervision teams to strengthen the implementation of

standardized clinical pathway models and patient record forms adapted /developed in FY 2006 for DCT

within TB services. To cover all the provinces and district, a total of 3000 copies of the Clinical guidelines

on Prevention of TB in Health Care Settings and 3000 copies of the Orientation package will be printed.

The guidelines will be disseminated at central level, to all partners and to all the nine provinces using the

orientation package developed from above. A total of 10 dissemination workshops will be conducted. One

dissemination workshop will be conducted in each province for the Provincial Managers and representatives

from the DHMTs. A total of about 400 people are expected to be reached during the dissemination

supported by JHPIEGO. The provincial management will in turn assist the District management to conduct

dissemination workshops for health care providers in each district.

Providers of HIV care and treatment services need significant strengthening in the recognition, diagnosis

and management of TB and other opportunistic infections (OIs). Because of the complexities of

presentation and manifestation of TB and other OIs, and the limited diagnostic capacities of providers and

facilities, initial basic training in OI management is only the tip of the iceberg. Experience from JHPIEGO's

work in FY 2005 shows that significant effort in hands-on mentoring and on-the-job training can dramatically

improve care and treatment for HIV patients.

Structured on-the-job training (OJT) is a non-traditional, intensive approach to in-service training in that it

involves a highly experienced clinician spending at least two weeks at a service outlet working with a team

of providers in their environment. It includes daily rounds together with structured, case study reviews,

allowing the teams of providers to work through diagnosis, clinical decision-making, and management of TB

and other OIs, building upon the national OIs and ART training materials. Between FY 2005 and FY 2007,

using clinical experts from the University of Zambia (UNZA) and University Teaching Hospital (UTH),

JHPIEGO provided OJT to 130 health care providers (including nurses, clinical officers and doctors) from

Livingstone General Hospital, Lewanika General Hospital and Mazabuka District Hospital along with

selected staff from hospital-affiliated health centers (HAHC). In FY 2008 an additional 75 service providers

will receive OJT in 10 additional district hospitals in Eastern, Southern and Western Provinces. Relevant

performance standards were drafted and implemented in FY 2006 and FY 2007. This should improve the

quality of care by providing sites with standards they can implement and monitor as well as tools for

supervisors to use in monitoring and supporting clinical services.

In FY 2006 JHPIEGO formalized an arrangement with UNZA and UTH to use the pool of clinical experts

from the institutions for this training program as a step towards building the capacity of those key national

institutions. In addition, in FY 2006 and FY 2007, JHPIEGO will increasingly involve the Clinical Care

Activity Narrative: Specialists from the Provincial Health Offices and the experienced clinicians from the Provincial Hospitals or

other larger facilities, to build local capacity to support and expand this program from the Provincial level.

Thus supervision, monitoring of the training and quality of services will increasingly be carried out by the

respective Provincial Health Offices with the support of JHPIEGO and the UNZA/UTH clinical experts as

needed.

Based on the TB DOTS model of community treatment support programs, HIV treatment programs are

similarly developing community treatment and adherence support programs. With the high rates of TB-HIV

co-infection, tremendous opportunities exist to increase the synergies in these programs and ensure that TB

treatment supporters are able to refer for and support HIV services, and visa-versa.

Between FY 2005 and FY 2007, 185 community counselors/ treatment supporters (CCTSs) were trained in

Livingstone, Mazabuka and Mongu districts in support of the sites where DCT and OJT activities were

conducted. FY 2008, JHPIEGO will draw upon earlier-trained CCTSs and local government or NGO staff,

building local capacity to expand and support these programs. In order to ensure sustainability of the

program the local trainers will increasingly take the lead in training and supervision activities, supported by

JHPIEGO and our local partners (Kara Counseling and Community-Based TB organization (CBTO) as

needed. The aim in FY 2008 is to train 100 CCTSs in 10 districts in Southern and Western Provinces and it

is expected that these trainers will conduct their own training activities using resources from the MOH,

Global Fund and other USG support, thus further expanding the pool of community resources in order to

attain geographical coverage of the services.

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

Funding for Prevention: HIV Testing and Counseling (HVCT): $200,000

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 activities in TBHIV and HVCT (particularly JHPIEGO, CARE, EGPAF, CRS, FHI ZPCT

and TBCAP, PCI, SHARE and Provincial Health Offices), as well as to HTXS and HBHC clinical activities

(EGPAF, CRS, ZPCT, JHPIEGO, and CHAMP).

This activity will increase access to counseling and testing, integrate diagnostic counseling and testing

(DCT) into TB and STI services, and strengthen linkage to HIV/AIDS care and treatment services.

CT is an essential intervention in all HIV/AIDS programs, serving as a key link between prevention, care

and treatment efforts. Those who test HIV negative have the opportunity to change their behavior in order to

prevent acquisition of the virus in the future. Those who test positive have the opportunity to change their

behavior to prevent transmission to their partner(s) and to make informed decisions about seeking

appropriate care and treatment including prevention of mother to child transmission (PMTCT), prevention

and management of opportunistic infections (including TB and STIs) and, when clinically indicated,

antiretroviral therapy (ART).

One of the most devastating impacts of the HIV/AIDS epidemic has been its effect on the healthcare sector.

As the need for skilled healthcare workers has increased exponentially due to the burden of disease caused

by HIV, TB and other infectious diseases, the number of healthcare workers available to care for the sick

has declined. Illness and death among healthcare workers as well as the brain drain have increasingly

pulled trained personnel away from the health sector at precisely the time that they are most needed.

The acute shortage of nurses and other skilled healthcare workers has resulted in woefully insufficient

number of trained counselors for HIV or psychosocial counseling to meet the demand (or potential demand)

for counseling and testing.

In light of this acute shortage, JHPIEGO in collaboration with the PHO and DHMTS and other partners will

promote "task-shifting" wherever possible. Task shifting means that tasks that are commonly conducted by

higher-level healthcare workers (i.e., nurses) should be shifted to lower-level providers or even lay people if

these cadres can competently conduct them. HIV counseling is a prime example. Lay counselors can

provide high quality HIV counseling, provided that they are properly trained and supervised, freeing up

professional nurses to perform the clinical skills for which they were trained.

In FY 2006 and FY 2007 JHPIEGO continued to work with the Southern and Western Provincial Health

Offices (PHOs) to build capacity to expand the integration of HIV into TB services. Working with the local

provincial trainers in FY 2006 and FY 2007 an additional 125 health care providers from ten new sites were

trained in DCT, in addition to the provinces' own programs of training beyond this number

In addition, 185 community lay counselors/treatment supporters (CCTS) were trained between FY 2005 and

FY 2007 in Southern and Western provinces. The community counselors are a link between the community

and health care services and are involved in providing group education and counseling and testing both at

community and facility level. Another aspect of ensuring increased continuous availability of trained

counselors at the service delivery sites is the "task-shifting" strategy by making greater use of lay

counselors.

In FY 2008, JHPIEGO will continue to build local capacity in supporting and expanding CT services. By

ensuring that the existing management and supervisory teams take the lead in both training and supervision

activities, with JHPIEGO's support, their ability to sustain and expand these programs will be enhanced.

JHPIEGO will work with the existing management and supervisory teams (e.g., from PHO, DHMT, etc.) to

provide supportive supervision (on-Job training) to at least 100 previously trained CCTS and quality

assurance to programs strengthened during FY 2005, FY 2006 and FY 2007. In addition quality assurance

exercises will take place using a variety of methodologies (i.e., client exit interview, mystery client, chart

reviews, etc.) In order to expand services, strengthen the community outreach around the target facilities;

improve the continuity of care and the uptake of services, psychosocial counseling training will be provided

to an additional 120 Lay counselors from Southern, Western and Eastern Provinces in districts selected in

consultation with the PHOs. This will compliment the trainings to be carried by the provinces themselves

and JHPIEGO will work in close collaboration with CBTO and KARA counseling to support the Provinces in

achieving this. The number of people who will be reached with counseling and testing from this activity will

be reported through the provinces thus will not be included here to avoid duplication.

