The funding level for this activity in FY 2008 will increase from FY 2007. Minor narrative updates have been

made to highlight progress and achievements.

Lusaka province has four districts, with the largest district being the capital of Zambia, Lusaka. The other

districts are Kafue, Chongwe and Luangwa, the latter two districts being predominantly rural districts.

Lusaka Province notifies over 30% of the total tuberculosis (TB) cases nationwide, though Lusaka district

accounts for the largest proportion of these cases. Outside of the provincial capital of Lusaka, access to

health care facilities and services, especially in Chongwe and Luangwa are limited, with many TB patients

traveling 20-25 km to the nearest health facility. The implementation of TB/HIV activities in these districts

has lagged behind that of Lusaka and as of mid 2007 there were only 13 sites providing TB/HIV services.

In the second quarter of 2007, of a total of 590 TB patients notified in the three districts of Chongwe, Kafue

and Luangwa, 405 (68%) received counseling and testing for HIV. Lusaka district is well served with health

services and receives considerable support for the implementation of programs through USG support to

Centers for Infectious Diseases research in Zambia (CIDRZ).

By end of FY 2007 the USG would have directly funded the Provincial Health Office (PHO) to expand and

support the TB/HIV integration activities in the three districts of Kafue, Chongwe and Luangwa. This will

result in the expansion of the TB/HIV integration activities that the USG has supported in Lusaka district

through EGPAFG/CIDRZ and will result in the development of an additional 12 sites, bringing the total

number of sites in the three districts to 25. The PHO will support the formation of a Provincial TB/HIV

coordinating committee that will be tasked with the strategic direction and supervision of the TB/HIV

integration activities throughout the province. Membership on this committee will include representation

from the TB Program, Clinical Care Unit (which oversees HIV/AIDS care), antiretroviral therapy program,

community care and advocacy groups, and HIV counseling/testing partners. Technical assistance for the

implementation of the program will be provided by CIDRZ.

Limited human resources, coupled with an expected increase in patient-load as a result of TB/HIV

integration, have been a barrier to implementing and maintaining TB/HIV integration. This human resource

shortage negatively impacts morale, supervision, and technical support. To address this, PHO will support

a TB/HIV coordinating officer that will be placed within PHO. This officer will be responsible for coordinating

TB/HIV activities, supervision, trainings, surveillance, and program monitoring and evaluation and will work

closely with the Provincial TB/HIV committee, and the provincial TB officer to coordinate activities in the

province and provide joint supportive supervision. Coordination of activities will be achieved through

quarterly meetings with other partners funded by the USG for TB/HIV activities, such as CIDRZ and

JHPIEGO.

By the end of FY 2007 support will also be provided to employ 4 clinicians responsible for TB/HIV care and

treatment. In FY 2008 PHO will support the placement of TB/HIV coordinators at the district levels as well

as continue support for the provincial TB/HIV coordinating officer and the 4 clinical officers.

Integrated TB/HIV training will be carried out in selected districts by PHO, in collaboration with JHPIEGO.

In FY2007, 93 health workers and 207 community treatment supporters will be trained in TB/HIV. This

training will provide skills and knowledge to health workers and the community as TB/HIV integration scale

up is undertaken. In FY 2008, MOH will have embarked on recruitment of health workers and we anticipate

new staff in the districts will need training in TB/HIV integrated activities. Support will be given for training 60

health workers in TB/HIV integration. Refresher trainings and/or technical updates will be provided for all

health workers. There is an expected rise in patient load as a result of TB/HIV integration which may further

negatively impact staff morale. In such circumstances the role of the community in patient care becomes

more critical and hence the need to train more treatment supporters and to keep existing ones motivated. In

FY 2008, support will be provided for training of 100 community volunteers and for capital investment in

income generating activities.

The focus for 2008 will be consolidation of TB/HIV activities in the sites that will have opened in FY2007.

Another area of focus will be strengthening linkages; between TB testing and treatment and anti-retroviral

therapy and between TB programs and other USG funded home based care programs to ensure continuum

of care for the anticipated large number of patients that will result from this program scale up.

Technical support and supervision will be maintained in these districts. The provincial team will make 2

visits per month to districts while support will be provided for weekly district to site supervision.

A training of trainers (TOT) program will have been developed to provide trainers in all districts based on the

national training curriculum. These trainings will focus on providing the skills for routine HIV counseling and

testing of TB patients and management of TB, HIV, and TB/HIV patients. The training will also include TB

screening for all clients testing positive for HIV in settings such as ART services, Prevention of Mother to

Child Transmission (PMTCT) and Sexually Transmitted Infections (STI) clinics. Support will be provided for

minor renovations to improve the physical infrastructure in selected health centers to provide integrated

TB/HIV activities. Cognizance is made of the fact that HIV+ individuals are susceptible to communicable

diseases due to their lowered immunity. In this case smear positive TB patients would easily transmit the

disease to HIV positive clients and also to health care providers. In view of this, support will be provided for

infrastructure renovations to improve ventilation and allow in sunlight as infection prevention measures. This

will be done on 2 sites for each district in FY 2008. The renovations will be specific for the site.

With an additional $75,000 plus up funds for TB/HIV, LPHO will renovate one additional site per district in

the 3 districts to improve the infrastructure and enhance infection prevention. The sites will be selected

based on need and taking into account the volume of patients on ART. In addition PHO will conduct

training for staff at the hospital level in the Prevention of TB in Health Care settings currently being

developed by JHPIEGO (Activity # 9032) in all 4 districts in the Province. It is estimated that an additional

20 staff will be trained in the national infection control guidelines.

All activities and trainings will be linked by PHO with activities that are supported by recent district-level

funding from the Global Fund to fight AIDS TB, and Malaria (GFATM). The GFATM has directly funded

these districts to scale up TB control by strengthening DOTS and TB/HIV integration and care. Technical

support and guidance for the use of this funding will be provided by PHO. As a result of this support, TB

patients will be tested for HIV in these three districts. Those found to be HIV positive will be referred for

appropriate HIV care. TB screening of HIV -infected patients will be a key component of these TB/HIV

integration activities. Links between TB and other USG funded home based care programs will be

established in order to ensure a continuum of care for the HIV infected TB patients. Regular review

meetings will be linked to TB directly observed treatment strategy (DOTS) review meetings and co-funded

Activity Narrative: by the Global Fund supported TB DOTS program.

Of an estimated 1,600 TB patients in the three districts, 90% (1440) will receive counseling and testing over

12 month and approximately 1008 (70%) will test HIV positive and be referred for HIV care and treatment.

Of the estimated 1750 patients receiving HIV services 70% will receive routine screening for TB disease at

least once. Isoniazid preventive treatment (IPT) for HIV positive individuals does not currently form part of

the national guidelines for TB/HIV activities and hence will not be implemented. How ever, should the

Ministry of Health adopt this intervention, the PHO will implement IPT. The National program has guidelines

on the use of IPT in under five (5) children whose mothers are sputum smear positive for TB.

Links will be strengthened between the TB and ART services in order to ensure that all HIV infected TB

patients are referred for ART, with screening to be based on the national guidelines. It is estimated that

about 80% of TB patients referred to the ART services will receive care and support. The TB patients found

eligible for ART will be commenced on treatment according to the National guidelines. A system to track the

referrals and ART treatment will be developed. Support will be provided for monthly meetings between the

2 departments to share information. In order to ensure a continuum of care, the districts will develop links

with USG funded and other organizations providing palliative care in a home based care setting. This will be

achieved through district TB/HIV coordinating bodies. Formation of these bodies will be supported by PHO

and the composition will be similar to the provincial body which will have been formed in FY 2007. Health

centers will be supported to facilitate the formation of support groups for TB/HIV patients.

To ensure sustainability, the trained staff will continue to provide skills and knowledge. The activities will be

enshrined in the GRZ district health plans.

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

The following activity is newly proposed ¬ for FY 2008.

HIV counseling and testing is the entry point for antiretroviral therapy (ART) services and offers an

opportunity for health promotion including education on prevention of HIV and other sexually transmitted

infections The HIV prevalence in Lusaka Province is estimated to be 21.5 % among adults aged 15-49

years (DHS 2002). These rates are the highest in the country and Lusaka Province Health Office (LPHO) is

working in collaboration with partners to curb these high figures. One strategy is to encourage all residents

to know their HIV status by going for voluntary counseling and testing. Another is scaling up provider

initiated counseling and testing in all health centers. The USG aims to support LPHO to build capacity to

coordinate and oversee counseling and testing services in the province, provide training to various levels of

health care providers, and expand counseling and testing services in 3 districts; namely Kafue, Chongwe

and Luangwa. Lusaka district is covered by the Centre for Infectious Disease Research in Zambia (CIDRZ).

Previously, the focus has been on Lusaka district which has the highest population in the province and

therefore the greater disease burden. The provincial population is 2,151,945 (CSO 2000). The population

per District is distributed as follows; Lusaka 1,617,843, Luangwa 26,650, Kafue 266,168, Chongwe

196,999. Lusaka and Kafue Districts have an estimated HIV prevalence of 22 percent while Chongwe and

Luangwa Districts both have 19 percent. With such high prevalence through out the province, it is evident

that prevention and treatment efforts should be spread out to all areas in the province. The Provincial Health

Office would like to scale up counseling and testing services to Kafue, Chongwe and Luangwa Districts by

expanding quality, confidential HIV counseling, testing and care through training of staff and community

volunteers in counseling skills and improving infrastructure to enhance the counseling environment.

Limited human resources, coupled with an expected increase in patient-load as a result of increased

community mobilization, are a barrier to implementing and maintaining services. This human resource

shortage negatively impacts morale, supervision, and technical support. Work related stress and fatigue of

counseling staff is another factor affecting service delivery. Currently 18 of the 41(44%) health facilities in

the districts are able to provide voluntary counseling and testing services. It is estimated that with training

and infrastructure support 30 centers will provide this service by end of FY2008.

In FY 2008, 40 health workers and 75 lay counselors will be trained in Counseling and Testing for HIV. An

estimated 30% of the adult population (92,933) will receive sensitization messages through various forms of

media.

It is expected that out of the sensitized population 8% (7435) will receive counseling and testing services

and 5500, will receive their results.

In order to enhance the counseling environment, support will also be provided for infrastructure

development by renovating 2 sites in each of the three (3) districts. In addition to the renovations

procurement of furniture will also be done.

LPHO will provide onsite technical support and supervision and will incorporate the concept of peer review

to encourage the exchange of experiences among sites. Quarterly supportive supervision will be done with

a view of mentoring district supervisors and thereby building supervisory capacity and ensuring quality of

counseling and testing services. In addition support will be provided for quarterly meetings for counselors

meetings in each district. This will be done to encourage counselors to deal with work stresses amongst

themselves.

To facilitate motivation among the community volunteers, income generating activities will be supported in

each district to provide some incentives. This will reduce the fall out rate among this cadre and promote

sustainability.

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

Oct 08 Reprogramming: Transferring skills to Zambian nationals in the field is critical. Thus the USG is

providing support to the Lusaka Provincial Health Office to support the Chainama College in renovating the

training laboratory to improve pre-service diagnostic training for graduating clinical officers as well as

continuing education activities to practicing health care workers . The center will also serve and expand

local training capacity for medical laboratory technologists within Lusaka.Currently most trainings are

performed in Ndola College of Biomedical Sciences, which is 250 Kilometers north of Lusaka.

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 the TB/HIV activity in LPHO, and the Comforce, CDL, and UTH Virology within the

Lab section.

This activity will provide local support to the Lusaka Provincial Health Office for implementation of the

University Teaching Hospital (UTH) National Prevention of Mother to Child Transmission of HIV (PMTCT)

and Voluntary Counseling and Testing (VCT) laboratory Quality Assurance (QA) Program within the districts

of this province. Some major limiting factors for implementation, support, and sustainability laboratory

programs outside of the capital city are due to: 1) travel distances; 2) lack of transport for onsite supervision

and feedback; and 3) lack of funds at the provincial and district levels. Although supervisory travel visits to

Lusaka districts outside of the city can be done on a day trip, time and number of technical experts available

are divided by the need to visit other sites throughout the country. The goal of this activity is to build

capacity and sustainability at the local level by training and providing support for activities to be conducted

by local staff within the province for PMTCT and VCT as well as care and treatment support. It will also

assist in the integration of the National TB/HIV activities in the Province. The goal will be to reach the 14

laboratories within rural Lusaka province districts.

Availability of laboratory services in districts out side of Lusaka district is limited due to several factors,

which include technical human resources, lack of suitable infrastructure, and services such as a source of

power, geography, and increasing numbers of persons participating in PMTCT and VCT programs at local

levels. Antiretroviral laboratory care and treatment services are limited. Sample preparation and transport

support can alleviate the lack of services due to laboratory infrastructure and technical limitations. In FY

2008, onsite training and technical support for existing personnel in basic laboratory testing and transport

will be assessed and provided. Laboratory equipment support will be provided by a non PEPFAR donor to

a new laboratory in Chongwe in FY 2008. Laboratory QA programs for rapid HIV testing currently

performed in the VCT and PMTCT will be supervised and supported by the National HIV reference

laboratory at University Teach Hospital (UTH). An integrated program on laboratory data management and

onsite quality assurance will assist in improving and equalizing antiretroviral therapy laboratory services to

people living with HIV and AIDS in these areas. Support will be provided for basic infrastructure

improvements and the provision of alternate sources of power such as solar panels at all laboratories

currently lacking this infrastructure. This activity will support and complement the UTH Virology National

quality assurance program for PMTCT and VCT, national TB program quality assessment, as well as other

care and treatment programs within the rural districts of this province.