This activity is a continuation from FY 2007. New activities and emphases include: focus on the palliative

care prevention package (including "Prevention for Positives"); cotrimoxizole prophylaxis; provision of

bednets to prevent malaria (supported by the President's Malaria Initiative through RAPIDS); Clorin to

ensure safe drinking water; increased support for pediatric ART (P-ART) through the use of Dried Blood

Spot testing of infants and referrals of HIV+ infants for P-ART. SUCCESS II will continue to provide a

quality package of adult and child palliative care, which will include pain management in hospices.

SUCCESS II will emphasize prevention for positives such as avoiding risky sexual behavior, promoting

abstinence and faithfulness, and reducing alcohol intake. Lastly, SUCCESS II will emphasize sustainability

and capacity building for it partners.

In FY 2008, CRS will continue to provide quality, community-based palliative care (HBHC) services through

six Catholic Diocese home-based care programs and ten faith-, community-based hospices in seven

provinces. In FY 2007, SUCCESS reached 33,984 PLWHA with home-based and hospice care. In FY

2008, the SUCCESS II project will operate in seven provinces and support 13 hospices serving at least

38,320 PLWHA in 45 districts providing geographic coverage to roughly 62% of all districts in Zambia at an

average cost of about $81 per client. Nationally, SUCCESS II will have 99 service locations. The

SUCCESS M&E system enables managers and staff to account for individual clients, analyze data

effectively, and use data for program management and planning.

SUCCESS II will link to other PEPFAR-funded projects, such as AIDS-Relief, CIDRZ, and ZPCT, and to

GRZ services, for treatment of opportunistic infections (OIs), sexually transmitted infections (STIs), and for

ART. SUCCESS II will strengthen linkages to and from Prevention of Mother to Child Transmission

services (PMTCT), such as ZPCT. For example, SUCCESS will provide PMTCT sites with coordinates of its

home-based care programs, to which PMTCT providers will refer PMTCT clients for follow-up in the

community from birth through at least six months to support breast-feeding and timely weaning using

appropriate weaning and complementary foods. SUCCESS will also refer female PLWHA who are (or may

be) pregnant to PMTCT.

SUCCESS II is a leader in hospice care in Zambia. It leverages the nationwide health care infrastructure of

the Catholic Church to reach underserved, rural areas. SUCCESS II collaborates with RAPIDS, a HBC

project serving urban PLWHA, and refers clients to government health facilities for clinical care and ARV

treatment. SUCCESS II provides a standardized package of quality, holistic HBHC and services in-line with

international and national HBC guidelines. Quality assurance mechanisms will include caregiver checklists,

patient chart review, and monthly care improvement meetings between caregivers and nurse supervisors.

The HBC service package includes home visits, basic nursing care, pastoral and psychosocial support,

malaria prevention, nutrition counseling, targeted nutritional supplements for malnourished PLWHA in line

with PEPFAR guidelines, Clorin for household safe water to reduce diarrheal disease, DOTS for HIV co-

infected TB PLWHA, plus clinical referral for OIs, TB and ART. SUCCESS will identify more HIV-positive

infants and children in need of HBHC, nutritional support, and/or referrals. .

SUCCESS II has established three care categories to provide a better match between client needs and

caregiver support: 1) newly infected but asymptomatic; 2) house- or bed-bound with advanced illness; or 3)

clients on ART returning to healthy, active living with adherence support. The SUCCESS II family-based

CT model will identify newly infected clients earlier for appropriate treatment and care. SUCCESS II will

support and extend the outreach of ART, sharing the load of patient follow-on monitoring and care.

SUCCESS will support Prevention for Positives. For example, SUCCESS will counsel PLWHA on behavior

change (reducing alcohol intake to decrease risky sexual behavior, increasing abstinence and faithfulness),

nutrition, and provide appropriate, factual information Other Prevention strategies.

SUCCESS II will continue to support hospices to improve the quality of in-patient care for PLWHA, and to

provide CT and family support including day-care for HIV+ children. FY 2007 was the launch of oral

morphine for hospices. SUCCESS II will support the provision of oral morphine for quality pain management

elsewhere and will continue to work with MOH to ensure that the initiative is extended further to HBHC

providers throughout Zambia. SUCCESS II will award block grants to qualifying hospices to help them

attain and maintain acceptable standards of care. Block grants may pay for medical equipment, training,

staff/patient transport, and quality improvement. SUCCESS II will work with the Twinning Center to support

the Palliative Care Association of Zambia (PCAZ. PCAZ will facilitate training and policy development.

PCAZ will provide sustainable PC leadership in Zambia, including training for caregivers and technical

assistance to the GRZ in designing national Palliative Care guidelines and standards.

SUCCESS II will continue to refine the quality of home-based care and hospice services and partners. It

will focus on symptom and pain control, patient and family education, linkages with OVC, PMTCT, ART, TB

program sites, and a standard quality training package for HBHC volunteers and staff. It will build partner

organizational capacity. It will increase referrals to pediatric services; ART and PC, ensuring clinical care

for children. SUCCESS II partners will procure basic medications especially oral morphine and supplies for

HBHC as needed, using private matching funds. SUCCESS II leverages non-PEPFAR sources to ensure

availability of basic medications for home-based care.

SUCCESS II care coordinators will refer clients to needed services, and link clients to clinical care in district

and provincial facilities, to ART services, and follow up with community-based adherence support. Partners

also link to local branches of PLWHA and OVC support groups and to local GRZ structures. Trained

volunteer caregivers, supervised by nurses, continue to form the backbone of this model. To ease gender-

based burdens in care giving, SUCCESS II will actively recruit male and youth caregivers. In FY 2008,

SUCCESS II will train over 2,000 individuals to provide HIV palliative care. SUCCESS II offers its

volunteers monthly support meetings, refresher trainings, tools for work, and CT services to boost retention.

SUCCESS will support gender equity efforts in palliative care (led by SHARe), for example, to reduce

violence against women related to HIV diagnosis or discordant HIV results. SUCCESS will also support

efforts by SHARe to promote leadership initiatives, especially those focusing on promoting increased

leadership roles for PLWHA in all HIV/AIDS activities. SUCCESS will support efforts by AIHA-PCAZ to

advocate for, promote, and disseminate policies and guidelines for comprehensive palliative care.

SUCCESS II will provide targeted nutritional supplements to malnourished PLWHA in line with OGAC and

Activity Narrative: GRZ guidelines. SUCCESS II will provide food and nutritional support with estimated value of $525,000.

SUCCESS II will leverage FFP and WFP food to obtain food rations for food insecure PLWHA and families,

in a wrap-around model. SUCCESS will participate in efforts by FANTA and IYCN to determine nutritional

needs, and promote better nutritional assessment, counseling, and support in all palliative care activities, in

coordination with GRZ agencies such as the National Food and Nutrition Commission (NFNC), NAC and

the MOH Nutrition focal persons.

For sustainability, CRS will continue to build the capacity of diocesan and hospice partners, training

providers and staff at multiple levels as well as training trainers. CRS will support PCAZ master trainers to

carry out HBHC training with diocesan home-based care programs and hospices, and work with PCAZ to

implement national PC standards and guidelines. SUCCESS will support efforts by AIHA, PCAZ and others

to establish professional accreditation standards and procedures for all palliative care services and facilities.

SUCCESS II will share best practices, lessons learnt across partners through meetings, exchange visits,

and disseminate end-line evaluation results. SUCCESS II will continue monitoring, for data accuracy, and

use performance and service data as tools to adjust program components.

To further promote sustainability, SUCCESS II will build Catholic Diocese management capacity through

organizational development, strategic planning, financial accountability, and policy development. Catholic

Church structures in Zambia, and their significant, enduring complementary role in the GRZ health system,

will outlive external funding. One advantage of SUCCESS II is the reach of Zambian Catholic structures

into rural communities. Partners are encouraged to link with local government institutions and

community/traditional leaders.

To diversify funding, SUCCESS II supports partners in accessing other funds as well linking with USAID

Economic Growth and Development implementing partners using their market survey and research

resources. In FY 2008, CRS will continue to support partners in their sustainability strategies.

All FY 2008 targets will be reached by September 30, 2009.

This activity is a continuation from FY 2007. New activities and emphases include: increased use of the

recently approved finger-stick protocol to allow an expansion of CT into the community; greater focus on the

palliative care prevention package in all service settings including CT; as well as increased support for

Pediatric ART (PART) through screening of infants using Dried Blood Spot (DBS) samples for diagnosis

using PCR technology, where available, with consequent referral of HIV positive infants for PART.

In FY 2008, SUCCESS II will also work on sustainability and capacity building in the last year of PEPFAR.

The most lasting gains in sustainability will be in terms of: organizational sustainability (organizations will

continue operations after PEPFAR); and sustainability of services (organizations will continue services as

resources permit). The most difficult to achieve will be financial sustainability (maintaining the same level of

funding).

SUCCESS II has established a large platform for HIV service delivery in six of nine dioceses (7 provinces)

in Zambia. SUCCESS II views CT as an integral component of high quality, community-based palliative

care (HBHC). SUCCESS II has achieved its CT targets. In FY 2007, SUCCESS II had a CT target of

12,000, and reached 100% of its target. In FY 2008, SUCCESS II will target 20,500 PLWHA in 45 of

Zambia's 72 districts (geographic coverage of more than 62% of all districts) with CT services and will train

850 persons, including health workers, caregivers, teachers, and local leaders in counseling or testing,

including pediatric CT. The cost per client counseled and tested, for 2008 will likely drop as SUCCESS'

partners increase the volume of counseling and testing, and become more efficient especially with the roll

out of finger-prick CT. However, because SUCCESS II works in rural areas, the cost per client will likely

remain higher than for CT delivered in densely populated urban and peri-urban areas. The target and cost

estimate rely heavily on provision of test kits by the GRZ's District Health Management Team, which the

USG is supporting through the JSI/Supply Chain Management Services project.

SUCCESS II will support its partners to provide on-site CT services that meet national and international

standards, focusing on those areas where other USG supported CT does not exist. CT, the entry point for

HIV/AIDS care and treatment, enables SUCCESS II to identify and refer PLWHA early for palliative care

and ART. Early identification of HIV infection allows PLWHA to initiate behavior change and participate in

Prevention-for-Positives programming. This reinforces USG Zambia Prevention targets. It also may help in

preventing or delaying orphanhood for Zambian children born to couples, in which one or both partner is

HIV-positive, provided that they take appropriate precautions. In FY 2008, SUCCESS will support 19

service locations providing counseling and testing according to national and international standards

SUCCESS II has set an indirect target of referring at least 4,550 individuals found to be HIV positive for

ART, including infants and children. Assuming that there is a reliable and adequate supply of test kits,

SUCCCESS II partners will scale up CT services through innovative methods, such as community CT, and

to the extent possible, will share its trained counselors with government health facilities when and where

they are short staffed.

Catholic Diocese partners will mobilize communities and use community participation to increase

acceptance and the uptake of CT, taking CT activities directly into the communities and households.

SUCCESS-II introduced finger-prick testing technology at a community level following NAC/GRZ and

International CT guidelines. This builds on the established care relationships in the communities and allows

for privacy and convenience of CT in the home. Since rapid testing is not effective in infants under 18

months, they will either: a) drawn a drop of blood for PCR analysis using Dry Blood Spot (DBS) technology

(available in Lusaka, Livingstone and Ndola); or b) where DBS and PCR are not available, home-based

care volunteers will visually screen infants for signs of "growth faltering" and other symptoms associated

with HIV/AIDS, and refer for presumptive clinical care until confirming diagnosis. This community CT model

also provides some relief for the health care human resource crisis in Zambia, by providing additional health

care providers to work in SUCCESS II rural service delivery sites and allowing scarce GRZ facility CT staff

to remain at their service sites to meet the increasing demand for CT services. In FY 2008, SUCCESS II

will train 850 individuals in counseling and testing according to national and international standards

SUCCESS II partners use a network model and create linkages to existing ART services. SUCCESS II

works hand in hand with the GRZ local health structures to coordinate CT services and link to other NGOs

and CT providers who operate Mobile Testing services. SUCCESS II will continue to provide training at

multiple levels, such as Rapid Test Training for registered nurses and counselors, and training on finger

prick testing for the many more ‘lay' counselors. In this technical area, appropriate GRZ trainers are

utilized, so as to carry on national protocols and guidelines.

SUCCESS II partners collaborate in numerous ways. The bi-annual meeting brings all SUCCESS II

partners together for cross-fertilization of programming ideas, issues, and lessons learned. Partners make

exchange visits to each other's sites, affording closer observation of on-the-ground best practices and skills

transfer. SUCCESS II monitoring and evaluation staff and program team continue to deepen the quality of

monitoring activities, not only for data accuracy but to use their performance and service delivery data as

programming tools for adjusting emphases or inputs.

SUCCESS II builds its partners' management capacity to promote sustainability within the Catholic structure

in Zambia, and the significant complementary role it plays to the GRZ health system. One of the

comparative advantages of SUCCESS II is the extensive reach of the diocesan structure into rural and often

isolated communities. Investment in their management capacity enhances program effectiveness and

sustainability. SUCCESS II trains its implementing partners in financial management and accountability,

logistics and commodities distribution, organizational development and strategic planning, as well as

providing mentoring on staff management and policy development. The projects are strongly encouraged to

link with local government structures and institutions. An example of strategic networking for sustainability

is having a Catholic Bishop sitting on the Board of Directors of a provincial government hospital. Key

networking also takes place at the integral community level, where local traditional leaders are involved in

parish home-based care coordinating committees. Each partner will be encouraged and supported to

become registered and/or accredited to receive drugs or kits supplied free by GRZ.

Diversification of funding support is also a key factor in sustainability. CRS management capacity building

also supports partners in accessing other funds when possible, and partners are in a better position to

attract other funds with their project management ability enhanced through SUCCESS II.

Activity Narrative:

All FY 2008 targets will be reached by September 30, 2009.

This activity is linked to activities in palliative care, counseling and testing and to other ART adherence and

PEPFAR-funded palliative care projects. SUCCESS does not provide ART directly, rather, it supports

adherence by clients of other direct ART providers. The CRS SUCCESS II Project is a follow-on to the first

SUCCESS Project and this activity is a continuation from FY 2007.

Through its adherence support efforts, SUCCESS will help the GRZ and USG Zambia to: support an

increase in the number of ART patients and sites receiving ART; and support ART quality improvement and

M&E. SUCCESS will also establish links to ART Centers of Excellence and other USG supported ART sites

as client referral destinations. SUCCESS will utilize the Centers of Excellence as a source of learning for

adults and pediatric ART.

SUCCESS will provide particular adherence support in remote, rural areas of Zambia through its vast

community based volunteer network nation-wide. These volunteers will direct clients to ART sites and in

cases where transport is a major barrier, will assist with client transport. In addition, SUCCESS will facilitate

where and when possible in bringing ART closer to clients, for example, through support of ART in hospice

or other community settings.

In FY 2007, SUCCESS targeted 2,500 PLWHA, located in the vicinity of ART sites, for a combination of

adherence support and nutritional supplementation. Program coordinators, volunteer caregivers, and

hospice staff were trained in ART and Adherence Support, relevant to their provider level. In addition,

SUCCESS formalized referral linkages between its diocesan partners and AIDS-Relief, CIDRZ, and ZPCT

ART sites in eight Provinces. 1,400 home-based care clients have received ART through CIDRZ in

Western Province, as well as many other ZPCT-supported GRZ clinical sites. These two-way referrals -

from home-based care to ART clinical facilities and back to home-based care for adherence support -

weave a strong continuum of care.

In FY 2008, SUCCESS II will continue to promote and support the rapid scale up of ART for Zambian

PLWHA through its partners. SUCCESS II will refine and expand its client referral to ART services

mechanism, and expand its ART literacy and adherence support programming to include community

adherence support groups. Pediatric ART (through referrals) and adherence referral and support will be

scaled-up. SUCCESS II will refer as many of its home-based care clients and post-test HIV positive people

to USG-supported ART sites as possible. SUCCESS II has set a target of providing adherence support for

6,850 PLWHA who will receive ART from the network model. SUCCESS II will provide support to

community based ART, transporting ART clients who live far from ART sites to the clinic for care or for ARV

re-supply, as a means to boost adherence, and to minimize the difficulty of reaching ART sites for PLWHA

who live in remote areas.

SUCCESS II will refer clients as follows: in Solwezi Diocese (Northwest province), to Mukinge Mission

Hospital (supported by AIDS-Relief); in Kasempa District, and Solwezi General, Kabompo District, Zambezi

District, and Mwinilunga District Hospitals (supported by ZPCT). In Mongu Diocese (Western Province),

SUCCESS will refer HBC clients to Lewanika General Hospital (CIDRZ) (1,400 HBC clients are already

linked to ART). In Mansa Diocese (Northern Province), clients are linked to Mansa General and

Kawambwa District Hospitals, (ZPCT). In Mpika Diocese (Northern Province), clients are referred to

Chilonga Mission Hospital (AIDS-Relief) and to Mpika and Chinsali District Hospitals and Nakonde Rural

HC (ZPCT). In Chipata Diocese (Eastern Province) clients will be referred to St. Francis Mission Hospital

(AIDS-Relief) in Petauke; in Kasama to Kasama General Hospital and Mbala District Hospital (ZPCT).

Monze Diocese (Southern Province) will refer to Macha and Mutendere. Mission Hospitals (AIDS-Relief).

AIDS-Relief is developing a further site in Monze, which will link with SUCCESS II palliative care support.

Adherence support, initially made possibly by GHAI rapid expansion funding, will continue with the

widespread training of caregivers on ART, ART literacy and Adherence support education, and the ensuing

application among the patients on ARVs in partner programs. The partners will continue to include PLWHA

in the adherence trainings to further empower those who are closest to the need and will strive to include a

balanced number of male and female adherence supporters.

SUCCESS II will continue to provide severely malnourished ART patients with nutritional supplements in

accordance with OGAC guidelines, or through wraparound arrangements with Food for Peace (FFP), the

World Food Programme (WFP), Global Fund or other donors. In FY 2008, SUCCESS II will continue to

provide High Energy Protein Supplements and Ready to Use Therapeutic with estimated value of $700,000.

‘Adherence vehicles,' managed by the dioceses, and also supported with GHAI Rapid Expansion funding,

will provide needed transport for non-ambulatory patients to often-distant ART sites, transport of test

samples to labs, and transport of adherence supporters to visit distant clients in need of regular follow up.

This vital support will continue and will provide a continuum of care from testing, palliative care, ART

treatment, and adherence.

SUCCESS II will support ART through many, well-established referral linkages for other services outside its

care and support package. SUCCESS II already has an established and effective network of trained

community volunteer caregivers who carry out ART literacy education and ART adherence support.

SUCCESS II will continue to provide training at multiple levels, for volunteers and staff for all partners. To

build local capacity, Trainings of Trainers are held and then training is cascaded to subsequent levels of

local personnel until all are trained in the programming area relevant to their role in the project. Due to the

sparse population in rural Zambia, the SUCCESS II project will continue to train a large cohort of potential

caregivers in order to cover the long distances between PLWHA homes and to ensure regular care and

support to clients. SUCCESS II will also train by leveraging and linking partners, such as carrying out ART

literacy and adherence support trainings with AIDS-Relief co-trainers in areas where SUCCESS II and AIDS

-Relief are co-located. Joint training strengthens the linking to ART, and follow on adherence support for

compliance to treatment. Further, the use of standardized adherence support training materials builds

sustainability.

A further dimension of sustainability will be achieved when home-based care/ART clients return to active

family and community life, knowing how to manage their now-chronic illness. Many positive-living PLWHA

become role models in their communities helping to reduce stigma and effectively breaking one of the

barriers of accessing treatment for HIV. Collaboration across SUCCESS II partners is achieved in

numerous ways. Annual meetings will bring SUCCESS II partners together for cross-fertilization of

programming ideas, issues, and lessons learnt. Partners will be encouraged to make exchange visits to

Activity Narrative: each other's operational sites, affording closer observation of on-the-ground best practices and skills

transfer. SUCCESS II monitoring and evaluation staff and program team will continue to strengthen the

quality of monitoring activities.

The second component of SUCCESS II sustainability is building management capacity of Catholic Church

structures in Zambia, and leveraging the significant complementary role of the Church health structures,

which will outlive external funding trends. One comparative advantage of SUCCESS II is the extensive

reach of diocesan structures into rural communities. To build capacity, SUCCESS II will train implementing

partners in financial management and accountability, logistics and commodities distribution, organizational

development and strategic planning, as well as staff management and policy development. The projects

are strongly encouraged to link with local government structures and institutions.

Another aspect of program sustainability includes the use of strategic networking, e.g. encouraging a

Bishop to sit on the Board of Directors of a provincial hospital. Key networking also takes place at the

integral community level, where local traditional leaders are involved in parish HBC coordinating

committees. SUCCESS II will also promote diversification of funding support as a key factor in

sustainability. Management capacity building will support partners in accessing other funds. Partners will

be in a better position to attract other funds with their project management ability enhanced through

SUCCESS II.

All FY 2008 targets will be reached by September 30, 2009.