In order to ensure sustainability of the program the local trainers will increasingly take the lead in training

and supervision activities, supported by JHPIEGO and our local partners (Kara Counseling and Community-

Based TB organization (CBTO) as needed.

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

Funding for Prevention: HIV Testing and Counseling (HVCT): $255,000

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 is linked to JHPIEGO's CDC funded programs in HVOP, HVAB and OPHS as well as activities

being conducted by the Health Communications Partnership (HCP) and JSI/Deliver.

Zambia is currently one of the leading countries in terms of integrating Male Circumcision (MC) into the

compendium of HIV/AIDS prevention activities. JHPIEGO has been supporting the male circumcision

program in Zambia for several years, beginning in 2004 when they teamed up with the government to begin

work on small scale efforts to strengthen existing male circumcision services to meet existing demand. This

early work in Zambia has informed the international efforts of WHO and UNAIDS, and the training package

that JHPIEGO developed with the Ministry of Health in Zambia formed much of the basis for the new

international WHO/UNAIDS/JHPIEGO training package. Likewise, assessment tools used in Zambia also

provided background for the WHO toolkit. The Government of the Republic of Zambia (GRZ) has

established an MC Task Force under the Ministry of Health (MOH) and the Prevention Technical Working

Group of the National AIDS Council, of which JHPIEGO plays a key role.

Based on initial experiences in FY 2007 JHPIEGO will expand MC services to additional service outlets

around Zambia taking into consideration demand and maximizing service coverage. These sites will benefit

from the training sites developed in FY 2007 for the government's effort to expand MC services and make

them available as part of the basic health care package. The training institutions will allow for structured

mentoring of service providers from expansion sites. This structured mentoring will take a comprehensive

approach as expose service providers to each of the steps included in providing MC services. MC services

start the moment a client visits a service outlet and receives counseling on MC and male reproductive

health and continue through the follow-up of clients after surgery. Target institutions will include Ministry of

Health and Zambia Defense Forces sites, and possibly Churches Health Association of Zambia sites

depending on the finalization of site selection criteria and outcome of the assessment of preparedness

outlined in the policy/systems support activities.

WHO recommends MC be promoted primarily to HIV negative males in areas of high HIV prevalence.

Since knowing one's HIV statues is critical to making informed decisions regarding MC and other sexual

health needs, it is critical that counseling and testing be integrated into all aspects MC service provision.

JHPIEGO will implement CT at all four expansion sites and it will expand MC service delivery to and VCT

will be offered to all men who seek MC services and are above the legal age for CT in Zambia. It is

expected that approximately 3,000 men will be reached for MC services.

To work toward the sustainability of quality MC services and the associated CT JHPIEGO will develop

training capacity within the model institutions developed in FY 2007 by conducting clinical training skills

workshops targeting 20 trainers. These workshops will provide the trainers with teaching skills and

methodologies as well as reinforce their knowledge and skills in comprehensive MC service provision. The

workshop will provide trainers with necessary skills for group-based training as well as structured mentoring,

which will enable them to train service providers in basic/baseline knowledge and skills as well as more

advanced concepts and skills. These trainers will form the core for the standardization and expansion of

MC services in Zambia.

These trainers will co-teach their first workshops with experienced MOH and JHPIEGO staff to consolidate

their training skills and ensure the quality of training given to service providers from the expansion sites.

These initial workshops will target at least 130 service providers.

With these funds, JHPIEGO intends to: (1) develop a strong counseling and testing component to support

the MC services; (2) integrate VCT as integral part of the MC services; and (3) training additional VCT

counselors and clinicians.

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

Funding for Treatment: Adult Treatment (HTXS): $400,000

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.

Expanded Activities: In addition to the ongoing activities outlined below, increased funding for this activity

will provide support to implement standardized quality improvement interventions to enhance quality of

service delivery across United States Government (USG)-sponsored Anti-Retroviral Therapy (ART)

programs. Of critical importance will be the integration of standardized quality assurance indicators in the

SmartCare system, finalization of special quality studies, and training of facility-based program managers

on utilization of quality indicator data to improve service delivery.

The national ART implementation evaluation published in April 2006 revealed numerous areas of need to

improve the implementation of services in Zambia. For example, eighty-four percent (84%) of institutions

visited, reported not having seen the national ART implementation plan with many sites having never

received key policy documents and guidelines. One can proximally assume then that quality improvement

and monitoring activities were few. Moreover, this evaluation did not include in-depth investigation of care

quality as part of its mandate. It is clear that as ART continues to be rolled-out at a rapid pace in Zambia,

quality must be assured to promote the sustainability of these services in the future. In cooperation with

JHPIEGO, USG through Centers for Disease Control and Prevention (CDC) -Zambia began support for a

joint program assessment of ART technical and financial support in Zambia in 2006 that revealed key areas

for quality improvement interventions. This evaluation activity is now an ongoing process of data collection

and feedback. It is therefore critical for funding in 2008 to implement sustainable activities that will aim to

close performance gaps identified in the ongoing evaluation process.

In FY 2007 CDC-Zambia entered into a collaborative partnership with JHPIEGO to implement the Zambia

Antiretroviral - Quality Improvement Project (A-QIP). A-QIP consists of four inter-related components

designed to facilitate quality improvement among the Government of the Republic of Zambia (GRZ) and

cooperating partners (CPs) in Zambia.

1.Collective and Routine Monitoring of Quality

Cluster evaluation with participation across ART service providers in Zambia to include GRZ, major private

sector companies, and CPs to include EGPAF/CIDRZ, ZPCT, AIDSRelief/CRS, University Teaching

Hospital Pediatrics/Columbia University, John Snow Incorporated/DELIVER, and JHPIEGO. The cluster

evaluation aims to convene GRZ and CPs to identify critical and common questions and a shared

evaluation strategy related to care quality, cost, service delivery and coverage, and continuity of care from a

sample of sites. The process will require regular meetings of project directors, M&E staff, and clinical

experts to identify indicators, collect and share information, and inform policy and service delivery

processes in Zambia. This process will also incorporate standard quality indicators in existence (for

example HIV QUAL indicators) into the group process. From this process, a standardized set of core

indicators for monitoring quality will be developed, and ultimately integrated into the Smart Care system to

ensure standardized, comprehensive and sustainable data quality for care. In addition to tracking a

common set of quality indicators, several special studies will be supported in areas identified by the group.

2.Data Use for Improved Care

SmartCare has been deployed in more than 100 sites between 2005 and 2007. It is anticipated that the

system will continue to be deployed where feasible in GRZ locations throughout the country in 2008.

SmartCare provides critical individual level data on health services as well as numerous opportunities to

query facility-based and eventually district and provincial data. Data use from the system, in cooperation

with other facility-based aggregations systems (e.g., ARTIS) and what will be a redesigned health

management information system for Ministry of Health (MOH), must be maximized to inform quality

improvement activities. This is a key feature and task of the A-QIP project and will include all sites with

SmartCare deployment.

3.Coordinated Quality Improvement Assistance

Based on findings from the cluster evaluation, key interventions for quality improvement will be elaborated

and delivered to sites identified most in need of support. A central organization will map and help to

coordinate technical support activities being delivered through GRZ and CPs. Additionally, the central

organization will have capacity to actively provide quality assurance and facilitation services to improve

individual and facility-level performance by providing on-the-job training (OJT) for quality improvement.

4.Creating International Networks for Learning

Distance learning will reinforce a response to findings from the cluster evaluation and the OJT, opportunities

for distance learning in cooperation with MOH facilities will be organized with a specific set of course work

and informal sharing focused on adult and pediatric ART. Lectures from within Zambia and abroad will be

taped and used in these sessions. A central organization will be required to moderate and facilitate ongoing

learning through session design and execution.

Funding for Treatment: Adult Treatment (HTXS): $150,000

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 is linked to Southern Provincial Health Office (SPHO). As other monies under this mechanism

will be sent to the JHPIEGO Zambia country office, monies for this activity will remain at Johns Hopkins

University.

The title of the study is "Factors influencing the care and treatment of HIV-1 infected children in rural

Zambia". FY 2008 will be year 2 of the study, which is scheduled to began in FY 2007. To date, funds for

FY 2007 have not yet been received by the study site. Additional monies needed for follow-up of the study

cohort total $150,000, which is being requested for FY 2008. The local co-investigator is Dr. Janneke van

Dijk at Medical/Malaria Institute at Macha (MIAM) in Macha, Zambia. The other co-investigator is Dr.

William Moss at the Johns Hopkins Bloomberg School of Public Health in the United States.

The purposes of this Public Health Evaluation (PHE) are to: 1) Measure immunologic and virologic

treatment responses and survival in a cohort of HIV-1 infected children and adolescents receiving ART at

Macha Hospital in rural Zambia; 2) Identify risk factors for antiretroviral treatment failure and death in

children and adolescents residing in rural Zambia and cared for at Macha Hospital, including antiretroviral

drug resistance, obstacles to adherence, barriers to care and the health status of the child's primary

caregiver; and 3) Measure the rate of disease progression in HIV-1-infected children and adolescents who

are not eligible for ART to evaluate treatment guidelines on when to initiate ART in rural Zambia.

Progress of the study to date includes the following: 1) have obtained ethical approval to conduct the study

from the Research Ethics Committee of the University of Zambia and the Committee on Human Research

from the Johns Hopkins Bloomberg School of Public Health; 2) have developed and pilot tested the consent

and assent forms and the study entry and follow-up questionnaires; and 3) explored the possibility of

performing HIV-1 DNA diagnostics and HIV-1 viral load testing at MIAM. We are awaiting release of the

funds to being hiring and training project staff and start enrollment.

Lessons learned include the following: The lessons learned will arise after study enrollment has begun.

We plan to disseminate study findings locally at Macha Hospital, nationally through meetings and

presentations in Lusaka, and through publications in peer-reviewed journals.

Planned FY 08 activities include continued follow-up of the study cohorts to measure treatment responses,

identify risk factors for treatment failure and death, and to measure the rate of disease progression in HIV-1

infected children not eligible for antiretroviral therapy.

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

$150,000 for FY 2008. Costs will support study personnel, supplies, travel, laboratory tests and equipment,

patient care costs, and defaulter tracing.

The budget breakdown is as follows:

Salaries/fringe$90,000

Equipment $2,000

Supplies $11,000

Travel $16,000

Laboratory, local transportation, patient care costs$20,000

Indirect costs$11,000

TOTAL $150,000

Funding for Treatment: Adult Treatment (HTXS): $500,000

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 relates to all activities in this section and palliative care (HBHC and TB/HIV) and antiretroviral

therapy (ART) projects funded by CDC, Department of Defense, and the United States Agency for

International Development, and works to address information on quality of care and fill gaps identified

through strategic information (SI) initiatives.

In Zambia the scale-up of HIV/AIDS care and treatment has rapidly expanded the numbers of sites and

health care workers providing HIV/AIDS treatment services with over 100 facilities and hundreds of health

workers providing ART services. HIV care and treatment programs require frequent modifications based on

changes in technical knowledge in the field, standards of care and information gathered from the services

themselves. As a result, providers who have had basic training need continuing opportunities to update

their knowledge and skills, as well as assistance in evaluating programs critically to identify gaps and

solutions toward improving their performance. This is critical not only to the provision of quality services, but

contributes greatly to job satisfaction, motivation, and retention of health workers. Guidelines and training

materials need to stay current and creative best practices must be established for replication in other

program areas.

In FY 2006, JHPIEGO assisted the MOH and NAC to update clinical training materials, and trainers, on the

recently revised clinical care guidelines. In FY 2007, JHPIEGO will assist the government, particularly the

Ministry of Health (MOH) and National AIDS Council, to adapt the revised clinical care guidelines and

training materials into more useful electronic formats accessible to providers through a variety of

appropriate technologies (e.g., CD Rom, web-based, handheld devices). This will be done in close

collaboration with other implementing partners and technical specialists working on ART programs, and will

ensure consistency and standardization of materials, messages, and approaches to maximize the efficiency

and success of HIV/AIDS clinical care and ART scale-up activities in Zambia. JHPIEGO will also work with

MOH and Zambia Defense Forces along with other collaborating partners to develop and test different

technologies available to make the clinical guidelines and resources available and accessible for HIV/AIDS

care and treatment providers.

JHPIEGO will also continue to provide support and national leadership in the area of performance support

for HIV/AIDS care and treatment providers, to address gaps identified in ART service delivery programs.

This support is critical to ensure that HIV/AIDS care and treatment services maintain an acceptable level of

quality, which will help to ensure not only that new clients are encouraged to enter care but also that

existing clients remain under care. To achieve this, JHPIEGO will continue to support the implementation of

continuing education opportunities for HIV/AIDS clinical staff at ART centers, reinforcing their basic skills

and expanding their knowledge on specific areas. In FY 2005 and FY 2006, JHPIEGO assisted the GRZ to

develop and pilot continuing education programs for ART service providers and teams. These programs

included a combination of distance education programs for use in low technology settings, as well as

internet and e-mail based education programs from the Johns Hopkins University Center for Clinical Global

Health Education. Through the end of FY 2006, initial programs will have trained 250 ART providers,

including at least some staff from all hospital and large urban-clinic based ART sites. In FY 2007, JHPIEGO

will continue to support these programs to reach additional clinical caregivers, while developing additional

content to fill identified gaps. One such gap to be addressed will be to strengthen the use of HAART in

pregnant woman for their own health (as well as to further reduce mother to child transmission of HIV), a

high priority for training in FY 2007 consistent with national PMTCT and ART guidelines in Zambia. In FY

2007, these continuing education programs will be made available to all functioning ART sites in the country

and are estimated to reach 150 sites and approximately 450 providers.

JHPIEGO will also work with the MOH, University of Zambia and the University Teaching Hospital

partnership and the Medical Council of Zambia to adapt and apply additional tools for performance support

which will be integrated into ART service provision programs such as those of Elizabeth Glazer Pediatric

AIDS Foundation and Zambia HIV/AIDS Prevention, Care, and Treatment Partnership, as well as

JHPIEGO's work with the Zambian Defense Forces. These tools and approaches will help not only to

support the quality of HIV/AIDS care and treatment services, but enhance the sustainability of technical

support. These efforts will focus on maximizing the use of tools that can be delivered onsite to reduce the

need for ongoing external technical assistance and additional manpower (e.g., trainers and supervisors).

One such tool is TheraSimtm's case-base simulation program, a computer-based interactive tool which

allows providers to go through a series of HIV care cases and receive feedback on their clinical decision

making. This is a tool which can be used both for advanced training as well as for monitoring performance.

To ensure sustainability of the program, JHPIEGO works in close collaboration with the MOH, NAC, Medical

and Nursing Councils, and University of Zambia Medical School / UTH, to build the capacity of those

institutions to design, develop, and implement programs to support quality ART services. Materials

developed in these programs are ‘owned' by the national program and these institutions, and are designed

to be implemented through existing channels (e.g., by involving the Provincial Clinical Care Specialists to

monitor and follow-up the distance education programs). By using appropriate technology, implementation

and support costs are reduced over other, more traditional approaches. For example, one focus is to

develop tools that can be delivered on site, requiring less movement by clinical staff, reducing costs of travel

and lodging while also ensuring less disruption of services and improving the ‘immediacy' of applying

training to service delivery on-site. Likewise, electronic versions of guidelines and continuing education

materials can be updated, reproduced, and disseminated at much less cost than print-based materials.

These approaches will assist the national program and local partner institutions to continue to support these

programs with limited levels of investment (as compared to the cost of traditional group-based in-service

training, for example).

Funding for Strategic Information (HVSI): $450,000

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 relates to The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF SI), AIDSRelief - Catholic

Relief Services (CRS), Ministry of Health (MOH), Technical Assistance/Centers for Disease Control and

Prevention (CDC), and COMFORCE.

Building upon fiscal year (FY) 2007 activities, JHPIEGO will continue to support the scale-up and

deployment of electronic patient monitoring and data management tools to enhance continuity of care. This

will be provided by a) training and b) supporting sites during the early implementation and use of the

growing number of modules in the SmartCare software - formerly called the Continuity of Care and Patient

Tracking System (CCPTS). Within the scope of a cooperative agreement with CDC, JHPIEGO will continue

to collaborate with the broad consortium of organizations involved in the development and deployment of

the SmartCare System nationwide. These organizations include the MOH, the CDC-Zambia, Provincial

Health Offices (PHO), District Health Management Teams (DHMT), the EGPAF/Center for Infectious

Disease Research in Zambia (CIDRZ), AIDSRelief, and the Zambia Prevention, Care and Treatment

Program (ZPCT), among others.

In FY 2005 and FY 2006 JHPIEGO supported the early development of the SmartCare software and its pilot

and scale-up in Kafue District. Starting in FY 2007 JHPIEGO supported the transition of the SmartCare

project from the pilot phase in Kafue district to the nationwide deployment of the system. Working with the

MOH and CDC-Zambia and in collaboration with the various other implementing partners, JHPIEGO

supported the training of over 500 managers, supervisors and service providers including District Health

Information Officers (DHIOs) and district Maternal and Child Health (MCH) coordinators, district level focal

persons in ART, PMTCT and TB as well as all nine Provincial Data Management Specialists (PDMSs). In

addition, JHPIEGO has supported staff focused on supporting all phases of deployment of SmartCare,

including pre-deployment, orientation, training, and post-deployment supervision of the SmartCare system.

Also JHPIEGO has supported the training of service providers at "independent" service outlets.

Independent is defined as a service outlet that does not have an implementing partner committed to directly

support the deployment of SmartCare and the training of service providers in the use of SmartCare.

In FY 2008 JHPIEGO will continue to support the implementation of the SmartCare through training, post-

deployment supportive supervision visits conducted jointly with provincial, district and other SmartCare

implementing partners, provision of logistical support for the deployment, and a small amount of site

readiness preparation. JHPIEGO deployment staff will work closely with the MOH, CDC-Zambia and other

implementing partners to prioritize activities focused on pre- and post-deployment to ensure that there is a

synergy of efforts as the nationwide deployment continues. JHPIEGO will take a leadership role in the

development and implementation of post-deployment supervision methodologies and tools that guide

managers and supervisors at all levels to measure gaps between actual and ideal usage of the SmartCare

System. These tools not only measure the gaps, but also provide managers and supervisors with the

information necessary to guide service providers on how to close the gaps and why it is important.

JHPIEGO training and implementation staff will also support the training of 250 service providers in the

provinces and districts targeted during the scale up. They will co-train with the provincial and district

trainers and work in conjunction with all the partners supporting the scale up of the system such as MOH,

CDC-Zambia, EGPAF/CIDRZ, ZPCT, CRS, and other implementing partners. They will make sure that the

quality of training is maintained from the Provincial Health Office (PHO) to the districts and collaborate with

the SmartCare team in the update and revision of training materials and the system matures.

Increasingly, the MOH is taking the lead in SmartCare collaboration, deployment authority, and field

support, and has solicited commitments for infrastructure from all major implementers. Through a

collaborative process, led by the MOH, and in close consultation with CDC-Zambia and other implementing

partners, a very aggressive deployment plan, including: a) training provincial level Trainers of Trainers at

central trainings, b) sending provincial technical leadership back to province to replicate training, with

SmartCare team support, with district leadership, and then c) having staff take the skills back to their

districts for implementation. So even before the FY 2008 activity period, the efforts of these initial three

SmartCare collaborators will be joined by efforts of all other HIV/AIDS care and treatment partners in

Zambia, including CRS-AIDSRelief and the Zambia Prevention, Care, and Treatment (ZPCT), HSSP,

JHPIEGO, as well as EGPAF.

In building this collaboration around the SmartCare solution, it is clear that the Ministry is comfortable taking

the initiative on this effort. The place for JHPIEGO will be, in coordination with CDC's feature developments

and other CDC partnerships, to leverage its long term good relationship with MOH and established ‘trainer'

role, by continuing to support strong technical staff to support the rapid national deployments and most of

the rest of this activity will be in support of the training and post-deployment supervision. While this

developing country EMR now provides services to more than 90,000 patients, with the additional partners

starting deployment before the end October, the rate of growth may increase non-linearly as the number of

electronic clinics increase, provided there are no supply limitations.

The methodologies employed by JHPIEGO, and the SmartCare team as a whole, are designed with the

express interest in developing a system that can be sustained by the Ministry of Health. By empowering all

levels of the Zambian Ministry of Health system with the knowledge and skills to deploy and manage the

SmartCare System, from the pre-deployment preparation through post-deployment supervision, it will be

within the scope of the MOH and Government of the Republic of Zambia to sustain the SmartCare system

as an essential tool in the provision of continuous, quality health care services in years going forward.

Funding for Health Systems Strengthening (OHSS): $35,000

The funding level for this activity in FY 2008 will remain the same as in FY 2007. The Agency however has

changed to CDC due to a reprogramming error in FY 2007 as this funding was mistakenly allocated to the

Department of Defense. Only minor narrative updates have been made to highlight progress and

achievements.

This activity is linked to JHPIEGO programs in HVOP, HVAB and HVCT as well as activities being

conducted by the Health Communications Partnership (HCP) and JSI/Deliver.

Zambia is currently one of the leading countries in terms of integrating Male Circumcision (MC) into the

compendium of HIV/AIDS prevention activities. JHPIEGO has been supporting the male circumcision

program in Zambia for several years, beginning in 2004 when they teamed up with the government to begin

work on small scale efforts to strengthen existing MC services to meet existing demand. This early work in

Zambia has informed the international efforts of World Health Organization (WHO) and Joint United Nations

Programs on HIV/AIDS (UNAIDS), and the training package that JHPIEGO developed with the Ministry of

Health (MOH) in Zambia formed much of the basis for the new international WHO/UNAIDS/JHPIEGO

training package. Likewise, assessment tools used in Zambia also provided background for the WHO

toolkit. The Government of the Republic of Zambia (GRZ) has established an MC Task Force under the

MOH and the Prevention Technical Working Group (TWG) of the National HIV/AIDS/STI/TB Council.

In FY 2007, plus-up funds were used to spearhead the development of national policy on MC, strategic

planning and implementation of scale-up efforts. In FY 2008, JHPIEGO will continue to support the

development of national policy and the development of materials to be used by service providers

communicating clearly and concisely the relevant information from the policies to the various cadres of

service providers to ensure clarity and consistence in the application of MC policy nationwide. JHPIEGO is

a key member of the MC Task Force and the Prevention TWG, and thus will be able to ensure that the

policy being developed is well informed and complements the whole prevention process and the overall

national HIV strategies in Zambia.

This initiative will focus on sustainability by supporting the GRZ and MOH to develop national policy and

putting in place a framework that will allow for the update of policy in the future by following a standard

stepwise process that can be replicated in the future.

JHPIEGO's work in policy and systems strengthening funds will focus on: (1) disseminating the MC policy

documents using a variety of media appropriate for service providers as well as clients; (2) collaborate with

the MOH and other partners in the development of information, education, and communication materials;

and (3) continue to monitor performance standards for MC, developed in FY 2007 to standardize and

enhance performance and quality improvement and supervision of MC services.

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

Subpartners Total: $0
Kara Counseling and Training Trust: NA
University Teaching Hospital - Zambia: NA
Johns Hopkins University: NA
Khulu Associates: NA
Health Communications Partnership: NA
Society for Family Health: NA
Community Based TB HIV AIDS Organization: NA
University of Zambia: NA
Johns Hopkins University: NA
TheraSim Inc.: NA
Johns Hopkins University: NA