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.

The Zambia Children New Life Center (a shelter for sexually abused children in Lusaka's Linda compound)

was started up in February of 2002 as a result of increasing cases of reported child sexual abuse in Lusaka

as well as financial support and recognition through the Rebook Human Rights award for young human

rights activists. The main objective of the centre is to work towards prevention and protection of children

against sexual abuse and promoting children's' rights by working closely with family, community and

government. A number of trainings on awareness about sexual abuse in children have been conducted in

Linda where the centre is located. The centre provides emergency accommodation for children at risk of

harm in their current environment, psychosocial counseling, and preparation for court sessions, medical

attention and more recently a link has been established with the one-stop centre for post exposure

prophylaxis (PEP) at the University Teaching Hospital Department of Pediatrics.

Among the achievements of the centre have been: the recognition of the centre (many of the children are

referred by the police, social welfare department, or NGO's and individuals); increased public awareness

with resultant increase in reporting of sexual abuse cases in Lusaka, particularly in Linda compound;

support from organizations like World Food Program to help feed the children; and some successful income

generating activities within the community. The centre has also managed to win limited financial assistance

from Kindernotehilfe in Germany and Cordaid Netherlands to pay towards educational programs, income

generating activities, food and rentals. On average 40 children are seen every month.

Funding from PEPFAR in 2007 supported training in the community to raise awareness in HIV/AIDS

transmission through child sexual abuse. Recognition and prevention of sexual abuse in children requires a

number of key elements be taken into account and noted. These trainings are conducted in such a manner

that people interacting with children are able to identify some key elements, "tell tale signs" of sexual,

physical and emotional abuse. To date most of the trainings have been confined to Linda compound.

Among the trained personnel are teachers, church leaders, police, parents and caregivers and other key

community leaders as well as children themselves. It is hoped that by extending the trainings to other

areas of Lusaka, we will be able to identify another suitable site to establish a second centre in the coming

year. As of FY 2007, there was no formal referral system between the various players who handle the

complex issues around child sexual abuse. The funding is being used to establish a formal referral system

between the police, law enforcement agencies, schools, hospitals, and churches.

In FY 2008, additional funds will be used to set up another shelter for temporary refuge for abused children

in Mazabuka district. Mazabuka has had among the highest reported case of child sexual abuse in Zambia.

It has also been strategically chosen as a number of new activities under the Pediatric Centre of Excellence

and Family Support Unit counseling and testing activities will be extended here in 2008, providing an

opportunity to refer children appropriately and integrate with existing services. Funds will be utilized to

continue community sensitizations and training. 400 community leaders in Mazabuka will be trained and

referral systems will be strengthened. Lessons learnt in establishing referrals from FY 2007 will be

extended to FY 2008 activities. Efforts will also be made to document the number of referrals between the

various partners.

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

An additional $170,000 USD will be used to support the purchase of a fully equipped mobile health unit and

provision of comprehensive primary health care services to children as close to their homes as possible.

The team will work with the local community leaders in order to ensure that the community is aware of the

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

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

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

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

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

programs.

In FY 2007, this activity linked to the United States Government (USG) support for the development of the

University Teaching Hospital (UTH) Pediatrics Centre of Excellence (PCOE) and also to the support

provided to the adult antiretroviral therapy (ART) clinic. This activity has three separate prongs, one dealing

with physiotherapy for HIV complications, micronutrient supplementation and management of Opportunistic

Infections (OI's) in children, and running of a mobile pediatric counseling and ART unit.

Some patients on (ART) recover with complications. Neurological complications such as paraplegia,

quadriplegia, and neuritis are common in patients on ART due to opportunistic infections (OIs) and HIV-

related malignancies. Arthritis is another common complication in HIV/AIDS patients. As part of palliative

care, these patients need rehabilitation in order to recover some degree of function and have an improved

quality of life. UTH, being a tertiary referral center receives a large number of such patients. The

Physiotherapy Department at UTH currently does what it can to actively re-habilitate these patients;

however, resources are limited and requires improved conditions and equipment in order to adequately

assist these patients.

As part of our strategy to improve palliative care for HIV/AIDS patients, part of the funding requested for this

activity in 2007 has been used to purchase some of the needed equipment, such as a shortwave diathermy,

interferential combo machine, and an electric massager. As the main referral center for rehabilitation, UTH

will use the funds to bring its re-habilitation center to meet basic standards and also act as the training

center and build capacity through providing technical assistance to other provincial centers as the activities

are scaled-up in FY 2008 and subsequent years. As part of FY 2007, the Physiotherapy Department

strengthened the referral system within five Lusaka Urban District Clinics so that most of the patients could

be seen as close to their homes as possible. The limitation of this plan however is that the clinic facilities are

inadequately equipped to provide physiotherapy.

By the end of FY 2007, the UTH Physiotherapy Department will have trained 15 physiotherapists in the

latest advances in HIV/AIDS care and ART-related complications and extend the training to

physiotherapists in Lusaka District Urban Clinics, who in turn will work closely with the home based care

groups within the clinic catchment area. 500 HIV positive patients, including both adults and children will

benefit from this at the end of the FY 2007. In FY 2007, this activity linked to the USG support for the

development of the PCOE (#8993) and the support provided to the adult ART clinic (#9000).

In FY 2008, with the same amount of funding (100,000), this activity will continue to expand training of

physiotherapist within UTH and also extend training and services to Livingstone in the Southern Province.

A total of 15 physiotherapists will be trained in Livingstone and it is hoped that in the second year another

500 patients will benefit directly from the services. Activities will include strengthening the referral links

between the clinics and the main referral hospital as well as between clinics and community/home based

care services already supported by the USG (#8946) and other organizations so that the patients can be

provided with continued home-based physiotherapy upon discharge from the hospital..

An additional but separate activity under this program is to support the management of OIs, preventive

therapies, micronutrient supplementation, and provision of insecticide treated bed nets (ITNs) to vulnerable

HIV positive children (150,000 USD). This activity relates to UTH (#9043, #9044, and #9765) and HTXS

(#8993). In FY 2006 and 2007, the President's Emergency Plan for AIDS Relief (PEPFAR) funding

supported the development and operation of the PCOE for HIV/AIDS care at the UTH. This is a tertiary level

health center and a national referral hospital in Lusaka and a similar centre will be opened in the tertiary

hospital for the Southern Province, the Livingstone General Hospital. Up to 75% of HIV-infected children

develop symptoms in the first two years of life. They often succumb to serious infections like tuberculosis

(TB), pneumonia, malaria, and persistent diarrhea. Effective preventive interventions do exist but are often

not available in these tertiary level health care settings.

In 2007, CDC supported the procurement of supplies which helped prevent and treat serious infections like

pneumonia, (especially Pneumocystis carinii pneumonia (PCP), TB, malaria and persistent diarrhea, as well

as provide nutritional support through micronutrient and vitamin supplementation in order to provide

comprehensive care to all HIV-positive children who may not necessarily be eligible for antiretrovirals

(ARVs). Cotrimoxazole prophylaxis is offered to all HIV positive children for PCP (and also has benefit in

preventing malaria, and some diarrheal illnesses); however, the appropriate syrup formulation is not always

readily available. Intravenous cotrimoxazole makes a difference between life and death in admitted patients

with severe PCP, but again this is not available. Isoniazid (INH) prophylaxis for HIV positive children to

prevent TB though recommended nationally, is not currently given due to the non-availability of the

appropriate formulation as currently only combination forms of INH with rifampicin or ethambutol are

available. This activity will ensure that these drugs (isoniazid and cotrimoxazole) are available in the

appropriate formulation.

Studies have shown that HIV positive children are more susceptible to malaria.

ITNs have proved very effective in preventing malaria in children living in high areas of transmission.

Though the malaria program under Global Fund (and soon support from Presidents Malaria fund) does

support provision of ITN's the focus has been mainly on the rural populations. This activity will ensure that

all hospital beds, at both UTH and Livingstone General, have ITNs that are treated regularly and also

provide ITNs to all HIV positive children attending the ARV clinic. Malaria is endemic in all areas of Zambia

and hospital acquired malaria is a frequent occurrence.

Providing nutritional care has been another area of focus in FY 2007. Micronutrient deficiencies are

common in HIV-infected and HIV-exposed children. The most common deficiencies are vitamin A, iron, and

Activity Narrative: zinc. Children who are weaned early as part of a prevention to mother to child transmission intervention are

also more vulnerable to deficiencies. Vitamin A supplementation is given routinely as part of the national

immunization schedule. This proposal will procure multi-vitamin and daily multiple micronutrient

supplements for all HIV positive children, to include those in the malnutrition ward. On discharge from the

hospital the children will be referred to RAPIDS (#8946) for continued nutritional support and home-based

care in the community.

In FY 2008, with the same level of funding (150,000 USD) the activities under the micronutrient and

management of OI's program will be continued as described for 2007 and it is anticipated that 1,000

additional children will benefit from these activities by the end of FY 2008. A total of 15 health care staff will

be given refresher training in the management of opportunistic infections, including Isoniazid prophylaxis

and intra-venous administration of Co-trimoxazole.

:

In FY 2008, an additional activity under this funding will be the set up of a mobile Pediatric unit (100,000

USD) that can reach out to disadvantaged children in the remote parts of Lusaka district. The services will

include regular growth monitoring, immunizations, health education, clinics for sick children, psychosocial

and HIV counseling and testing services and linkages with local community initiatives (USG partners like

RAPIDS and SUCCESS) all of which will impact on better health and palliative care for the children's well-

being. Funds from this activity will be used largely to employ a complement of full-time dedicated staff that

can provide a range of comprehensive primary health care services to children as well as the purchase of

consumable supplies. By the end of the first year of this mobile initiative, it is hoped that at least 500

children will have received HIV related palliative care. CDC will assist with the purchase of a fully equipped

mobile unit under activity # 9025 to reach these disadvantaged children in peri-urban populations.

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

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

updates have been made to highlight progress and achievements.

Related activities: UTH HVCT , NIH HLAB and Social Marketing PSI HVCT.

The University Teaching Hospital has received funding from CDC through two co-operative agreements

established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3).

Though both agreements are managed by the central administrative office, the accounts are separate and

the location of the two departments is physically separate. To communicate the importance of the breadth

of activities and for purposes of coordination, the activities linked to the two departments have been

submitted as separate narratives.

The Clinic 3 is a dermato-venereology clinic which falls under the Department of Internal Medicine within the

University Teaching Hospital (UTH) in Lusaka. Clinic 3 offers tertiary level services for the Lusaka District as

well as primary care services to walk-in patients with sexually transmitted infections (STIs) and skin

complaints. STI clients referred to the clinic from other health centers often have complicated infections that

do not respond to first-line drugs or a history of repeated STIs. STIs are a major public health problem in

Zambia; the incidence has been reported at 16 per 1000 person-years. The presence of an STI can

increase the likelihood of acquiring HIV by two to five times and increase the probability of HIV transmission

through an increased level of viral particles in the genital secretions. Therefore, providing testing and

treatment of STIs can help prevent the spread of HIV.

The presence of an STI can indicate that either the client or his/her partner have engaged in risky sexual

behavior and hence are at increased risk of acquiring HIV. The incorporation of HIV counseling and testing

(CT) into the routine clinical management of clients with a STI is an opportunity to reinforce behavior

change messages and refer the HIV-infected individuals to the antiretroviral treatment (ART) program.

From fiscal year (FY) 2004, the United States Government (USG) has provided support to the UTH STI

clinic for a number of activities including: laboratory and infrastructure support, Neisseria Gonorrhea

surveillance, CT training, and the implementation of routine counseling and testing for all STIs. These

activities have included clients referred from any other clinical setting within the hospital and other walk-in

clients. All HIV positive clients are linked to the treatment and care program within the clinic facility. In

addition to referral of all STI clients for routine CT, all HIV positive clients in the CT center or in the ART

program within Clinic 3 are also screened for STIs. These services were expanded during FY 2006 to

include STI screening of clients undergoing HIV testing at a stand-alone CT center that has been

established by RAPIDS (#8947) in the neighborhood with support from the USG. In the last annual report, a

total of 801 STI and skin clients were seen and referred for counseling and testing.

FY 2007 funds activities will focus on continuing to link STI clients to HIV diagnosis, treatment and care, and

screening of HIV positive clients for STIs. All STI clients (100%) are referred for counseling and testing

(unless clients already have proof of being tested within the last three months). All HIV positive STI clients

who up to now had difficulty with accessing CD4 testing will be linked to the National Institutes of Health

CD4 testing services (Activity # 9015) within the hospital so that clients are identified in good time for

treatment. Partner tracing and treatment is part of the standard approach to management of STI clients. All

STI and HIV-related services will be extended to partners of our initial STI clients including PMTCT and care

services.

An additional activity that the Clinic 3 will undertake in FY 2008 is to link-up with the departments' in-patient

wards and provide CT services to all partners of patients admitted in the hospital. The department has

applied for USG funds (Diagnostic Counseling and Testing (DCT) (#9716) to support the recent Zambian

national policy of routine diagnostic counseling and testing in the hospital setting and all in-patient adults

admitted to hospital. Upon obtaining permission from the patient tested under this DCT program, partners

and relatives will be encourage to attend Clinic 3 for CT. HIV test kits are provided through the national

medical stores system.

Due to rapid staff attrition, human capacity in the clinic will need to be improved. Activities to address this

need in FY 2008 include the addition of two laboratory and counseling staff positions as well as the

development of continuing education opportunities and in-service training for existing staff. One of the main

barriers to improving care and treatment for HIV in Zambia has been the lack of human capacity and trained

health care providers. This activity will address these needs. While the cost per person of CT services is

greater than most programs, it is due to the additional support to the STI reference laboratory in terms of

laboratory equipment for STI diagnostics (including molecular technology) and support to the staff salaries

particularly laboratory, counseling and clinical staff..

In FY 2008, clinic 3 will use the funds to continue to provide all the current activities supported in FY 2006

and FY 2007. These include routine counseling and testing services to high risk STI clients (as well as any

other clients referred or interested in the service), laboratory support to set-up the molecular laboratory

testing for STI's, GC surveillance and CD4 testing, STI screening among PLWHA, treatment of dually

infected STI/HIV infected clients, health education activities and appropriate referral to other services will

continue to be strengthened in this fiscal year.

The activities of the Clinic 3 are part of the government-run tertiary referral and teaching hospital. All

activities in this proposal are within the confines of the priorities of the UTH which strives to establish a

sustainable program, by training of health care workers, developing standard treatment protocols,

strengthening physical and equipment infrastructures, implementing a facility-level quality assurance/quality

improvement program, improving laboratory equipment and systems and development, and strengthening

health information systems. The UTH management has contributed and shared some of the costs for this

program with the President's Emergency Plan for AIDS Relief funds by providing: part time staff, some of

the supplies (needles, syringes, and test kits) and supportive lab services. The benefit of this shared cost

approach is that in the long-term UTH will only require minimal funding once staff is trained and systems are

in place.

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

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

updates have been made to highlight progress and achievements.

Related activities: Linked to HTXS UTH (#9043), HTXS UTH Centre of Excellence (#9765) and OVC

(#8947).

The University Teaching Hospital has received funding from CDC through two co-operative agreements

established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3).

Though both agreements are managed by the central administrative office, the accounts are separate and

the location of the two departments is physically separate . To communicate the importance of the breadth

of activities and for purposes of coordination, the activities linked to the two departments have been

submitted as separate narratives.

The Family Support Unit (FSU) provides a number of activities including CT services to inpatient and

outpatient children that are seen in other departments of University Teaching Hospital (UTH) and

community. HIV testing is carried out onsite and enables the center to provide same-day results to their

clients. Child sexual abuse cases are also counseled, tested, and given psychosocial support in the unit

(#9043). Children who test HIV positive are referred to a specialized HIV clinic within the Department of

Pediatrics. Adults who test positive are supported with initial CD4 (laboratory support through United States

Government (USG) funds) testing and referred to appropriate antiretroviral therapy (ART) centers within the

hospital (UTH Department of Medicine (activity # 9716) or at the nearest district health clinic providing ART

services. Pediatric and Family Centre of Excellence (COE) is fully established and integrated with the

Pediatric Centre of Excellence (HTXS # 9765), within the Department of Pediatrics and will continue to play

a key role with provision of CT and ongoing psychosocial support for children and their caregivers.

The FSU also runs an outreach program focused in three sites, one at the UTH and two others in urban

communities within the district. These outreach activities provide: community sensitization on issues

around pediatric HIV testing services to orphans, follow-up on children enrolled in care and treatment

services, and provisions for psychosocial support to the children living with HIV/AIDS and their care givers.

Educational and recreational activities for children within the three sites are also offered. This activity is

supported by RAPIDS (#8944) Children are encouraged to express themselves in writing, drawings, and

games. Play therapy involving HIV+ children is used to build confidence and reduce stigma and

discrimination. RAPIDS will support non-medical services of the FSUs, linking children to ART services,

and support ART adherence.

A total of 5,000 children have been enrolled in the unit in the last three years. Ongoing educational and

recreational activities will be incorporated into the multi-disciplinary approach of the pediatric COE that will

be established in the Department of Pediatrics with support from the USG.

The FSU is also a training center in psychosocial counseling following the Zambian National VCT training

guidelines and facilitates training courses as requested by the general public. These courses are very

popular; however trainees must secure their own funding for training costs. The program will continue to

support through 2007 and 2008 the training of selected counselors who may not have the financial means

to secure funding for the training.

The FSU activities in FY 2005 and were supported by PEPFAR funds through FHI and RAPIDS (HKID

#8947) and RAPIDS continues to provide support programs that encourage parents and guardians to seek

CT for OVCs, provide community based support and address the specific needs of the OVCS. Beginning in

FY 2006, specific support for the counseling activities, including salary support for counselors has been

provided by CDC, while the OVC support has been provided by RAPIDS. In FY 2006, counseling was

provided with a greater focus on community outreach and pediatric ART adherence issues.

In FY 2007 additional direct funding will be used to expand to five additional sites in the Lusaka District that

will link children directly with the ART and counseling program in the peripheral clinics currently supported

by the USG. The unit will also add two additional activities to increase the number of trainings devoted to

child counselors and work closely with home-based health care programs supported by the USG (RAPIDS,

HKID #8947) and other partners to integrate pediatric care and support into their activities.

An additional activity in 2008 will be to work closely and support the establishment of Pediatric ART

satellites in Mazabuka and Monze through child counseling training and on-going supervisory support.

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

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

updates have been made to highlight progress and achievements.

Related activities: HVCT UTH/ZVCT, HVCT UTH, Renal, and FSU

The University Teaching Hospital (UTH) has received funding from CDC through two co-operative

agreements established directly with the Department of Pediatrics and the Dermato-venereology clinic

(Clinic 3). Though both agreements are managed by the central administrative office, the accounts are

separate and the location of the two departments is physically separate. To communicate the importance of

the breadth of activities and for purposes of coordination, the activities linked to the two departments have

been submitted as separate narratives.

The UTH is the only tertiary teaching hospital and the main national referral center for Zambia. The

Department of Internal Medicine admits on average 1,000 patients every month. An estimated 69% of

clients in the adult admission wards are HIV-infected. The department has six low cost wards (bed capacity

of 240) and one emergency admission ward (bed capacity 42).

A small study conducted in 2003 to determine HIV prevalence among all in-patients admitted to the medical

wards, concluded that 69% of patients were infected. Approximately 99% (n = 103) of patients agreed to be

tested after counseling, however, 50% of these clients never received results due to delays in obtaining the

HIV test results. Even with the use of rapid tests, samples sent to the main laboratory in a large hospital

lead to unnecessary delays and missed opportunities for diagnosing and identifying clients that need to be

placed on antiretroviral (ARV) medications. The medical emergency and inpatient wards are also important

settings for identifying HIV-infected individuals who are can be enrolled into treatment and care programs.

Since the beginning of 2006, the Department of Medicine has encouraged the medical residents to offer

routine HIV testing to all patients admitted in the medical wards. In March 2006 the Zambia National

Guidelines for HIV Counseling and Testing recommend routine "opt-out" testing in all clinical care settings

where HIV is prevalent and where ARV treatment is available. These guidelines have helped strengthen

the departments' guidelines to routinely test all patients.

Anticipated funds in fiscal year (FY) 2007 to the Department of medicine will be used to embark on an

aggressive program to routinely test all patients admitted in the medical wards and provide same day

results. To achieve this, the department will ensure that all wards have a room dedicated to CT. This room

would need minimal rehabilitation which would include obtaining furniture and cupboards to store the test

kits. All the wards currently have at least one or two nurses who are trained psychosocial counselors. Due

to the attrition rate of medical staff (especially nurses), UTH will train all the nurses and doctors in the

department in counseling skills as well as rapid HIV testing on-going training in-service dept. The Zambia

Voluntary Counseling and Testing has long experience in training HIV counseling and testing using national

guidelines and will be consulted. As the feedback time of all results improves, increased uptake of HIV

testing will occur and in turn improve the level of care provided to HIV-infected individuals because they will

have been identified at an earlier stage.

Partners (spouses) and other relatives, after obtaining permission from the client, will be contacted and

encouraged to seek voluntary counseling and testing (VCT) services at the dermato-venereology clinic

(#9042), which also falls under the Department of Medicine. VCT services would include risk reduction

programs and prevention of transmission among those that test positive (positive prevention). Finally

parents will be encouraged to have all their at-risk children tested through the Family Support Unit in the

Department of Pediatrics (#9044). Links have been established with the Department of Pediatrics for

referrals of HIV-infected parents from the center..

In FY 2008, the Department of Medicine will continue to work on strengthening the uptake of Counseling

and testing (CT) among patients admitted in the medical wards. The Department will also emphasize on

"family approach" to counseling and testing as well as integration into appropriate care and treatment

programs for the sero-positive clients. We will require training for diagnostic counseling and testing (DCT),

minor renovations to accommodate CT and strengthening links with other partners such as CIDRZ. FY 2008

funding will support the setting up of an adult referral ART centre and transition into the new adult ART

building funded by CDC and CIDRZ. Working with CDC and CIDRZ, UTH Department of Medicine will

establish SmartCare in the new adult ART Center and will use this system for monitoring and evaluation of

the quality of the ART service provision in the department. The department will also work closely with the

UTH Department of Obstetric and Gynecology to strengthen the referral system between PMTCT services

and ART services so that mothers requiring ART should access care at an earlier time,

The activities of the Department of Internal Medicine are part of the government-run tertiary referral and

teaching hospital and all activities in this proposal are within the confines of the priorities of UTH. This

system strives to establish a sustainable program through training health care workers, developing standard

treatment protocols, strengthening the physical and equipment infrastructures, implementing facility-level

quality assurance/quality improvement program, improving laboratory equipment and systems and

development, and strengthening its health information systems. The hospital management will be able to

cost share with the President's Emergency Plan for AIDS Relief funds by provision of some aspects of the

program that include: staff time, supplies such as needles and syringes, specimen bottles and test kits, and

supportive laboratory services. The benefit of this shared cost approach is that in the long-term UTH will

only require minimal funding once staff is trained and systems are in place.

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

The funding level for this activity in FY 2008 has increased since FY 2007. Narrative changes include

updates on progress made and expansion of activities.

Related activities: This program is linked to the development and operation of a Pediatric and Family Center

of Excellence (COE) for HIV/AIDS Care (#8993) at the Department of Pediatrics at UTH in Lusaka, the

Family Support Unit (#9044) and child sexual abuse (#9043) programs.

The University Teaching Hospital has received funding from CDC through two co-operative agreements

established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3).

Though both agreements are managed by the central administrative office, the accounts are separate and

the location of the two departments is physically separate. To communicate the importance of the breadth

of activities and for purposes of coordination, the activities linked to the two departments have been

submitted as separate narratives.

Routine opt-out HIV testing is gaining increasing support in many parts of the world today. The World

Health Organization now recommends routinely offering an HIV test if antiretroviral (ARV) treatment is

available, and the United States CDC has released new guidelines aimed at making HIV testing a routine

part of American health care.

Botswana was the first African country to successfully introduce routine opt-out HIV testing in 2004.

Integrating HIV testing into conventional health services in Botswana increased the testing uptake from 64%

in 2004 to 83% in 2005.

The 2006 Zambia National Guidelines for HIV CT recommend routine opt-out testing for all clients seen in

the clinical care setting where ARV treatment is available.

The UTH Department of Pediatrics, with direct support from CDC, embarked on a program to offer routine

opt-out testing to all children admitted at the UTH and their care-givers in September 2005. Since the

inception of this program in fiscal year (FY) 2005, the uptake for routine testing has risen from 30% in 2005

and in FY 2007, the department saw an increase in uptake of > 80% and extension of services to

Livingstone General Hospital in Southern Province, we hope to sustain this above 90% in FY 2008.

In FY 2008, the UTH PCOE will work closely with the Ministry of Health to extend activities to two satellite

sites, one in Mazabuka and another in Monze. Supervision and mentoring for the second site in Livingstone

and the newer site to be opened in Ndola (through USAID/ZPCT) will also be provided by the UTH PCOE

staff.

The funds for this activity will be used to train health workers in the provision of opt-out counseling and

testing services, identifying and rehabilitating appropriate space for counseling, purchase of back up

supplies and reagents, and strengthening referral systems from the referral hospitals to local clinics.

Initiating the program in Mazabuka and Monze will require some initial start-up costs, including basic

renovation and some training. The cost per person receiving CT services will initially be higher in the new

sites.

The activities of the Department of Pediatrics and Livingstone General Hospital are part of the government-

run tertiary referral and teaching hospital. All activities in this proposal are within the confines of the

priorities of the two tertiary hospitals that strive to establish a sustainable program by training health care

workers, developing standard treatment protocols, strengthening physical and equipment infrastructures,

implementation facility-level quality assurance/quality improvement program, improving laboratory

equipment and systems and development, and strengthening health information systems. The UTH

management will be able to cost share with PEPFAR funds by provision of some aspects of the program,

these include: staff time, supplies such as needles and syringes, specimen bottles and test kits and

supportive laboratory services. The benefit of this shared cost is that in the long run, sustainability requires

minimal funding once staff is trained and systems are in place.

The FY 2008, additional $50,000 funds will be used to support the scale-up of current activities in Mazabuka

and Monze, support more child counseling staff, and improve on follow-up, reporting, and recording

systems. From the 5 sites in 2008, it is anticipated that 5,000 children will be reached and 100 counselors

will be trained.

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

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

updates have been made to highlight progress and achievements.

Related activities: EPHO HVCT, SPHO HVCT, and WPHO HVCT.

The University Teaching Hospital has received funding from CDC through two co-operative agreements

established directly with the Department of Pediatrics and the Dermato-venereology clinic (Clinic 3).

Though both agreements are managed by the central administrative office, the accounts are separate and

the location of the two departments is physically separate. To communicate the importance of the breadth

of activities and for purposes of coordination, the activities linked to the two departments have been

submitted as separate narratives.

The Zambia Voluntary Counseling and Testing (ZVCT) program is a Ministry of Health (MOH) initiative

started in 1999 with the support from Norwegian Agency for Development (NORAD). It is also supported

through the National HIV/AIDS Council (NAC). From an initial 22 sites, the program has expanded to 696

sites throughout the country. This includes government and non-governmental organization (NGO) run

centers. Through support from United States Agency for International Development (USAID), the ZVCT

program has developed a voluntary counseling and testing (VCT) and preventing mother to child

transmission (PMTCT) information system that is currently being used by all VCT service providers

throughout the country. The program has recently attained national status and is integrated with the PMTCT

program. In conjunction with NAC and through the VCT technical working group, Zambia VCT services has

developed a revised HIV testing algorithm. This is in an effort to make HIV testing standard and accessible

throughout the country with the most practical non-cold chain dependent rapid tests. All test kits for the

counseling and testing (CT) programs are purchased through the existing USG supported central system

with the Central Medical Stores.

In spite of all these achievements, the services have not yet reached many of the rural areas. VCT services

are by and large urban concentrated. It is against this back drop, that the MOH and NAC through the ZVCT

program would like to take the VCT services to the most rural parts of Zambia.

The ZVCT has the experience and technical knowledge of conducting CT trainings and continues to provide

support to trainings conducted in Lusaka and other urban areas (will work closely with UTH Department of

medicine in trainings in CT, (activity # 9716). However the program lacks capacity to increase coverage to

rural areas due to financial constraints including lack of viable and reliable transport. The two operational

vehicles purchased in 2000 have outlived their expected use with extensive use for national level coverage

in all the 72 districts of Zambia.

In FY 2007 funds have been used to set up VCT sites in 11 districts (55 rural sites in all) of Zambia. The

funds for this activity in 2007 has supported the purchase of a vehicle, counseling testing refresher training

and training in rapid testing (Zambia has recently changed options for rapid testing to accommodate use of

finger prick testing and do away with tests that require refrigeration or high technology), establishing

operational VCT sites with follow up technical support visits, quality assurance checking and monitoring and

evaluating the program.

Funding in 2008 is requested to continue scale up of VCT access for rural disadvantaged communities. 10

districts will be chosen (with 3 new sites per district) in conjunction with the Ministry of Health to make VCT

more accessible to the rural populations. The actual districts were this will be done have been listed in the

table but are still to be confirmed. The focus will be on choosing relevant sites, where adequate space for

counseling is available and where there are adequate health personnel. Training will focus on the new

Zambian testing protocols, data management and quality assurance. A total of at least 60 staff will be

trained by the end of the fiscal year. All new and already established old sites, including PMTCT will be

supported by technical support visits.

The Zambia VCT program is part of the government initiative under the MOH and works within the confines

of government health facilities. It strives to establish a sustainable program, through training of health care

workers, developing standard testing protocols, strengthening physical and equipment infrastructures,

implementing facility level quality assurance/quality improvement program, improving laboratory equipment

and systems and development, and strengthening health information systems.

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

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

updates have been made to highlight progress and achievements.

This activity is linked to UTH CT, EGPAF HTXS, JHPIEGO HTXS, Columbia HTXS, UTH DCT, UTH ZVCT,

UTH Hepatitis B and C.

Title of study: Evaluation for renal insufficiency in patients commencing Highly Active Antiretroviral therapy

at the University Teaching Hospital in, Lusaka, Zambia.

Time and money: The funding requested is for year 2 of the evaluation. We are expecting $40 000 for year

1 and another $40,000 is being requested for year 2 in which we expect to complete the evaluation.

Local Investigator: Dr Shabir Lakhi of the University Teaching Hospital is the Principal Investigator on this

study and has overall responsibility for implementation and management for the study.

Project Description: The objectives of this activity are 1) to describe the prevalence of renal pathologies in

patients on highly active antiretroviral therapy (HAART); 2) to examine the relationship between abnormal

urinalysis and renal dysfunction; and 3) to determine possible predictors for abnormal renal function in HIV

positive patients on ARVs. Four thousand participants will be screened with a first-morning macroscopic

urinalysis for the detection of proteinuria. The effectiveness of albustix as a simple low cost tool for

detecting early renal dysfunction in Zambian HIV positive adults will be evaluated. Equal number of patients

with evidence of renal dysfunction (glomerular filtration rate (GFR)<60ml/min) and normal renal function will

be compared. Further quarterly follow-up of patients with normal GFR but abnormal urinalysis (albustix) will

be followed to determine if they develop overt renal dysfunction. In FY 2008, the renal unit will continue

follow-up of the cohort patients. According to literature, up to 20% may go on end stage renal disease.

Patients with some element of renal dysfunction (i.e. proteinuria and/or reduced GFR) will be followed up to

determine factors affecting rate of progression to end stage renal failure. In addition we would also like to

carry out histological studies of HIV positive patients with proteinuria to better determine the actual

prevalence of the type of glomerularnephritis in HIV positive clients.

These results if positive could then be recommended to the national ARV program in baseline evaluation

and management of patients who have renal insufficiency detected by proteinuria at baseline with HAART.

Detecting proteinuria could be a cheaper way to establish a diagnosis and predict the outcome of most

renal diseases. Urinalysis specifically albustix could prove to be an important simple test for detecting early

renal dysfunction in patients with HIV-infection on Highly Active Antiretroviral Therapy (HAART) especially

in rural areas with limited laboratory capacity. Microalbuminuria could also be useful as an early sero-

marker of systemic infection

Lessons Learned: We haven't commenced the evaluation yet but we already have learnt valuable lessons

in protocol development, planning, and establishing the clinical set up and staff to be involved in the

evaluation.

Information Dissemination Plan: The results will be shared with the Ministry of Health, National AIDS

Council and other implementers of the HIV treatment program in Zambia through a results dissemination

meeting that will be conducted after the final analysis of results. The results will also be shared at both local

and international conferences and will be submitted for publication in peer reviewed journals.

Budget Justification for FY08 monies :

Salaries/fringe benefits: U$14,000

Equipment: U$00.

Supplies: U$18,000

Travel: U$ 3,000 for one person to an international renal/HIV conference

Participant Incentives: U$ 1,500 Laboratory testing:

U$ 3,000 for possible biopsies + shipment

Other: U$ 500

Total: U$ 40,000.

All children admitted to the pediatric department of University Teaching Hospital (UTH) in Lusaka, Zambia

are routinely offered HIV testing and counseling. Lusaka has good (believed to be at least 75%) PMTCT

(prevention of mother-to-child HIV transmission) program coverage and with opt-out testing, >90%

acceptance is now the norm in Zambia. However, a high percentage of children admitted to UTH with

HIV/AIDS related illnesses, are apparently not covered by the PMTCT program. A cross-sectional survey of

hospitalized children will be performed in order to investigate potential factors which may explain the high

number of previously unrecognized HIV-exposed and infected children admitted to UTH despite a well-

functioning PMTCT program with good coverage in Lusaka. We will administer a questionnaire to a sample

of all consenting caregivers of children aged = 24 months who are admitted to UTH, regardless of the child's

HIV status/exposure. This will be done over a 6 month period to cover differing admission rates. The

evaluation is expected to include 1300-2400 children, including 400-700 HIV-exposed and/or infected

infants and 900-1700 HIV-negative infants. It is intended that this will answer the following:

• What percentage of mothers of admitted children received PMTCT HIV testing and counseling and, if HIV-

infected, PMTCT interventions?

• What were the reasons and risk factors for mothers not receiving PMTCT HIV testing and counseling?

The evaluation intends to identify missed opportunities for HIV prevention in infants and children in the

Lusaka district and thus answer the question "why are so many mothers of children, admitted to UTH with

HIV/AIDS related illnesses, not registered within the PMTCT program?" This information will help Lusaka

and Zambia as a whole to improve the followup of mothers and babies. It is critical that we quickly find out

why we miss these infants and put in place programmatic activities to reduce the missed opportunities.

This evaluation has IRB clearance from both CDC Atlanta and Zambia.

This program was first funded in fiscal year (FY) 2005 through Columbia University, to support the

development and operation of a Pediatric and Family Center of Excellence (COE) for HIV/AIDS care at the

Department of Pediatrics at UTH in Lusaka. Since FY 2006 the Department of Pediatrics has received

direct funding to allow for program implementation and build local capacity and has continued to work in

close collaboration with Columbia University, which provides technical support. The primary goals of the

center are to: 1) increase the number of children engaged in care and receiving antiretroviral therapy (ART);

2) develop a regional training center for multidisciplinary teams (MDT) in pediatric HIV/AIDS care and

treatment and 3) be the prime referral site for children with advanced and complicated HIV/AIDS disease.

The COE will provide state-of-the-art care and demonstrate best practices for infected and exposed

children, which will be disseminated through off-and on-site training activities. In addition to providing on-site

training to teams of providers, the COE will also support mobile training teams to train, supervise and

support MDT initiating pediatric HIV care in neighboring provinces and districts. The program began

implementation of activities at the UTH Department of Pediatrics in September 2005 and in Livingstone

General Hospital in October 2006. Some of the system achievements to date include:

•Recruitment of management and implementation staff to support the COEs

•Establishing data systems, logistics and referral flow between various service points

•Supporting ongoing and dynamic training, technical assistance and supportive supervision. In 2006/2007,

423 PCOE health personnel were was trained in pediatric technical areas such as sexual abuse, palliative

care, child development, adherence, TB/HIV, and ART in pregnancy.

•Establishment and initiation of the infant diagnostic protocols and guidelines.

The PCOEs has continued to expand the inpatient pediatric HIV testing program. Between January 2006

and December 2006, 8,238 admitted children have been counseled, 6,299 tested (31% seropositive) and

received their results. In UTH, the proportion of admitted children tested for HIV increased from 59% in

January 2006 to 78% by December 2006 and 1,125 (50% positive) parents/guardians of children have also

accepted counseling and testing services. During 2006, 856 children were initiated on ART. Cumulatively,

1,894 children have received ART since 2005 (a subset of the 2,542 children in care).

In FY 2008, this mechanism will continue to support the development and operation of the existing UTH

PCOE, expansion of activities in Mazabuka and Monze, and integrate childhood malnutrition with HIV

related services.

•The PCOE will continue to offer comprehensive pediatric care and treatment by ensuring that all exposed

and infected children: 1) receive quality and continuous clinical care; 2) are properly monitored and

assessed for treatment eligibility; and 3) are continuously assessed for immunologic response to treatment,

toxicities and adverse events.

•The PCOE will begin to support the expansion of pediatric services to two new districts (Monze &

Mazabuka) as well as "down" referral to district sites that filter into the COEs (4 new sites). This will include

supporting the sites by initially supporting "satellite" clinic services by PCOE staff and in tandem building the

capacity of the sites to independently provide comprehensive pediatric care and treatment services. The

PCOE will do so by supporting staff augmentation, training, task-shifting, clinic reorganization, and minor

renovations. Depending on the site needs, enhancing PMTCT services to deliver care and treatment to

pregnant women can be a focus for technical support.

•The burden and mortality of severely malnourished children in HIV infected children is very high (up to

40%). With additional plus-up funds, PCOE will work in two of Lusaka's neighboring compounds, Misisi and

Chawama, to identify children less than 5 years with early malnutrition. An innovative comprehensive,

community screening program will be established with greater community participation and will include early

identification of HIV positive children. Community involvement will ensure local ownership and sustainability

of the program. A rehabilitation centre will be set up in Misisi where there is an existing adult nutrition

program. This activity will link with the mobile multi disciplinary pediatric clinic that will offer HIV care and

treatment services to all HIV positive children within the communities. Through this additional activity, it is

estimated that 5,000, will be screened for HIV and malnutrition and 300 will access care, treatment and

nutritional rehabilitation

•Using Plus-Up funds ($1M total for scaling up infant HIV diagnosis nationwide in Zambia), UTH will

collaborate closely with Clinton Foundation, CDC, and with all service cooperating partners (MOH, EGPAF,

ZPCT, BU, CRS-AIDSRelief, and other partners) to scale up the availability of infant HIV diagnosis

nationwide. CDC-Atlanta and the lab team at CDC-Zambia will continue to provide quality assurance for

infant HIV diagnosis through provision of proficiency testing panels and regular technical supervision. UTH

will provide direct collaboration and supervision also for the remaining two laboratories performing DNA

PCR in Zambia. A subset of specimens will continue to be retested using a total nucleic acid (TNA) real-

time PCR technique developed at CDC-Atlanta and validated on dried blood spot specimens from sub-

Saharan Africa (J Virol Methods 2007). This activity will link in closely with PMTCT services and infant

follow-up as well as with routine opt-out diagnostic HIV testing of all hospitalized infants at UTH, Livingstone

Activity Narrative: Hospital, and other facilities. UTH will also provide direct infant diagnosis services to rural mission hospitals

through its collaboration with CRS-AIDSRelief and the Churches Health Association of Zambia. Earlier HIV

diagnosis in Zambia will lead to earlier referral and start of ART at a much younger age, leading to improved

long-term pediatric outcomes.

•The PCOE will continue to support and expand comprehensive community outreach and patient follow-up

activities. This includes a patient follow-up and tracking program supported by teams of outreach workers

and "expert" caregivers trained in locating and supporting families of clients who have discontinued care

and treatment services. Additionally, the PCOE will support a community advisory board to solicit input

from constituents to design and revise programs/services to ensure continuous quality services.

•The PCOE will continue to strengthen the pediatric patient tracking and monitoring system in the PCOE by

implementing the Ministry of Health designed M&E tools and electronic data collection system on site. In

addition to further enhancing local systems that track patients from inpatient testing through enrollment and

follow-up in care and treatment.

•The UTH PCOE will continue to support and build National pediatric HIV/AIDS capacity by implementing a

comprehensive training program that includes onsite on-the-job training whereby staff at sites targeted to

initiate pediatric HIV/AIDS services visit UTH for rotation throughout the various PCOE clinical and

supportive services.

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

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

updates have been made to highlight progress and achievements.

This activity relates to Columbia University, University Teaching Hospital Pediatric Center of Excellence

(UTH PCOE) and Zambian Children New Life Center (ZANELIC).

Since FY 2005, the United States Government (USG) has provided support to the Department of Pediatrics

at the University Teaching Hospital (UTH) to strengthen activities developed for the management and

monitoring of cases of child sexual abuse (CSA). These activities included training of health care workers in

the recognition and care of child sexual abuse, the provision of post exposure prophylaxis with antiretroviral

therapy, development of a monitoring system, and a follow-up program for reported cases. Other activities

include strengthening links between the Department of Pediatrics and the Zambia Society for Child Abuse

and Neglect, development of activities to increase community awareness of child sexual abuse, and the

provision of psychosocial support to sexually abused children and their families.

In the second year of operation (April 2006 - March 2007) a total of 860 cases of child defilement were

seen. 228 were commenced on PEP, with an improvement in completion of PEP course in the last year.

All children testing positive for pregnancy are referred appropriately for antenatal care, which includes,

PMTCT intervention and those that test HIV positive at first contact are referred to the pediatric ARV

program.

CSA has received increasing media attention since September 2003 in Zambia, when a young 11 year old

girl died in the UTH in Lusaka as a result of complications of multiple sexually transmitted diseases

contracted after she was raped by her step-brother. Cases of child sexual abuse are on the rise, though

many cases remain unrecognized or underreported. The perpetrators are often relatives of the victim,

neighbors or close friends, and often only those that develop complications like physical trauma or STI's

reach the health service. One case of child sexual abuse is reported every day in Zambia and it is

estimated that for every reported case there are at least ten others not reported (press release Sept 2003).

One in five sexual abuse cases involve young children. Increasingly girls less than 15 years of age are

testing positive for HIV which contributes to the higher prevalence of HIV among women.

Factors that contribute to the practice of CSA in the population include: misconceptions that sex with virgins

will cure AIDS, or that young girls are HIV negative; traditional sexual cleansing practice with young girls;

poor law enforcement strategies; lack of awareness and knowledge in the communities about victims' rights

and appropriate action to take.

Funding for FY 2006 supported a continuation of activities as well as expansion of similar services to

Livingstone Hospital in Southern Province.

In FY 2007, funds were used to continue current activities, strengthen and integrate networks with the law-

enforcement agents, and other non-governmental organizations working in the area of CSA. Initial

assessments have been carried out to extend services to a third site at Ndola Central Hospital in the

Copperbelt Province and to intensify community sensitizations to ensure early referral of cases to the

hospital as well as to strengthen post exposure prophylaxis and follow-up of abused children.

FY 2008, funds are being requested to improve accessibility of PEP by establishing community based

centers in Lusaka, Livingstone, and Ndola. These will be within the public health sector at the health

centers. As a result of sensitization activities conducted in year 2007, it is anticipated that a larger number

of children will seek the service. Experience has also shown that many children report late due to lack of

transport, missing the chance for appropriate and early PEP therefore there is a need to take these services

closer to the community in 2008. Emphasis will also be placed on adherence to PEP course for those that

start treatment. To date, the referral of children already HIV positive and in need of treatment is well

established. This program is closely linked with the community ZANELIC initiative under activity 12330.

All the CSA sites are being established within the government health care setting. This will ensure long-term

sustainability through staff training, systems development for quality assurance, monitoring, and referrals.

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

Oct 08 reprogramming: Additional funding is being provided for the Microbiology department to purchase

equipment and essential reagents, training activities, infrastructure and human resource capacity

development will be provided for national microbiology reference laboratory to support patient care and

treatment of HIV/TB and other opportunistic infections

The funding level for this activity in FY 2008 has increased since FY 2007. Narrative changes include

updates on progress made and expansion of activities.

This activity is linked to Southern, Eastern, Western and Lusaka Provincial Health Office programs.

Since 1998, the University Teaching Hospital (UTH) Tuberculosis (TB) Laboratory was previously supported

by Japanese Inter Cooperation Agency (JICA) at UTH. However, the JICA project at UTH came to an end

in March 2006 resulting in an ending of support for their activities, which included external quality

assessment (EQA) for Lusaka Province that supports the national TB program. In FY 2007 $20,000 from

the CDC Laboratory TA budget was reprogrammed to assist the UTH TB Laboratory in conducting limited

TB smear microscopy external quality assessment in the province.

There are four districts within the Lusaka Province, namely: Lusaka Urban, Kafue, Chongwe, and Luangwa

Districts. Each district has numerous government and private clinics and hospitals located within each. The

UTH TB Laboratory under the national TB program was responsible for conducting TB EQA activities as a

model for the country. UTH TB Laboratory serves a reference center for the 38 TB diagnostic centers in

Lusaka Province. The UTH TB laboratory facility has both EQA capacity for Zeihl Neelsen and fluorescent

smear microscopy, rapid culture and drug susceptibility testing capacity. In FY 2008, the laboratory will

expand to support full TB program support services including rapid liquid culture and first line drug

susceptibility testing. The UTH laboratory staff is experienced in carrying-out these activities and will serve

as a resource to the national TB Reference Laboratory as well as to urban and rural health centers within

the province. The UTH laboratory is well equipped with three certified bio-safety cabinets, several light

microscopes and a fluorescent microscope. The laboratory also has the rapid Mycobacteria Growth

Indicator TB (MGIT) culture system; maintenance reagents, DNA probe Identification system and support

for validation of the biosafety cabinet and maintenance of MGIT TB system is also required.

The UTH TB Laboratory has experience in EQA, rapid culture, and drug susceptibility testing activities

through many years of experience running an effective TB program. They will initiate full TB program

support in FY 2008 for the four Lusaka Province districts. Laboratories/clinics where TB microscopy is

performed in Lusaka District include (17) are as follows: Matero Reference, Matero Main Clinic, Chainama,

St John's Hospital - Private, Maina Soko Military Hospital, Lusaka Trust Hospital - Private, George,

Kabwata, Arakan Barracks, Chipata, Mtendere, Kalingalinga, Kamwala, Chilenje, Chelstone, Chawama,

and Kanyama. Kafue District clinics include eight, which are: Kafue Estate, Chilanga, Chilanga Hospice, Mt

Makulu, Zambian Helpers Society Hospital, Chikupi, Mwembeshi, and Kazinva Clinic. There are eight

newly trained/opened private clinics in Lusaka Urban District to be included as well; these are: Kara

Laboratory, Pear of Health, Dr. Wang, Victorian Clinic, Family Health Centre, CorpMed, Mutti, and Nkanza

Laboratories. These laboratories/ clinics bring the total number of Lusaka District sites to 33. For Chongwe

District there are two sites and these include Chongwe Clinic and Mpanshya Mission Hospital. In Luangwa

District there are also two; which are Katondwe Mission Hospital and Luangwa Clinic.

The UTH Laboratory will provide onsite visits and collect 25 smears per quarter from each laboratory for

rechecking, provide panel testing once per year for all staff in the laboratories within the four provincial

districts.

The University Teaching Hospital serves as the national HIV reference laboratory and will over see and

provide national quality assurance guidance to the provincial laboratories and more than 1,000 rapid HIV

testing sites within the country. In FY 2007, the UTH Virology laboratory initiated work with the national HIV

rapid quality assurance program in collaboration with other partners. In FY 2008, the laboratory will focus on

expanding the EQA program and work toward international accreditation for the reference facility. This

funding will support the acquisition and development of quality control material as well as support technical

staff in conducting these activities. The laboratory will reach 50% (46) of the district laboratories with quality

assurance samples and data collection within selected provinces during FY 2008.