This PHE activity, "Effectiveness of HIV Viral load monitoring on patient outcome in resource-poor settings

", was approved for inclusion in the COP. The PHE tracking ID associated with this activity is ZM.06.0213.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Estimated amount of funding that is planned for Public Health Evaluation $986,872

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Program Budget Code: 10 - PDCS Care: Pediatric Care and Support

Total Planned Funding for Program Budget Code: $4,985,056

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

This is the first pediatric program area narrative incorporating care, support and treatment. Pediatric care and treatment

comprises health services for HIV-exposed or HIV-infected children. It extends and optimizes quality of life for HIV-infected

children, providing clinical, psychological, social, spiritual and prevention services.

In 2000 the Government of the Republic of Zambia (GRZ) launched its national PMTCT program. In 2002 the GRZ launched a

public sector ART program to provide access to treatment for adult Zambians at a fee. In 2005 the GRZ extended "free" treatment

services to all Zambians. Nonetheless, few children (less than 10%) access HIV care, support and treatment. The goal of both

the GRZ and U.S. Mission in Zambia is to provide ART to at least 80% of all children in need of treatment by 2010.

The GRZ recognizes the needs of pediatric patients and has begun to address the needs of children. The year 2007 was a major

milestone for the Pediatric ART (P-ART) program: two P-ART program officers were appointed at the Ministry of Health (MOH)

with support from the Clinton HIV/AIDS Initiative (CHAI) to manage Pediatric care and treatment at national level; the Zambia

National P-ART guidelines and the Zambian Pediatric Training Manual were produced to train health care workers; the MOH

issued guidance on routine provider initiated counseling & testing (PICT) for all children in health care settings; and the MOH

began to train health care workers country-wide and improved availability of pediatric formulations at district level hospitals

including fixed dose combinations (FDC's). Finally, in 2007, three Polymerase Chain Reaction (PCR) referral laboratories became

functional alongside a training program for collection of dried blood spot (DBS).

In FY 2007, the U.S. Mission in Zambia began to link pediatric Care and Support (CS) services to P-ART and prevention of

mother to child transmission of HIV (PMTCT) services. The goal is early initiation of pediatric treatment to reduce infant mortality.

CS partners will link to PMTCT partners for referrals of HIV positive mothers and infants, and will provide ongoing support in the

community for exclusive breast-feeding (EBF) up to six months, unless replacement feeding can meet WHO-mandated ("AFASS")

conditions, and for timely, appropriate weaning with nutritious foods. The U.S. Mission in Zambia will document pediatric referrals

in FY 2009 through referral feedback loops. CS partners have modified M&E systems to track pediatric referrals and to count

pediatric CS clients. They have also trained caregivers in Pediatric CS. Selected CS partners have developed child-friendly

environments, such as "Family Support Units" for pediatric clients in tertiary hospitals, as well as child-friendly wards or rooms in

hospices. Services designed for pediatric clients include "play therapy" and day schools at clinical sites to promote on-going

education.

UINCEF estimated in 2006 that 130,000 children in Zambia were infected with HIV; of these, 40,000 were in immediate need of

anti-retroviral therapy (ART). By mid-2008, 15,000 children had begun to receive anti-retroviral therapy. Current Care and

Support (CS) reporting systems do not identify pediatric clients separately, but of the 211,000 clients receiving CS as of March

2008, approximately 8-10% were pediatric clients. Though the scale up of pediatric HIV services has been progressing, it is still in

its early stages as only 8% of all ART clients are children.

A number of initiatives supported by the U.S. Mission in Zambia accelerate the scale-up of pediatric treatment. First, the PMTCT

initiative was scaled up to focus on linkages to pediatric follow-up care and treatment services. To date, PMTCT population

coverage is over 60% in Zambia. In FY 2009, U.S. Mission in Zambia will focus on the challenge of linking PMTCT and care and

treatment for positive mothers through newly revised under 5 health cards. These cards will be used for all health visits and will

clearly indicate exposure status of the child, co-trimoxazole prophylaxis (CPT), data from the six week follow up, Dried Blood Spot

(DBS) for Polymerase Chain Reaction (PCR), as well as weight and nutrition monitoring. Immunization coverage in Zambia is

over 70% and this will present a good opportunity to identify exposed and infected children. DBS collection is conveniently linked

to the immunization program, a widely accessed service.

Second, the MOH provided guidance to routine provider-initiated counseling and testing (PICT) for children in healthcare settings.

The UTH Pediatric Center of Excellence is a model for training. An assessment in 2008 indicated that provincial hospitals and

selected urban clinics were implementing PICT with high acceptance rates. Routine testing in children brought for under-5 clinic

weight, nutrition monitoring, and immunizations are being piloted at selected sites with U.S. support. The outcome of this pilot will

inform policy on PICT in under-5 clinic settings.

Third, availability of three PCR reference laboratories with designated access for all provinces has greatly improved early infant

diagnosis. This includes training in DBS across the country with close to 200 providers from various centers trained at the UTH.

Fourth, Zambia adapted the recent WHO guidance to treat infants below 12 months with confirmed HIV regardless of CD4 count.

This will improve pediatric outcomes. In FY 2009, treatment programs will enroll more infants reducing mortality in this age group.

Finally, U.S. Mission in Zambia will focus on child specific counseling and testing. U.S. partners will make greater efforts to train

counsellors to handle children and adolescents with their specific psychosocial needs.

The lack of healthcare worker knowledge and skills has hindered access to HIV care and treatment for children. Training and

clinical mentorship to build healthcare worker capacity is critical to scaling up HIV services for children. Since 2007, over 1,500

healthcare workers, including doctors, clinical officer nurses, and 50 community volunteer caregivers have learned P-ART and/or

care and close to 10,000 PCR tests have been performed.

The U.S. Mission in Zambia will continue to scale up the number of PMTCT sites and coverage, as well as improve links with care

and treatment. The U.S. Mission in Zambia will also provide more effective P-ART, including dual therapy for HIV positive

pregnant women, and HAART for pregnant women with CD4 counts below 350.

Entry points used to identify HIV-exposed and infected children include PMTCT, counseling and testing (CT) sites, maternal child

health (MCH) clinics, and community-based OVC and care and support services. Other plans include expanding the linkages

between PMTCT and community OVC and care/support programs.

In 2009, the U.S. Mission in Zambia and its partners will work intensively to link PMTCT, OVC and Palliative Care and Support

activities more closely, in order to facilitate the early identification, care and treatment of HIV positive infants and children. Clinic-

based programs like PMTCT will refer clients to community-based programs such as OVC and Palliative Care and Support, so

that tens of thousands of trained community caregivers can follow up and screen HIV exposed infants for potential danger signs

such as growth faltering, and refer them for pediatric testing, care and treatment. Community caregivers may also be linked

directly to the pediatric testing initiative once the GRZ authorizes them to collect dried blood spots (DBS) for analysis. It should be

noted that all community volunteers work closely with the health center staff.

In FY 2009, the U.S. Mission in Zambia will set up a number of model sites for pediatric care and treatment in Zambia. These will

serve as training and referral sites. In addition, training programs will incorporate follow-up on-site pediatric care and treatment

mentorship of health staff who receive the largely didactic one week training.

Scale up of P-ART includes early infant diagnosis (EID) through the PCR program and strengthened linkages between PMTCT

and P-ART. In the FY 2009 COP, the two aspects of pediatric EID and care of the exposed child will continue to be under PMTCT

as the health workers that implement this activity are based at MCH clinics and trained in PMTCT. The DBS courier system is

currently supported by CHAI, who strive to ensure timely delivery of samples and reduced turnaround time for results.

In FY 2009 pediatric ART training will target 313 health facilities that currently provide treatment. Healthcare providers will learn to

provide comprehensive care and treatment to children. Training of adult service providers in the management of children

promotes a "family centered" approach to care and treatment. In FY 2009 Family Support Units (FSU's) will expand as an entry

point to counsel, test, care for and treat the family. Services are being re-designed to make them "child-friendly" with "play

therapy" and the provision of basic education. This approach will be expanded to cater to military families and an FSU will be

constructed at the Maina Soko Military Hospital. As the military is running a parallel health system to MOH, an MOU between the

Ministry of Defense and MOH has been developed (and is awaiting signature) to strengthen services delivery and linkages to

support improved child care.

Trauma-Focused, Cognitive Based Therapy (TF-CBT) is a new, research-based method of assessing child counseling needs and

providing targeted mental health services to HIV-positive children most in need. TF-CBT estimates that approximately one-third of

children become traumatized and require specialized therapeutic care.

The introduction of TF-CBT, on a small scale, will provide traumatized HIV-Positive children with proven-effective mental health

services. Care and Support volunteers will learn to screen children with mental or emotional trauma, and refer them to TF-CBT

sites.

HIV exposed and infected children are routinely provided with co-trimoxazole prophylaxis. This will continue as part of routine care

in FY 2009. Exposed infants receive syrup form of CPT prophylaxis from six weeks of age until HIV is excluded. HIV positive

infants receive prophylaxis in their first year of life until they reach the immunological criteria to stop.

In FY 2009, U.S. programs are increasing attention to the food and nutrition aspects of care. A number of projects will provide

infant and child nutritional assessments (using anthropometric measures), micronutrient supplementation, and food and nutrition

support for moderate to severe malnutrition in infants and children, using ready-to-eat foods as well as high energy protein

supplements. Nutrition support will include therapeutic and supplementary feeding for clinically malnourished mothers and

infants, and will augment micronutrient supplementation for all.

Volunteer caregivers will support mothers' efforts to ensure appropriate infant feeding options. Using revised under-5 cards, U.S.

partners can trace exposed infants and provide information on options for infant feeding. Trained caregivers in the community will

provide ongoing support for exclusive breast feeding up to six months, unless replacement feeding can meet the WHO mandated

("AFASS") conditions. Trained community volunteers will help ensure that HIV-positive mothers return to clinics regularly for well-

baby and well-mother visits, and will assist with clinic visits if they become ill.

At tertiary level, children with severe malnutrition often have complications; they also have a 40% mortality rate and 35% are HIV

positive. In FY 2009, a novel community nutrition program in Lusaka will check for malnutrition in its earlier stages and screen for

HIV to avoid severe outcomes.

The prevention care package also includes safe water through provision of chlorine and education on water treatment, safe

storage and basic hygiene education. Other interventions include wrapping around the President's Malaria Initiative (PMI) and

National Malaria Center in the on-going residual spraying program and supply of insecticide treated bed-nets (ITNs) for all

pregnant women, their babies and infected children in an effort to prevent malaria in the households. The U.S. Mission in Zambia

and the GRZ prioritized a donation of 500,000 ITNs in 2007 to protect pregnant and lactating women and their infants, especially

HIV-positive female clients of home-based caregivers, and their HIV-exposed infants. This has contributed to a national reduction

in cases of malaria.

Comprehensive care for infected children will remain a priority with early identification and management of opportunistic infections

like tuberculosis, diarrheal diseases and fungal infections. The 2008 revised integrated management of childhood illnesses

(IMCI), a front-line workers guide to manage all common illnesses, includes a specific chapter on management of HIV and

opportunistic infections at the primary healthcare level.

The supply chain management system directs all drugs and supplies related to pediatric care and treatment. This includes all first

-line and second drugs (both syrup and FDC formulations); opportunistic infections drugs, EID supplies, rapid testing related

supplies, pain medications, and other laboratory supplies for routine biochemistry and hematology tests.

Retaining and monitoring and children enrolled in care and treatment continues to be a challenge. An expansion of electronic

medical records could help. Monitoring and evaluation (M&E) systems are being re-formatted to identify and track pediatric clients

for clinical follow-up and for reporting purposes. Cellular phone networks have proved a useful, low cost initiative for follow up of

clients.

Challenges that still need to be addressed with the expansion of pediatric programs include: pain management in children; issues

around social stability, long term food security, and access to education; more attention to prevention among adolescents and

care for the increasing HIV infected adolescent population, with the need to disclose to clients; continued strengthening of links

between PMTCT and pediatric care and treatment; and strengthening M&E systems to track children enrolled into care and

treatment and policy issues that empower non-healthcare providers to participate in treatment and care programs including DBS

collection.

Table 3.3.10: