Hiring consultants to research, design, and pilot test community compacts. The community compacts are

agreements directly with communities, as well as incentive rewards for effective prevention programs.

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety

Total Planned Funding for Program Budget Code: $4,000,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

The Biomedical Prevention program area narrative describes blood safety, injection safety, and male circumcision programs in

Zambia.

Blood Safety

Zambia has a comprehensive national blood transfusion program aimed at ensuring equity of access to safe and affordable blood

throughout the country. Blood transfusion needs in Zambia are currently estimated at 120,000 units (450 mls each) of blood per

year with the current operations at about 80%. Since the initiation of funding from the President's Emergency Plan for AIDS Relief

(PEPFAR) in August 2004, mobile collection sites have increased from 9 to 21 while blood collection has increased significantly

from a baseline of 8,715 units in 2004 to 22,798 units for the quarter ending June 2008, exceeding its target by nearly 200 units.

About 40% of the collected blood is transfused to children under the age of five and 20% in complicated pregnancies. With

support from PEPFAR, transfusion sites will increase from 81 to 128 by the end of FY 2009 covering all nine provinces and

operating in all 72 districts. Previous funding allowed for the expansion of collection sites and the purchase of 18 vehicles and five

trailers for transporting blood. Past funding also allowed for the acquisition of nine large blood storage refrigerators for the nine

regional sites, 34 small blood storage refrigerators for the blood transfusion sites; and 3 plasma freezers. About 710 providers

have been trained on safe blood operations. There is strong collaboration between the The Zambia National Blood Transfusion

Services (ZNBTS) and other donors such as World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria to ensure

funding for blood safety are coordinated and streamlined for efficiency.

The ZNBTS is the Government of the Republic of Zambia (GRZ) unit responsible for ensuring a safe, adequate blood supply

throughout the country. ZNBTS goals include (1) rapidly increasing blood collections to meet the estimated national demand of

120,000 units of blood per year by the end of 2009; (2) increasing and maintaining the percentage of regular repeat donors from

32% in 2005 to 55% in 2009; and (3) reducing HIV discards from 8% to 2% by 2009.

Funding from 2004-2008 has considerably expanded ZNBTS activities. The blood safety system in Zambia comprises the

coordinating center in Lusaka and nine regional blood transfusion centers in each of the nine provinces. Together these facilities

are responsible for donor mobilization, collection, laboratory screening, and distribution of blood, and maintaining 81 hospital-

based blood banks located in government and mission hospitals. They are also responsible for blood grouping, cross-matching,

and monitoring transfusion outcomes for their respective hospitals. There are over 125 facilities, including government, mission,

military, and private facilities that are currently involved in the clinical use of blood. The existing blood transfusion infrastructure is

fairly developed and equipped with the requisite equipment for blood collection, testing, distribution, and cold chain maintenance.

Since its inception, additional staff were employed, operational and financial support was extended to all regional centers, and

management was strengthened. The main strategies applied to ensure safe and adequate supplies of blood include: recruitment

and retention of voluntary, non-remunerated blood donors from low risk population groups and application of strict criteria for

selection of blood donors. Updated blood screening equipment, mandatory laboratory screening of 100% of blood collected for

HIV, Hepatitis B and C, and syphilis, promotion of appropriate clinical use of blood, appropriate staff training and capacity building,

and continuous improvements in management and coordination have all contributed to the successful strategy.

Provincial blood banks are responsible for blood collection, laboratory screening, and distribution. Under the current arrangement,

ZNBTS collects and screens all blood, while other partners are mainly involved in the clinical use of blood.

Since mid-2005, ZNBTS has embarked on the development of an appropriate legal and regulatory framework for blood

transfusion services in Zambia. From October 2008 to March 2009, stakeholders will review the draft policy documents for the

GRZ to approve and enact law. In the past, the lack of an appropriate blood donor tracing system contributed to over-reliance on

first time donors, instead of regular, repeat donors, which led to increased discards. However, ZNBTS developed, and is

implementing a blood donor tracing system. To further strengthen the system and improve the efficiency and accuracy of the

blood donation data, CDC Zambia is providing technical, material, and financial support for the implementation of a SmartCard

based donor management system as part of the roll-out of the national SmartDonor system. The ZNBTS intends to assure

rational use of blood and blood products through a series of activities, e.g. the updating, distribution, and dissemination of the

national guidelines on the appropriate use of blood; strengthening hospital blood transfusion committees; training clinicians and

medical school students in the appropriate methods of rational use of blood; improving and expanding capacities for production of

various blood components; and strengthening the systems for monitoring blood transfusions.

The ZNBTS is working with VCT centers to facilitate the referral of blood donors who test positive for HIV so they receive follow-

up care, treatment, and support. Additionally the VCT center link will encourage people testing HIV negative to consider enrolling

as regular blood donors. The ZNBTS has submitted its action plans for inclusion in the restructured Ministry of Health (MOH), and

if approved will receive core operational funds from the GRZ to support the program.

Injection Safety

The transmission of HIV through unsafe medical practices accounts for 5% of all HIV transmissions in Zambia. Transmission of

HIV through unsafe medical practices (medical transmission of HIV) is largely preventable. Infection prevention (IP) and injection

safety (IS) are implemented with Track 1.0 funding. The U.S. Mission in Zambia has supported the MOH and the Ministry of

Defense (MOD) in IP/IS: blood safety, handling and processing of sharp instruments, handling and disposal of clinical waste,

procurement of IP/IS commodities, and management of the supply chain for IP/IS commodities.

The U.S. Mission in Zambia supports the GRZ in reducing and/or stopping medical transmission of HIV through: 1) provision of

training in IP/IS to health care workers; 2) advocacy for policies and guidelines that enhance IP/IS in Zambia; 3) procurement of

commodities needed to promote IP/IS in Zambia; and 4) development, production, and implementation of behavior change and

communication (BCC) materials in IP/IS.

Training in IP/IS includes: 1) a week-long residential training for front line health care workers in IP/IS; 2) U.S. Mission in Zambia

technical support to districts that have already completed training; 3) U.S. Mission in Zambia trains trainers of trainers in the MOD

health facilities; and 4) U.S. Mission in Zambia trains health managers and policy makers in IP/IS. Follow-up visits to managers

who have received orientation have demonstrated that they all have integrated IP/IS activities in their annual work plans. In

addition, all the districts/facilities reached with IS/IP training have adopted and implemented the standard post-HIV exposure

prophylaxis (PEP) protocol. In FY 2009, the U.S. Mission in Zambia will support the MOH to implement IS/IP training activities in

14 new districts, translating into a national coverage of 72 districts from FY 2005 through FY 2009. It is envisioned that the U.S.

Mission in Zambia will support the training of 270 MOH health care workers in IP/IS. Additionally, the U.S. Mission in Zambia will

support training of 150 health care workers in the MOD.

From FY 2005 - FY 2008, the U.S. Mission in Zambia procured and supplied essential IP/IS commodities such as disposable

needles, sharps boxes, protective boots, utility gloves, plastic aprons, color coded bin liners, and disinfectant solutions to the MOH

and the MOD for effective implementation of IP/IS activities. In FY 2009, the U.S. Mission in Zambia will continue to procure

essential IP/IS commodities for Zambia. The U.S. Mission in Zambia will also continue to engage in dialogue with health-care

managers and policy makers on the need to allocate sufficient resources for IP/IS commodities.

Under BCC, the U.S. Mission in Zambia will collaborate with the GRZ and other communication partners to develop, harmonize,

and implement up to date and context-specific BCC communication materials. The U.S. Mission in Zambia will also work with

local communities and their respective leaders to foster behaviors that reduce the risk of medical transmission of HIV, including

reducing provider and consumer preference for injections and staying away from clinical waste disposal sites.

The U.S. Mission in Zambia will undertake the following activities to ensure that key program investments are sustained with FY

2009 funds: collaborate with the GRZ and other key stakeholders to ensure the GRZ develops and implements a national infection

prevention policy that compels institutions to build capacity to anticipate, recognize, evaluate, and control factors that contribute to

poor IS/IP practices. The U.S. Mission in Zambia will also continue to advocate for increased public health expenditure on IS/IP

commodities, to extend training in IS/IP to the private/commercial sector, and to ensure that IP/IS guidelines and protocols are

updated as necessary.

Male Circumcision

Male circumcision (MC) has been shown to reduce men's risk of becoming infected by HIV through heterosexual intercourse by at

least one-half, and possibly as much as two-thirds. Three randomized clinical trials (RCTs) have shown that men who were

circumcised were less than half as likely to become infected with HIV within the trial periods. This finding is supported by over 40

sociological and epidemiological studies which show a strong link between MC and reduced HIV prevalence.

Preliminary data suggest that MC may also reduce male-to-female transmission of HIV, however the data on direct male-to-

female transmission remain unclear. What is clear from modeling, is that a significant decrease of HIV prevalence among men will

undoubtedly convey protection to women when it comes to heterosexual transmission of HIV. In the long run, lowered prevalence

in men will ultimately translate into lowered prevalence in women.

MC has been shown to significantly reduce the risk of acquiring HIV, but does not provide complete protection from HIV infection.

Data from the three RCTs show that circumcised men were not significantly more likely to engage in high risk sexual practices

after the procedure than uncircumcised men, some studies demonstrate that circumcised men's sexual risk behaviors were

actually reduced.

About 15% of the Zambian male population are currently circumcised (ZDHS, 2007). It is estimated that more than one million

Zambian men will need to be circumcised in the next five years for MC to have a measurable impact in reducing HIV prevalence.

This will require dramatically scaling-up quality MC services in Zambia and nation-wide training of providers and counselors to

ensure standardization of safe, high quality, and affordable MC services. The basic MC package, as defined by WHO, must be

offered at a minimal cost, and as near to the community as possible. Models for MC service delivery include: 1) neonatal MC; 2)

Static MC sites (public and private); 3) Mobile MC services; and 4) Re-training/self-certification of traditional MC providers.

In order to develop a comprehensive MC program, the GRZ established the MC technical working group (TWG) as a task force

under the Prevention of Sexual Transmission (PST) sub-committee of the Prevention Theme Group at the National

HIV/AIDS/TB/STI Council (NAC). The MC TWG consists of governmental and non-governmental organizations involved in

development of guidelines, planning, and service delivery related to MC in Zambia.

The U.S. Mission in Zambia has supported the MC program in Zambia since 2004. Initially, the U.S. partners teamed up with the

government to work on small scale efforts to strengthen existing MC services to meet demand. This activity led to clinical provider

training at University Teaching Hospital (UTH), Chainama Clinic and George Clinic in Lusaka, and Livingstone General Hospital.

The U.S. Mission in Zambia provides technical expertise for training, learning materials, site assessments/preparation, and expert

input during development of educational materials and MC guidelines.

In FY 2008, the U.S.-supported the scale-up of MC activities to 10 sites countrywide. This support will also be extended to the

military population where health delivery sites will be strengthened to provide MC services. Other activities include six MC

operating rooms (three of which are operational), recruitment, and training of nurses and clinical officers in MC. In permanent

sites, the U.S. Mission in Zambia supported the provision of MC services to more than 900 clients between 8 and 60. Mobile MC

activities have also been introduced. In FY 2009, the U.S. Mission in Zambia will support training activities across the country,

establishing training centers in all provincial capitals by 2010. This will prepare trainers in all provinces to serve as future trainers

and supervisors of activities in their locality. Additionally, U.S. Mission in Zambia will support the training of approximately 30

healthcare providers to perform neonatal MC, to conduct a feasibility study examining acceptability of neonatal MC, and to

determine the optimal method for scale-up of neonatal MC.

Table 3.3.04:

Engage cost modelers to conduct an assessment of the ARV costs.

This activity will include data collection and interpretation as well as workshops with stakeholders on the

assumptions required in the model, as well as dissemination of the outputs.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.09:

Hiring consultants for approximately 12 months to coordinate efforts between the GRZ, Cooperating

Partners (CP's), National Aids Council (NAC), Ministry of Health (MOH) and the PEPFAR Coordinator's

office in thHiring consultants for approximately 12 months to coordinate efforts between the GRZ,

Cooperating Partners (CP's), National Aids Council (NAC), Ministry of Health (MOH) and the PEPFAR

Coordinator's office in the design and approval of the Partnership Framework. The GRZ's national health

strategy expires at the end of 2010; the PF will need to nimbly span the current and subsequent health

strategy. e design and approval of the Partnership Framework. The GRZ's national health strategy expires

at the end of 2010; the PF will need to nimbly span the current and subsequent health strategy

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.19: