The new mechanism will build on the skills-based abstinence and being faithful (AB) interventions

implemented under the CHANGES2 program, focusing especially on promoting positive social and health

behaviors in basic schools. This program will wrap around education activities that build instructional

methods and school management practices funded using Africa Education Initiative (AEI) funds and other

educational resources.

Though there is generally a high awareness of HIV/AIDS in Zambia, growing numbers in student

pregnancies show that more girls in school are exposed to the risk of contracting HIV. Reported

pregnancies for both rural and urban areas in basic and secondary schools increased from 10,441 in 2005

to 12,833 in 2007. Over 80 percent of all reported pregnancies affect girls enrolled in basic schools in rural

areas. The girls are predominantly at risk of infection, largely due to economic factors, cultural practices,

intergenerational sex and gender bias. Using PEPFAR funding, the new mechanism will target basic school

students, teachers and managers mainly in rural schools to influence attitudes and practices around health

behavior and management in schools. PEPFAR funding will be used to train teachers and school

managers in HIVAIDS education delivery, develop AB messages and tackle HIV/AIDS in the broader

context of a comprehensive school based health management approach that incorporates other PEPFAR

funded interventions such as the workplace program and student driven AB initiatives such as peer

education, Anti-AIDS clubs and Youth Friendly Corners and scholarships for orphans and vulnerable

children (OVC) in secondary schools. Experience has shown that school based HIV/AIDS interventions are

not only disjointed but also operate outside a coherent school health management framework with

participation that is based highly on self selection. PEPFAR funds will also be used to promote positive

relations between boys and girls and teaching staff to mitigate sexual abuse and violence in school. Using

in-service training structures, the wrap around of PEPFAR and AEI funding will be used to promote

institutionalization of HIV/AIDS and other health management aspects at the school level.

PEPFAR funding will also be used to promote both community participation in school health management

and also school partnerships with local referral services. By awarding small grants to communities, the

school health management support structure will be extended to surrounding communities with a focus on

prevention and psychosocial support for orphans. School-based activities must be mirrored in the homes

and surrounding community in order to change social norms and behavior in the communities where young

people live and spend most of their time. Furthermore, HIV/AIDS interventions such as life skills training will

be most effective if measures designed to protect school children are reinforced in the community. As part

of an effort to strengthen community participation in school-based HIV/AIDS activities, teachers and

community members will continue to be trained in mobilizing the community. Schools, in partnership with

communities, will develop locally relevant health management action plans and will be eligible to apply for

small grants to implement the plans. It is expected that 1,600 basic schools, including community schools,

and their surrounding communities will establish school based health management structures. The

resulting structures will deliver and provide access to AB information and related support to 800,000

students and over one million community members.

Through close collaboration between the school, District Education Board Secretaries (DEBS) and local

referral services, the new program will promote a wider network of support for school health management

structures. The new program will continue to build on CHANGES2 efforts to build the capacity local NGOs.

This approach is necessary to ensure the sustainability of school based HIV/AIDS interventions.

As part of its support to OVC, the new program will provide scholarships to 15,000 needy HIV affected

secondary school students per year (#8850).

The new program will work with implementing partners to adapt and develop IEC materials which will

support its school-based focus. For a budget of $200,000, a program evaluation of school based HIV/AIDS

interventions will be conducted to establish a baseline and better inform the development of IEC materials

because little is known about behavioral issues among basic school students. This evaluation will build on

past efforts to understand the impact of school based HIV/AIDS activities. All FY 2009 targets will be

reached by September 30, 2010.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Estimated amount of funding that is planned for Education

Water

Table 3.3.02:

The current education sector mechanism will end in September 2009. In order to ensure fair and open

competition, new core education mechanisms will be identified. The 2009 PEPFAR wrap around

mechanism will build on the previous OVC supported interventions implemented by CHANGES 2 program

that specifically focused on the provision of scholarships. The activity links with ABY program .The new

program will continue to provide scholarships to orphans at the high school level in order to keep the most

at risk children in school. This program will continue to leverage resources from the African Education

Initiative (AEI) in five target provinces and be part of a larger education development program funded by

USAID.

As a consequence of the HIV/AIDS pandemic, children of diseased parents are vulnerable and in need of

additional support. Zambia is experiencing a growing number of households headed by children and poor

elderly grandparents. AIDS orphans are more likely to drop out of school than their non-orphaned

counterparts Orphan-hood is usually accompanied by prejudice and increased poverty factors that can

further jeopardize children's chances of completing school education and may lead to survival strategies

that increase vulnerability to HIV. It is estimated that there are between 800,000 to one million orphans in

the country. Many of these children want to attend school but do not have the resources required. In order

to assist these children, the GRZ and partners have provided scholarships to many needy OVC in primary

school. The new program will provide scholarships to OVC attending secondary schools.

In FY 2008, PEPFAR provided scholarships to over 8,000 AIDS-affected OVC. Over the past three years,

the USAID supported education sector has utilized PEPFAR funds to provide scholarships to 14,280

students. In FY 2009 it is anticipated an additional 8,000 students will be provided scholarships.

The PEPFAR supported OVC scholarship program will be implemented in close collaboration with the

Ministry of Education's (MOE) Bursary Scheme and AEI scholarships. The USG scholarship program is

consistent with and complementary to the MOE program: (a) MOE provides scholarships for primary school

children; (b) PEPFAR supports high school students; (c) PEPFAR scholarships are specifically for AIDS

affected orphans and HIV+ children in grades 10 - 12 with priority given to OVC living in child-headed and

grandparent-headed households that are below the poverty level. The USG supported scholarships will

also include special support for the orphans and livelihood training.

AEI and the new program will work synergistically to compliment each other with AEI scholarships provided

to girls through grade nine. Many of these OVC do not continue with secondary schooling due to the

expense of the high school tuition. Support will be provided to the AIDS affected scholarship recipients from

the AEI program that complete grade nine and perform well on their exams to make the transition from

primary school to high school.

USG-supported scholarships for OVC include payment of tuition, boarding or housing costs, books,

uniforms, transportation costs, and other basic needs. This total scholarship package costs approximately

$200/250 per recipient per year plus administrative and capacity building costs. The scholarships will be

administered through sub-grants to three - four local NGOs. USG will ensure that the required capacity

building and other necessary support to the NGOs is provided. Communities will participate in selection of

the scholarship recipients through local selection committees made up of the Head Teacher, community

members, religious leaders and at least one student. The local NGO partners will train and supported the

selection committees at each school receiving scholarships.

The scholarship interventions will be implemented in collaboration with the rural schools in the four most

critical provinces in the country and will be an important component within the recently redesigned USAID

education program portfolio. Emphasis of the USAID education programs has shifted from supporting

access to education to encouraging the development of quality education services.

In addition to providing the scholarship package, emphasis in the future will be on supporting the

scholarship student's academic performance, setting up systems and support for the students in the

program to ensure they are in safe living environments and have the needed support in the event of

emergencies. A critical component will be to ensure the scholarship student and the entire school

population actively participates in HIV/AIDS prevention learning sessions. In addition, the prime partner will

be responsible for providing opportunities for the scholarship students to learn skills that will allow them to

be productive. This could include arranging work experiences or participating in volunteer community

activities.

The prime partner will collect data on relevant indicators from NGO partners. Staff will visit schools which

receive scholarships in order to verify the fairness and transparency of the selection process and payment

of fees as well as to monitor and support HIV/AIDS activities which compliment the scholarships.

To ensure sustainable services for OVC, the prime partner will support and train, as required the local NGO

partners to efficiently provide scholarships and support. The NGOs will receive support to ensure that they

have sound financial management and reporting competences and implement scholarship support activities

as required. The NGOs, in turn, will strengthen local selection committees to ensure that the most

deserving children are selected for scholarships. In addition, the prime partner will continue to work with

MOE on coordinating all scholarship programs to ensure that the maximum number of OVC receive

support.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Estimated amount of funding that is planned for Education

Water

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $20,183,182

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Counseling and Testing (CT) represents an important link between prevention programs and referral of HIV positive persons and

their families for services. Ensuring wider access to CT services is central to Zambia's response to HIV and AIDS. CT services

began in 1999 as a Ministry of Health (MOH) initiative in 22 pilot facilities, supported by the Norwegian Agency for Development

Cooperation, through the National HIV/AIDS/STI/TB Council (NAC). The U.S. Mission in Zambia partnership through the support

of the PEPFAR program, joined this effort in earnest in 2004.

All CT related activities in the country are coordinated through the NAC CT working group, including those conducted by the

government, non-governmental organizations (NGOs), and faith-based organizations, and coordinating bodies such as Provincial

AIDS Task Forces (PATFs), District AIDS Task Forces (DATFs), Community AIDS Task Forces (CATFs) and the private sector.

The U.S. Mission in Zambia collaborates with the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), Japan International

Cooperation Agency (JICA), the Clinton Foundation/UNITAID, United Nations Children's Fund (UNICEF), and the Zambia

National AIDS Response (ZANARA) in supporting training, technical assistance, and procurement of HIV test kits.

Great progress has been made in scaling-up CT services nationwide with the support of two key GRZ/MOH directives, issued in

2006 and 2007, respectively, that established, inter alia; HIV CT guidelines calling for routine, opt-out HIV testing and use of finger

-prick tests when appropriate in all clinical and community-based health service settings where HIV is prevalent and where anti-

retroviral therapy (ART) is available (March 2006); and a directive to all health centers to begin to provide routine HIV counseling

and testing (PITC) for all patients, especially children, admitted in the facilities (August 2007). These guidelines encourage the use

of rapid HIV tests, and emphasize that testing be voluntary and based on informed consent. Further, GRZ conducted the first

national VCT Day (June 2006) to increase access to CT services and encourage testing across the country; this practice has

continued since. Mobile CT has also contributed significantly to the scale up of CT through the public and private sectors.

As of August 2008, Zambia had nearly 1030 operable MOH accredited static CT sites, operating in all of the country's 72 districts,

with the U.S. Mission in Zambia working in 64 of those districts, representing a coverage of some 86% of the population. More

specifically, by the end of FY 2008, U.S. partners had supported the national CT and treatment goals of reaching 1,000,000 and

160,000 persons respectively (National HIV/AIDS Strategic Framework), by supporting 701 CT sites and reaching 611,043

persons with CT services. In 2008, a follow up assessment in all the provincial hospitals and key urban clinics showed that PITC

is indeed being provided on a greater scale, noting, however, that children are targeted more than adults. The assessment

recommended that technical guidelines be provided on the PITC initiative at national level.

In FY 2009, the U.S. Mission in Zambia will continue activities to support training of health care workers and lay counselors in CT

and commodity management. A major focus will be to integrate prevention into CT as well as linking CT services with tuberculosis

(TB) and sexually transmitted infection (STI) diagnosis and treatment sites, antenatal (ANC) clinics, and family support units

(FSUs). In FY 2009, additional emphasis will be placed on couples CT, including enhancing strategies for disclosure between

couples, integrating CT into counseling services for survivors of gender based violence (GBV), and openness to address TB/HIV

in communities. Treatment adherence counseling, client referral for appropriate follow-on services, and information, education,

and communication materials distribution activities will be continued. PEPFAR is increasing support for community mobilization

for CT as well as provision of CT services in: private and public sector workplaces; FSUs at the household level through home

based care programs and door-to-door campaigns at places of worship; and military facilities and among the defense forces; peri-

urban and rural mobile sites; and in refugee camps. PEPFAR also increases support for CT community mobilization during

national days such as the national VCT day, World AIDS Day, and World TB Day. The door-to-door CT approach allows

communities to integrate CT in homes, schools, social gatherings, and income generating activities. These activities have led to

an increase in the number of individuals and families accessing CT services. The family centered approach to testing and follow-

up care and treatment helps with disclosure within households, improves adherence and support between partners and within

families as well as saves time and money for the family when all members are seen on the same day.

The U.S. Mission in Zambia will continue to expand training for people living with HIV/AIDS (PLWHA) to advocate for CT, and to

mobilize communities to increase demand for CT services (where available, PEPFAR-funded Peace Corps volunteers will help

ensure community involvement). In FY 2009, activities will include: expansion of CT services for children and adolescents,

including child counseling; linking clients to medical, social, economic, spiritual and psychosocial support services such as

Prevention of Mother to Child Transmission; ART; palliative care (PC) including care for patients co-infected with TB; under-five

and antenatal care; sexually transmitted infections; general in-patient and out-patient departments, including children's wards;

family planning; youth programs; orphans and vulnerable children; child health; pediatric ART; positive living counseling; support

groups; prevention services; and integration of male circumcision into CT services. HIV negative clients will also receive positive

living counseling and will be referred to prevention related services. By working through GRZ structures (MOH, NAC, PATFs,

DATFs and CATFs), and participating in various working group meetings, the U.S. partners will coordinate and communicate

selection of catchment areas to avoid duplication of efforts.

In FY 2009, 40% of the CT target will be reached through mobile CT that is managed from a central, district-based static facility.

The cost per client varies due to variation in activities provided by partners and the location of mobile sites. For example, partners

offering mobile CT in remote areas incur higher costs than those provided in the urban or peri-urban areas. With the rapid scale-

up of mobile CT, quality assurance (QA) will be a critical priority in FY 2009, and will be implemented through training (using GRZ

approved curriculum), regular supervision, and utilization of the national CT guidelines and the 2007 NAC QA guidelines

developed with support from JICA. The U.S. Mission in Zambia will continue to support a network of private sector clinics, both

stand-alone and mobile, to serve people unable or unwilling to access public sector CT. The branded network approach helps

develop national CT capacity and demand for CT through coordinated efforts to educate Zambians about the benefits of knowing

one's HIV status. The branded private sector CT centers are being franchised in the effort to scale up provision of quality CT

services. Partners use the Zambia National Counseling Council CT registers and forms for reporting HIV testing information;

these forms were updated in 2008 to capture additional information for monitoring and evaluation purposes.

In FY 2009, the U.S. partners will continue to target adult men and women, children, and adolescents/youth, with emphasis on

male involvement. The U.S. Mission in Zambia will also target most-at-risk populations to ensure that these individuals have

access to CT services. For example, partners have increased efforts to offer couples CT, including the development of a

procedures manual for couples CT and a multi-media demand-creation campaign to increase the number of couples accessing

CT. Efforts are also being made to increase access to CT in the education sector, including support to the Ministry of Education

to administer CT services among their 61,000 employees, most of whom are teachers. The private sector will continue to increase

CT through the use of innovative campaigns such as "the need to know" campaign. This campaign was launched in 2007 by

participants in the U.S. Mission in Zambia's HIV/AIDS Global Development Alliances. In the first two months,12,148 people were

tested. In the months leading up to World AIDS Day 2007, 7,849 people were tested and received their results. To serve mobile

populations -- sex workers, truckers, traders, customs officials and other uniformed personnel -- the U.S. Mission in Zambia will

provide CT services along borders and high-transit corridors. Finally, to increase pediatric HIV testing, the U.S. Mission in Zambia

will train counselors in best practices for child and family HIV testing, sensitizing communities about pediatric HIV, and providing

psychosocial support and follow-up to children living with HIV/AIDS and their caregivers. Wrap around activities will include

prevention, child survival, malaria (PMI), safe motherhood, and family planning.

Despite these many efforts, CT expansion, especially in rural, remote areas, remains difficult. Limited availability of CT staff,

poorly developed communications efforts, gender inequities in access to CT services, lack of community empowerment to

engage in community mobilization for CT, and a weak logistics system hinder CT. It is estimated that only 13.4% of Zambians

have ever been tested and know their HIV status. It is therefore assumed that 86.6% of Zambians do not know their HIV status

and cannot be linked to appropriate services until they fall ill. Furthermore, these individuals do not have the full information they

need to adopt appropriate HIV prevention or positive living measures.

In FY 2009, the U.S. Mission in Zambia will continue to procure HIV test kits in collaboration with GRZ, GFATM, JICA, the Clinton

Foundation/UNITAID, and. The U.S. Mission in Zambia HIV test kit contribution will represent approximately 1,800,000 tests or

70% of all HIV tests conducted in FY 2008 (this includes confirmatory, tie-breaker, and tests performed by the National Blood

Transfusion Services). FY 2007 saw a transition in the HIV testing protocol and algorithm, from the use of screening test Abbott

Determine, confirmatory test Genie II, and tie-breaker Bionor to three rapid finger-prick and non-cold chain dependent tests. The

screening test remains the Abbott Determine test, the confirmatory test is now the Unigold test, and the tie-breaker is the Bioline

test. To date all CT sites use these tests, employing mainly the finger-pric

Table 3.3.14: