Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 12219
Country/Region: Zambia
Year: 2009
Main Partner: Johns Hopkins University
Main Partner Program: NA
Organizational Type: University
Funding Agency: HHS/CDC
Total Funding: $4,040,000

Funding for Biomedical Prevention: Voluntary Medical Male Circumcision (CIRC): $1,390,000

April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD

Zambia is currently one of the countries leading in integrating Male Circumcision (MC) as part of HIV/AIDS

prevention activities. JHPIEGO has been supporting the male circumcision program in Zambia for several

years, beginning in 2004 when they teamed up with the Government of the Republic Zambia (GRZ) to begin

work on small scale efforts to strengthen existing male circumcision services in order to meet existing

demand. This early work in Zambia has informed the international efforts of the World Health Organization

(WHO) and Joint United Nations Agency UNAIDS, and the training package that JHPIEGO developed with

the Ministry of Health (MOH) in Zambia formed much of the basis for the new international

WHO/UNAIDS/JJHPIEGO training package. Likewise, assessment tools used in Zambia also provided

background for the WHO toolkit. The GRZ has established an MC Task Force under the MOH and the

Prevention Technical Working Group of the National AIDS Council, of which JHPIEGO plays a key role.

In FY 2009, TBD will continue to support these groups and facilitate the hosting of an annual consultative

and update workshop for all stakeholders involved in MC activities.

This activity has four components: 1) Development of local capacity to provide quality MC services, 2)

Promotion of abstinence, being faithful, and condom usage (ABC) messaging, 3) counseling for prevention

and testing integrated in MC services, and 4) creating a favorable policy environment for the expansion of

MC services.

Development of local capacity to provide quality MC services

In FY 2009, TBD will support the sites developed in FY 2007 and FY 2008 with the aim of consolidating

their MC services and ensuring that clients receive high quality, comprehensive services. Services should

include standardized counseling, safe and efficient procedure, and client follow-up. Emphasis will be placed

on developing provincial level training centers with capacity to train new service providers in the

comprehensive approach to MC service provision within this framework. TBD will work to strengthen these

provincial centers and continue to improve the environment for scaling-up MC services. These training

centers will be used to guide other expansion sites for FY 2009.

In FY 2007, JHPIEGO worked with four model sites (three sites in Lusaka, one in Livingstone) to ensure

that they met the minimum standards to provide quality MC services, and trained 50 clinicians (10-14 per

site) to provide MC services, and 50 counselors (10-14 per site) to provide comprehensive counseling on

circumcision services and male reproductive health. Sites were supported to provide integrated services,

strengthening links to STI and family planning programs, provision of routine opt-out HIV counseling and

testing, and strong components of HIV prevention counseling and services. In FY 2009, TBD will continue

to provide ongoing support to these sites, to ensure that they provide high quality, comprehensive MC

services, through supportive supervision using a standard-based management and recognition approach.

In addition, TBD will also continue to monitor changes in the sexual risk behavior of clients post-procedure,

to ensure that adequate, effective counseling and HIV/AIDS prevention measures are in place and well

integrated with the new MC services.

In FY 2008, JHPIEGO expanded to five additional sites in Ndola, Kitwe, Solwezi, Chipata, and Kasama,

based on demand for maximization of service coverage. Sites trained included MOH, Zambian Defense

Forces (ZDF) and Churches Health Association of Zambia (CHAZ) affiliated institutions. Sixty MC providers

and 60 counselors were trained following the same training curriculum as in FY 2007, 12 providers and 12

counselors per site. Twenty of these providers, four from each site, were later trained as clinical trainers as

part of JHPIEGO's efforts to increase the local training capacity in MC.

To ensure that trained providers can actually start providing services, the project conducts detailed initial

assessment, evaluating the site infrastructure, level of administrative support, providers' readiness to

engage in the new service, as well as demand for MC services in the catchment area. Only sites that meet

the criteria for a project site are involved in the training.

In FY 2009, TBD will expand MC skills training to six additional sites as follows: three provincial sites in

Central, Luapula, and Western Provinces, and three large district sites; locations will be identified in

consultation with CDC and District Health Management Teams (DHMTs). Working in these sites, JHPIEGO

will prepare 72 additional MC providers and 60 counselors, 12 clinicians, and 10 counselors per site. Later,

24 of these providers will be trained as clinical trainers, four trainers per site. This will produce 132

individuals (72 clinicians and 60 counselors) trained to promote HIV/AIDS prevention through other

behaviour change.

Development of local capacity and decentralization of training and supervisory responsibilities is one of the

cross-cutting objectives in JHPIEGO's work in Zambia. During FY 2009, the emphasis will be placed on

establishing training teams and supporting local providers to coordinate MC activities at provincial level.

The established network of trainers will be tasked with identification of additional training sites, providing

training and conducting supervisory visits to sites. TBD will continue overseeing all these activities and will

supervise training and follow up activities.

In this way, management and supervision of MC work will gradually be transferred to local establishments

under MOH to ensure ownership and sustainability of services.

As part of the support, JHPIEGO provides the project sites with standardized list of commodities to 1) start

the MC services, and to 2) sustain them. The initial commodities include MC surgical equipment identified

during the initial assessment visit. After training, the sites are provided with additional supplies as required.

As part of national scale-up efforts, TBD will continue providing all sites with start-up surgical equipment and

supplies, and will periodically replenish the supplies as required. The itemized list of standardized MC

equipment is available on request.

As result of TBD support, it is expected that at least 7,000 clients will receive quality MC services, including

counseling, at the new sites through the end of FY 2009, assuming that each of these new sites is providing

Activity Narrative: at least 140 procedures a month within three months after training.

Promotion of ABC usage message

In FY 2008, working with the MOH in the development of ABC strategies and messages, JHPIEGO reached

6,000 individuals with AB messages delivered through various communications media that ensured the

most coverage possible. By providing the MOH with the framework with which to develop new messages

and initiatives JHPIEGO ensured that there will be continuity and sustainability in prevention message

development and dissemination.

In FY 2009, TBD will work with the MOH and other partners to build a strong message focused on

abstinence for youth, including the delay of sexual debut and abstinence until marriage, being faithful in

marriage and maintaining monogamous relationships; and correct and consistent usage of condoms (ABC

message) as part of the MC service package, which includes the development and dissemination of

counseling guidelines for men undergoing MC. ABC messages will play a key role in the pre- and post-

circumcision counseling that is part of the comprehensive MC services package. TBD will additionally focus

on including messages that specifically target female partners of circumcised men. Apart from encouraging

female participation in decision making regarding sexual intercourse, dangers of early intercourse before

the wound completely heals will be addressed. TBD will work with the MOH to design culturally appropriate

messages and disseminate them through already established channels. In addition, TBD will work to

strengthen community involvement in promoting MC and preventing HIV transmission, and will engage

community leaders in disseminating these messages.

Specifically, FY 2009 funds will be used to: (1) support the development and testing of additional messages

and implementing the effective messages as part of the national prevention strategy; (2) develop take home

brochures, radio, and TV spots emphasizing ABC as integral part of MC education; and (3) support the

development of counseling protocols that include ABC messages during MC service delivery, and train

counselors on the importance of delivering ABC messages with this service; (4) develop materials

specifically targeting female partners of circumcised men, stressing the importance of abstinence before the

wound fully heals.

Counseling and testing integrated in MC services

The WHO recommends that MC be promoted primarily to HIV-negative males in areas of high HIV

prevalence. Since knowing one's HIV statues is critical to making informed decisions regarding MC and

other sexual health needs it is critical that counseling and testing be integrated into all aspects of MC

service provision. In FY 2009, TBD will continue integrating CT at all expansion sites and will expand MC

service delivery while offering CT to all men who seek MC services and are above the legal age of CT in

Zambia. It is expected that approximately 3,000 men will be reached through MC services.

To work toward the sustainability of quality MC services and the associated CT, JHPIEGO conducted

clinical training skills for 20 providers within the model institutions developed in FY 2007 and FY 2008.

These workshops provided the trainers with teaching skills and methodologies as well as reinforcing their

knowledge and skills in comprehensive MC service provision. The trainers will form the core for the

standardization and expansion of MC services in Zambia. Over 60 providers were trained through the

second-generation MC workshops conducted by these new trainers with JHPIEGO's support and

supervision.

FY 2009 funds will be used specifically to: (1) strengthen the CT component developed earlier to support

the MC services; (2) ensure that CT remains an integral part of MC services; and (3) training additional VCT

counseling and clinicians.

Creating a favorable policy environment for MC services

In FY 2007 in FY 2008, JHPIEGO spearheaded and supported the development of national guidelines on

MC, strategic planning and implementation of scale-up efforts, including development and dissemination of

materials to ensure clarity and consistence in the application of MC policy nationwide. In FY 2009, TBD will

continue to work with MOH, NAC and other stakeholders to update and consolidate the contents of the MC

guidelines/policy documents to ensure that they are thorough and clear for providers to follow.

This initiative will contribute to sustainability by supporting the GRZ and MOH to develop national

guidelines and putting in place a framework that will allow for the further update of this document by

following a standard stepwise process that can be replicated in the future.

In FY 2009, TBD work in policy and systems strengthening will focus on: (1) disseminating the MC

guidelines using a variety of media appropriate for service providers as well as clients; (2) collaborating with

the MOH and other partners in the development of information, education, and communication materials; (3)

continuing to monitor performance standards for MC, developed in FY 2007 to standardize and enhance

performance and quality improvement and supervision of MC services; and (4) hold annual

consultative/update workshops in order to obtain consensus and updates regarding new developments in

the MC arena.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Gender

* Addressing male norms and behaviors

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $1,390,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.07:

Funding for Treatment: Adult Treatment (HTXS): $500,000

April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: Work with pre-service institutions has been

added to improve educational process and further quality of services, and support sustainability of the

program.

Activity Narrative

This activity has several components: 1) revision of clinical care guidelines and corresponding updates for

service providers, 2) provision of national leadership in the area of capacity building and performance

improvement through implementation of continuing education opportunities for HIVAIDS clinical staff at

antiretroviral therapy (ART) centers, and 3) adaptation and integration of new performance improvement

tools into ART service provision. Efforts to ensure sustainability of the program through development and

using appropriate technologies and working in close collaboration with the MOH and national institutions cut

across all components.

Revision of clinical care guidelines and corresponding updates for service providers. In FY 2006,

JHPIEGO assisted the Ministry of Health (MOH) and National HIV/AIDS/STI/TB Council (NAC) to update

clinical training materials and trainers to be consistent with the recently revised clinical care guidelines. In

FY 2007, JHPIEGO assisted the government, particularly the MOH and NAC, to adapt the revised clinical

care guidelines and training materials to more useful electronic formats accessible to providers through a

variety of appropriate technologies (e.g., CD-ROM, web-based, handheld technologies). This was done in

close collaboration with other implementing partners and technical specialists working on ART programs,

and ensured consistency and standardization of materials, messages, and approaches to maximize the

efficiency and success of HIV/AIDS clinical care and ART scale-up activities in Zambia. In FY 2008,

JHPIEGO with expertise of the Johns Hopkins Point of Care Information Technology (POC-IT) Center

worked with MOH and other collaborating partners to develop and test different technologies (CD-ROMs

and handheld technologies such as Palm handheld or smartphone) to make the clinical guidelines and

resources available and accessible for HIV/AIDS care and treatment to providers. In FY 2009, three

hundred (300) more CD ROMs and handheld devices will be purchased, loaded with HIV/AIDS clinical

guidelines, and disseminated to the healthcare providers working at ART sites nationwide.

Provision of national leadership in the area of capacity building and performance improvement for HIV/AIDS

care and treatment providers is an important component to address gaps identified in ART service delivery

programs. This support is critical to ensure that HIV/AIDS care and treatment services maintain an

acceptable level of quality, which will help to ensure not only that new clients are encouraged to enter care

but also that existing clients remain under care. To achieve this, JHPIEGO will continue to support the

implementation of continuing education opportunities for HIVAIDS clinical staff at ART centers, reinforcing

their basic skills and expanding their knowledge in specific areas. In previous years, JHPIEGO assisted

the GRZ to develop and pilot continuing education programs for ART service providers and facility teams.

These programs included a combination of distance education programs for use in low technology settings

as well as internet and e-mail based education program developed by the Johns Hopkins University Center

for Clinical Global Health Education. Through the end of FY 2008, initial programs had trained 250 ART

providers, including staff from hospital- and large urban clinic-based ART sites. JHPIEGO supported these

programs to reach additional clinical caregivers, while developing additional content to fill identified gaps.

One such gap addressed was strengthening the use of highly active antiretroviral therapy (HAART) in

pregnant women for their own health (as well as to further reduce mother to child transmission of HIV), a

high priority for training in FY 2008 consistent with national PMTCT and ART guidelines in Zambia. In FY

2008, JHPIEGO developed new modules in prevention of mother to child HIV transmission (PMTCT) and

Pediatric ART according to the national guidelines and disseminated to service providers who finished the

initial update course.

In FY 2009, the initial and new modules will be further disseminated to 450 healthcare providers and 10 pre

service education institutions nationwide, to support educational process of medical and nursing students.

TBD's blended learning approach—one that combines electronic and face-to-face learning—will ensure that

frontline providers and students alike are given the knowledge and the skills that they need to provide

quality service. We will continue to increase gender equity in provision of ART services, by imparting this

knowledge and skills to equal proportions of males and females in all our programs.

Adaptation and integration of new performance improvement tools into ART service provision. TBD will

work with the Ministry of Health (MOH), University of Zambia and the University Teaching Hospital (UTH)

partnership and the Medical Council of Zambia to adapt and integrate additional tools for performance

improvement into ART service provision programs such as those of Elizabeth Glaser Pediatric AIDS

Foundation and Zambia HIV/AIDS Prevention, Care, and Treatment Partnership, as well as TBD's work with

the Zambian Defense Forces. These tools and approaches will not only help to support the quality of

HIV/AIDS care and treatment services, but enhance the sustainability of technical support. Further efforts

will focus on maximizing the use of tools that can be delivered onsite to reduce the need for ongoing

external technical assistance and additional manpower (e.g., trainers and supervisors). One such tool is

TheraSim™'s case-base simulation program, a computer-based interactive tool which allows providers to

go through a series of HIV care cases and receive feedback on their clinical decision making skills. This is

a tool which can be used both for advanced training as well as for monitoring performance.

To ensure sustainability of the program, TBD will continue working in close collaboration with the MOH,

NAC, Medical and Nursing Councils, and the University of Zambia Medical School/UTH, to build the local

capacity to design, develop, and implement educational programs to support quality ART services.

Materials developed in these programs are ‘owned' by the national program and these institutions, and are

designed to be implemented through existing systems (e.g., by involving the Provincial Clinical Care

specialists to monitor and follow-up the distance education programs). By using appropriate technology,

implementation and support cost are reduced comparing to other, more traditional approaches. The

program focus to develop tools that can be delivered on site, require less movement by clinical staff,

Activity Narrative: eliminate costs of travel and lodging will ensure less disruption of services and improve the ‘immediacy' of

applying new skills and knowledge at the workplace. Likewise, electronic versions of guidelines and

continuing education material can be updated, reproduced, and disseminated at much less cost than print-

based material. Using these approaches and tools, the national program and local partner institutions will

be able to continue supporting these programs with minimal levels of investment, as compared to the cost

of traditional group-based in-service training. Furthermore, smartphones or other handheld devices will be

used both as a source of latest HIV/AIDS clinical guidelines by providers and as a supervisory tool by

trainers and supervisors.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15531

Continued Associated Activity Information

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

System ID System ID

15531 3689.08 HHS/Centers for JHPIEGO 7173 3017.08 UTAP - $500,000

Disease Control & U62/CCU32242

Prevention 8 / JHPIEGO

9033 3689.07 HHS/Centers for JHPIEGO 5019 3017.07 UTAP - $500,000

Disease Control & U62/CCU32242

Prevention 8 / JHPIEGO

3689 3689.06 HHS/Centers for JHPIEGO 3017 3017.06 Technical $250,000

Disease Control & Assistance/JHPI

Prevention EGO

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $500,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Treatment: Adult Treatment (HTXS): $400,000

April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD

The scope of work and funding level for this activity in FY 2009 will remain the same as in FY 2008. Only

minor narrative updates have been made to highlight progress and achievements.

As outlined below, funding for this activity will provide support to continue implementation of standardized

quality improvement interventions to enhance quality of service delivery across United States Government

(USG) sponsored Antiretroviral Therapy (ART) programs. Of critical importance will be use of findings from

the special quality studies to improve quality of services and close gaps in ART service provision.

The national ART implementation evaluation published in April 2006 revealed numerous areas in need to

improve the implementation of services in Zambia. For example, 84%of institutions visited, reported not

having seen the national ART implementation plan with many sites having never received key policy

documents and guidelines. One can proximally assume then that quality improvement and monitoring

activities were few. Moreover, this evaluation did not include in-depth investigation of care quality as part

of its mandate. It is clear that as ART continues to be rolled-out at a rapid pace in Zambia, quality must be

assured to promote the sustainability of these services in the future. In cooperation with JHPIEGO, USG

through Centers for Disease Control and Prevention (CDC)/Zambia began support for a joint program

assessment of ART technical and financial support in Zambia in 2006 that revealed key areas for quality

improvement interventions. This evaluation activity is now an ongoing process of data collection and

feedback. It is therefore critical for funding in FY 2009 to implement sustainable activities that will aim to

close performance gaps identified in the ongoing evaluation process.

In FY 2007, CDC-Zambia entered into a collaborative partnership with JHPIEGO to implement the Zambia

Antiretroviral Quality Improvement Project (A-QIP). Under this project, in FY 2008, JHPIEGO implemented

standardized quality improvement interventions to enhance quality of service delivery, finalized special

quality studies, and trained facility-based program managers on utilization of quality indicators to improve

service delivery.

A-QIP consists of four inter-related components designed to facilitate quality improvement among the

Government of the Republic of Zambia (GRZ) and cooperating partners (CPs) in Zambia. JHPIEGO's

overall work in capacity development and performance improvement is closely linked with this initiative, and

is integrated in some of the components, such as implementation of SmartCare software at ART sites

nationwide to improve quality of services and JHPIEGO's ongoing work in development and implementation

of continuing education courses for ART providers at sites throughout the country.

Below are the descriptions of TBDs activities within the frame of each component for the FY 2009.

1.Collective and Routine Monitoring of Quality

Evaluation activities with participation across ART service providers in Zambia will bring together the

Ministry of Health (MOH), major private sector companies, and CPs, including Elizabeth Glaser Pediatric

AIDS Foundation (EGPAF), Centre for Infectious Disease Research in Zambia (CIDRZ), Zambia

Prevention, Care, and Treatment (ZPCT), AIDSRelief/ Catholic Relief Services (CRS), University Teaching

Hospital Pediatrics/Columbia University, John Snow Incorporated/DELIVER, and JHPIEGO. MOH and

CPs will be convened to identify critical and common questions and develop a shared evaluation strategy to

evaluate care quality, service delivery and coverage, and continuity of care from a sample of sites. The

process will require regular meetings of project directors, monitoring and evaluation (M&E) staff, and clinical

experts to identify indicators, collect and share information, and further inform policy development and

service delivery in Zambia. This process will also incorporate existing standard quality indicators (such as

HIV-QUAL indicators) into the evaluation process. As a result of these activities, a set of core indicators for

quality monitoring will be developed, and ultimately integrated into the SmartCare system to ensure

standardized, comprehensive and sustainable data for quality of care. In addition to tracking a common set

of quality indicators, a special study will be supported in the area identified by the group.

2.Data Use for Improved Care

The SmartCare system has been deployed in more than 100 sites between 2005 and 2007. It is

anticipated that the system will continue to be deployed where feasible in GRZ locations throughout the

country in 2008. SmartCare provides critical individual level data on health services as well as numerous

opportunities to query facility-based and eventually district and provincial data. Data use from the system,

in cooperation with other facility-based aggregation systems (e.g., ARTIS) and what will be a redesigned

health management information system for Ministry of Health (MOH), must be maximized to inform quality

improvement activities. This is a key feature and task of the A-QIP project and will include all sites with

SmartCare deployment. JHPIEGO has been involved in the development, piloting, and implementation of

SmartCare from its inception, and will continue providing technical assistance in the areas of training and

supervision. This activity is closely linked with JHPIEGO's activity under strategic information in this COP.

3.Coordinated Quality Improvement Assistance

Based on findings from routine monitoring and evaluation, key interventions for quality improvement will be

elaborated and delivered to sites identified most in need of support. In close collaboration with the MOH,

the group will identify an organization that will map out and help to coordinate technical support activities

delivered through GRZ and CPs. It's important that this organization will have capacity to actively introduce

quality assurance and facilitation services to improve individual and facility-level performance by providing

on-the-job training (OJT) for quality improvement. JHPIEGO's ongoing work in performance improvement

and capacity building through development and implementation of performance improvement tools and OJT

training of providers is deeply integrated in this component, and will help build the basis for sustainable

quality assurance.

4.Creating International Networks for Learning

Distance learning will be used to reinforce a response to findings from routine monitoring and assessment.

In cooperation with MOH facilities, distance learning will be combined with OJT opportunities and organized

Activity Narrative: in a specific set of course work and informal sharing focused on adult and pediatric ART. We will continue

to increase gender equity in provision of ART services, by providing distance learning opportunities to equal

proportions of males and females in all the programs. Lectures from Zambia and international experts will

be recorded and used in these educational sessions. In close collaboration with the MOH, the group will

identify an organization to take responsibility to moderate and facilitate ongoing learning through session

design and execution. JHPIEGO's ongoing work in development of continuing education opportunities for

service providers via distance learning is integrated within this component and will further progress in close

collaboration with A-QIP activities.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15529

Continued Associated Activity Information

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

System ID System ID

15529 9745.08 HHS/Centers for JHPIEGO 7173 3017.08 UTAP - $400,000

Disease Control & U62/CCU32242

Prevention 8 / JHPIEGO

9745 9745.07 HHS/Centers for JHPIEGO 5019 3017.07 UTAP - $300,000

Disease Control & U62/CCU32242

Prevention 8 / JHPIEGO

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $400,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Care: TB/HIV (HVTB): $650,000

April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD

The funding for this activity in FY 2009 will remain the same as in FY 2008.

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: Work with pre-service institutions has

been added to improve educational process and further quality of services, and support sustainability of the

program.

This activity relates to activities in counseling and testing, laboratory infrastructure, palliative care, and basic

health support activities.

Activity Narrative

This activity is closely linked to Jhpiego's other work in Zambia, focused on strengthening integrated HIV

prevention, care, and treatment services, including counseling and testing (CT) and palliative care, as well

as Jhpiego's work on integrating diagnostic CT into TB and STI services. It also linked with cross-cutting

Jhpiego's work to promote task shifting through training lay workers in counseling and testing skills. It also

incorporates work under Jhpiego's ART program in development of distance learning opportunities for

providers of HIV prevention, care and treatment.

In Zambia, rates of HIV and TB co-infection are more than 70% and TB is one of the leading causes of

death among PLWHA. To ensure appropriate care for TB patients, HIV counseling and testing should be

integrated into TB programs.

Jhpiego is working to strengthen the integration of HIV/AIDS and TB care and treatment services in

Southern, Western, and Eastern Provinces through: 1) Training for Provider Initiated HIV counseling and

testing (PICT); 2) On-the-job training (OJT) for diagnosis and management of opportunistic infections; 3)

Training of community counselors and treatment supporters; 4) Supportive supervision in clinical training

skills; and 5) Building provincial and district team capacity in TB infection control

In FY 2009, TBD will continue strengthening and expanding the capacity at the provincial level in training

skills, supervision and monitoring, continue with the TB infection control activity, and expand OJT activities

to improve providers' skills in diagnosis and treatment of opportunistic infections without taking them away

from their workplaces.

TB patients must be effectively counseled and tested for HIV, and, if found positive, referred to HIV care

and treatment services in a timely manner. Based on successful approaches in integrating CT into

antenatal care for PMTCT, in FY 2005, Jhpiego adapted Centers for Disease Control and Prevention's

(CDC) counseling protocols and training materials to incorporate DCT into TB services more effectively. In

FY 2005, Jhpiego trained 63 health care providers in DCT from 14 sites in three districts (Livingstone,

Mazabuka and Mongu) of Southern and Western Provinces, who then provided counseling and testing to

1,300 clients during that year. Also, Jhpiego provided technical assistance to the Ministry of Health (MOH),

CDC, World Health Organization (WHO), Tuberculosis Control Assistance Program (TBCAP), Churches

Health Association of Zambia (CHAZ), and Center for Infectious Diseases Research in Zambia (CIDRZ), to

further build capacity in DCT clinical training skills by training 50 MOH TB focal point persons from all the

nine provinces of Zambia and staff from other implementing partners' programs.

In FY 2006-2007, Jhpiego continued to work with the Southern and Western Provincial Health Offices

(PHOs) to support integration of HIV counseling and testing into TB services. Working with the local

provincial trainers in FY 2006 and FY 2007, 125 health care providers from ten new sites were trained in

DCT, in addition to the provinces' own programs of training. To ensure that these programs are

sustainable, in FY 2009, Jhpiego will strengthen and expand the capacity at the provincial level in training

skills in all the provinces, and supervision and monitoring, through joint training and supervision activities in

Southern, Western and Eastern Provinces. In FY 2007, Jhpiego used plus-up funds to train a total of 216

trainers in DCT from all the 72 districts of Zambia and developed the training capacity of the Zambia

Defense Forces by holding a DCT clinical training skills workshop for 12 ZDF trainers who later trained 80

service providers. In FY 2008, JHIEGO worked with these trainers to conduct additional DCT workshops

targeting 100 ZDF service providers from sites nationwide. This number was in addition to the 80 ZDF

health care providers who were trained in TB diagnosis and management under the DOD-Jhpiego TB/HIV

activity #9090.

In FY 2009, TBD will continue FY 2007 plus-up and FY 2008 funding initiatives to develop district level DCT

clinical training skills by ensuring that new trainers receive support in their first trainings by co-training with

experienced trainers who will provide support and feedback on their training skills. In FY 09, Jhpiego will

train 100 new trainers national wide to account for the attrition of trainers in the districts.

In FY 2009, TBD will also continue with the TB infection control activity started in FY 2007 and FY 2008

when the guidelines were developed and disseminated at the central level and to all PHOs. TBD will work

to build capacity of provincial teams and later will support them to conduct orientation and oversee the

implementation of TB infection control activities at the district/facility level. TBD will also provide support to

the local teams in conducting supportive supervision.

Providers of HIV care and treatment services need significant strengthening in the recognition, diagnosis

and management of TB and other opportunistic infections (OIs). Because of the complexities of

presentation and manifestation of TB and other OIs, and the limited diagnostic capacities of providers and

facilities, initial basic training in OI management is only the tip of the iceberg. Experience from Jhpiego's

work in past years shows that significant effort in hands-on mentoring and on-the-job training can

dramatically improve care and treatment for HIV patients.

Structured on-the-job training (OJT) is a non-traditional, intensive approach to in-service training that

involves a highly experienced clinician spending extended period of time at a service outlet working with a

Activity Narrative: team of providers in their environment. OJT includes daily rounds together with structured mentoring, case

study reviews, and working with the teams of providers through diagnosis, clinical decision-making, and

management of TB and other OIs, using the national guidelines and training materials. Between FY 2005

and FY 2008, with assistance of clinical experts from the University of Zambia (UNZA) and University

Teaching Hospital (UTH), Jhpiego provided OJT to 150 health care providers, including nurses, clinical

officers and doctors, from Livingstone General Hospital, Lewanika General Hospital, Chipata General and

Mazabuka District Hospitals along with selected staff from hospital-affiliated health centers (HAHC). In FY

2009, an additional 95 service providers will receive OJT in 10 additional district hospitals in Eastern,

Southern, and Western Provinces. Relevant performance standards were drafted and implemented in FY

2006 and FY 2007. This should improve the quality of care by providing sites with standards they can

implement and monitor as well as tools for supervisors to use in monitoring and supporting clinical services.

In FY 2006, Jhpiego formalized an arrangement with UNZA and UTH to use the pool of clinical experts from

the institutions for this training program as a step towards building the capacity of those key national

institutions. In addition, in FY 2008, Jhpiego increasingly involved the Clinical Care Specialists from the

Provincial Health Offices and the experienced clinicians from the Provincial Hospitals and other larger

facilities, to build local capacity to support and expand this program from the Provincial level. In FY 2009,

the respective Provincial Health Offices will increasingly carry out supervision and monitoring of the training

and quality of services with the support of TBD and the UNZA/UTH clinical experts as needed.

Based on the TB DOTS model of community treatment support programs, HIV treatment programs are

similarly developing community treatment and adherence support programs. With the high rates of TB-HIV

co-infection, tremendous opportunities exist to increase the synergies in these programs and ensure that TB

treatment supporters are able to refer for and support HIV services, and vice-versa. There are no gender

disparities in the provision and access to TB/HIV diagnosis and treatment in Zambia.

To strengthen TB/HIV collaborative activities, between FY 2005 and FY 2008, Jhpiego trained 285

community counselors/treatment supporters (CCTSs) in Livingstone, Mazabuka, Monze, Kazungula, Itezhi-

tezhi, Sesheke, and Mongu districts in support of the sites where DCT and OJT activities were conducted.

The CCTS are involved in providing HIV/TB education, TB treatment support and ART treatment adherence

support at community level and referral for TB and HIV services. In FY 2009, TBD will draw upon earlier-

trained CCTSs and local NGO staff, building local capacity to expand and support these programs. In order

to ensure sustainability of the program, local trainers will increasingly take the lead in training and

supervision activities, supported by TBD and our local partners (Kara Counseling and Community-Based TB

Organization [CBTO]) as needed. The aim in FY 2009 is to support the training of 120 CCTSs in 10 districts

of Southern, Western and Eastern provinces. The focus will also be on strengthening supportive

supervision and exploring an integrated system that includes HIV/TB/PMTCT/Malaria. Home visit diaries

will be provided to the CCTSs to enhance record keeping. To ensure that community counselors have

necessary set of skills to provide services needed in the community, TBD will also build their capacity in

counseling and testing using finger prick under the Jhpiego's HVCT program. It is expected that local

trainers will conduct roll-out training activities using resources from the MOH, Global Fund and other

sources, thus further expanding the pool of community resources in order to attain geographical coverage of

the services.

TBD will also support the pre-service education institutions in strengthening their TB/HIV curricular

component through access to the continuing education programs with the latest evidence-based

information. These programs include a combination of distance education programs for use in low

technology settings developed by Jhpiego in collaboration with the MOH, as well as internet and e-mail

based education program developed by the Johns Hopkins University Center for Clinical Global Health

Education for service providers. In FY 2009, the initial and new educational modules will be provided to 10

pre-service education institutions nationwide, to support educational process of medical and nursing

students. Jhpiego's blended learning approach—one that combines electronic and face-to-face learning—

will ensure that frontline providers and students alike are given the knowledge and the skills that they need

to provide quality service.

To ensure sustainability, these activities are enshrined in the Ministry of Health District Plans.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $650,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

Funding for Prevention: HIV Testing and Counseling (HVCT): $200,000

April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

•Update on current activities

•Plans for 2009

•Increased training targets.

Activity Narrative

This activity is closely linked JHPIEGO's other work in Zambia, focused on strengthening integrated HIV

prevention (MC #12519.08, #12524.08, #12530.08, New PMTCT), care and treatment services (including

counseling and testing (CT) and palliative care - #DOD) , as well as JHPIEGO's work on integrating

diagnostic CT into TB and STI services (#3644.08). It also linked with cross-cutting JHPIEGO's work to

promote task shifting through training lay workers in counseling skills.

This activity has two components: 1) training lay workers in HIV counseling and testing using finger prick,

and 2) ensuring that trained lay counselors provide quality services and meet the demand for HIV

counseling and testing, both in service delivery sites and in the community. Promotion of shifting the task of

HIV counseling and testing to lay workers, and strengthening of local training and supervisory capacity are

cross-cutting objectives in this activity.

Counseling and testing (CT) is an essential intervention in all HIV/AIDS programs, serving as a key link

between prevention, care and treatment efforts. Those who test HIV negative have the opportunity to

change their behavior in order to prevent acquisition of the virus in the future. Those who test positive have

the opportunity to change their behavior to prevent transmission to their partner(s) and to make informed

decisions about seeking appropriate care and treatment including prevention of mother to child transmission

(PMTCT), prevention and management of opportunistic infections (including TB and STIs) and, when

clinically indicated, antiretroviral therapy (ART).

One of the most devastating impacts of the HIV/AIDS epidemic has been its effect on the healthcare sector.

As the need for skilled healthcare workers has increased exponentially due to the burden of disease caused

by HIV, TB and other infections diseases, the number of healthcare workers becoming ill as well as the

brain drain have increasingly pulled trained personnel away from the health sector at precisely the time that

they are most needed.

The acute shortage of nurses and other skilled healthcare workers has resulted in woefully insufficient

number of trained counselors for HIV or psychosocial counseling to meet the demand (or potential demand)

for counseling and testing.

In light of this acute shortage, JHPIEGO in collaboration with the Provincial Health Offices (PHOs), District

Health Offices (DHOs), and other partners, is promoting "task-shifting" wherever possible. Task shifting

means that tasks that are commonly conducted by higher-level healthcare workers (e.g., nurses) should be

shifted to lower-level providers and even lay people if these cadres can competently conduct them. HIV

counseling is a prime example. Lay counselors can provide high quality HIV counseling, provided that they

are properly trained and supervised, freeing up professional nurses to perform the clinical skills for which

they were trained.

The community (lay) counselors are a link between the community and health care services and are

involved in providing group education and counseling and testing both at the community and facility levels.

Task-shifting strategy and making greater use of lay counselors is another way of ensuring continuous

availability of trained counselors at the service delivery sites.

JHPIEGO works to build local capacity in supporting and expanding CT services. In FY 2008, in order to

expand services and strengthen the community outreach around the target facilities, improve the continuity

of care and uptake of services, JHPIEGO conducted counseling and testing (using finger prick) training for

120 lay counselors from selected districts of Southern (Livingstone, Monze, Mazabuka,), Western (Mongu

and Senanga), and Eastern (Chipata) Provinces.

JHPIEGO worked with the existing management and supervisory teams of PHOs and DHOs to provide

supportive supervision and on-the-job training to at least 100 community (lay) counsellors who were trained

in FY 2007, as well as quality assurance to programs strengthened during previous years. Quality

assurance exercises are focused on the two key components: quality of counseling and quality of testing.

The project uses a variety of methodologies to evaluate the quality of counseling, such as client exit

interview, mystery client, and chart review. To assure the quality of finger prick testing, internal and external

quality control systems were used.

In FY 2009, TBD will continue training of new lay counselors in counseling and testing using finger prick in

Southern, Western and Eastern Provinces, in the six districts mentioned above and four additional districts

to be selected in coordination with the PHOs, and will train at least 160 community (lay) counselors ( 16 per

district). These lay counselors will provide services in the communities and at the clinics, allowing qualified

medical personnel to attend to clinical care duties.

Taking in consideration the number of local and international agencies working to strengthen CT services in

Zambia, location of trainings and distribution of trainees will be discussed and closely coordinated with the

PHOs and DHOs to ensure that TBD's training activities fit in the local strategy and avoid overlap of efforts.

In addition to training of new lay counselors, JHPIEGO works to ensure that previously trained lay

counselors have ample opportunity to apply their new skills and that they provide quality services to the

community. With this purpose, in FY 2009, TBD will continue providing supportive supervision and on-site

updates, working with 120 community counselors trained in FY 2008. To strengthen local supervisory

capacity, TBD will work closely with the PHOs and DHOs to ensure that they are capable to further

Activity Narrative: strengthen the monitoring of the quality of services.

To ensure that community counselors have necessary set of skills to provide services needed in the

community, TBD, in addition to the CT skills, will also build their capacity in TB/HIV integration activities

under the TBD's TB/HIV program. This program will include training in TB/HIV group education, TB

treatment support and ART adherence support at the community level. The districts will be selected in

consultation with the PHOs.

These activities will be complimented by the CT and supervision trainings conducted by the provinces

themselves; TBD will work in close collaboration with Community-Based TB Organization and Kara

Counseling to strengthen their capacity and support the provinces in conducting these trainings. Provinces

will further report the number of people reached with counseling and testing through this activity thus it will

not be included here to avoid duplication.

TBD will continue providing support to the local management and supervisory teams to ensure that they will

soon take the lead in both training and supervision activities and will work to enhance their ability to sustain

and expand these programs.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15527

Continued Associated Activity Information

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

System ID System ID

15527 4527.08 HHS/Centers for JHPIEGO 7173 3017.08 UTAP - $200,000

Disease Control & U62/CCU32242

Prevention 8 / JHPIEGO

9035 4527.07 HHS/Centers for JHPIEGO 5019 3017.07 UTAP - $235,000

Disease Control & U62/CCU32242

Prevention 8 / JHPIEGO

4527 4527.06 HHS/Centers for JHPIEGO 3017 3017.06 Technical $235,000

Disease Control & Assistance/JHPI

Prevention EGO

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $200,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14:

Funding for Strategic Information (HVSI): $900,000

April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: Per CDC-Zambia request, work with

nursing schools to improve pre-service nursing education will be initiated. The rest of the activity is

unchanged from FY 2008.

This activity also relates to Ministry of Health (# 3713.08), EGPAF (#3709.08), COMFORCE (#9692.08),

CDC-TA (#3714.08).

Activity Narrative

Building upon FY 2008 activities, TBD will continue to support the scale-up and deployment of electronic

patient monitoring and data management tools to enhance continuity of care. This will be provided by a)

training and b) supporting the project sites during the early implementation and use of the growing number

of modules in the SmartCare software (formerly called the Continuity of Care and Patient Tracking System

[CCPTS]). Within the scope of a cooperative agreement with CDC, TBD will continue to collaborate with

the broad consortium of organizations involved in the development and deployment of the SmartCare

System nationwide. These organizations include the Ministry of Health (MOH), the CDC-Zambia, Provincial

Health Offices (PHO), District Health Management Teams (DHMT), the Elizabeth Glaser Pediatric AIDS

Foundation (EGPAF), Centre for Infections Disease Research in Zambia (CIDRZ), AIDSRelief, and the

Zambia Prevention, Care and Treatment Program (ZPCT), among others.

In FY 2005 and FY 2006, JHPIEGO supported the early development of the SmartCare software and its

pilot and scale-up in Kafue District. Starting in FY 2007, JHPIEGO supported the transition of the

SmartCare project from the pilot phase in Kafue District to the nationwide deployment of the system.

Working with MOH and CDC-Zambia and in collaboration with other implementing partners, JHPIEGO

supported the training of over 500 managers, supervisors and service providers, including District Health

Information Officers (DHIOs) and district Maternal and Child Health (MCH) coordinators, district level focal

person in ART, PMTCT and TB, as well as all nine Provincial Data Management Specialists (PDMSs). In

addition, JHPIEGO has supported staff involved in all phases of deployment of SmartCare, including pre-

deployment, orientation, training, and post-deployment supervision of the SmartCare system. Also,

JHPIEGO has supported the training of service providers at "independent" service outlets which are service

outlets that do not have an implementing partner committed to directly support the deployment of

SmartCare and the training of service providers in the use of SmartCare.

In FY 2009, TBD will continue to support the implementation of SmartCare through training, post-

deployment supportive supervision visits conducted jointly with provincial, district and other SmartCare

implementing partners, provision of logistical support for the deployment, and limited site readiness

preparation. TBD deployment staff will work closely with the MOH, CDC-Zambia and other implementing

partners to prioritize activities focused on pre- and post-deployment to ensure that there is a synergy of

efforts as the nationwide deployment continues. TBD will take a leadership role in the development and

implementation of post-deployment supervision methodologies and tools that guide managers and

supervisors at all levels to measure gaps between actual and ideal usage of the SmartCare System. These

tools not only measure the gaps, but also provide managers and supervisors with the information necessary

to guide service providers on how to close the gaps and why it is important.

TBD training and implementation staff will also support training of 250 service providers in the provinces

and districts targeted during the scale-up. They will co-train with the provincial and district trainers and work

in conjunction with all the partners supporting the scale up of the system such as MOH, CDC-Zambia,

EGPAF/CIDRZ, ZPCT, CRS, and other implementing partners. They will make sure that the quality of

training is maintained from the PHOs in the districts and collaborate with the SmartCare team in the update

and revision of training materials as the system matures.

Increasingly, the MOH is taking the lead in SmartCare collaboration, deployment authority, and field

support, and has solicited commitments for infrastructure from all major implementers. The MOH, through

collaboration and in close consultation with CDC-Zambia and other implementing partners, developed a

very aggressive deployment plan that includes a) training provincial level Trainers of Trainers centrally, b)

sending provincial technical leadership back to province to replicate training for district leadership with

SmartCare team support, and c) tasking the trained providers with implementation at their districts. So even

before the FY 2009 activity period, the efforts of the initial three SmartCare collaborators will be joined by

efforts of all other HIV/AIDS care and treatment partners in Zambia, including CRS-AIDSRelief, ZPCT,

JHPIEGO, Health and System Strengthening Project (HSSP), and EGPAF.

In building this collaboration around the SmartCare solution, it is clear that the MOH is comfortable taking

the initiative on this effort. TBD, in coordination with CDC's future developments and other CDC

partnerships, will leverage its long-term good relationship with the MOH and established ‘trainer' role.

JHPIEGO's strong technical staff will continue to support the rapid national deployments and most of this

activity will be focused on the training and post-deployment supervision. While Zambian electronic medical

records (EMR) system now provides services to more than 90,000 patients, with the additional partners

starting deployment before the end of October, the rate of growth may increase non-linearly along with the

number of electronic clinics, provided there are no supply limitations.

The methodologies employed by JHPIEGO and the SmartCare team as a whole are designed with the

express interest in developing a system that can be sustained by the Ministry of Health. By empowering all

levels of the Zambian Ministry of Health system with the knowledge and skills to deploy and manage the

SmartCare system, from the pre-deployment preparation through post-deployment supervision, it will be

within the scope of the MOH and Government of the Republic of Zambia to sustain the SmartCare system

as an essential tool in the provision of continuous, quality health care service in years going forward.

In FY 2009, per request from CDC-Zambia, JHPIEGO will start identifying opportunities to improve the

Activity Narrative: nursing pre-service education. It will include identification of gaps in the curriculum content, especially in

presentation of evidence-based information and particularly in the area of HIV/AIDS. At the same time, a

needs assessment will be conducted to identify gaps in current training methodologies, including

development of competencies to manage EMR.

JHPIEGO will work with nursing schools in the development of a learning management system framed

around EMR. It will also include the potential development of E-learning materials to enhance the transfer

of knowledge, skills and attitudes related to the target competencies (such as TB, STI, OIs, and provider-

initiated counseling and testing [PICT]) while simultaneously preparing future providers to work with the

EMR as part of the SmartCare approach.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $75,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.17:

Cross Cutting Budget Categories and Known Amounts Total: $3,215,000
Human Resources for Health $1,390,000
Human Resources for Health $500,000
Human Resources for Health $400,000
Human Resources for Health $650,000
Human Resources for Health $200,000
Human Resources for Health $75,000