April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD

Changes to this narrative include updates on progress made and expansion of activities. This activity is

linked to Southern Provincial Health Office (SPHO) PMTCT (#9739) and Boston University (BU) prevention

of mother to child transmission (PMTCT) of HIV (#3571) whose mechanism under UTAP expired in fiscal

year FY 2008. A new mechanism is anticipated to be in place by January 2009.

Boston University Center for International Health and Development (CIHD), through its prime partner Tulane

University and local non-governmental organization Boston University Center for International Health and

Development-Zambia (BUCIHDZ), in 2006 began collaborating with the SPHO, to provide PMTCT services

throughout Southern Province through the Boston University PMTCT Integration Program (BUPIP). By the

end of FY 2008, BUPIP directly supported over 185 sites in eight districts, and indirectly supported sites in

the remaining three districts through the provision of technical assistance.

(CIHD) has continued its commitment to building local Zambian capacity. In FY 2008, BU received funds to

expand PMTCT services in Southern Province, continued building local capacity such that the program is

sustainable, provided technical assistance to directly and indirectly supported sites, continued trainings on

PMTCT and data management, and expanded on innovative solutions to reach extremely marginalized

populations.

In FY 2008, BU continued extensive training programs for health sector personnel, providing direct technical

assistance to provincial and district health staff, established inclusion and training of auxiliary health cadres

such as trained traditional birth attendants (tTBAs) and community health workers (CHWs), and employed

Zambian nationals for nearly all project staff positions. In FY 2008, BUPIP trained 160 health facility

personnel in the national PMTCT Training package, and 107 community agents in the national lay

counselor PMTCT training package developed primarily by JHPIEGO.

CIHD currently directly supports 140 of the 187 health centers (74.8%) in eight of the 11 Southern Province

districts, and met our target to expand to 185 by the end of FY 2008.

From its inception, through March 2008, the CIHD program has: 1) counseled, tested, and notified 45,168

pregnant women; 2) identified 9,930 as HIV positive (22% of those tested); 3) given 6,242 women (62.9% of

HIV+) ARVs in a PMTCT setting and; 4) given 4,336 (43.6% exposed) exposed infants ARVs in a PMTCT

setting.

In FY 2008, we also had a successful and innovative community sensitization agenda focused on promoting

general awareness of PMTCT and male involvement to increase demand and uptake of PMTCT services.

Our community program is organized around the key leadership role of Chiefs and Headmen in rural

communities. We worked closely with 18 chiefs, their wives, and senior headmen to build an on-going

series of PMTCT informational and awareness meetings. CIHD reinforced the important endorsement of

these leaders with PMTCT radio programs, drama and special events within the communities. The third

part of the community sensitization package includes increasing the capacity of facilities, CHWs and tTBAs

to provide outreach and accurate information, education, communication (IEC) materials.

FY 2009 activities with a new partner yet to be determined will result in 1) Increased access to quality

PMTCT activities; 2) Improved quality of PMTCT services integrated into routine safe motherhood activities;

3) Increased coverage of counseling and testing services; 4) Higher use of a complete course of

antiretroviral ARV prophylaxis by HIV positive women as compared with previous years based on the new

Ministry of Health (MOH) protocol guidelines; 5) Improved referral and linkages to antiretroviral treatment

(ART) programs as they are developed within the districts; 6) Expansion of community-based PMTCT to

rural populations not ordinarily reached through facility-based PMTCT services both with tTBAs and by

scaling-up the Government of the Republic of Zambia (GRZ) Sinazongwe model, and the trained TBA pilot

program. The GRZ ‘Sinazongwe model' refers to a mother-infant pair follow-up system using community

cadres that has had success in this specific district, and is a model that CIHD is working closely with the

SPHO to scale-up and implement in more districts throughout the province.

Additionally, FY 2009 activities will result in program expansion to all 11 districts in the province. The

primary objective will continue to be to support efforts by the GRZ in scaling-up quality and sustainable

PMTCT services within maternal neonatal and child health programs in accordance with the national

PMTCT strategic objectives. Secondary essential goals are 1) to support and expand the implementation of

a province-wide early infant diagnosis program (EID) (see PDCS # 12331). This wraparound activity in EID

will result in the scale-up of infant HIV diagnosis in Southern Province by continued collaboration with the

SPHO, University Teaching Hospital, Clinton HIV/AIDS Initiative, Center for Infectious Disease Research

Zambia (CIDRZ) and other partners. Activities will focus on building and operational a stronger referral

system to ART care and treatment centers. Earlier HIV diagnosis will lead to earlier referral and initiation of

antiretroviral therapy at much younger ages, as well as identifying high risk exposed, but uninfected

children, leading to improved long-term outcomes; 2) to provide quality palliative care to HIV-affected

children (see PDCS #12331); 3) to implement and scale-up innovative approaches to reach poorly

accessible rural populations through the use of community workers, TBAs and CHWs, and 4) to develop

effective community networks for increasing awareness and program participation through the Supporting

Healthy Exclusive Breastfeeding in Zambia (SHEBA) and Traditional Birth Attendant Prevention of Mother

to Child Transmission Assessment Project (TRAP) programs; 5) to strengthen ART referral and linkages as

PMTCT is a critical entry point for ART services not only for pregnant women, but their spouses and families

as well. BU will also begin to strategize a clear exit strategy such that the PMTCT program is fully

integrated and sustainable in the Southern Provincial Health System by the end of five years.

The new mechanism will continue to expand and continue providing leadership to the USG partners on the

work piloted in FY 2007, involving TBAs in the provision of PMTCT services. This strategy has

demonstrated the potential to extend essential PMTCT services to an otherwise difficult-to-reach but

majority-segment of pregnant women in rural health districts in Zambia. If successful, this approach can be

implemented throughout the entire southern province and other rural areas in Zambia.

Activity Narrative: Masters level students, from the Department of International Health at the BU School of Public Health, will

continue to be recruited to work with the project in Southern Province.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Health-related Wraparound Programs

* Safe Motherhood

Human Capacity Development

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01:

April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD

ACTIVTIY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

This activity is continuing from 2008. The funding level for this activity in FY 2009 has remained the same,

but shifted activity narratives to pediatric program in FY 2009. This activity also relates to activities in

prevention of mother-to-child transmission (PMTCT) (#3571).

This activity has two different components: 1) Palliative care support for HIV infected and affected children

and 2) Expansion of Early Infant Diagnosis to complement the existing PMTCT and Pediatric Treatment

efforts throughout Southern Province (SP). The activity has been modified in the following ways: The two

aforementioned components are now combined under one new activity code (formerly HTHX and HBHC);

both components will be shifting and expanding activities and coverage in FY 2009. The following narrative

includes updates on progress made and planned expansion of existing and new activities for both of these

components.

The first component of this activity focused on palliative care support. In FY 2008, Boston University (BU)

continued developing palliative care services to support children who were HIV-infected, HIV-exposed or

have been the subject of HIV-exposure through child sexual abuse. In FY 2008, BU concentrated efforts on

following up exposed children and ensuring cotrimoxizole prophylaxis was improved in SP, and actively

promoted exclusive breastfeeding in the communities. Additionally, BU worked with partners to begin

strengthening the link to ART for HIV positive children, to ensure an uninterrupted continuum of care. BU

also worked closely with the Child Sexual Abuse Clinic (CSAC) at University Teaching Hospital (UTH) to

build an efficient data management system, provided technical assistance for data analysis and integrated a

strong, sustainable psychosocial and trauma-based therapy component into the clinic for HIV exposed

children. BU successfully developed, validated and implemented culturally appropriate psychosocial

measurement tools, previously unavailable in Zambia, and built local capacity by training nationals on these

measurements. The data system helped to improve follow up and care of HIV-exposed children, indirectly

improving palliative care services.

In FY 2009, BU will continue to provide palliative care to children who are HIV-infected or exposed.

Specifically funds will 1) ensure that co-trimoxazole is available and being prescribed to all children born to

HIV-infected women within the overall BUPIP (see activity PMTCT 3571.08); 2) will continue to actively

promote breastfeeding among HIV-infected children through the scale up of the Exclusive Breastfeeding

Project conducted in FY 2008; 3) strengthen PMTCT mother-infant follow up by enlisting Trained Traditional

Birth Attendants (tTBAs), Community Health Workers (CHWs), and assisting the government in scaling up

its successful Sinazongwe pilot follow-up program as requested by the Ministry of Health (MOH); 4) and

provide continued technical assistance on the psychosocial and child trauma components as necessary in

the CSAC clinic. In FY 2009, BU will develop and implement a strategy to handover data management and

analysis to CSAC clinic at UTH, providing technical assistance to UTH and Livingstone General Hospital as

necessary to ensure the program is fully sustainable and integrated into the existing system. This will be

achieved by transitioning the Teleforms database into a manual entry database, and by building on the local

facility-based capacity that was significantly strengthened by FY 2008 activities. Additionally, BU will

continue building linkages with family planning programs and home based care programs in SP including

but not limited to RAPIDS, SUCCESS, and Mothers 2 Mothers (Health Related Wraparound Activities) such

that the program is sustainable within the context of the existing PMTCT program, as explained in that

narrative.

The second part of this activity is expansion and strengthening of the Early Infant Diagnosis (EID) Program

in SP as a means to promote child survival by identifying both HIV positive infants and referring them, as

well as supporting health programs (see cotrimoxazole and breastfeeding above) for HIV exposed but

negative infants, a group with poor child survival rates.

EID services have only recently become available in SP, lagging behind other ART services provision. In FY

2008 BU worked (and continues to work) closely with MOH and other partners including the Center for

Infectious Disease Research in Zambia (CIDRZ) and the Clinton HIV/AIDS Initiative (CHAI) to systematize

the EID program in SP and ensure a strong link between PMTCT and ART clinics. In FY 2008 BU trained

191 health workers in EID from 107 Boston University PMTCT Integration Program (BUPIP)-supported

facilities and assisted in developing and implementing the strategy to transport specimens from District

Hubs to Lusaka via courier. Though 107 facilities have been trained, only about 1/3 are currently

implementing.

FY 2009 activities in EID will result in the scale up of infant HIV diagnosis in SP by continued collaboration

with the SP Health Office (SPHO), UTH, CHAI, CIDRZ and other partners. Activities will focus on building

and operationalizing a stronger referral system to ART care and treatment centers. Earlier HIV diagnosis

will lead to earlier referral and initiation of antiretroviral therapy at much younger ages, as well as identifying

high risk exposed, but uninfected children, leading to improved long-term outcomes.

FY 2009 activities will also include designing and implementing a more efficient system to deliver EID

results to the very rural areas of SP. Some of the inherent logistical difficulties surrounding EID in SP stem

from delays in promptly returning dried blood spot (DBS) results to the rural health facilities. The current

system allows for a child to receive results approximately 4 to 5 weeks after testing - a significant problem

given the rapid disease progression in children. In partnership with the MOH and a private information

technology company operating in Lusaka, BU proposes to implement a DBS online laboratory database

system which will allow results to be accessed both via internet as well as through direct cell phone SMS

communication to the facilities where they were collected. Confidentiality will be ensured by using only

patient identification numbers. SP District Health Management Teams (DHMTs) and the Province Health

Office (PHO) can then access the database securely via the internet to get immediate results.

Concurrently, rural and urban healthcare facilities with cell phone access (a majority of facilities in SP even

in remote locations) will be sent batched DBS results for their specific facility via SMS messages. This will

Activity Narrative: decrease the time it takes to receive DBS results at the facilities by at least 2 weeks.

Sustainability for this activity will be achieved primarily by integrating it into the existing government health

system and building local capacity to manage follow-up and the technical requirements of EID. Additionally,

the program will be strengthened and more likely to sustain itself if it is strongly linked to the existing ART

care and treatment centers, as outlined in the narrative above.

The program will be monitored and progress evaluated by the BUPIP (see PMTCT activity narrative

3571.09) monitoring and evaluation plan. Currently the system captures all required indicators, but will be

modified slightly in order to stratify tested infants by gender.

New/Continuing Activity: Continuing Activity

Continuing Activity: 17069

Continued Associated Activity Information

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

System ID System ID

17069 12331.08 HHS/Centers for Tulane University 7186 2929.08 UTAP - Boston $350,000

Disease Control & University-ZEBS

Prevention -

U62/CCU62241

0

12331 12331.07 HHS/Centers for Tulane University 4938 2929.07 UTAP - Boston $150,000

Disease Control & University-ZEBS

Prevention -

U62/CCU62241

0

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $100,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.10: