The 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 achievement.

Since FY 2006, CARE International has been supporting the implementation of prevention of mother to child

transmission of HIV (PMTCT) services in three districts of Eastern Province namely Chadiza, Chama, and

Lundazi. PMTCT services were established and strengthened in 30 service outlets. In FY 2009, CARE will

continue to strengthen the implementation of PMTCT services in these same locations. The model is based

on a rural expansion program that will use other health cadres for counseling and testing (CT) and health

workers for the implementation of the service. Building on synergies created by the HIV/TB work in these

districts, a comprehensive package of HIV services will be used to mainstream these services. CARE

International in Eastern Province will continue to strengthen partnerships with Center for Infectious Disease

Research in Zambia (CIDRZ), JHPIEGO, and Ministry of Health (MOH), in particular the Provincial Health

Office (PHO) and their respective District Health Offices (DHOs) to carry out this task.

To have a significant impact on reducing mother to child transmission of HIV, services need to be integrated

in all maternal, neonatal and child health (MNCH) services. CARE International will in FY 2009 ensure that

sustainable PMTCT services are integrated in all areas of MNCH and these include antenatal care, family

planning, delivery, and postnatal care which will incorporate mother-infant follow-up activities. A training

needs analysis (TNA) and assessment review will be undertaken of all MCH staff that were trained by the

project in FY 2008 and those that were not trained to assess training gaps that will need to be addressed in

FY 2009. Since there is always new information and new technologies being introduced in the prevention of

new HIV infections, the project will ensure that health workers are updated regularly with new developments

in PMTCT through refresher training. Some of the technical interventions that the project will strengthen

include the provision of a more effective ARV prophylaxis as recommended by the MOH PMTCT protocol

guidelines in pregnant mothers that test HIV positive and also link mother-infants pairs with CIDRZ for early

infant diagnosis. Currently all the health facilities that the project is supporting are providing dual therapy in

the PMTCT program. Some bigger health facilities have already initiated short course ARV prophylaxis with

a tail which consists of Zidovudine (AZT), Nevirapine (NVP) and Lamivudine (3TC). The project will

continue to co-ordinate PMTCT activities with CIDRZ and the PHO through the Provincial Maternal and

Child Health Coordinator.

To date,

CARE International has conducted PMTCT trainings to 122 health workers in Chama, Chadiza, and Lundazi

districts of Eastern Province. Community health cadres such as Traditional Birth Attendants and

Community Health Workers have also been trained in community mobilization activities, referrals for

increased uptake of maternal, neonatal and child health services including, PMTCT services.

Building from FY 2008 activities, CARE International in FY 2009 will scale-up and roll-out PMTCT services

to the remaining health facilities in the three project districts bringing the total number of facilities supported

to 63. The target for expected deliveries in Chama is 5,305, Lundazi, 16,868 and Chadiza has 6,231.

Currently, 30 health facilities in the three districts have established PMTCT services. Provider initiated

counseling and testing will continue to be provided to all pregnant women to know their HIV status in the

three districts. Counseling and referrals for HIV testing will be done by community volunteers at community-

level so as to increase the uptake of women who access HIV testing and later benefit from other PMTCT

interventions. HIV-positive mothers will be provided with a range of information on measures to reduce HIV

transmission to their babies, how to avoid potential health problems during pregnancy, HIV care and

treatment options, infant care, and family planning. HIV-negative mothers will be supported with

interventions that will help maintain their negative status. This program will map existing support programs

at the respective districts hospitals or neighboring districts for service referrals and linkages with

antiretroviral therapy (ART) will be developed and strengthened. It is envisaged that CIDRZ will introduce

ART clinics at some of the health facilities in Chama district where CARE International provides support for

PMTCT services. If implemented, this will complement PMTCT programming efforts and further enhance

the quality of service in PMTCT. The project will work closely with the PHO to ensure that ART services are

scaled up to remote areas so that more women who are eligible are linked to the ART clinic and

commenced on therapy.

Early infant diagnosis will also be emphasized and health workers will be trained on how to collect dried

blood spots for polymerase chain reaction (PCR) testing at the referral laboratories in Lusaka using the

network established by CIDRZ. Capacity will be built to ensure accurate entries of all the relevant patient

information in the PMTCT registers, a task that has posed a challenge in some health facilities, probably

due to non-availability of adequately qualified staff in the project sites. This also implies that efforts will be

made in conjunction with the PHO, DHOs and other partners to identify and place staff in strategic sites.

Traditional Birth Attendants (TBAs) and other community health workers (e.g. home based care givers) play

vital roles in the delivery of safe motherhood and reproductive health services. Traditional Birth Attendants

are instrumental in delivering PMTCT services to pregnant women at community-level, referral of these

women to antenatal care services and in providing follow-up advice and encouragement for women at the

community-level. An innovative approach of incorporating TBAs in the provision of PMTCT services was

rolled out in FY 2008. A package that encompasses all aspects of the PMTCT protocols was used for

training. CARE International in FY 2008 facilitated the training of active community volunteers in multiple

roles (polyvalent volunteers). In FY 2009, CARE International will conduct a training analysis on the

community volunteers to identify information gaps pertaining to new developments in PMTCT. A training

program will be implemented to enhance the knowledge and skills of these volunteers in PMTCT service

provision. This will form part of specific programs targeted at developing the capacity and skills of TBAs in

PMTCT service delivery. Specifically the TBAs will continue to be updated with information and provided

with skills on how to identify, counsel and refer antenatal mothers for PMTCT services and to also continue

to provide on going support to women.

During the FY 2009 period, CARE International will facilitate management of the supply chain by DHOs to

access, store and distribute supplies related to PMTCT. A key way of doing this will be to better link DHOs

Activity Narrative: to the PHO for supplies.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15506

Continued Associated Activity Information

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

System ID System ID

15506 3573.08 HHS/Centers for CARE 7164 2933.08 CARE $302,500

Disease Control & International International -

Prevention U10/CCU42488

5

8818 3573.07 HHS/Centers for CARE 4948 2933.07 CARE $275,000

Disease Control & International International -

Prevention U10/CCU42488

5

3573 3573.06 HHS/Centers for CARE 2933 2933.06 Technical $150,000

Disease Control & International Assistance-

Prevention CARE

International

Emphasis Areas

Health-related Wraparound Programs

* Family Planning

* Safe Motherhood

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $50,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01:

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

•Increase support for coordination through the establishment of district, health centre, and community

TB/HIV coordinating committees

•Strengthen the monitoring and evaluation of TB/HIV data through training of health staff in data collection

and analysis

•Development of a Quality of Care tool

•Deploy trained health workers to improve human resources in zonal centers

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

health support activities.

CARE International has supported the implementation of TB/HIV activities since 2005 and will draw on

lessons learnt in the past four years to improve quality of service delivery for tuberculosis (TB) and HIV

activities in the districts of Chipata, Petauke, Katete, and Lundazi. These activities will include strengthening

the links between TB, HIV and antiretroviral therapy (ART). CARE realizes its contributions have previously

focused on enhancing the technical capacity of health service providers and community volunteers. The

focus in FY 2009 will be to expand and institutionalize multi-level linkages between the response to TB,

HIV/AIDS and ART. CARE International will strengthen the linkages of HIV positive patients to ART services

provided by Center for Infectious Diseases Research in Zambia (CIDRZ), Catholic Relief Services (CRS),

and, Provincial Health Office (PHO) in strategic health facilities within the project districts. A referral system

to link HIV positive patients to ART is already in place through existing intervention strategies like HBC,

Mobile VCT and diagnostic CT, PMTCT, and TB DOTS. This is expected to contribute to increased

numbers of HIV-infected patients accessing ART and subsequently improve treatment outcomes and quality

of life for TB/HIV clients due to improved patient management. In addition through the established TB/HIV

referral network, 3,500 HIV infected patients attending HIV care/treatment are targeted to receive TB

treatment. CARE will strengthen the capacity of health providers to increase TB case detection from the

current 23% to 32%. CARE International will scale-up interventions aimed at increasing TB treatment

success rate from 81% to 83% and strengthen infection control measures at facility level through providing

supplies such as aprons, bin liners and other waste disposal methods, as well as training TB treatment

supporters and health workers in infection prevention.

In FY 2008, CARE International scaled-up its support for TB/HIV activities to all 117 health facilities in the

four districts to increase the coverage of integrated TB/HIV activities to the more remote areas in Zambia.

The focus in FY 2009 will be to ensure improved quality of service delivery. CARE working closely with the

PHO and DHMT will undertake joint performance assessments to these health facilities. Technical support

will be provided based on identified gaps. Recommendations made during these visits will be followed-up to

ensure that these have been implemented and where staff needs support this will be provided.

In order to ensure that there is coordination in implementation of TB/HIV activities, CARE will support the

establishment or strengthening of TB/HIV Coordinating bodies at district, health centre, and community

levels in all four districts. CARE International will ensure there are regular meetings to share information on

best practices and lessons learnt in the implementation of integrated TB/HIV programs. CARE will help to

ensure that all activities are in-line with the national strategy for TB/HIV and the overall national health

strategic plan.

CARE International will strengthen its linkages to other organizations doing similar work; whether United

States Government (USG)-supported (e.g. Center for Infectious Disease Research in Zambia) or non-USG

supported (e.g. Mwami Mission Hospital) to ensure a comprehensive response within the province. Within

CARE, additional support for strengthening the DOTS program through the THANZI project which is funded

by USAID will ensure that there is decreased morbidity and mortality due to TB and HIV co-infection as

THANZI aims to increase TB case detection rates and improve treatment success rates. In order to

increase the number of treatment supporters at community level, CARE International through THANZI

intends to train 400 treatment supporters in TB with an emphasis on case finding, awareness creation,

promotion of health seeking behaviors, treatment support, adherence and sputum collection. Identification

of treatment supporters will be done with the help of health centre staff and the neighborhood health

committees (NHC), who will also to be trained as treatment supporters. This intervention will include Faith-

Based Organizations and women's groups. Support from STAMPP, an EU funded project, will promote

improved health seeking behaviors for individuals for prevention, care and treatment of HIV and TB.

CARE International's proposed interventions aim to assist the government by increasing the expertise of

field-based staff and lay volunteers including TB treatment supporters while building stronger referral

networks so that the planned national response can reach beyond its current extent.

Strengthening community-focused responses and networks will be the platform for information, education

and communication (IEC) work centered on reducing the stigma and discrimination surrounding both TB

and HIV/AIDS. CARE will strengthen information dissemination through various channels including

community radio stations. Materials developed by other organizations will be collected and disseminated in

order to support the IEC work. CARE International will also continue to engage TB treatment supporters,

former TB patients and those on ART to promote treatment adherence and help reduce the stigma

associated with TB and HIV. Formation of circle of friends who are former TB patients will be supported

and scaled up to all health centre catchment areas.

Since 2006 CARE International has supported health worker training in diagnostic counseling and testing.

Current work has revealed significant weakness in regard to data collection, management and analysis. In

2009 a specific focus will be on training health workers and TB treatment supporters in proper data

collection, management and analysis. CARE International, as a member of the Provincial TB/HIV

Coordinating Committee, will continue to be involved in the review of existing tools and where necessary

participate in the development of tools to improve information management system and reporting. CARE will

ensure that the M&E tools used to capture data are those developed and supplied by the National TB

program. A Quality of Care (QOC) Tool will be developed to assess overall program performance and

quality service delivery by looking at skill utilization, client satisfaction and supply chain management, etc.

Activity Narrative: Prior approval will be obtained from the Ministry of Health.

Using standard data capture tools for TB, CARE International will continue to strengthen information flow

from the community (TB treatment supporters) through zones up to health facilities and back down the

chain. This will be done on a monthly basis with quarterly meetings for zonal leaders, health centre focal

point persons and the District TB Focal persons to review data flow.

CARE International recognizes the challenges that the health sector faces with trained human resources.

Therefore in 2009, CARE International will work with the PHO to identify areas that have critical shortages

of trained health personnel to implement integrated TB/HIV activities. The project will then support the

deployment of seven trained staff especially in the zonal centers to address the challenges faced with

regard to human resources. In collaboration with the PHO and other organizations, specific training

programs will be developed and implemented for 455 service providers broken down as follows; 200 health

workers including classified daily employees, 200 treatment supporters and 55 lay counselors and

microscopists who will support health workers in service delivery thus promoting task shifting at all levels to

reduce the strain on the system. CARE International will draw lessons from the training of microscopists

that was done by Churches Health Association of Zambia (CHAZ) in Petauke and develop a program for in-

service workshops for already trained microscopists and laboratory technologists. CARE International will

work with the DHMT to ensure requisitions for laboratory reagents, testing kits, drugs for opportunistic

infections and other supplies are met by linking them to JSI - Deliver. One of the strategies that CARE

International seeks to adopt in ensuring program sustainability is building the capacity of DHMT in logistics

management, storage and distribution of supplies. Supplies procured by CARE International will be stored

and distributed by the respective DHMT whilst CARE provides technical support in supply chain

management. CARE International will also work closely with the PHO and the DHMT to establish/strengthen

an external quality control system on the work done by microscopists whereby examined specimens will be

sent quarterly to the district laboratory for quality control and semi-annually to the provincial laboratory. This

will be done by using services available in zonal centers such as Kapata health centre and hospitals such

as Mwami and St Francis.

Of the 2450 (estimated number of TB patients) in the 4 districts, it is expected that at least 80 %( 1,960) as

per National target will receive HIV counseling and testing in FY 2009.

Based on feedback from a needs assessment, five health facilities will be rehabilitated for improved service

delivery. CARE International will support the PHO so that TB corners are established and functioning in all

the health facilities. CARE International will also facilitate a process where the Zonal centers will be

equipped with facilities to enable them conduct diagnosis for TB. Where this is not possible, CARE

International will work closely with the PHO and selected DHMTs to develop a courier system for sputum

collection. Sputum collection points will be identified in TB treatment centres which are not TB Diagnostic

centres. Working with existing programs such as THANZI and RAPIDS, bicycles will be provided to TB

treatment supporters to facilitate the collection of sputum specimens in communities while in some case, the

ITAP VCT vehicle will be used to transport specimens from TB treatment centres to TB diagnostic centres.

This will be done with the supervision of trained health workers. Strengthening this system will ensure that

districts conduct intensified case finding thus improving the case notification rates for TB.

Supportive supervision for TB/HIV activities in the districts will be strengthened and carried out in

conjunction with the Provincial TB officer and the Provincial TB/HIV Officer. Regular review meetings will be

linked to TB Directly Observed Treatments (DOTS) review meetings.

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

Targets set for this activity cover a period ending September 30, 2010.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15507

Continued Associated Activity Information

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

System ID System ID

15507 3650.08 HHS/Centers for CARE 7164 2933.08 CARE $515,000

Disease Control & International International -

Prevention U10/CCU42488

5

8819 3650.07 HHS/Centers for CARE 4948 2933.07 CARE $400,000

Disease Control & International International -

Prevention U10/CCU42488

5

3650 3650.06 HHS/Centers for CARE 2933 2933.06 Technical $400,000

Disease Control & International Assistance-

Prevention CARE

International

Emphasis Areas

Construction/Renovation

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $110,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

This activity also relates to CARE International activities in TB/HIV (# 3650), PMTCT (# 3573), HIV

treatment (#3650) and Laboratory services (#9795) as well as Eastern province counselling and testing

activity #3669.08.

According to preliminary findings of the Zambia Demographic and Household Survey (2006-2007) the HIV

prevalence rate among adults 15-49 years now is at 14.3%. For Eastern Province alone, the prevalence is

10.3%. Counselling and Testing (CT) for HIV is a key entry point for HIV prevention, care and support.

However, only few Zambians know their HIV status. The difficulties communities face in accessing quality

CT services could be attributed to lack of information on availability of services, limited services available

due to poor infrastructure, inadequate human resources to provide the service, and also due to stigma and

discrimination associated with HIV and AIDS.

In FY 2008 CARE International's intervention increased the coverage of and access to CT services in

Chipata, Katete, Petauke, Chama, Chadiza, and Lundazi districts of Eastern Province. The work focused on

infrastructure rehabilitation and increased community mobilization to encourage uptake of voluntary

counseling and testing (VCT) in 31 sites. The activity targeted the general population, including adults,

children, couples and individuals. These CT activities were complemented by a comprehensive mobile

service in each district. As a result of this support, over 10,000 clients received counseling and testing for

HIV and received their results through this funding mechanism. This activity links closely with the EPHO

HVCT (# 3669.08) to ensure wider coverage of other districts in the Eastern province and avoid duplication

by facility level support in districts that overlap (Chama and Chadiza). Links with treatment and care

services, EPHO HTXS (#9751) and EPHO HLAB (#9795) have been established as well.

In FY 2009, CARE International will continue to assist the Government of the Republic of Zambia (GRZ)

through the Eastern Provincial Health Office (EPHO) and respective District Health Management Teams

(DHMTs) to continue scale up of CT services, through field based staff (lay counselors) as well as

strengthening referral networks. CARE International will continue to support scale up CT in the six districts,

with increased coverage to 120 health facilities. Links between CT services and ART will continue to be

strengthened so clients who test HIV positive and are eligible for therapy will be commenced on ART at an

early stage. Once people have been tested and are receiving antiretroviral drugs (ARVs) adherence

becomes an important issue. CARE International will continue training health staff and community

volunteers (including treatment supporters) in adherence counseling for clients on TB treatment and ART,

including PMTCT clients. The training will include helping clients understand what adherence is, how to

recognize side effects of the drugs and how to cope with those side effects. Mechanisms to strengthen

follow up will be developed and shared during training to ensure that they are culturally appropriate and

feasible.

In order to enhance service delivery and motivate health workers to deliver services effectively, CARE

International will support the DHMTs to undertake simple infrastructure rehabilitation at 15 Zonal VCT and

PMTCT sites. The project will also provide basic equipment and furniture to all the zonal VCT sites that did

not receive support in FY 2007 and 2008. In all the districts CARE International will work hand in hand with

the PHO and the respective DHMT to conduct a needs assessment of where the needs are greatest.

To increase access in more remote areas, CARE International will implement an integrated mobile CT

service in all the six districts. Integrated mobile services include CT, PMTCT and ART services inclusive.

Linkages will also be strengthened with other providers of mobile CT services in areas where CARE

International operates.

CARE International will work closely with EPHO to provide prevention focused CT. Integration of prevention

for both HIV positive and negative clients will be a priority. Additionally, couples counseling and child

counseling will be an area of focus in FY 2009 to increase access to care and treatment for all.

This piece of work is envisaged as part of a longer-term supportive partnership with GRZ in the selected

districts aimed at establishing a functioning comprehensive CT network to which everyone in the general

population has access and is linked to an equally effective referral system.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15508

Continued Associated Activity Information

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

System ID System ID

15508 9714.08 HHS/Centers for CARE 7164 2933.08 CARE $400,000

Disease Control & International International -

Prevention U10/CCU42488

5

9714 9714.07 HHS/Centers for CARE 4948 2933.07 CARE $400,000

Disease Control & International International -

Prevention U10/CCU42488

5

Emphasis Areas

Construction/Renovation

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 3.3.14: