PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
Narrative changes include updates on progress made and expansion of activities.
This activity links with other PMTCT programs in Western Provincial Health Office (WPHO) (#9744),
Eastern Provincial Health Office (EPHO) (#9736), and CARE International (#8818).
The Center for Infectious Disease Research in Zambia (CIDRZ), under the Elizabeth Glaser Pediatric AIDS
Foundation (EGPAF) mechanism, will continue to expand the prevention of mother- to- child transmission of
HIV (PMTCT) implementation program in collaboration with the Ministry of Health (MOH). There are two
Public Health Evaluations under this activity. In FY 2009 a particular focus will be improving quality of care
for antenatal and postnatal women in the PMTCT program through the following five activities: 1) support a
full package of integrated care at existing PMTCT sites in Lusaka, Eastern, and Western Provinces; 2)
support the MOH plan to increase access to more effective PMTCT regimens and high active antiretroviral
therapy (HAART) for women who are eligible; 3) increase district ownership of program by promoting district
oversight, data monitoring, and use of data to improve services; 4) evaluate progress of the PMTCT
program through selected cord blood surveillance evaluations in a random sampling of urban and rural
sites; and 5) increase clinic support by peer educators and lay counselors and community outreach
activities.
EGPAF will continue supporting the existing PMTCT sites and expand coverage to reach 301 available sites
out of a total of 316 by February 2010 in the three provinces. They will target all women accessing
antenatal and postnatal services of which 18% of sites are urban and 82% are rural. In FY 2009 EGPAF
will focus on providing improved and more integrated services at PMTCT sites. A complete basic integrated
care package should be provided to all women through 18 months postpartum. Two hundred health care
providers will be trained in the provision of integrated care. There will be minor renovation of selected
clinics to improve service delivery. The key elements of the package include: a) HIV, syphilis, malaria and
CD4 testing; b) safe delivery practices; c) a continuum of PMTCT services, offering HIV testing during
antenatal, labor and delivery, and postnatal visits. Labor ward PMTCT interventions have successfully been
implemented in all delivery centers in Lusaka and will be scaled-up to all delivery sites in Lusaka province,
Eastern and Western provinces in 2009. In FY 2009, EGPAF will focus on rural areas where women may
not have the opportunity to become tested in antenatal care but present for labor and delivery; d) increase
access to contraceptive services as a method of prevention of unintended pregnancies as a wrap around
activity; e) follow-up of HIV-exposed infants and infant testing. The widespread rollout of a new MOH under
-five card with PMTCT information, initially developed by Centre for Infectious Disease Research in Zambia
(CIDRZ), should improve the identification of exposed infants and provision of cotrimoxazole prophylaxis. In
FY 2009, EGPAF will continue to improve, through use of under-five cards and logs, the follow-up of
exposed babies via community workers and lay counselors. We will improve turnaround time of dry blood
spot test results through strengthening the ‘hub model' courier and feedback system and link polymerase
chain reaction (PCR) testing to infant co-trimoxazole, and f) community-based follow-up of HIV infected
infants. As described in the pediatric section of the HIV/AIDS treatment narrative, we will support
community peer educators to actively follow up HIV-infected infants to facilitate initiation of HAART
according to national and WHO guidelines. We will work with the antiretroviral treatment (ART) program to
indentify infants less than 12 months. (Please see Pediatric ART section for detail).
Secondly, EGPAF will increase access to more effective PMTCT regimens and HAART for eligible women
through the following three activities:
ART and AZT in Lusaka District
Program data in Lusaka demonstrates that over 70% of HIV infected women successfully receive a "reflex"
blood draw for CD4 count. However, far fewer women start more efficacious regimens or ART. In 2009,
EGPAF will continue to support integration of reflex CD4 testing and tailored interventions based on CD4
cell count results. Using increased support through peer educators and lay counselors, their goal is to
initiate over 70% of HIV infected pregnant women in Lusaka on the most efficacious regimens possible.
ART in MCH at Provincial Capitals
Areas outside Lusaka lag behind in trained staff, lab capacity, and systems. In the past year, pilot referral
systems in Mongu, Chongwe and Kafue Districts for CD4 counts for pregnant women have been successful
in allowing more eligible women to commence ART prior to delivery. Based on this success we will
strengthen ART scale-up in all provinces with a goal of a minimum of three sites in total in Western and
Eastern Provinces providing integrated ART in MCH model.
Improve linkages to ART clinics in all districts with a focus on district hospital offering ART and maternal and
child health (MCH) services
In all 16 districts in which CIDRZ is supporting PMTCT services, we will strengthen linkages and
communication between ART and MCH service providers. We will work in the different hospitals to develop
systems of referral as well as support providers in the intricacies of taking care of pregnant women. In
addition, we will work with other partners to strengthen awareness of accessing ART during pregnancy in
the communities.
Thirdly, EGPAF will increase district ownership via the fixed cost model to ensure sustainable PMTCT
services. In an effort to promote district ownership and accountability, performance-based funding through
the fixed cost obligation model was successfully implemented in 2008 in all districts supported by CIDRZ.
Since implementation of this model, districts have taken their own initiative in expanding PMTCT sites as
well as increasing the numbers of women counseled, tested, and provided HIV prophylaxis. Districts have
demonstrated nascent ability to ensure that PMTCT program activities continue without disruption and that
human resources are readily available for integrated PMTCT service. With this model, PMTCT programs
are beginning to be perceived as district-owned initiatives.
In FY 2009, we will adjust the fixed-cost model to assess more sophisticated performance measures. To
increase the number of women receiving a more effective regimen, we will modify indicators for
performance-based funding from the number of women tested for HIV and the number of maternal NVP
Activity Narrative: doses dispensed to the number of women receiving a more effective regimen, number of infants tested for
HIV, and number of infants receiving cotrimoxazole prophylaxis. In FY 2009 we will roll this out in Lusaka
District with the aim of increasing the percentage of women receiving more effective regimens from 40% to
70%. In addition, we will devote a considerable amount of time to training district teams in the interpretation
of data collected in registers and use of data to improve quality of care.
In FY 2009 we will also establish a monitoring team which will monitor fixed cost performance, building on
the successful evaluation work conducted in FY 2008. The concept of this type of support combined with
ongoing technical assistance has been well appreciated by the districts. Our FY 2008 audit found a data
trail at all levels and found no evidence of mismanagement of funds. Documentation of receipt of funds by
health care providers was available and reviewed and tools have been developed by the team to monitor
and evaluate the program on site. In FY 2009 we will conduct audits of all districts with emphasis on
performance of districts implementing more sophisticated fixed cost model.
In FY 2008, through CDC funding, CIDRZ implemented a novel method of evaluating "uptake" of PMTCT
services via anonymous cord blood surveillance at randomly selected sites. Preliminary results indicate a
much lower than expected rate of NVP coverage among pregnant HIV-infected women. In 2009, with input
from the Ministry of Health, we will select sites in which we are working to evaluate coverage of our PMTCT
program and compare this with previous data.
The last objective is to increase involvement of peer educators and lay counselors.
With the scale-up of more complicated PMTCT regimens, infant testing, infant cotrimoxazole prophylaxis,
and counseling for primary prevention and breastfeeding, it has become evident that health care extenders
and community workers are critical to the process of providing quality antenatal and postnatal services. In
FY 2009, we will evaluate two different community interventions to improve the uptake of more efficacious
PMTCT regimens and prevent prenatal and postnatal HIV infections. We will pilot the use of mother baby
packages (pre-packed AZT Nevirapine (NVP) maternal and infant doses) dispensed by community lay
counselors in five sites in Lusaka province, five sites in eastern province, and five sites in western province.
We will document the results of providing the mother baby packages. We will also work to create support
groups in five centers led by peers and lay counselors to promote adherence to more effective regimens. In
addition, we will support lay counselor integration of PMTCT services in all supported sites. Working
through DATFs we will continue community outreach and awareness of PMTCT services.
New/Continuing Activity: Continuing Activity
Continuing Activity: 15518
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
15518 3788.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $4,520,500
Disease Control & Pediatric AIDS U62/CCU12354
Prevention Foundation 1
9002 3788.07 HHS/Centers for Elizabeth Glaser 5007 2998.07 EGPAF - $4,484,500
3788 3788.06 HHS/Centers for Elizabeth Glaser 2998 2998.06 TA- CIDRZ $2,500,000
Disease Control & Pediatric AIDS
Prevention Foundation
Emphasis Areas
Construction/Renovation
Health-related Wraparound Programs
* Family Planning
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $641,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
This PHE activity, "PMTCT program effectiveness", was approved for inclusion in the COP. The PHE
tracking ID associated with this activity is ZM.07.0185.
Continuing Activity: 17258
17258 17258.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $189,000
Estimated amount of funding that is planned for Public Health Evaluation $43,844
This PHE activity, "Elizabeth Glaser Pediatric AIDS Foundation Antiretroviral Pregnancy Registry, a multi-
country study
", was approved for inclusion in the COP. The PHE tracking ID associated with this activity is ZM.08.0193
Continuing Activity: 17257
17257 17257.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $275,000
The PHE "Observational study of treatment effectiveness and resistance patterns among women initiating
treatment with NNRTI HAART after previous single dose Nevirapine in pregnancy" has been approved for
inclusion in the FY 2009 COP. Its tracking number is ZM.07.0178.
Estimated amount of funding that is planned for Public Health Evaluation $0
Program Budget Code: 02 - HVAB Sexual Prevention: AB
Total Planned Funding for Program Budget Code: $17,576,028
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Zambia faces a generalized HIV/AIDS epidemic with about one in seven adults infected. The U.S. Mission in Zambia in Zambia
takes the lead in supporting the Government of the Republic of Zambia's (GRZ)'s national strategic objective of intensifying
prevention, under the Zambia National HIV and AIDS Strategic Framework (ZASF) (2006-2010), the 2006 National HIV and AIDS
Policy, the Ministry of Health's National Health Strategic Plan (2005-2010), and the 2006-2010 Fifth National Development Plan.
The ZASF and the U.S./Zambia Strategy under PEPFAR both prioritize: a comprehensive prevention strategy promoting
abstinence, partner reduction, and mutual fidelity among young people aged 10-25 and among adult men and women; increasing
the availability of condoms; addressing male norms and gender and sexual violence; improving timeliness and effectiveness of
sexually transmitted infection (STI) treatment; promoting behavior change communication (BCC) and education; promoting post-
exposure prophylaxis (PEP); promoting substance abuse prevention and treatment; scaling up male circumcision; and creating
linkages with to other HIV/AIDS services.
The HIV prevalence rate in Zambia is 14.3% among the 15-49 year age group (2007 Zambia Demographic Health Survey). Thirty
-four percent of sex workers and 11% of long distance truck drivers consume alcohol daily, heightening their exposure to risky
behaviors. Only half of sex workers (51.8%) and truck drivers (59.5%) consistently use condoms. The 2005 Biologic and
Behavioral Surveillance Survey (BBSS) indicated that STI prevalence among sex workers is 56.9%, excluding HIV, and 86.2%
with HIV. According to the 2004 Zambia Defense Force HIV Prevalence and Impact study, 28.9% of military personnel are
infected with HIV. The 2005 Zambia Sexual Behavior Survey (ZSBS) highlighted that sexual debut of young people increased
from 16.5 to 18.5 years, but there is little change in the number of men and women reporting having multiple sexual partners from
2003 to 2005. Findings of these studies have been used to inform policy and program decisions in FY 2009.
In Zambia, prevalence among men who have sex with men (MSM) is not yet known. The 2004 MSM study undertaken by Zambia
Association for the Prevention of HIV and Tuberculosis (ZAPHIT) indicates that although all of the respondents had knowledge
about HIV/AIDS and the common modes of transmission, 70% of them were not aware that they could be infected through anal
sex. MSM are becoming more aware of the need to seek HIV/AIDS and STI services.
Sexual transmission is responsible for the vast majority of new HIV infections in Zambia. The rate of sexual transmission is
exacerbated by: early sexual debut; multiple and concurrent sexual partnerships (MCPs), sexually transmitted infections; low and
inconsistent condom use; gender inequity and inequality; harmful practices and traditions; limited male circumcision; poor socio-
economic status of women and girls and gender issues that perpetuate male dominance and infidelity (including lack of male
involvement and responsibility); high levels of stigma and discrimination for people living with HIV/AIDS (PLWHAs); high levels of
sex work, transactional, and intergenerational sex; and unregulated availability of cheap alcohol and widespread alcohol abuse.
Alcohol plays a major role in reducing sexual inhibition among both men and women and in increasing women's vulnerability to
forced and/or unprotected sex.
The U.S. Mission in Zambia collaborates closely with the GRZ, local organizations, community and religious leaders, the private
sector, and donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the Joint United Nations Program
on HIV and AIDS (UNAIDS), United Nations Population Fund (UNFPA), and the World Health Organization (WHO). In 2008, the
U.S. Mission in Zambia supported the development and launch of the five-year National Prevention Strategy focusing on the
drivers of the epidemic in Zambia as key priority areas. U.S. implementing partners in collaboration with the United Nations
Agencies, and UNDP, and other cooperating partners will fund NAC activities outlined in the national strategy. The National AIDS
Council Prevention Theme Group will work with partners in all of Zambia's nine provinces to provide technical assistance, to
ensure that partners understand the new prevention agenda and redirect current interventions to address the key priority areas in
the strategy.
FY 2008 activities targeted in and out-of-school youth, adult men and women, orphans and vulnerable children (OVC),
parents/guardians, teachers, health care providers, uniformed personnel, farm workers, government/private sector employees,
miners, migrant workers, discordant couples, people living with HIV/AIDS, businesses owners, and traditional leaders. The most
at risk populations include discordant couples, those engaged in transactional and intergenerational sex, sex workers and their
clients, mobile populations, transport workers, cross-border traders, prisoners, refugees, fishing communities, transients, migrant
workers, sexually active youth, STI patients, victims of sexual violence, and uniformed civilian and military personnel.
The GRZ prevention strategy is a holistic approach to prevention, comprising: life skills training, interpersonal counseling, peer
education, age-appropriate information, education and communication (IEC), community and social mobilization, abstinence
programs, condom education and distribution, workplace program prevention activities, community-based HIV prevention
activities, institutional capacity building, gender disparities, referral systems, behavior change and communication (BCC) activities,
and promotion of responsible sexual behaviors. U.S. partners provide training, community based education, technical assistance,
institutional capacity building including supervision, monitoring and evaluation, IEC materials including development, and support
to resource centers. These activities are being provided in all 72 districts in Zambia's 9 provinces.
By September 2008, 1,487,343 individuals were reached with AB messages, 24,390 trained as peer educators, and 1,166,282
individuals were reached with other prevention messages. Despite the significant ABC prevention achievements, some U.S.
partners continue to face challenges of limited local implementing partner capacity, high attrition of peer educators associated with
voluntarism, low condom uptake, and reaching the hard-to-reach population in rural areas. In 2009, the U.S. Mission in Zambia
will reach 2,865,742 and 1,124,816 individuals with AB and A only messages respectively, and 732,750 with other prevention
activities. An estimated 320,000 female and 15,500,000 male condoms will be distributed through 2,641 outlets including social
marketing entities, and private and public sector health facilities. The U.S. Mission in Zambia will train 5,590 and 12,039
individuals to provide other prevention and AB messages.
In FY 2009, the U.S. Mission in Zambia, in collaboration with GRZ line ministries and implementation structures such as the
District AIDS Task Forces (DATFs), Community and Neighborhood Health Committees, private sector partners, faith-based
organizations (FBOs), international organizations, and NGOs, will intensify and coordinate prevention of sexual transmission
activities. Areas that will receive increased focus include: the coordination of training; building knowledge, skills, comfort and
confidence of parents to discuss sexuality issues with their children; and expanding outreach activities aimed at encouraging
responsible behavior, delayed sex/secondary abstinence, and messages that promote fidelity and partner reduction. Prevention
activities will be expanded at the community level, in schools, colleges, universities, health facilities, counseling and testing (CT)
centers, youth livelihood programs in public and private workplaces, in agricultural and mining businesses, in the military, in
places of worship through engagement of the clergy, in home-based care programs, at border and high transit areas (including
refugee camps), in prisons, night clubs and bars, truck and bus parks, hotels and guesthouses, in fishing communities, military
bases, at STI and TB clinics, on farms that use seasonal labor, and through mass media. Mass media activities will reinforce
community mobilization, i.e., community radio programs. U.S. partners working in high prevalence locations will extend
appropriate AB education to children as young as seven years of age and their parents to prevent early sexual debut, abuse, and
exploitation. Partners will also address prevention with positives and negatives at HIV care outlets.
The U.S. Mission in Zambia will promote and support routine HIV CT for STI patients and improve STI diagnoses and treatment
by: assisting the GRZ with revision of STI management guidelines and protocols; training health care workers, lab technicians, lay
counselors, and peer educators; and supplying STI test kits, lab equipment, and drugs to the Zambia Defense Forces (ZDF),
public health facilities, and non-governmental static and mobile services.
Partners will: accelerate AB interventions targeted at men in the general population and in workplaces to reduce multiple and
concurrent sexual partners and sexual coercion; develop a national MCP campaign; and integrate alcohol messages in existing
prevention messages including linkages to alcohol prevention and treatment services. U.S. partners will continue to use trained
drama groups to deliver prevention messages to the Zambia Defense Forces (ZDF) using scripted stories and other target
populations. Partners will address stigma and discrimination, gender issues, and strengthen negotiation skills to delay sexual
debut. The programs will continue to focus on the ABC approach, identifying and addressing individual and community risk
factors and risk perceptions, and involving PLWHA and their partners as leaders in HIV prevention. The U.S. Mission in Zambia
will train peer educators in both private and public workplaces and within communities to deliver prevention measures and
approaches. There will be increased emphasis on community engagement and participation in seeking ways to effectively
address prevention that leads to locally sustainable behavior change.
In 2009, the U.S. Mission in Zambia will finalize and disseminate results of the MSM HIV prevalence and behavior study and
disseminate the baseline data from the MARCH program (a behavior change program utilizing radio serial drama and other
interventions) on sexual behaviors for use in the design and development of effective targeted prevention and treatment
programs. In addition, the U.S. Mission in Zambia will work with partners and communities to implement prevention for positives
and explore effective ways to increase condom use. The U.S. Mission in Zambia will assess the effectiveness of current BCC to
determine future direction. In FY 2009, the U.S. Mission in Zambia will also conduct the next round of the BBSS.
In 2007, the U.S. Mission in Zambia purchased 15 million condoms for social marketing and received a donation of 40 million
male condoms which were given to Zambia's public sector, a supply intended to last through the end of FY 2009. The U.S.-
procured condoms will be socially marketed to increase correct and consistent use while simultaneously reducing stigma,
negative myths around condom use, and related taboos. Public and private health workers will be trained on condom use. The
U.S. Mission in Zambia will target at least 2,641 rural and urban condom service outlets in 2009. Condom sales will be
complemented by communications and behavior change interventions targeted to reduce high-risk behaviors.
In close collaboration with the NAC, U.S. partners will continue to: contribute education and training materials to the NAC resource
center; contribute database and program activity reports to the NAC M&E database. U.S. prevention interventions will be linked to
other HIV/AIDS services such as, PMTCT, ART, CT, support networks, and STI diagnosis and treatment and AB activities will
also be linked to CT and condom provision. In addition, PEPFAR-funded Peace Corps volunteers will work with U.S. partners to
enhance prevention activities at the community level. Partners associated with the New Partners Initiative (NPI) will also continue
to support prevention activities in the country and build local organizational capacity.
The U.S. Mission in Zambia will continue to emphasize monitoring and supervisory visits, use of standardized monitoring and
evaluation data collection/reporting tools, data quality audits, community outreach participant exit interviews, peer educator review
meetings, and monthly compliance visits and financial backstop sub-grantees.
To ensure the sustainability of prevention programs in Zambia, the U.S. Mission in Zambia will strengthen the capacity of local
NGOs, public and private sector workplaces, high-risk communities, youth organizations, the GRZ, health facilities, BCC
programs, and the ZDF to plan, monitor, and implement prevention programs and facilitate social change to reduce sexual
transmission. The U.S. Mission in Zambia will prioritize implementation of graduation strategies for abstinence for youth (ABY)
activities through the capacity building of local partner organizations and through development of transition plans for continuity of
youth prevention programs. This will include increased capacity-building for local partners to manage programs and seek
additional funding from other donors to sustain essential programs. Institutional capacity building will include sub-grant
management; developing workplans, proposal narratives, organizational strategic plans, and community mobilization and
advocacy strategies including integration of prevention into all aspects of care and increasing community involvement in
prevention activities.
In addition, Embassy Lusaka will explore the use of "community compacts," or agreements directly with communities that provide
incentive rewards for effective prevention programs. Organizational capacity/viability and community competence will be
benchmarks for success. Such measures will also be criteria for evaluations of sustainability that U.S. Mission in Zambia will use
to judge the readiness of provinces and districts for "graduation" from assistance. Mission Zambia will beta-test such community-
based incentives through HIV-prevention projects funded by the Ambassador's Small Grants Program beginning in FY 2009. The
2009 COP includes a new PEPFAR Small Grants program in Sexual Prevention to test these incentives.
Table 3.3.02:
This PHE activity, "Evaluation of safety and acceptability of neonatal circumcision in Zambia using Gomco
and Plastibell methods", was approved for inclusion in the COP. The PHE tracking ID associated with this
activity is ZM.07.0183.
Continuing Activity: 15519
15519 12525.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $255,000
12525 12525.07 HHS/Centers for Elizabeth Glaser 5007 2998.07 EGPAF - $255,000
Estimated amount of funding that is planned for Public Health Evaluation $187,738
Table 3.3.07:
Activity Narrative:
This activity links with the Zambia Prevention, Care, and Treatment Partnership (Project HEART) PMTCT
(#8886), ART (#8885), Counseling and Testing (CT) (#8883), TB/HIV (#8888), and Laboratory Support
(#8887) activities as well as with the Government of the Republic of Zambia (GRZ) and other US
Government (USG) partners.
Though Project Help Expand Anti-Retroviral Therapy for Children & Families (HEART) is primarily a
provider of antiretroviral therapy (ART) services, this involves treatment of opportunistic infections (OI)
including TB, sexually transmitted infections (STI) and others, as well as pain and symptom management,
and clinical care for severe malnutrition. This represents 30-40% of the clinical care provided to people
living with HIV/AIDS (PLWHA) at ART sites. The ART training package includes basic training on common
OI recognition and treatment, STI screening, TB screening and cotrimoxazole prophylaxis but more
extensive training is required to competently handle the vast array of symptoms that accompany HIV
infection.
Clinical palliative care activities will include the following components: 1) provide training to health care
workers (clinicians, pharmacy staff and nurses) in provision of medications and care for pain and symptom
control of conditions related to HIV and/or drug side effects or toxicities 2) increasing referral linkages within
and between ART facilities and community home based care(HBC) and hospice care; 3) participating in and
assisting the Ministry of Health (MOH), the National HIV/AIDSSTI/TB Council to develop a strategy,
guidelines, and standard operating procedures for provision of quality clinical palliative care in ART sites
and services. The palliative care components have not changed from FY2008 and in FY2008 240 people
were trained.
In the first component, strengthening palliative care services within health facilities, Project HEART will
continue to support 68 ART facilities in 22 districts. In addition to the ART/OI/STI/TB/Triage training
mentioned in the ART narrative, 80 health professionals will also be trained, using MOH-approved
curriculum, to provide cotrimoxazole prophylaxis, symptom, pain assessment and management, both in
clinic and home settings.
The Ministry of Health in collaboration with USAID | DELIVER PROJECT has expanded its mandate to
include essential and anti-malarial drugs with primary focus on drugs used in treatment of OIs. Part of this
mandate will also be a focus on drugs used in Palliative care. Clinicians, Nurses, and Lay health care
workers will be trained in how to manage common debilitating conditions that cause much distress to
patients. Trained health care workers and lay health care workers shall be taught how to take a multi-
faceted approach to the alleviation of symptoms of anorexia, (loss of appetite), painful mouth, discomfort
swallowing, fevers, nausea, vomiting, and diarrhea. Special focus will be on the control of various types of
pain syndromes, including acute and chronic; neuropathic, somatic and visceral pain. This will include the
use of drug combinations such as non-narcotic and narcotic analgesics, nonsteroidal antinflammatories and
antidepressants. A combination of medical treatment and dietary supportive treatments will be promoted to
enhance the quality of life in these patients. We will provide central training for clinicians and nurses in ART
Clinics to help them to manage end of life care for patients. We will continue to increase gender equity in
provision of palliative services, by imparting knowledge and skills to equal proportions of males and
females in care provision.
In the second component, increasing referral linkages within and between health facilities and communities,
Project HEART will promote linkages and referrals from clinics to existing Faith-Based Organizations and
Community-Based Organizations that provide home-based care for people living with HIV/AIDS. These
organizations serve as critical partners for facility-based programs supported by MOH and USG. In the third
component, Project HEART will continue its participation in and provision of assistance to the USG
Palliative Care Forum as well as coordinate with the Palliative Care Association of Zambia to develop a
national palliative care strategy, guidelines, and standard operating procedures. Through these efforts,
Project HEART aims to improve access to quality clinical palliative care services, promote use of evidence-
based practices, share lessons learned in project implementation, and support the revision of national
palliative care guidelines and protocols in accordance with MOH policies.
Continuing Activity: 17073
17073 17073.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $100,000
Estimated amount of funding that is planned for Human Capacity Development $82,500
Table 3.3.08:
This PHE activity, "Causes of early mortality in adults starting ART ", was approved for inclusion in the COP.
The PHE tracking ID associated with this activity is ZM.07.0179.
Continuing Activity: 17699
17699 17699.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $350,000
Estimated amount of funding that is planned for Public Health Evaluation $279,475
Table 3.3.09:
This PHE activity, "Population-level surveillance of antiretroviral drug resistant HIV in Zambia ", was
approved for inclusion in the COP. The PHE tracking ID associated with this activity is ZM.07.0180.
Continuing Activity: 17702
17702 17702.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $400,000
ACTIVITY UNCHANGED FROM FY2008 EXCEPT FOR MINOR CHANGES TO REFLECT UPDATES AND
TRANSITION PLAN. Ten percent has been moved to support EGPAF Pediatric HIV/AIDS Treatment
activities
SITE EXPANSION:
The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) and the Center for Infectious Disease Research
in Zambia (CIDRZ) proposes to expand the antiretroviral therapy (ART) service support to the Government
of the Republic of Zambia (GRZ) sites through the creation of Satellite sites. In FY 2009, there are six
components to this activity: (1) expansion of services to ten Satellite sites in six districts; (2) sustainability of
quality of care and quality improvement at project sites; (3) integrate CIDRZ provincial teams with existing
Ministry of Health (MOH) Structure in Eastern, Western and Southern provinces focusing on capacity
building to improve and sustain quality of care; (4) work with the MOH to improve Health Care Worker
(HCW) access to care and treatment services and to improve retention of district HCWs; (5) development of
a model to support provision of care and treatment services within the private sector and (6) as part of steps
towards sustainability, multi-level involvement of central and provincial MOH staff in the development of the
reapplication workplan and its implementation. There are also five Public Health Evaluations detailed in
other activity narratives.
The EGPAF/CIDRZ-supported Government of the Republic of Zambia (GRZ) sites have enrolled 154,237
adults and children and started 97,978 on antiretroviral therapy (ART) as of the end of June 2008.
Presently, 62 ART sites in Lusaka, Eastern, Western, and Southern provinces are being supported.
EGPAF/CIDRZ has trained 1,648 health care workers in adult and pediatric ART delivery. CIDRZ has
presented 48 abstracts and published 36 papers related to these activities.
1. Expansion of services to ten Satellite sites: Building on past successes, EGPAF/CIDRZ will continue to
support sustainability and scale-up of services through the following activities: In Lusaka satellite sites will
be opened in four health posts determined in conjunction with the Lusaka District Health Management
Team (DHMT). This will relieve congestion in the highest-volume clinics within Lusaka. In consultation
with the Eastern, Western, Southern, and Lusaka Provincial Health Offices we will concentrate our
implementations in Zonal health posts to improve access to care for rural and isolated populations. In FY
2009 as part of transitioning program responsibility to MOH we will continue to assist the provinces by
providing technical assistance to open two satellite sites in each province for a combined total of ten
satellite sites. CIDRZ involvement in the satellite sites will be composed of a limited amount of supplies
and logistics support and technical assistance. EGPAF/CIDRZ will further support the full implementation
(full lab, supplies, mentoring support) to one site in each province, but will continue to encourage the
provincial and district staff to spearhead all components of the implementation in the interest of transitioning
full responsibility to the District and Provincial Health Offices.
These interventions along with existing sites will enable an additional 33,000 new enrolled and 22,000 new
on ART between March 2009 and February 2010, for a cumulative target of 209,000 enrolled and 132,000
on ART as of the end of February 2010. We will continue to increase gender equity in provision of ART
services, through community based sensitization programs aimed at encouraging both males and females
to access ART services.
2. Sustainability of quality of care: Working towards sustainability, Project HEART will continue to work
with key medical staff within MOH. Within Lusaka District a focal person for HIV/ AIDS has been hired with
whom we closely collaborate. This Medical Officer is involved in disseminating the performance reports,
meeting with DHMT Medical Officers to promote awareness of quality issues and jointly conducting training
and updates for Medical and Clinical Officers. In the past year this Medical Officer and other Medical
Officer's from Lusaka District assisted with trainings and updates. For FY 2009 we will build on this, and
encourage more involvement of district Medical Officers in training and quality assurance.
In addition, we will work with Provincial Health Officer's to train and mentor clinicians in provincial sites in all
aspects of HIV care and treatment and in quality of care thereby increasing commitment to quality. The
establishment of the CIDRZ provincial teams will assist the Provincial Health Officers to achieve improved
quality of care in ART sites. We will continue to train nurse managers to incorporate quality improvement
activities in their daily activities.
3. Integrate CIDRZ provincial teams: CIDRZ provincial teams have been recruited and located in Eastern,
Western and Southern provinces. Their mandate is to collaborate closely with the MOH Provincial Offices
and the CDC Field office managers to jointly improve quality of care through capacity building in the
following areas: lab, pharmacy, clinical care, and information systems. This will include: 1) implementing
new sites, 2) providing trainings and updates, 3) mentoring and 4) performance measurement and
feedback. At this time we are discussing with the MOH procedures to include these staff within MOH
structures.
The challenge will include ensuring the commitment of the MOH to assign sufficient GRZ staff in both the
Provincial and District offices to pair with the CIDRZ staff for capacity building. The Medical Council
accreditation forum is an excellent place to continue to discuss these important long term issues, as this
working group is comprised of representatives from National HIV/AIDS/STI/TB Council, Medical Council,
MOH, WHO, and collaborating partners.
4. Work with the MOH to improve Health Care Worker access to care and treatment services: In FY09, we
will work with the MOH to improve Health Care Worker access to care and treatment services and to
improve retention of district Health Care Workers. In FY 2008 we conducted a survey on Health Care
Worker attrition, burnout and stigma. This showed that almost 25% of staff had signs of burnout and
almost 50% were not comfortable accessing HIV-related care at existing facilities. These findings were
presented in an open forum to MOH officials and MOH staff and the following collaborative action items
were proposed: 1) Health Care Worker support group creation, 2) a clinic focused solely on providing care
Activity Narrative: and treatment for HIV+ Health Care Workers, 3) Health Care Workers education to reduce occupational risk
and HIV-related stigma and 4) development of district policies for HIV-related illness. MOH has been
working on a retention scheme for some time and we hope to get involved with the planning and
implementing of the scheme. Ongoing discussions will be held with HSSP to learn about their program and
utilize lessons learned. Some of the challenges for retention include recruitment of qualified staff in a
timely manner, lack of space in clinics to accommodate the number of staff needed and monetary
incentives.
5. Development of a model to support provision of care and treatment services within the private sector: In
Zambia, private sector clinics provide a significant amount of HIV-related care. Some patients have
personal health insurance but many others pay out-of-pocket to access private care (including HIV care) for
various reasons (shorter waiting times, to maintain anonymity, perceived better care). Private sector clinics
may have excess capacity and may be able to absorb substantial numbers of patients needing HIV-related
care. To investigate this, we propose in FY 2009 that we will conduct surveys of the private sector clinics in
Lusaka and propose alternate payment plans for HIV-related care, including ART, for non-insured patients.
Once a payment schedule has been agreed upon we will conduct pilots to assess the acceptability of this
approach to both clinic and patients and feasibility of scaling-up to other facilities. Our implementation and
quality assurance teams will be involved to assist clinics with data collection and the provision quality care
issues, consistent with MOH guidelines.
6. Development of the reapplication work plan and its implementation with MOH and Provincial MOH staff:
In considering issues of sustainability and transition of the program to the MOH we request participation
from DHMT and the Provincial Health Offices on all new activities and trainings. Currently, the Provincial
Health Offices and the DHMT suggest new sites for implementation, and assist with training and setting up
systems in new sites and we request their assistance for training and mentoring activities. We have been
invited to and have attended planning cycles with the PHO offices in Eastern and Southern provinces. The
new project HEART supported provincial teams will work with the MOH Provincial Health Offices to improve
the quality of care. New trainings are being planned for the coming year in which the PHO and District
Offices will take a leadership role in training and mentoring selected clinicians to improve the quality of care
in provincial sites.
Transition: Over the next few months meetings will be held with the MOH, DHMT and PHOs to discuss a
detailed transition plan. This will include maintenance and expansion activities, both clinical and
community activities, as well as, programmatic, logistic and financial management. This plan will have a
timeline and bench marks that must be met over the coming years. The details of this transition plan will be
included in the Project HEART PY6 reapplication (FY2009/10).
Targets set for this activity cover a period ending February 2010.
Continuing Activity: 15521
15521 3687.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $5,337,000
9000 3687.07 HHS/Centers for Elizabeth Glaser 5007 2998.07 EGPAF - $6,502,000
3687 3687.06 HHS/Centers for Elizabeth Glaser 2998 2998.06 TA- CIDRZ $7,500,000
Estimated amount of funding that is planned for Human Capacity Development $931,996
This PHE activity, "Stevens-Johnson Syndrome after initiating Nevirapine-based HAART", was approved for
inclusion in the COP. The PHE tracking ID associated with this activity is ZM.08.0195.
Continuing Activity: 17697
17697 17697.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $350,000
This PHE activity, "Community impact of HIV/AIDS services ", was approved for inclusion in the COP. The
PHE tracking ID associated with this activity is ZM.07.0177.
Continuing Activity: 17696
17696 17696.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $165,000
Estimated amount of funding that is planned for Public Health Evaluation $105,000
THIS IS A CONTINING ACTIVTY BUT HAS BEEN PULLED OUT OF THE MAIN HIV TREATMENT
COMPONENT WITH SPECIFIC EMPHASIS ON TREATMENT OF CHILDREN
This activity is related to adult treatment (# 4549.08 and 3687.08), PMTCT (#3788.08), all provincial
pediatric treatment activities (# NEW SPHO, EPHO and WPHO) and a number of public health evaluations
that are ongoing.
in Zambia (CIDRZ) propose to maintain existing and expand the antiretroviral therapy (ART) service support
to the Government of the Republic of Zambia (GRZ). All EGPAF/CIDRZ supported sites offer pediatric
services. The EGPAF/CIDRZ program has not yet met the target of at least 15% of ART clients being
children. This is due, in part, to the continued difficulty in diagnosing and recruiting pediatric patients,
especially infants. While the absolute number of children accessing ART care and treatment has steadily
increased, the overall number of children as a percentage of clients accessing treatment has remained
between seven and eight percent. In FY 2009 a number of activities are planned to increase this
percentage: (1) a multi-prong approach to increase the focus on pediatric care, (2) expand the model of
HIV care and treatment for orphans and vulnerable children residing in orphanages and (3) improve
outreach to vulnerable children by using the existing community network to share information regarding
local treatment services available for children.
The EGPAF and CIDRZ-supported government sites have enrolled 154,237 adults and children and started
97,978 on antiretroviral therapy (ART) as of the end of June 2008. Presently, 62 ART sites in Lusaka,
Eastern, Western, and Southern provinces are being supported. EGPAF/CIDRZ has trained 1,648 health
care workers in adult and pediatric ART delivery. CIDRZ has presented 48 abstracts and published 36
papers related to these activities.
(1) Multi-prong approach to increase the focus on pediatric care: The new MOH guidelines recommend the
initiation of ART to all infants with a confirmed (virological) diagnosis of HIV infection, regardless of CD4
percentage. EGPAF/CIDRZ will assist the MOH to scale-up this activity and this should increase the
numbers (and percentage) of children starting ART. EGPAF/CIDRZ will strengthen linkages with PMTCT to
increase enrollment of children into care and treatment. In addition, as requested by the MOH,
EGPAF/CIDRZ will pilot the use of a protease inhibitor (lopinavir) based regimen in children at selected site
(s). EGPAF/CIDRZ supports and advocates for provider initiated counseling and testing (PITC) through a
variety of means. Clinicians are trained and encouraged to advise sick parents to have their children tested
irrespective of age and encourage siblings of children already in care and treatment to be tested as well. In
ongoing pediatric specific training, clinicians review PITC and brainstorm on how more children can be
reached.
EGPAF/CIDRZ will improve psychosocial support offered by pediatric peer educators through a two week
training program for 60 pediatric peer educators called Psychosocial Care and Counseling for HIV Infected
Children and Adolescents (ANECCA/AIDS Relief). The program will also refurbish and equip child-friendly
counseling rooms with basic supplies and will develop appropriate job aids to improve pediatric treatment
literacy. Examples of job aids include guidelines for pediatric dosing, re-dosing, and medicine
administration in laminated or wall chart form. Focus group discussions will be held with pediatric providers
to ensure that the job aids developed or purchased are relevant to the challenges they face. Targeted
supportive supervision and clinic mentoring will be provided to pediatric healthcare providers by pediatric
mentors and information, education and communication (IEC) materials will be shared which focus on
improving parent-provider communication. In collaboration with HCP, we are developing a positive living flip
chart for children which will also assist clinicians and families in initiating and maintaining children on ART.
Discussions are underway between the CIDRZ, MOH, Lusaka Provincial Health Office, Lusaka District
Health Management Team, the University Teaching Hospital Pediatric Centre of Excellence (PCOE), and
Columbia University, to increase access to care and treatment and provide comprehensive clinical and
psychosocial services under one roof by renovating a large, pediatric community clinic in Lusaka. If support
is gained for this community based Children's HIV referral clinic, clear roles of all the partners involved will
be identified to avoid duplication of efforts including the role of the PCOE in comprehensive training of
health care workers, provision for referral of complicated cases and down referral of stable clients to the
community centre or nearest health facility. This will be a community based Children's HIV referral clinic
and will also be used to improve the skills of the health care workers who treat pediatric patients at the
primary level. This is not meant to duplicate activities of the PCOE. This will be a model clinic for pediatric
care at the primary level.
(2) Expand the model of HIV care and treatment for orphans and vulnerable children: Despite intensive
efforts at the Fountain of Hope Program at Kamwala, this site has not been able to enroll children into care
and this intervention has been closed. Fountain of Hope is no longer housing children on a long-term basis
and has had a number of issues in recruiting and retaining qualified clinical staff.
Instead we have been focusing our efforts to support a local NGO "Tiny Tim and Friends" to provide care
and treatment to vulnerable children. This comprises general medical, as well as HIV care and treatment.
The focus of this program is to stabilize children on initial ART treatment and then refer them back to the
MOH clinics for long-term care. HIV care and treatment has also been initiated at Bwafano Day Care
Centre where 102 children have been enrolled into HIV care and treatment and 40 commenced on ART.
Bwafano also has an established psychosocial support service which can be used as a resource to
strengthen psychosocial support and counseling as outlined above.
(3) Improve outreach to vulnerable children: To improve outreach to vulnerable children a number of efforts
will continue to strengthen community linkages with locally available treatment services. The puppetry
program which explains care and treatment in a child-friendly manner will continue and be expanded in a
controlled manner to maintain high quality performances.
Activity Narrative: We will also strengthen community outreach activities including development and expansion of child and
adolescent peer support groups, community based education campaigns on pediatric ART. Community
outreach will follow up women from PMTCT services for early identification and testing of exposed children
for commencement of ART if found positive. These will occur as wrap around activities to current child
survival activities such as growth monitoring, expanded program on immunizations and training and support
for intensive follow up of HIV exposed infants.
Other organizations providing services in Lusaka and the provinces to vulnerable children will be contacted
locally by community outreach workers and information will be provided to them regarding care and
treatment services offered at the EGPAF/CIDRZ supported clinics. Specifically they will be referred to the
clinics where there are pediatric friendly rooms and counselors who can support the vulnerable child and
caregiver.
Laboratory Support:
The EGPAF/CIDRZ ART (adult and pediatric) and PMTCT activities are supported by a Central Laboratory
at Kalingalinga District Clinic. The Central Laboratory performs multiple assays designed to provide clinical
support for the service programs and the ongoing projects at CIDRZ. The laboratory performs assays on
clinical specimens for hematology, clinical chemistry, clinical microbiology, coagulation, HIV diagnostics,
molecular biology diagnostic, serology, specimen archiving, and HIV monitoring (CD4 counting and HIV
viral load). All assays, including are enrolled in international quality assurance programs and blinded
specimens are received throughout the year for testing and comparison with other labs in a similar peer
group. Clinical specimens are transported to the laboratory from various clinics and hospitals throughout
Lusaka and Zambia via a dedicated specimen transport system. All specimen records are managed with a
computerized laboratory information system, which is interfaced with the high-throughput instruments in the
laboratory. Complete client test results reports are generated for each specimen received and distributed to
the appropriate clinic by the dedicated specimen transport system.
Currently, the Central Lab is performing approximately 11,000 CD4 tests, 10,500 complete blood counts
(CBC's), 11,000 chemistry (liver and kidney function tests), and 2,000 syphilis tests per month for the ART
Service and PMTCT programs. The number of molecular biology tests performed is increasing to
approximately 7,000 HIV RNA viral loads and 600 HIV DNA polymerase chain reaction (PCR) infant
diagnostic tests per year.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.11:
April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD
This PHE activity, "Evaluation of the WHO algorithm for diagnosis of sputum negative TB in an out-patient
setting", was approved for inclusion in the COP. The PHE tracking ID associated with this activity is
ZM.08.0189.This PHE activity, "Evaluation of the WHO algorithm for diagnosis of sputum negative TB in an
out-patient setting", was approved for inclusion in the COP. The PHE tracking ID associated with this
activity is ZM.08.0189.
Continuing Activity: 17632
17632 17632.08 HHS/Centers for Tulane University 7185 3080.08 UTAP - CIDRZ - $115,000
Disease Control & U62/CCU62241
Prevention 0
Estimated amount of funding that is planned for Public Health Evaluation $193,646
Table 3.3.12:
This PHE activity, "Enhanced TB screening to determine incidence and prevalence of TB in a cohort of ART
clinic patients", was approved for inclusion in the COP. The PHE tracking ID associated with this activity is
ZM.08.0190.
Continuing Activity: 17634
17634 17634.08 HHS/Centers for Tulane University 7185 3080.08 UTAP - CIDRZ - $196,000
Estimated amount of funding that is planned for Public Health Evaluation $377,131
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
The level of funding to this activity has been reduced as cost for laboratory services for people living with
HIV/AIDS (PLWHA) has been moved to Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) adult and
pediatric ART services program and the prevention of mother-to-child transmission (PMTCT) program. This
activity is modified to support local human capacity building and quality assurance/control laboratory
program.
This activity is linked to adult care and treatment, and to Chest Diseases Laboratory (CDL #3703), Centers
for Disease Control and Prevention - Technical Assistance (CDC-TA #9022), Eastern Provincial Health
Office (EPHO # 9795) , Lusaka Provincial Health Office (LPHO #9796), Southern Provincial Health Office
(SPHO # 9797), and Western Provincial Health Office (WPHO #9799) activities of the laboratory section
Under the EGPAF, Project Help Expand Anti-Retroviral Therapy for Children & Families (HEART) and the
Centre for Infectious Disease Research in Zambia (CIDRZ) manage a Central Laboratory at Kalingalinga
Clinic, which supports the ART Services and PMTCT Programs. The Laboratory team also supports
capacity building activities, training and equipment for Lusaka, Southern, Western, and Eastern Provinces
and coordinates with the Ministry of Health (MOH) and the CDC in support of the provincial, district, and
rural labs that support the ART sites in the provinces. Coordination will be intensified so duplication of
activities will not occur.
The main laboratory area of the Central Laboratory is set-up for automated and manual testing of blood
samples including CBC, CD4 counting, chemical analysis, and serological rapid testing including HIV and
Rapid Plasma Reagin (RPR) syphilis testing. A level II bio-containment suite is used for microbiological
testing with two class II bio-safety cabinets. TB culture testing is performed in this suite using the Becton
Dickinson Company Mycobacterium Growth Indicator Tube (MGIT) liquid culture system; another suite is
provided for TB smear staining and reagent preparation. Two additional suites are available for PCR
amplification and detection preparations.
The Central Laboratory performs multiple assays to support Project HEART and other programs and
studies. The Central Laboratory has training facilities including a conference room, audio-visual capacity,
and IT support for training. The laboratory has a full range of state-of-the-art instrumentation and the
human resources to provide laboratory training on- or off-site. The Central Laboratory does support training
activities of provincial and district laboratory personnel.
Quality Control and Quality Assurance QC/QA:
Presently the quality of many testing outcomes in the district and rural labs is not as high as in the provincial
and central labs. The technical assistance provided by the MOH and all partners is still being scaled up.
The laboratory team will work with the MOH to strengthen QC/QA in our rural supported laboratories in the
Southern (eight), Eastern (seven), Western (six), and Lusaka (six) Provinces and at the provincial laboratory
level CIDRZ work in coordination with ongoing CDC efforts. CIDRZ is an active participant in the Project for
Strengthening HIV/AIDS Laboratory Network with CDC, Japan International Cooperation Agency (JICA),
and other partners. All QA activities will be coordinated through this committee.
Plans for FY 2009: The Ministry of Health (MOH) has a QA/QC sub-committee to create quality strategies
for Zambia. All partners have been encouraged to support the recommendations of the sub-committee to
harmonize all activities with the MOH. The CIDRZ Laboratory team will continue to work with the MOH and
partners to create quality systems for all supported laboratories through the National QA Plan. All
EGPAF/CIDRZ supported training in QA/QC will be harmonized with the National Plan.
Training Plans:
Laboratory staff requires further training in the use and maintenance of existing and new instruments. Two
trainings were completed for 25 staff each in FY 2008 focusing on the use, repair, and maintenance of both
the existing and newly acquired instruments to ensure sustainability of laboratory capacity. The lab will also
expand the week long National Institutes of Health Division of Acquired Immunodeficiency Syndrome
(DAIDS) sponsored Good Clinical Laboratory Practice (GCLP) training from 12 Biomedical Scientists/ year
to 16 scientists/ year. In addition to this external training, CIDRZ trained 23 rural laboratory technologists in
a one week course in "GCLP for rural Zambian laboratories". The curriculum included QA/QC,
fundamentals of the ART program, maintenance of standardized laboratory instruments, supply chain
management, waste management (including sharps and biological) and review of the national standard
operating procedures for lab testing. A second training of six provincial laboratory supervisors from
EGPAF/CIDRZ and MOH laboratories was also provided in 2008.
In FY 2009 the highest priority is to continue the GCLP training for all supported laboratories. GCLP is the
cornerstone for all capacity building and was evaluated very highly by the participants as a necessity for
improved lab development and quality. We recommend as the first priority three trainings, of 20 lab
technicians, in the 1st, 2nd and 4th quarters of 2009. A second priority is training to support the MOH
Supply Chain Management Program. CIDRZ will provide a trainer for the MOH Supply Chain Management
training in the pilot Eastern Province. The third priority will be establishment of an incentive system to
reward higher performing laboratories. It is recommended that one staff member, preferably a supervisor,
be supported to attend regional GCLP training provided by DAIDS. The cost for transport and lodging is
approximately $2,200/person. This would not only build capacity but also motivate laboratory teams to work
hard and be recognized for such performance. Other incentives for high performing teams would be skills
training at the Central Laboratory in Lusaka or attend conferences/workshops in lab-related areas for
professional development.
Technical Support:
The Laboratory team provides technical support to the provincial, district and rural labs. There is a CIDRZ
Lab person in each province that is part of a multi-sector team including PMTCT, TB, ART, Pharm and QA
supporting the sites/pharm/labs. These CIDRZ provincial Lab staff mentor district lab staff and ensure
supplies are available at the provincial labs. They provide mentoring and technical advice on the existing
equipment (chemistry and Hemoglobin and CD4 instruments) and ongoing support in the utilization of the
Activity Narrative: existing provincial reagent ordering system. They are supervised by the CIDRZ Provincial Coordinator.
The CIDRZ provincial Lab staff support the CIDRZ supported labs.
12 Guava CD4 machines have been procured and placed in five labs in Eastern, three in Southern, and four
in Western Provinces. Six more have been procured in FY 2008 and will also be placed in the provinces.
Twenty-seven labs are supported by the laboratory team (not including the Central Lab) four are
categorized as large, seven as medium, and sixteen as small. The categories are based on staff numbers,
equipment and tests available. The Laboratory team also supports a rural logistics system to transport
specimens to sites with the capacity to run the tests. Currently, the CIDRZ laboratory team supports the
following labs: Livingstone, Choma, Mazabuka, Chikankata, Nakambala, Magoya, Mbaya Msuma, and
Kalomo labs in Southern Province, Chipata, Petauke, Lundazi, Nyimba, Kapata, Chadiza, and Chama in
Eastern Province, Sesheke, Lewanika, Senanga, Kalabo, Limulunga, and Kaoma in Western Province and
in Lusaka Province Kafue, Chongwe, Luangwa, Kafue Estates, Mweubeshi, and Lukulu. There is no plan to
expand support to additional labs in FY 2009 as the program is going to be supporting expansion to satellite
ART sites that will feed into existing ART sties. The Laboratory team will coordinate closely with and report
to CDC provincial lab contacts and MOH to avoid duplication and waste of resources.
Continuing Activity: 16956
16956 16956.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $1,000,000
Workplace Programs
Estimated amount of funding that is planned for Human Capacity Development $60,000
Table 3.3.16:
Narrative changes include updates on progress of deployment and system development activities.
This activity relates to: JHPIEGO SI (#3710.08), AIDSRelief-Catholic Relief Services (AIDSRelief)
(#3711.08), Ministry of Health (MOH) (#3713.08), Technical Assistance - Centers for Disease Control and
Prevention (CDC) (#3714.08), and COMFORCE (#9692.08).
The funding level for this activity in fiscal year (FY) 2009 has decreased since FY 2008. The decreased
amount, $1,500,000, has been moved in large part to other local SmartCare implementing partners such as
the Ministry of Health (MOH) and Provincial Health Offices ($860,000), as they are now shouldering the
majority of the SmartCare deployment costs for logistics and initial trainings, $450,000 to increase allocation
to training through our previous lead training partner (now TBA), and the remainder is being used for rural
systems support efforts employing new graduates of the Churches Health Association of Zambia
(CHAZ)/LinkNet rural information technology (IT) school in Macha. The funds remaining with Elizabeth
Glaser Pediatric AIDS Foundation (EGPAF) will be used as they were in 2008: purchasing SmartCare
workstations and smart cards for the national electronic health record system, and support for ongoing
development of required health record elements.
In FY 2005 and early FY 2006 the SmartCare software development effort reflected primarily an effort to
merge (into the Continuity of Care framework) the two earlier efforts (the Centers for Disease Control and
Prevention (CDC) Continuity of Care EHR Program and the Centre for Infectious Disease Research in
Zambia (CIDRZ) Patient Tracking System (PTS) software). The activity of 2007 was focused on increasing
the system functionality and preparation for national scale-up training and implementation, which began mid
-2007 with the training of more than 150 District Health Information Officers, Maternal Child Health (MCH)
Coordinators, District Directors of Health and Management and Planning Directors. This was followed by
more in-depth District-focused re-trainings for 64 of the 72 districts by early 2008. In the last 12 months the
number of SmartCare clinics has more than tripled to over 200 and about 250,000 patients are enrolled.
Increasingly the Zambia Ministry of Health (MOH) is taking leadership in engaging collaborators, providing
authority for deployment, and contributing field support from within the Ministry. In mid FY 2006, the MOH
corralled the efforts of all major care and treatment implementers, asking each for commitments of
infrastructure for deployment of the system nationwide. In 2007, the MOH formally requested support from
USG for deploying to 900 locations in the subsequent 18 months, and over a dozen implementing partners
are helping to meet this demand, ranging from the Zambian Defense Force to the Peace Corps, and
including private mine operated clinics, Microsoft, Churches Health Association of Zambia, and many
others.
Uniquely among PEPFAR countries, the Zambian MOH identified this one system as the national standard
for electronic clinical systems by April 5, 2006, demonstrating a remarkable achievement of national
leadership and consensus, as well as technology assimilation, in a short period of time. The immediate
targets of this effort remain constant: the quality of health care in Zambia and ‘local ownership' by the MOH.
However, as the software is internationalized, it may fill a niche in other PEPFAR countries (eg, Ethiopia),
thus further leveraging the investment made in Zambia.
The clinical services which have been integrated to date are HIV care, antiretroviral therapy (ART),
tuberculosis (TB) care in the context of ART, antenatal clinic services (ANC), prevention of mother to child
transmission (PMTCT) protocols with opt-out counseling and testing (CT), labor and delivery, and voluntary
counseling and testing (VCT). New Pediatric ART and Post-natal care services are being deployed.
Other record systems which have been integrated, or data converted, include: the MOH paper systems,
ARTIS, PTS, and CareWare. The Zambia Electronic Peri-natal Record System (ZEPRS), will be converted
into SmartCare in FY 2009, SmartCare as a developing country EHR is likely now the largest in Africa, and
with the increasing numbers of implementing partners in 2008, the rate of growth of persons served may
continue to increase non-linearly in FY 2009 as the number of electronic clinics will continue to increase
rapidly.
Continuing in FY 2009, strong emphasis will be given to support for outpatient malaria, TB and STI services
in light of substantial interactions of these diseases with HIV care and prevention, and on their own merit.
The SmartCare card will increasingly assure and document clinical referral integrity between all ambulatory
services such as V/CT, PMTCT, TB, general OPD, and ART, as well as increasing levels of inpatient
support, as systems deployments saturate points of service in a community.
The EGPAF activity in FY 2008 included: 1) support for some of the equipment required for the national
scale-up; 2) contributing software development resources via subcontractors and the hiring of national staff
to the collaborative software development effort guided by the MOH with CDC TA; and 3) ongoing training
of the core capacity to support this technology in country, including some supportive and collaborative work
with Microsoft volunteer trainers,
In the EGPAF FY 2009, EGPAF appears on target 1) to provide substantially increased SmartCare
workstation and smartcard support (via large commodities purchase, to procure a) essential medical record
workstations to one third to one half of the 1584 clinics identified in 2007 and b) portable medical records for
1.7 million persons), 2) to continue to provide software resources through contractors but to further
transition this work to lower cost contractors based in Zambia, and increasingly to locally employed staff,
and 3) to significantly expand support for training through three Peace Corps extension volunteers and/or
Crisis Corp volunteers to assist with national scale-up.
In FY 2009, ongoing systems integration activities will include:
1) Replacing yet more of the manual elements of the Zambia Health Management Information System
(HMIS), an older manual tally tool for aggregate facility data collection. This will improve data timeliness,
quality, and completeness, in the clinics that are prepared to ‘go electric'. All facility based HMIS indicators
should be produced simply as a report derived from routine recording of patient care data in SmartCare.
This information feeds into the HMIS software via a SmartCare report export, improving the sustainability of
the HMIS system and minimizing duplication.
2) Collaborating with JSI to provide the terminal point in a facility for the supply chain management system
for both drugs and consumable lab supplies. This key integration feature will be implemented in FY 2009,
closing the loop for the supply chain, and providing both supply and demand information streams to allow
validation of supply distribution and utilization down to the patient level.
3) Implementing support for many more and new health indicators. The mapping capacity created in FY
2007 has developed into a more complete geographic information system (GIS) functionality in 2008, and
supports highly scalable displays of MOH and PEPFAR static data in addition to dynamic patient and
Activity Narrative: provider data. This functionality is available at all facility, district, and MOH administrative levels. Specific
efforts are being initiated via other partners to encourage automation of linkage of NAC National AIDS
Reporting Form data with facility data at district level to further enrich information available for local decision
-making.
4) Piloting and deployment support for the SmartDonor version. In August 2008, SmartCare was adapted to
serve the clients of the Zambia National Blood Transfusion Service (ZNBTS) and this version is called the
SmartDonor system. It is designed to improve the capacity of the ZNBTS to recruit repeat ‘safe' donors.
This tool is in turn being integrated with the international Blood Safety web-based aggregate reporting
system. A new Transfusion module in SmartCare will provide for vein-to-vein tracking for monitoring
untoward effects, and capacity will be built via training of ZNBTS staff.
5) Evaluating and implementing an open source Laboratory Information systems (LIS) extension.
6) Incorporating new national HIV/AIDS care standards, user experience, and international guidance into
updated reports.
7) Working with orphans and vulnerable children (OVC) service providers to identify the optimal intersection
between home based ‘well-care' OVC services and health care. Solution may record moving SmartCare
client record management and role-based security engineering to a PDA to address system environment
constraints for documenting OVC services.
8) Improving the human capacity of the MOH both centrally and in clinics to operationally own and manage
this national EHR application by providing localized trainings due to high staff turnover.
9) Supporting continued deployment at MOH sites nationwide, and in those MOH sites supported by
different United States Government-funded or privately-funded partners, now including CIDRZ, Catholic
Relief Services/ AIDSRelief, ZPCT, Churches Health Association of Zambia, CHAMP, LinkNet, Konkola
Copper Mines, Flying Doctors, CDC, Boston University, and others in collaboration with DOD, State, Peace
Corps, and USAID, all of whom are now actively engaged with SmartCare national deployment. EGPAF will
continue providing logistics support for the MOH rapid scale-up including: maintaining the SmartCare
workspace and warehousing, and employing administrative support for the project manager.
10) Mentoring of the ministry software developers and IT support will remain a requirement of all soft-ware
contractors in 2009, to build local ownership and capacity. This will be done in part in collaboration with the
Microsoft volunteer trainer specific trainings and other technical contributions, in part with CDC-TA and in
part with other implementing partners as their field experience increases. This will utilize the new E-
Learning Center developed through an MOH PEPFAR cooperative agreement and other venues.
SmartCare will be central to generating data mentioned in the MOH, NAC, and other SI and Systems
Strengthening mechanisms.
Targets set for this activity cover a period ending September 30, 2010.
Continuing Activity: 15522
15522 3709.08 HHS/Centers for Elizabeth Glaser 7172 2998.08 EGPAF - $6,390,000
9001 3709.07 HHS/Centers for Elizabeth Glaser 5007 2998.07 EGPAF - $1,150,000
3709 3709.06 HHS/Centers for Elizabeth Glaser 2998 2998.06 TA- CIDRZ $1,600,000
Estimated amount of funding that is planned for Human Capacity Development $75,000
Table 3.3.17:
