Due to the request from CDC/GAP to move 1/12th funding to ‘PEPFAR II Track 1.0 ART EGPAF,' this

funding level has now decreased. This adjustment was done to ensure that funds are available for ART

services during the one month lag between when Track 1 PEPFAR 1 funds are due to end and when

funding will be available under the next congressional notification. Minor narrative updates have been

made to highlight progress and achievements.

This activity relates to activities under EGPAF/CIDRZ, the Ministry of Health, and JHPIEGO. The Elizabeth

Glaser Pediatric AIDS Foundation (EGPAF)-Center for Infectious Disease Research in Zambia (CIDRZ)-

supported government sites have enrolled 95,145 adults and children and started 59,084 on ART as of the

end of April 2007. Presently, 45 ART sites in Lusaka, Eastern, Western, and Southern Provinces are being

supported. EGPAF-CIDRZ has trained 1,184 health care workers in adult and pediatric ART delivery.

EGPAF-CIDRZ has presented 23 abstracts, published five papers with seven additional papers currently in

preparation. EGPAF/CIDRZ plan to maintain the existing programs at the joint Government of the Republic

of Zambia (GRZ) sites. There are six proposed components to this track 1.0-funded activity, including: (1)

continued support for existing services at 45 sites in 19 districts; (2) a continued focus on women's health

care with the cervical cancer screening program; (3) a pilot to work with a new model of service provision

through ‘fixed cost obligation grants' provided to private clinics; (4) to expand the pilot clinic-wide model for

complete integration of HIV care and treatment services; 5) to emphasize diagnosis of HIV in tuberculosis

(TB)-infected patients and early referral for entry into HIV care; and (6) a focus on improved quality of care

in delivery of palliative care.

EGPAF through its partner CIDRZ will continue to provide support for 54,951 adults and 4,133 children

under antiretroviral therapy (ART) care at 45 existing sites in four provinces. CIDRZ is on track to reach

78,000 cumulative on ART by March 2008 and will continue to support these individuals through September

2009.

The CIDRZ team is particularly strong in women's health expertise with five full-time obstetrician-

gynecologists in country. Since the inception of the "See and Treat" Cervical Cancer Prevention Program,

in FY 2006, over 5,000 women have been screened, nine new clinics have been established, four Zambian

doctors, nine Zambian nurses have been trained, twelve Cervical Cancer Peer Educators have been hired

and three Data Associates have been employed. Towards our 2007 goal of establishing eight new clinics,

we have presently opened five. We have also trained three new nurses, developed a nursing education

manual untitled "Setting Up ‘See and Treat' Cervical Cancer Prevention Services Linked to HIV Care and

Treatment Programs in Primary Healthcare Sites in a Resource-Constrained Environment", developed

patient and partner education brochures, implemented the cervical cancer peer educator training program

and organized cervical cancer support groups. The importance of this program is evident in the very high

rates of intervention required among women who present for screening. Of 4,524 women in whom data are

presently available, 1,954 (43%) have required either immediate cryotherapy or referral for biopsy and/or

surgery.

During FY 2008, we will maintain the number of nurses trained; however, we will increase the numbers of

clinics serviced by taking our present staff of twelve nurses and initiating services in twelve new clinics.

Although the hours of each clinic will be reduced (full-time to part-time), we will be still be able to expand our

much needed services throughout Zambia. The project will also design a certification program for nurses in

cervical cancer prevention that will be approved and formally recognized by the Ministry of Health and will

develop a radical pelvic surgery training program at the Monze Mission Hospital. Advanced training and

education of health care providers will include onsite support to peer educators and ongoing professional

education around the subject of cervical cancer. The project will also conduct an evaluation of peer

educator activities. It is planned to have 10,000 new women screened in FY 2008.

Currently, all EGPAF/CIDRZ-supported sites provide Antiretroviral Therapy (ART) services in clinics

dedicated to the care of HIV-infected patients. This is a common model throughout Zambia despite

discussion of service "integration". Most conditions such as pregnancy and diseases such as tuberculosis

are managed in a vertical fashion, often without knowledge of the HIV status. This model may have worked

well in the past, but as increasing numbers of HIV-infected patients are identified and the availability of ART

increases there is an urgent need to integrate patient care. In addition, HIV is a confounding factor in the

presentation of virtually any disease or condition and continuing the vertical approach to patient care may

affect patient outcomes.

To implement this integration model we are proposing that all patients attending OPD (adult and pediatric),

MCH and TB Clinic undergo provider initiated, opt-out HIV testing. Those found to be HIV-infected will

undergo immediate ("reflex") CD4 testing and WHO screening to expedite ART initiation. Expedited referral

to HIV care will be arranged for patients with advanced disease (CD4< 200 and/or WHO stage 4). All others

will be referred electively to ART Clinic. In addition, we will take this opportunity to improve TB screening in

OPD for patients identified as TB suspects. This EGPAF/CIDRZ initiative will link with a new pilot (Doris

Duke Award, P. Killam PI) which is being scaled-up in 8 Lusaka clinics. In this initiative CIDRZ is working on

improving enrollment of pregnant HIV-infected women in ART services. All women identified as HIV-infected

through PMTCT will be provided ART in MCH clinics with referral to the standard ART clinic after delivery.

These integration activities build on existing programs of TB/HIV integration at EGPAF/CIDRZ supported

sites and will link all clinic departments with high HIV prevalence to HIV care & treatment.

EGPAF-CIDRZ proposes to pilot in FY 2008 a new model of service provision, working with private sector

facilities to expand HIV/AIIDS care and treatment services in Lusaka. This pilot will build on our prior

experience with providing "fixed cost obligation" awards to districts for the provision of PMTCT services.

EGPAF-CIDRZ will recruit two to four reputable private sector health care facilities and agree upon a set of

deliverables to ensure the minimum package of care, as set out by Ministerial guidelines, are being met.

Special attention will be paid to care quality and to adherence counseling. Outcomes and patient retention

will be monitored by providing government forms and by installing the Smart Care system.

TB/HIV co-infection will be a focus this year with more emphasis on the diagnosis of HIV in TB-infected

patients and early referral for entry into HIV care. In addition, the screening of TB suspects and the

diagnosis of TB in ART clinics will be a priority area. ART clinicians will be trained on the varying and

atypical presentations of TB in HIV-infected patients as well as the limitations of available diagnostics and

guidelines for empiric treatment. TB screening will be encouraged during all patient contacts. Special effort

Activity Narrative: will be made to address the issue of co-treatment, especially the timing of ART initiation and presentation of

immune reconstitution syndrome. Improving TB diagnostics will be critical for this intervention.

Building on FY 2007 activities in delivery of palliative care, quality of care will be a priority in pre-

antiretroviral care phase, chronic ART care, diagnosis of TB and TB/HIV co-treatment. Monitoring and

improvements in patient quality of care will be on-going and will include the utilization of the SmartCare

System to identify treatment failure and gaps in implementation of patient care protocols as well as

coordination with JHPIEGO's AQIP. Monitoring will be achieved by teams of QA/QC nurses overseeing

patient care, based on QA/QC tools and patient care protocols. In addition, there will be a QA/QC team

specifically dedicated to monitoring diagnosis and treatment of TB. Weekly clinical meetings are convened

in each ART clinic to discuss and present cases and medical officers work as mentors with clinic staff to

improve care.

In order to provide quality services in ART clinics, CIDRZ will continue the training of nurses to equip them

with the knowledge and skills needed to function in an expanded role, to thoroughly assess, examine,

diagnose, and treat simple conditions commonly encountered in HIV care and treatment. Long-term

mentoring and follow-up will be provided to ensure that nurses continue to develop and enhance their

physical assessment and patient management skills.

Traditionally HIV prevention efforts have focused on HIV-negative individuals. "Positive Prevention" aims to

protect the health of HIV-infected individuals and prevent the spread of HIV to sex partners. The rapid scale

-up of care and treatment has created an important opportunity to reach many HIV-infected individuals and

clinic-based prevention interventions aimed at people infected with HIV will be included together with

counseling on ARV adherence and alcohol use.

For ease of management of reporting for the USG team, there are no targets listed for this activity as all the

targets are accounted in the country-funded entry for EGPAF/CIDRZ in this section.