Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 11667
Country/Region: Zambia
Year: 2009
Main Partner: To Be Determined
Main Partner Program: NA
Organizational Type: Implementing Agency
Funding Agency: USAID
Total Funding: $0

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $0

United States Agency for International Development Zambia issued a new bilateral Nutrition RFA by

December 2008 to establish a bilateral Nutrition activity. Following current Office of the Global AIDS

Coordinator (OGAC) Food & Nutrition guidance, the bilateral mechanism funded by the RFA will provide

food and nutrition support to PMTCT Clients (HIV positive pregnant and lactating women, and their

children), with a special focus on moderately to severely malnourished clients who are on antiretroviral

treatment (ART) or eligible to begin ART. The new activity funded by the RFA will link these new PMTCT

services with other PEPFAR program areas in Zambia, including ART, Care and Support, counseling and

testing (CT), and orphans and vulnerable children (OVC). The new activity will also liaise closely with the

PATH IYCN activity in COP FY 2008 to ensure coordination, collaboration, and a smooth transition without

gaps in services when PATH IYCN funding ends.

Emphases of this new activity in 2009 will include increased efforts to link PMTCT activities especially

Nutrition support for HIV positive pregnant and lactating women, and their Infants and Young ART, OVC,

home-based care (HBC), and CT services, in order to minimize HIV transmission and maximize survival

time for HIV positive women and children. AWARDEE TBD will take the USG lead in Zambia on promotion

of improved nutrition for HIV positive (or exposed) women and infants, including community-based

promotion of exclusive breast-feeding up to six months, as well as timely introduction of appropriate

weaning and complementary foods.

In addition, United States Agency for International Development has underscored that AWARDEE TBD will

collaborate actively and openly with the Government of the Republic of Zambia (GRZ) and with other United

States Government (USG) partners. The aim of collaboration will be to ensure optimal provision of

Technical Assistance (TA) and training to USG partners and GRZ. In order to expand sites and services

with the new reprogramming funds, AWARDEE TBD will embrace a partner-friendly and client-oriented

approach. AWARDEE TBD will consciously minimize the demands on overstretched clinical staff and

community caregivers, while empowering them with skills and materials for clinical and community

nutritional care and support. AWARDEE TBD will help design and support services and referrals to simplify

and facilitate client continuity of care in clinic and community settings, and in-between.

Lastly, AWARDEE TBD will work on sustainability and capacity building in the last year of PEPFAR. The

most lasting gains 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).

The objectives of this activity are to integrate nutritional assessments, counseling, and appropriate, cost-

effective, targeted nutritional supplementation, into PMTCT services to reduce post-partum HIV

transmission and mortality among exposed infants. This activity will provide strong community outreach to:

promote six months of exclusive breastfeeding for HIV-exposed newborns (mixed feeding increases the risk

of HIV transmission); integrate nutritional screening and targeted nutritional supplements into PMTCT

services for HIV+ pregnant and lactating women, especially those with low CD 4 counts; and support

appropriate weaning of HIV exposed and HIV+ infants through nutritional counseling, as well as timely and

targeted provision of appropriate weaning and complementary foods.

This activity focuses primarily on the post-partum period and has a strong clinic-community linkage

component. The community linkage will come through directly linking PMTCT clients to existing cadres of

thousands of home-based care and OVC volunteer caregivers, who will be trained to support exclusive

breast feeding until six months and appropriate weaning and complementary feeding practices thereafter.

This activity will build on existing and planned PMTCT services. By providing support for safer feeding

practices and preventing/treating malnutrition, it will help ensure that women and children are protected

against post-partum transmission. In addition, this activity will help increase PMTCT uptake by offering a

more comprehensive PMTCT package to HIV positive pregnant and lactating women and their infants,

including nutritional assessment, counseling, and, where needed, nutritional supplements. This, combined

with expanded ART access, will constitute a very attractive PMTCT package for many eligible women.

AWARDEE TBD will work jointly with USG Zambia funded partner(s) and the GRZ, to provide technical

assistance, offer training technical advice and materials and other inputs to support nutritional assessment,

counseling, and supplements at various clinical locations. This will ensure that approaches recommended

at the clinic level are supported thereafter by community-based caregivers. Antenatal clinics and PMTCT

sites will first identify high-risk women (low CD4 counts and/or malnourished) and "prescribe" and

"dispense" appropriate, cost-effective maternal nutritional supplements to support the health of the mother

and reduce the risk of low birth weight infants. These same women and their infants would then benefit

from the standard PMTCT services, reducing the risk of transmission.

After the birth of the child, AWARDEE TBD-supported training and TA will ensure ongoing clinical

assessment and nutritional counseling at clinical sites, such as well-child/maternal-childhood health (MCH)

clinics, which will advise on exclusive breastfeeding (EBF) and Acceptable, feasible, affordable, sustainable

and safe (AFASS) practices up to six months and on how to introduce appropriate weaning and

complementary foods thereafter. Selected clinic sites will also "prescribe" and "dispense" nutritious weaning

and complimentary foods for infants who are deemed to need them, and to mothers who present with low

CD4 counts and/or signs of serious malnutrition.

AWARDEE TBD will work with United States Agency for International Development and CDC PMTCT

projects to select and establish as many "demonstration sites" as COP FY2008 funding will allow, based on

such criteria as HIV prevalence, client load, malnutrition rates, facility-perceived need, capacity, and

willingness each in the Northern and Southern half of Zambia. The catchment areas for each site will

include ART and PMTCT clinical services, and community support services (HBC and/or OVC caregivers),

as well as well-child/MCH/under-five clinical care. The combination of these services will allow a complete,

integrated PMTCT-HBC-ART network to function.

Activity Narrative: Recent research has confirmed the value of exclusive breast-feeding for PMTCT clients and their infants.

This approach will afford PMTCT partners (Zambia Prevention, Care and Treatment Partnership (ZPCT)

and Zambia Exclusive Breastfeeding Services (ZEBS)) an option to improve maternal and infant survival

and mortality, through strengthened nutritional assessment, counseling, and support, beyond the first six

months of life. It would also help determine the value of community-based promotion of EBF and

appropriate weaning and feeding practices linked to a network of clinical PMTCT and ART services.

AWARDEE TBD will assist United States Agency for Inernational Development Zambia to adapt or adopt

the United States Agency for International Development Kenya "Food by Prescription" model, as well as

other experience with nutrition assessment and supplementation in Zambia (e.g., CIDRZ, SUCCESS). The

models offer opportunities for replication and expansion. Based on a detailed assessment of local private

sector food processing capacity, AWARDEE TBD will assist United States Agency for International

Development to make best use of existing private producers to cost-effectively produce (and/or procure)

and distribute appropriate food and nutrition support products. AWARDEE TBD will incorporate a private

sector orientation fully into the activity from the outset, and will provide ample private sector skills and

capacity for success in this area via a combination of direct staffing and/or consultancy services.

It is anticipated that through technical and training assistance, and design of materials and products,

AWARDEE TBD will be able to support a full range of services including nutritional assessment and

counseling and, as required, nutritional supplements to approximately 10,000 HIV positive women and

infants at ten carefully selected sites. AWARDEE TBD will begin with those sites selected and supported by

PATH IYCN, and expand to others as resources permit. This number of sites assumes that the women and

children will benefit from food supplements on average for three-six months.

This activity has a strong capacity building aspect for both clinical sites (PMTCT, ART, and well-child/MCH

clinics) and the OVC and HBC community caregivers, who will acquire and make use of valuable nutritional

assessment and counseling skills.

The initial investment in production and distribution of appropriate food supplements for mothers and

weaning foods for infants will stimulate the private sector investment in appropriate food supplements, as

well as attract wrap-around funding, such as income-generation, other appropriate forms of food aid for

malnourished people living with HIV/AIDS (PLWHA) and their infants, or support to increase agricultural

yields.

If successful, the model can be replicated/expanded to serve more sites and all under-five children of HIV

positive mothers through better nutrition guidelines and training in nutritional assessment and counseling for

clinical and community based caregivers. This will depend on funding availability. Demonstration of the

effectiveness of this approach may facilitate future access to further funding from a variety of sources.

All FY 2008 targets will be reached by September 30, 2010.

New/Continuing Activity: Continuing Activity

Continuing Activity: 20732

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

20732 20732.08 U.S. Agency for To Be Determined 11947 11947.08 Nutrition RFA

International

Development

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01:

Funding for Treatment: Adult Treatment (HTXS): $0

USAID Zambia issued a new bilateral Nutrition RFA by December 2008 to establish a bilateral Nutrition

activity. Following current OGAC Food & Nutrition guidance, the bilateral mechanism funded by the RFA

will provide food and nutrition services to People Living With HIV/AIDS (PLWHA), primarily, moderately to

severely malnourished clients who are on ART or eligible to begin ART. The new activity funded by the

RFA will link to ART service delivery providers (CIDRZ, AIDS-Relief, and ZPCT), Palliative Care services

(RAPIDS, SUCCESS, PCI/ZDF, ZPCT, and others) as well as to PMTCT clients who receive either a full

course of prophylaxis or a full course of ART, and to OVC providers

Emphases of the RFA will include: increased efforts to link to ART OVC, HBC, and PMTCT activities, and

to provide nutritional support and counseling to benefit malnourished PLWHA, OVC and HIV positive

infants, especially those on ART. Goals are to optimize treatment outcomes and survival time, minimize

HIV transmission, and help reduce malnutrition in PLWHA through targeted, time-limited nutritional support.

The goal of this new activity will be to improve ART patient outcomes by introducing nutritional assessment,

nutritional counseling, and therapeutic feeding for severely malnourished ART clients. Severely

malnourished palliative care clients who have not yet initiated ART will also be eligible for therapeutic foods.

This approach is in line with OGAC Food & Nutrition Guidance issues in September 2006. This activity will

address clinical malnutrition, a medical condition common in individuals with HIV/AIDS, and will not be used

to address food security -a broader, non-clinical problem.

This activity will be modeled at least partially on the successful USAID Kenya "Food by Prescription"

program. It will carefully target nutrition interventions to improve clinical outcomes in malnourished

PLWHA. The program will screen and target malnourished clinically malnourished adults and children with

HIV, following Zambian guidelines on treatment of malnutrition and will have strict client "entry and exit"

criteria as recommended by OGAC. The "Food by Prescription" initiative will follow WHO recommendations

and will be evidence-based.

The awardee TBD will work with USG partners and the GRZ to continue to develop and finalize guidelines

to integrate nutrition and therapeutic feeding into ART and palliative care services. An initial regimen of

therapeutic feeding, with a timely transition to supplementary food and then to a regular diet, corresponds to

the need for clients who have experienced the "wasting" effect associated with the onset of ARC, to: rebuild

lost body mass; enabling them to resume a normal, active life as they respond to ART, rebuild their immune

systems; and go back to work.

AWARDEE TBD will build capacity to provide nutritional assessment, nutritional counseling, and nutritional

support (therapeutic and then supplementary foods) for 7,500 or more severely malnourished PLWHA who

are either ART clients, or eligible HBC clients waiting for ART.

To meet this target, AWARDEE TBD will provide training and technical assistance to clinical staff and

community-based health workers (volunteer home based caregivers as well as their registered nurse

supervisors, etc) at a number of selected sites which have a constellation of existing ART, HBC, and other

HIV/AIDS related services. AWARDEE TBD will also provide funding to support the cost of producing,

distributing, monitoring and reporting on therapeutic and supplementary foods.

The AWARDEE TBD will address private sector, market orientation, as well sustainability concerns by

working with one or more private sector partners, such as local food processing plants, to produce the

RUTF and HEPS products, as well as by using a training of trainers (TOT) model. By using existing local

food processing with the requisite quality control, the USG will not have to pay for plant or equipment. Local

food processors will have to demonstrate that they can produce a consistent, quality product while adhering

to strict cost control as well. This may allow the processors to market therapeutic and supplementary foods

of high quality through the private sector, positioning them for sale in pharmacies and doctors' practices. In

cases where clients cannot afford to buy them at retail prices, the USG could use "social marketing" price

schemes to reduce the cost, or could provide them at no cost to truly destitute clients.

The AWARDEE TBD will build local capacity and strengthen local institutions. There are possibilities for

Public-Private Partnerships (PPP), leveraging and wrap-arounds, such as the Land O'Lakes PPP funding

for a food processor to produce fortified food products for malnourished PLWHA. The AWARDEE TBD will

explore leveraging opportunities to mobilize corporate donations to reduce the cost of production, or provide

free constituents for food products.

New/Continuing Activity: Continuing Activity

Continuing Activity: 20731

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

20731 20731.08 U.S. Agency for To Be Determined 11947 11947.08 Nutrition RFA

International

Development

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09: