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
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
•Increased focus on prevention at all points of care
•Promote prevention through couples counseling and testing
•Increase education and response to sexually transmitted infections (STIs)
•Renovate space to accommodate prevention with positives program activities
•Engage community in seeking ways to increase less risky behaviors among adults and youth
This activity will be linked to the counseling and testing (CT) activity number 9713, ART HTXS (#8829,
8827) HBHC SUCCESS II (#9180), Catholic Relief Services (CRS) HVTB (#9703), School of Medicine
(SOM) prevention activity and the Intrahealth prevention with positives program.
The continued high HIV prevalence at 14.3% coupled with low numbers (15%) seeking to know their HIV
status calls for Zambia to rethink and redirect prevention interventions (Zambia Demographic Health
Survey, 2007). It is apparent that as the populations of people living with HIV/AIDS (PLWAs) increase with
availability of drugs, HIV/AIDS service institutions should incorporate prevention with positives/negatives
programs. Currently, there is very limited prevention with positives activities implemented by any of our
partners specifically targeting those that test positive, negative, and are out of school youth.
As an attempt to intensify prevention, as outlined in the Zambia National Strategic Framework 2006-2010,
this activity will engage innovative strategies to influence behavior change at all points of care. The
University of Zambia (UNZA) School of Medicine (SOM) through the National Institutes of Health funding
has been piloting the Partner Project in a clinical setting. The Partner Project is a behavioral intervention
designed to reduce high-risk behavior among HIV positive men and women through engaging them in safer
sex discussions, reproductive choice, and partner participation. Topics addressed include but are not
limited to, HIV prevention, STIs, alcohol use, and acceptability to the use of both male and female condoms
and lubricants. The SOM will work with partners including AIDSRelief through its sub-partner Chreso
Ministries to build capacity through training and to adapt materials for prevention with positives program.
Following the training, AIDSRelief through its sub-partner Chreso will collaborate with the antiretroviral
therapy (ART) treatment, CT, and the prevention of mother-to-child departments in Lusaka, Kabwe, and
Livingstone including their prisons' outreach work to integrate behavior change through prevention with
positives interventions. Three approaches will be emphasized: 1) asking clients if their partners have
tested, and if not, they will be encouraged to bring them to test during which they will be counseled on
prevention. The emphasis will be in the importance of a couple knowing their HIV status together, 2)
couples will be enrolled and engaged in two hour discussions once a week for four weeks exploring
HIV/STI/TB prevention and to strategize ways to limit new infections. Education about condoms will be a
major part of the discussions as work currently being done by SOM has shown that when couples know
how to use both male and female condoms they do use them. 3) after the four sessions, couples/individuals
will be referred to community support /discussion groups formed and with people trained to promote
prevention. Community groups will be led by community leaders trained in prevention and behavior change
using participatory learning activities. Community leaders will also be trained on the use of both male and
female condoms and be encourage to distribute them to the community. Therefore sensitization messages
targeting particularly male participation will be employed through the media, using the traditional, religious,
and local leadership in addition to using information, education, and communication messages (IEC) on
pamphlets and posters written in both English and local languages. There will also be a community
prevention groups composed of youth to address their prevention challenges and needs.
The funds will be used to hire a Prevention for Positives Coordinator and additional counseling staff
required at each point of care to engage patients into longer counseling sessions that address prevention,
alcohol abuse and adherence. Staff will also be hired to run the discussion groups and train community
leaders in prevention. Funds will provide transportation such as motorcycles to implement and monitor
community discussion groups.
FY 2009 activities that will be undertaken to conduct community discussion groups will require renovations
to create space, procurement of furniture and supplies, printing information, education, and communication
(IEC) materials needed to run the program, as well as a computer and printer to track and process program
evaluation data.
Targets set for this activity cover a period ending September 30, 2009.
New/Continuing Activity: Continuing Activity
Continuing Activity: 15542
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
15542 12325.08 HHS/Health Catholic Relief 7200 3007.08 AIDSRelief- $200,000
Resources Services Catholic Relief
Services Services
Administration
12325 12325.07 HHS/Centers for Population 6148 6148.07 $73,000
Disease Control & Services
Prevention International
Emphasis Areas
Construction/Renovation
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
* Reducing violence and coercion
Health-related Wraparound Programs
* Safe Motherhood
* TB
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 3.3.03:
•Palliative care- Care for Care Givers, focusing on caring for care givers during all trainings as a measure to
limit burn out and address team support
•Pain as a fifth vital sign- monitoring pain more closely in triage and initial assessment
•Additional provision of drugs for opportunistic infection (OI) and pain management
•Additional 4,389 clients will be supported with palliative care services and an additional 112 health care
workers will be trained
•Services will be provided that encourage male involvement in HIV testing, prevention of mother-to-child
transmission (PMTCT) of HIV and family center care programs (more specifically outlined in HIV treatment
services counseling and testing (CT), and PMTCT narratives
The following activity is continuing for fiscal year (FY) 2009.This activity links with the Zambia Prevention,
Care, and Treatment Partnership, PMTCT, antiretroviral therapy (ART), CT, TB/HIV, and Laboratory
Support activities as well as with the Government of the Republic of Zambia (GRZ) and other US
Government (USG) partners.
Activity Narrative: Although the AIDSRelief Project is primarily a provider of ART services, comprehensive
HIV care involves treatment of OIs, including TB, sexually transmitted infections (STI) and others, as well as
pain and symptom management and clinical care for severe malnutrition. This activity will strengthen and
expand clinical palliative care services in eight provinces and 15 districts. AIDSRelief Zambia has
incorporated a Family Center Care Health approach to addressing the needs of Palliative Care in the area
of basic health care and support. Our Family Centered Care team has focused on trainings that are
designed to incorporate the entire family unit into the health care facility model. This approach develops
sustainable care as the family unit is equipped to assume greater responsibility for its health. This approach
has had impact on reducing stigma, encouraging more consistent follow-up, increased testing of family
members, and greater adherence among individual family members. As part of our comprehensive care and
treatment plan, the palliative care services include management of all OI and follow-up of patients at
community level. Training and on-site mentoring on pain management has taken place and has been a
critical component of AIDSRelief program.
In FY 2008, AIDSRelief reached 43,664 clients with clinical palliative care services through support to 18
facilities in the 15 districts. In FY 2008, AIDSRelief trained 200 health professionals (doctors, nurses, clinical
officers) in ART/OI/STI/pain management through full and refresher curriculum. AIDSRelief follows the
National Standards for ART and OI. In addition, specific onsite mentoring is conducted by the family-
centered AIDS resident team.
In FY 2009, AIDSRelief will train 312 Health professionals in initial ART/OI management curriculum. In
addition, AIDSRelief Project will conduct specific customized training which will respond to the needs of the
treatment facilities based on the results of the Quality Assurance and Quality Improvement process. In FY
2009, 48,053 clients will receive clinical palliative care services in 19 supported facilities. During FY 2009,
AIDSRelief will consolidate on FY 2008 efforts by providing technical support to ensure quality services and
build capacity to manage clinical palliative care services. AIDSRelief Zambia will continue to work with its
national partner Churches Association of Zambia (CHAZ) as part of its sustainability plan. Key elements of
the work plan include transferring technical, managerial and financial skills to CHAZ and secondment of
technical staff for clinical and monitoring and evaluation (M&E) direct support. In the same line with this
plan, AIDSRelief Zambia plans to initiate the development of HIV Residency for Zambian nationals to
become expert in clinical HIV including clinical palliative care. Trainings will also link encouragement of
male involvement in HIV testing, PMTCT, and family-centered care with other training efforts.
Clinical palliative care activities will include these components: 1) strengthening palliative care services in
health facilities; 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/AIDS/STI/TB Council to develop a strategy, guidelines, and standard operating procedures for
provision of quality clinical palliative care in ART sites and services; and 4) increasing program sustainability
with the GRZ.
In the first component, strengthening palliative care services within health facilities, AIDSRelief will continue
to support 19 ART facilities in 15 districts. In addition to the ART/OI/STI/TB training mentioned above,
health professionals will also be trained, using GRZ-approved curriculum, to provide co-trimoxazole
prophylaxis, symptom and pain assessment and management, patient and family education and counseling,
management of adult and pediatric HIV in the home setting, and provision of basic nursing services in clinic
settings as part of the overall package of clinical palliative care services. A new activity for FY 2009 will be
to incorporate a section on Care for the Care Giver into all trainings to try and minimize provider burn out
and build team support. Pain will also be introduced into triage and assessment plans as a ‘fifth vital sign' to
attempt to highlight this important component of palliative care. Pharmacy staff will be trained in data
collection/reporting and ordering, tracking, and forecasting HIV-related commodities to ensure availability of
critical medical supplies and drugs. AIDSRelief will also liaise closely with the USAID/Deliver Project and
Partnership for Supply Chain Management Systems (SCMS) on forecasting drug supply requirements.
AIDSRelief will also increase the availability of drugs for opportunistic infections that are out of stock or
unavailable, plus ensure adequate supplies of medications for pain management.
In the second component, increasing referral linkages within and between health facilities and communities,
AIDSRelief will build on Zambia's long history of working with Faith-Based Organizations (FBOs) and
Community-Based Organizations (CBOs) that provide home-based care for people living with HIV/AIDS
(PLWHAs). These organizations serve as critical partners for facility-based programs supported by GRZ
and USG. Therefore, as in FY 2008, AIDSRelief will work closely with these established entities to
strengthen referral networks linking clinical palliative care services with community-based programs. For
example, AIDS Relief will continue the implementation of the linkages and integration work plan with
Catholic Relief Services/SUCCESS RTL and RAPIDS to better link clinical services to related community
programs.
Activity Narrative: In the third component, AIDSRelief 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,
AIDSRelief 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 GRZ policies.
In the final component, increasing program sustainability with the GRZ, AIDSRelief will continue to work
with CHAZ to build on the quality assurance activities started in FY 2005. In FY 2008, in collaboration with
the GRZ and CHAZ, the AIDSRelief-supported sites will receive direct support from CHAZ to guarantee
consistent quality clinical palliative care services
Continuing Activity: 17070
17070 17070.08 HHS/Health Catholic Relief 7200 3007.08 AIDSRelief- $100,000
Estimated amount of funding that is planned for Human Capacity Development $85,930
Table 3.3.08:
•Increased capacity building of Community Based Treatment Services with task shifting and utilization of
SmartCare tools, plus increased effort toward clients with substance abuse and mental health issues
•Expansion of HIV Diploma course in conjunction with University Teaching Hospital (UTH) to include
Medical Licentiate Practioners
•Expansion of nurse training as triage officers and antiretroviral therapy (ART) prescribers in conjunction
with General Nursing Council (GNC), and technical lead and partnership with the University of Alabama at
Birmingham (UAB) and the UTH School of Nursing (SON) to develop nursing curriculum and certification as
ART nurse prescribers
•Increased effort within laboratory services to develop good laboratory practice (GLP) and external and
internal quality assurance programs
•Management assistance with budget development and site level needs assessment to move toward
sustainability
•Services will be provided that encourage male involvement in HIV testing, prevention of mother to child
transmission (PMTCT), and family center care programs (also outlined in counseling and testing (CT) and
PMTCT narratives)
•AIDSRelief will provide ART for 29,365 patients and the expansion of ART to an additional 9,257 patients
in FY 2009. AIDSRelief Zambia will provide HIV care to a total of 48,053 individuals throughout FY 2009.
This activity relates to Catholic Relief Services Track 1(#8829) and will complement activities in track 1
(#8829) and will enhance scale-up and consolidation of ART services in areas served by AIDSRelief.
Activity Narrative: AIDSRelief has continued to contribute to the United States Government's HIV/ AIDS
strategy in Zambia by activating and supporting 19 local partner treatment facilities (LPTFs) and additional
satellite facilities to provide antiretroviral therapy, as well as HIV care and services. As of February 2008,
AIDSRelief had 20,108 patients actively on antiretroviral therapy (ART) out of which 1,286 were children
and 43,664 patients were receiving basic care and support.
The AIDSRelief program is founded in the provision of durable comprehensive quality care for persons
infected and affected with HIV/AIDS. All of the strategic program implementation components are
developed toward increasing the sustainability of quality. The cornerstone of HIV services wraps around
our Family Centered Care approach to care and treatment, and most activities are designed to integrate a
family approach to success. Our activities and strategic plan can be divided into six major categories:
Community Based Treatment Services; Medical including early infant survival (incorporated into our
pediatric and PMTCT narratives), palliative care, training and professional development; Nursing; Outcomes
and Evaluation; Laboratory; and Health Care Management. Our plans for transitioning our program and
sustainability are incorporated into each of these areas of focus. Our Local Partner Treatment Facility
(LPTF) support is accomplished by multi-disciplinary teams with members representing each of the above
categories. These teams provide regular on-site support to address critical issues and ensure the
necessary components for comprehensive quality care are developed and maintained.
1.Community Based Treatment Services (CBTS) focuses on utilizing the community to maximize health
care outcomes. The CBTS specialists work with adherence staff, community health worker and volunteers,
and treatment support groups to provide training on treatment preparation and ongoing treatment support.
They are also focused on training to utilize the patient as a window into the family using the SmartCare
Patient Locator as a tool to family identification and tracking. The CBTS specialists also help identify HIV
positive individuals at risk for poor adherence through substance abuse and mental health issues. CBTS
works closely with the CRS network of Home Based Care providers and services. Finally, the CBTS team
will focus on male involvement into HIV testing and increased involvement in Family Centered Care. This
focus on male involvement will be directed toward increasing male support, addressing male norms and
behavior, and reducing violence and coercion.
2.The Medical component of our team focuses on three primary components: early infant survival (covered
in our Pediatric and PMTCT narratives), palliative care, and training and professional development. One of
the center pieces of our program is our commitment to on-site training and mentoring. During our regular
LPTF site support visits Ministry of Health (MOH) sponsored trainings are often conducted for sites in a
particular region, and incorporated into all of these trainings as mentoring opportunities in both the various
out patient clinics and the in patient setting. During COP08 in conjunction with the MOH, University of
Zambia (UNZA), and the University Teaching Hospital (UTH) a fully UNZA accredited HIV Diploma course
was initiated for advance training for medical officers. This year long course was in response to the MOH
request for a cadre of designated HIV Specialist to ensure expertise within Zambia in the coming years.
The course is taught by a combination of faculty from the University of Maryland and the UTH, with in depth
classes on all aspects of HIV care and treatment. The inaugural class commences September 15th, 2008
with the selection of the top six candidates out of 30 applicants. The second semester commencing in April
2009 will add an additional six students. The program will then continue to graduate twelve students each
year. The initial response has been greater than anticipated and there is consideration for expansion to
greater numbers. This diploma course will produce the next generation of HIV educators and decision
leaders in Zambia. Additional professional development at the LPTF level is accomplished through our
monthly newsletter highlighting challenging clinical cases and recent literature updates, our phone hotline to
medical team leaders for clinical case reviews, and our bi-annual Partners Forum for LPTF case
conferences and experience sharing.
3.Nursing is the pivot point for effective task shifting and addressing the ever increasing human resource
crisis in Zambia. The nursing team focuses on providing appropriate MOH approved trainings for nurses,
and continue to work closely with General Nursing Council of Zambia (GNC) to develop curriculum and
plans for accreditation of nurses as ART prescribers and providers. The nursing strategic plan centers
around three stages of task shifting: level one focuses on shifting basic nursing care and triage to
community health workers, level two on preparing nurses to triage and refill prescriptions on stable patients,
and level three on developing a cadre of nurses to become nurse prescribers. AIDSRelief is providing the
nursing technical lead in specific trainings in cooperation with the GNC, University of Alabama, and MOH to
support these transitions, develop curriculum, and certification for ART nurse prescribers and conducted at
the University Teaching Hospital School of Nursing.
Activity Narrative: 4.The Outcomes and Evaluations (O&E) team have done yearly assessments of viral load outcomes
demonstrating durable quality care in our sites. Formal chart reviews, adherence surveys, and HIV
knowledge questionnaires have been collected since 2005. The program evaluation of a 10% sampling of
patients on ART for between 9-15 months this last year indicated a 92% viral suppression rate. This
program will continue to monitor the effectiveness of the AIDSRelief care and treatment model through this
quality assurance program.
5.Our Laboratory team is working with the National Laboratory Services to ensure quality control and good
laboratory practices at each LPTF. During LPTF visits the laboratory staff receives on-site training on
equipment use and care, stock management, and conducts an assessment using indicators to demonstrate
the level of quality incorporated at the LPTF.
6.The Health Care Management team is primarily focused on linking the LPTF Care and Treatment plan to
site level budgets and developing sustainability. AIDSRelief has found increasing LPTF capacity to develop
appropriate care and treatment plans and budgets integral to quality outcomes.
Building on fiscal year FY 2008, AIDSRelief will provide AIDS treatment services primarily through faith-
based facilities that typically treat the most marginalized populations and provide services in rural areas.
The cost of providing care in these areas is usually limited infrastructure that makes it difficult and costly to
maintain quality medical care and to transport supplies. The AIDSRelief goal is to ensure that people living
with AIDS have access to ART and high-quality medical care. AIDSRelief believes that care and treatment
for HIV-infected individuals should be integrated in the existing health care infrastructure to promote
sustainability. AIDSRelief will provide ART for 29,365 patients at 19 faith-based and non-faith based
hospitals and clinics, including the maintenance of 20,108 patients from FY 2008 and the expansion ART to
an additional 9,257 patients in FY 2009. AIDSRelief Zambia will provide HIV care to a total of 48,053
individuals throughout FY 2009.
AIDSRelief will continue to provide, on a sustainable basis, the provision of ART to the greatest number of
patients consistent with good medical science, national priorities and programs, and cost-effective
deployment of program resources. Sustainable ART programs will be supported by a commodities
management system that ensures a continuous supply of drugs to patients by mobilization of patients and
communities to encourage knowledgeable, consistent adherence to treatment plans. AIDSRelief will
continue activities with Churches Health Association of Zambia (CHAZ) related to joint involvement at site
level for sustainability purposes. Results from an external evaluation of CHAZ in cooperation with the
Centers for Disease Control and Prevention (CDC), MOH, and USAID will identify key areas of focus, and
allow orientation of the Board of Directors for CHAZ on AIDSRelief sustainability so a common vision is
developed. In some of the sites, CHAZ will use Global Fund resources along with PEPFAR fund from
AIDSRelief in order to reach more patients.
Finally, AIDSRelief continues to be actively engaged in supporting the MOH by participating in every
available technical working group and committee, and being available to respond to requests from the MOH
ART Coordinator for technical assistance. The AIDSRelief team also contributes to the CDC and other
cooperating partners request for assistance whenever possible.
Continuing Activity: 15617
15617 3698.08 HHS/Health Catholic Relief 7200 3007.08 AIDSRelief- $7,900,000
8827 3698.07 HHS/Health Catholic Relief 4951 3007.07 AIDSRelief- $4,580,000
3698 3698.06 HHS/Health Catholic Relief 3007 3007.06 AIDSRelief- $5,750,000
Estimated amount of funding that is planned for Human Capacity Development $1,134,280
Table 3.3.09:
THIS IS A NEW ACTIVITY NARRATIVE BUT FUNDED FROM PREVIOUS YEARS UNDER HIV
TREATMENT CARE AND SUPPORT AND HAS BEEN REMOVED AS A SEPARATE ACTIVITY IN FY
2009.
Activity Narrative
This activity is related to activities under adult treatment (#17694.08 and #4548.08) adult care and support
(# 17070.08), pediatric treatment (# CRS NEW) all provincial pediatric treatment programs (# NEW SPHO,
WPHO EPHO), counselling and testing (#9713.08) and strategic information services (#3711.08)
Integral to the AIDSRelief family-centered approach to HIV care and treatment services is a strong
emphasis on the provision of quality, comprehensive care for children. While gaps currently exist in the
care, support and treatment services provided to infants and children progress has been made as is
demonstrated by expanded access to ARV treatment and early testing and diagnostic services. The
AIDSRelief strategy to further close these gaps is anchored by a focus on early infant/childhood survival
and includes six target areas to be addressed across all 19 sites: mother-to-child transmission; pediatric
HIV testing and counseling for infants, children, adolescents, and their families; comprehensive care of
exposed infants and their HIV+ mothers, including provision of co-trimoxazole (CTX) prophylaxis for
exposed and infected children, as well as a comprehensive preventive care package for exposed, infected,
and affected children; treatment of infected children, including ART (discussed in the "Pediatric Treatment"
narrative), OI treatment, palliative care, and psychosocial support services; care for families; and outcomes
and evaluation. Our goals for the end of FY 2009 COP will be to have 7,500 pediatric patients in care and
treatment; 90% of HIV-exposed infants on CTX prophylaxis; and 90% of HIV-exposed infants receiving DBS
testing by eight weeks of age.
Prevention of maternal-to-child transmission is the first and most critical step to reversing current trends in
pediatric HIV, and bridging the gap between adult and pediatric HIV services. The AIDSRelief strategy for
minimizing such transmission is detailed in the separate PMTCT narrative. Specific strategies to link
PMTCT, general ART and pediatric ART services to ensure that HIV-infected women, their infected
partners, and their infected and affected children, are receiving appropriate services are described below.
In order to improve the significant morality associated with pediatric HIV, the diagnosis of HIV infection must
be made more and made earlier. The availability of DNA PCR testing in Zambia (Early Infant Diagnosis -
EID), as well as the Ministry of Health's mandate for Provider Initiated Testing and Counseling (PITC) have
both greatly improved diagnostic capabilities for children - particularly those less than 18 months of age. In
order to be effective, however, we must ensure that sites are doing the test on all eligible children, and that
the results are getting back to them in a timely manner. Key staff at all sites have been trained on the
current EID and PITC guidelines, and we will continue to provide updates and trainings as needed to ensure
that testing is being done appropriately. In FY 2009 staff at all levels of care, from the RHC to the pediatric
inpatient ward, will be updated in guidelines that recommend that HIV-exposure status be established and
documented for all children at their first contact with the health system. Additionally, we will work with sites
to identify and overcome barriers to successful implementation of EID and PITC, such as a need for more
counseling staff and additional training for counselors in pediatric-specific issues, as well as to identify and
solve logistical issues which may be contributing to delayed diagnosis in some children. Finally, the
importance of using clinical symptoms, such as growth failure, recurrent bacterial infections and
hospitalizations, and neurodevelomental delay, will continue to be emphasized as critical for the
identification of potentially infected infants and children.
The third target area, comprehensive care of exposed infants and their HIV+ mothers, is equally critical; in
addition to the high mortality rates infants known to be HIV-infected sited above, even those who do not
acquire the virus from their HIV-infected mothers (the HIV-"affected") have been shown to have higher
mortality than their HIV-non-exposed counterparts (Brahmbhatt, et al. 2006. JAIDS. 41(4): 504-508).
Because such data demonstrate a strong link between maternal health and infant survival, our first strategy
is to ensure that HIV-infected mothers are receiving comprehensive HIV care and treatment services,
beginning during pregnancy and continuing throughout their lifetime. Success of this strategy depends on
establishing strong linkages between antenatal clinics, the labor and delivery ward, rural health centers,
traditional birth attendants, and ART clinics. In FY 2009, this will be achieved by evaluating and improving
referral systems within each LPTF, as well as through strengthening community-based outreach programs
which can identify HIV-infected mothers and mothers-to-be and link them to the appropriate ART clinic. We
will also work with CDC and other partners on the continuous improvement of the SmartCare system so
that future versions will enable easy identification and tracking of all family members enrolled in the
program.
The second strategy within this target area in FY 2009 is to enroll all exposed children into the
comprehensive HIV care and treatment program from birth through their second birthday. Sites will begin
enrolling all HIV-exposed infants (and their infected mothers) prior to discharge from the hospital, and both
static and mobile under-5 clinic staff will be trained to refer all HIV-exposed children (and their mothers) to
the program as soon as they are identified. This will ensure that all HIV-exposed children can receive CTX
prophylaxis according to current guidelines, and that those that are identified as HIV-positive through EID
can continue it for as long as they are eligible. Because these children will be receiving the majority of their
care during their first two years of life from the ART clinic, CTX prophylaxis will be integrated into well child
care, and information about their exposure status and receipt of CTX can easily be recorded on their under-
5 card. In addition to providing CTX prophylaxis, a comprehensive preventive care package will be
provided for all HIV-exposed children through their second birthday, regardless of their ultimate infection
status. This care package will also include the following; continuous, evidence-based nutritional
assessment, counseling and support, such as assessment of relevant anthropometric indices, education
about feeding options, and provision of micronutrient supplements and therapeutic feeds when indicated;
monitoring of growth and development, including assessment for neurodevelpmental delay; timely HIV
testing - i.e., at 6 weeks of life, or at first contact with the health care system, whichever is earlier; education
about safe water and malaria prevention, and provision of specific interventions such as insecticide-treated
nets by partnering with other groups within CRS which already provide such services (e.g. SUCCESS and
Activity Narrative: RAPIDS); identification and treatment of acute illnesses; and provision of immunizations and other "well-
child" services such as Vitamin A supplementation and routine de-worming.
AIDSRelief will collaborate with USG Zambia partners on an effort to shift to a Food by Prescription
approach, which is client focused rather than family focused, and seeks to ensure good nutritional status as
an adjunct to Pediatric ART; and support the development and implementation of a USG Zambia food and
nutrition strategy, as well as consider adopting a common technical approach to food and nutrition support.
Once an infant or child has been diagnosed with HIV infection, AIDSRelief is committed to ensuring their
long term health through the provision of quality care and treatment, the fourth target area; this includes
provision of ART to all eligible children (ART-related activities are described in a separate narrative),
management of opportunistic infections (OIs), palliative care, and psychosocial support services. Ongoing,
on-site training and mentoring will be provided for clinical staff at all sites in the principles of OI diagnosis
and management and palliative care for children. Particular emphasis will be placed on the following:
improving TB case finding, e.g. by training staff and community-based health workers in basic screening
questions; ensuring that laboratory/diagnostic capacity exists to assist with timely diagnosis of common OIs
such as TB, malaria, PCP, and cryptococcal meningitis; working with sites to maintain an adequate stock of
pediatric formulations of medications to treat OIs and pain; and training in pediatric pain assessment and
management. Additionally, increased emphasis will be placed on providing age-appropriate psychosocial
support services, including training for providers and counselors in disclosure, caregiver support, and
developing support groups for infected children and their families. Centralized pediatric trainings will,
whenever possible, integrate all of the above into the training sessions.
The fifth target area on which AIDSRelief will focus in an effort to improve early infant/childhood survival is
care of the family. Specifically, we want to ensure that all family members of infected mothers and children
are engaged in care at some level: this includes testing of children and partners of infected women; testing
of mothers, fathers, and siblings of infected children; family-based tracking of patients; and linking with other
community-based programs (e.g., Men in Action) to increase paternal involvement in care.
Lastly, as is true for all program areas within AIDSRelief, we believe that meaningful outcomes assessing
the efficacy of our approach to maternal child health care in general and early infant/childhood survival in
particular, should be measured. While more details of the outcomes and evaluation strategy can be found
in the narrative explaining that program, examples of outcomes to be measured within this program area
include: percentage of HIV-exposed children receiving Septrin prophylaxis; percentage of HIV-exposed
children receiving DNA PCR testing by 8 weeks of life; and percentage of HIV-exposed children who
acquire the virus.
New/Continuing Activity: New Activity
Continuing Activity:
* Child Survival Activities
* Malaria (PMI)
Estimated amount of funding that is planned for Human Capacity Development $150,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $20,000
and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Commodities $30,000
Table 3.3.10:
This is a new narrative from previous years and sections from HVTX related to pediatric care and support
have been removed from HVTX and incorporated into this narrative.
(# 17070.08), pediatric care and support (NEW CRS) all provincial pediatric treatment programs (# NEW
SPHO, WPHO EPHO), counselling and testing (#9713.08) and strategic information services (#3711.08)
emphasis on the provision of quality, comprehensive care for children. There is currently a significant gap
between the level of care provided for HIV-infected adults and that provided for exposed and infected
infants and children. For example, UNAIDS data indicate that children represent nearly 15% of new HIV
infections each year, yet children younger than 15 years of age represent less than five percent of patients
on antiretroviral therapy (ART) in many clinics throughout Zambia. The number of pediatric patients on ART
within AIDSRelief has grown from 276 to almost 1,600 currently, with a 16% increase in the proportion of
pediatric patients of all those on ART (from 5.8% to 7.3%). The strategies implemented during the last 18
months are just now beginning to reflect in a higher pediatric ART enrollment each successive quarter. Our
strategy to build on these successes, and further strengthen the program, is anchored by a focus on early
infant/childhood survival and includes six target areas to be addressed across all 19 sites: mother-to-child
transmission; pediatric HIV testing and counseling for infants, children, adolescents, and their families;
comprehensive care of exposed infants and their HIV+ mothers, including provision of co-trimoxazole (CTX)
prophylaxis for exposed and infected children, as well as a comprehensive preventive care package for
exposed, infected, and affected children; treatment of infected children, including ART, opportunistic
infection (OI) treatment, palliative care, and psychosocial support services; care for families; and outcomes
and evaluation. This narrative addresses treatment only, as all the others are discussed in the "Pediatric
Care and Support" narrative. Our goal for end of FY 2009 is to have 3,500 pediatric patients on ART
equaling 10% of all ART enrollments within AIDSRelief; of those who are newly initiated, 20% will be < 1
year old at the time of initiation, and 50% will be less than five years.
AIDSRelief is committed to ensuring the long-term health of all HIV-infected children through the provision
of comprehensive quality care and treatment. At the site level, ongoing technical support will be provided in
three key areas: determining eligibility; treatment initiation, monitoring and follow-up; and practical pediatric
treatment challenges. Treatment initiation begins with early diagnosis of pediatric HIV infection, which has
been discussed in detail in the "Pediatric Care and Support" narrative; the second step is to ensure that, as
guidelines for treatment initiation continue to change based on available evidence, the local clinical staff are
oriented to the new guidelines so that it is clear which children are eligible. For example, Zambia has
recently changed its treatment eligibility guidelines so that all children less than one year of age are
considered eligible for treatment, regardless of clinical stage or immune status; AIDSRelief will work with
sites to ensure that this has been communicated and is being implemented. Additionally, ongoing, on-site
training and mentoring in the recognition and management of key clinical conditions - PCP, HIV
encephalopathy, growth failure, and others - which render a child eligible for ART treatment will be
provided.
Once a child has been deemed eligible for treatment, an appropriate first-line regimen must be selected.
Training and mentoring in how to choose this initial regimen, and how to dose the individual components,
will be provided to clinical staff at all sites, based on current guidelines and available data. This will include
current information on which regimen to use for children with a known history of NNRTI exposure - in
Zambia, use of an NNRTI is still recommended due to concerns about the feasibility of using a PI-based
regimen for first-line treatment - as well as appropriate treatment of HIV-TB co-infection.
Providers will also receive ongoing training and mentoring in recognizing and treating ARV-related toxicities;
treatment failure; OI treatment and prevention; and nutrition recommendations for infected children on
treatment.
Third, providers, adherence counselors, and pharmacy staff will be trained and updated in practical issues
which can create specific challenges for pediatric ART care, such as treatment preparation; disclosure
counseling; treatment support; how to store and administer the ARVs; and when and how to re-dose ARVs.
AIDSRelief staff will provide both central and local training in the MOH Pediatric HIV Care Training Course
for staff and providers that have not yet received it. In an effort to both decentralize care and strengthen
district-level capacity, providers from rural health centers affiliated with our local partners, as well as those
from the associated district-level facilities, will be included in these trainings. Follow-up for those trained will
be done through AIDSRelief's ongoing participation in the Ministry of Health's (MOH) Pediatric Mentorship
In addition to its activities at the site level, AIDSRelief will continue to work with the MOH and other local
partners to review national guidelines, ensuring that the most current relevant data is considered and
changes made when appropriate and feasible. We also plan to work with CHAZ, MSL, and JSI to ensure
availability of appropriate pediatric ART formulations, including fixed-dose combinations when appropriate,
as well as the supplies (e.g., appropriately-sized syringes) necessary to administer them correctly and
accurately.
include: viral suppression rates of children on therapy for at least 12 months; percentage of children on ART
that were started at less than one and five years of age; and percentage of children with an identified ARV
toxicity who were managed appropriately.
Activity Narrative:
Estimated amount of funding that is planned for Human Capacity Development $200,000
Table 3.3.11:
The funding for this activity in FY 2009 has slightly reduced from FY 2008.
This activity relates to activities in counseling and testing, laboratory infrastructure, palliative care, and basic
health support activities.
During the fiscal year (FY) 2008 funding cycle the following has been accomplished to date:
•2,200 number of persons with HIV/AIDS have been treated for TB
•42 medical providers have been trained and mentored in advanced TB diagnosis and treatment
•86 Community Health Care Workers have been trained on TB recognition and links with HIV for
encouraging CT
•54 hospital staff have participated in TB updates
•Referral linkages between TB and HIV programs at 12 Local Partner Treatment Facilities (LPTF) have
been strengthened
•Integration of TB/HIV programs using nurse educators through on site training, mentoring, and technical
assistance at two Churches Health Association of Zambia (CHAZ) supported facilities
•10 hospitals have had evaluation and upgrade of safety standards for protection of health care workers
with installation of extractor fans, bio-safety cabinets, and windows where indicated
•Chest x-ray (CXR) services were expanded to two LPTF sites for TB diagnosis
•Training on LPTF TB specific data management to capture and report accurately on TB/HIV co-infection
was conducted at six sites
•Information, education and communication (IEC) materials addressing TB/HIV co-infection were sourced
and disseminated
•Emphasis will be placed on intensified TB case finding
•Infection control for TB with major emphasis of reducing TB among health care workers and clients utilizing
health care facility
•Working with the MOH to encourage Isoniazid prevention therapy.
•In order to intensify TB case finding all sites will be trained on intensified case finding into the range of HIV
related service activities such as HIV Counseling and Testing (CT) sites, Home Based Care programs, and
treatment support groups in addition to the specific treatment facilities
•Partner with the District Health Management Team s (DHMTs) on the formation and strengthening of
TB/HIV linkages, reporting systems, and site supervision
•Family case finding will become routine for any TB case, and screening questionnaires will be employed
until the WHO TB score card screening questionnaire is fully developed
•Increase the utilization of provider initiated counseling and testing (PICT) in the health care facilities
through training and monitoring indicators.
Activity Narrative: Tuberculosis (TB) is a major cause of morbidity and mortality in people living with HIV
and needs specific attention. Emphasis must be placed on intensified TB case finding, infection control for
TB, and continuing discussions with the MOH on Isoniazid prevention therapy. In order to expand TB case
finding all sites will be trained on intensified case finding into the range of HIV related service activities such
as HIV CT sites, Home Based Care programs, and treatment support groups in addition to the specific
treatment facilities. Family case finding will become routine for any TB case, and screening questionnaires
will be employed until the WHO TB score card screening questionnaire is fully developed. Routine quality
testing of TB patients for HIV is an efficient means of identifying HIV in the community. PICT will be
strengthened both in the ART clinic and the TB clinics through increased utilization of Diagnostic
Counseling and Testing (DCT). Infection control for TB is essential both within the health care work place,
and in areas where clients congregate. Trainings will be conducted on teaching the key actions for TB
prevention in these settings, and supplemented by educational posters.
Health care infrastructure will be improved at nine AIDS Relief sites and four CHAZ sites. Evaluations of the
sites for laboratory diagnostic accuracy and safety will be conducted with appropriate measures taken to
ensure compliance with national standards. Quality assurance programs will be strengthened at all 19 AIDS
Relief sites through our laboratory teams program in conjunction with National Laboratory Services to
develop Good Laboratory Practices and expansion of the internal and external quality control (EQA)
mechanisms. Our EQA activities will be linked to national EQA program through regional TB centers. Other
emphases will include training, community mobilization/participation, strengthening of networks and referral
linkages, and activities that will contribute to infection control. AIDS Relief will also partner with the DHMTs
on the formation and strengthening of TB/HIV linkages between the local treatment facility and the DHMT.
Support will be given to form and strengthen TB/HIV coordinating bodies at district, health center and
community levels. Special emphasis will be placed on accurate reporting to the DHMT in its supervisory
role, and ensuring courier systems are in place for specimens and results.
The following populations are targeted: health care providers (including Community Health Workers), faith-
based organizations, community-based organizations, and all persons affected by HIV and AIDS.
Based on the principle that all HIV positive persons in the AIDS Relief program are screened for TB based
on symptoms and exposure history, and all patients being prepared for ARV drugs receive TB screening,
this activity will be implemented in the following components:
(1) Enhancing laboratory capacity to diagnose TB accurately;
(2) Strengthen referral linkages between AIDS Relief facilities and the Zambian government TB directly
observed treatment strategy (DOTS) sites to ensure timely diagnosis and treatment;
(3) Ensure accessibility to IEC materials on the relationship between TB and HIV at health facilities as well
as surrounding communities;
(4) Enhance the capacity for the diagnosis of smear negative and extra-pulmonary TB based on national
program recommendations.
(5) Reduce the potential risk of nosocomial transmission among patients through assessment, training, and
education of hospitals and clinics. Emphasis will be placed on understanding the transmission of TB in
Activity Narrative: these settings and implementing plans to reduce this transmission. CDC and WHO educational materials
will be incorporated into the process with visual educational materials posted at the sites.
To ensure routine screening and accurate diagnosis of TB in all patients enrolled for HIV care at all 19 AIDS
Relief health facilities and four (4) CHAZ supported Health Facilities, all laboratories will be equipped to
perform sputum smear to detect acid fast bacilli and will be engaged in quality assurance and quality
improvement activities with nearby reference laboratories. Funds will be used to strengthen laboratory
capacities at AIDS Relief facilities to conduct TB diagnostic tests, to ensure that chest X-ray is available for
all sputum-negative individuals, and to provide training and ongoing technical assistance to laboratory staff
in sputum diagnosis of TB, training all cadre of staff to identify potential TB cases and to make the diagnosis
(counselors, nurses, community health workers, treatment support specialists, etc). In addition, patients with
smear negative specimens but suggestive clinical signs will have their specimens referred to a National
reference laboratory for culture.
Ensuring that patients diagnosed with TB at AIDS Relief facilities have access to quality care involves
strengthening the capacity of the facilities to meet the special needs of persons living with HIV/AIDS and
TB. Funding towards this component will go to supporting training of all cadres of clinical staff (doctors,
clinical officers, nurses, counselors, treatment support specialists, and community health workers, etc.) on
TB management especially as it relates to the HIV positive patient, establishment of referral linkages for HIV
patients diagnosed with TB at AIDS Relief sites on TB DOTS for community-level follow-up for care and
support, and developing and implementing joint strategies to assist with patient adherence to antiretrovirals
(ARVs) and anti-TB drugs by utilizing community health workers, treatment support specialists and other
community support groups. It is further planned to strengthen the dual referral system between AIDS Relief
facilities with HBC for patients co-infected with HIV and TB. Additionally targeted co-infected TB/HIV
patients will be linked with SUCCESS for the provision of Ready to Use Therapeutic Food (RUTF) and
complementary food.
In FY 2009 up to 60 health workers will receive specific training on TB/HIV as it relates to their job
responsibilities. The focus of these trainings will be on accurate assessment and diagnosis of TB (both
pulmonary and extra-pulmonary), intensified TB case finding, infection control for health workers and
clients, and increased utilization of PICT. These parameters will be evaluated by using AIDS Relief
indicators that are part of our TB/HIV Integration Program Plan that assess LPTF progress toward quality
care and sustainability during site support team visits each quarter. It is estimated that a total of 4,500
persons living with HIV/AIDS will be treated for TB under AIDS Relief using drugs obtained through the
National TB program and is not included in the budget. A total of 1,400 TB patients will receive counseling
and testing results. All patients who are diagnosed and treated for TB under AIDS Relief will be entered in
the Zambian Government's register with appropriate linkage of medical records between TB and HIV.
Funds under the Strategic Information activity will be used to implement the use of TB registers in all AIDS
Relief facilities, train medical records staff, laboratory staff and clinicians on entering information on
suspected cases, TB screening, diagnosis, treatment, and follow-up laboratory tests for patients seen at the
health facility.
The education and sensitization component under this activity will include the development of a
communication strategy to sensitize the communities served by AIDS Relief on the linkage between TB and
HIV. Funds will be directed at working with local organizations to distribute IEC materials related to TB/HIV
issues to communities and health facilities, conducting educational sessions at support groups and other
community-based groups, training in voluntary counseling and testing (VCT) and other counselors to
provide information on TB/HIV to their clients during counseling sessions. All nineteen AIDS Relief health
facilities and four CHAZ supported facilities and surrounding communities will benefit from having IEC
materials available.
The training of health staff and community volunteers providing care in both urban rural mission health
facilities will ensure sustainability of the program.
There are no gender disparities in the provision and access to TB/HIV diagnosis and treatment in Zambia
To ensure sustainability, these activities are enshrined in the Ministry of Health District Plans.
Continuing Activity: 15614
15614 9703.08 HHS/Health Catholic Relief 7200 3007.08 AIDSRelief- $1,043,000
9703 9703.07 HHS/Health Catholic Relief 4951 3007.07 AIDSRelief- $730,000
Table 3.3.12:
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 achievements.
Related activities: This activity also relates to activities in HBHC SUCCESS II (#9180), CRS HVTB (#9703),
HTXS (#8829) (track 1.0), CRS HTXS (#8827), CRS HKID (#8852) and USAID, RAPIDS 8947.08)
As of July 31, 2008, AIDSRelief has formally trained 136 health care workers, including nurses, Clinical
Officers, community health workers and lay counselors in counseling and testing (CT). Additionally,
afternoon lectures have been done in four sites on counseling and testing. A cumulative number of 62,374
people have been offered CT through AIDSRelief services. We plan to continue this active outreach for
scale up and continue training at Local Partner treatment facilities.
Based on the Zambia National HIV and AIDS Strategic Framework 2006-2010 (ZASF), there has been a
low uptake of counseling and testing (VCT). In FY 2009, AIDSRelief will aim to improve uptake of CT by
increasing the availability of counseling and testing in health facilities and through community outreach,
through training of staff and strengthening linkages with other services. This activity will be conducted in
different clinical settings including adult and pediatric antiretroviral therapy (ART), prevention of mother to
child transmission (PMTCT), and sexually transmitted infection (STI) clinics. The suggested form of testing
would be Provider initiated testing and counseling (PITC). This is in conjunction with the Government of the
Republic of Zambia (GRZ) plans of introducing a more comprehensive approach and increasing the number
of people receiving CT services. Most of the rural mission hospital AIDSRelief sites where AIDSRelief is
currently working have clinics where these activities will be implemented.
This activity will target persons affected by HIV/AIDS, faith-based organizations (FBOs), and community
health care providers. There are three main components to this activity: 1) provision of comprehensive CT
services within hospital settings and in the surrounding communities; 2) training of staff to provide CT
services; and 3) the strengthening and expansion of linkages to ensure continuity of care for persons who
test HIV positive.
The first component of this activity is to provide comprehensive CT through integrated VCT services within
hospital settings and in the surrounding communities. This will include supporting 19 hospitals and clinics to
PITC for diagnostic purposes for persons attending in-patient and out-patient services. PITC will be offered
to the following principal target populations: pregnant women, patients diagnosed with STIs, as well as
family members of persons living with HIV/AIDS (PLWHA) and self-referred members of the general public.
To enhance patient uptake, CT services will be offered at community outreach activities in the surrounding
communities, and home testing for families of PLWHA. Funding under this activity will specifically go to
support the cost to conduct community-level testing and use systematic task shifting strategies to training
lay counselors in CT. Through this component support will be provided to 19 service outlets to train 100
individuals in PITC and CT, conduct and provide PITC and CT services to an estimated 35,000 individuals.
The second component of this activity is the training of staff at the hospitals to provide PITC and CT and the
training of supervisory staff at the hospital to ensure that minimum quality standards of service are met.
Counselors, laboratory staff, and VCT counselors will be trained on how to conduct pre-test and post-test
counseling so that counseling supervision is ensured, and on providing full and accurate information on HIV
prevention, and also on how to make the appropriate referrals for patients and their families who test either
positive or negative. The training of trainer concept will be used for persons involved in workshops. This
component of the activity will work to train 100 individuals in PITC and CT. All CT training activities will use
the standard Zambian VCT guidelines and testing protocols. Also, the laboratory will ensure the correct use
of the HIV rapid test kits and be supported to develop internal and external quality assurance.
The final component is strengthening and expanding linkages to ensure continuity of care for all persons
accessing CT through AIDSRelief. Strong linkages will be formed with other HIV-related activities including
palliative care provided by the SUCCESS and RAPIDS projects, as well as other orphans and vulnerable
children projects conducted by the CHAMP and RAPIDS projects (HKID activity #8947). AIDSRelief will
also work to establish linkages with other community groups to ensure social, psychological, legal support,
and income generation activity which is available for all patients who test positive for HIV. Funds for this
component will be used to establish and strengthen referral networks between community groups and social
service providers, as well as with other related projects conducted by CRS and other USG partners.
Continuing Activity: 15615
15615 9713.08 HHS/Health Catholic Relief 7200 3007.08 AIDSRelief- $440,000
9713 9713.07 HHS/Health Catholic Relief 4951 3007.07 AIDSRelief- $440,000
Table 3.3.14:
•Reduction in funding amount needed for ARV Drugs
The funding level for this activity in fiscal (FY) 2009 will decrease from the funding level in FY 2008. This is
due to the recent drug accreditation of all AIDSRelief sites that can now access ARV drugs through the
government system.
AIDSRelief provides HIV care and services, including anti-retroviral (ART), primarily to the most
marginalized populations through faith based organizations in rural areas. AIDSRelief works through the
local partner treatment facility (LPTF) to provide treatment and care and builds the capacity of the treatment
facility to provide this care as a means of building a sustainable care system. In the initial phases of the
program, the ARV drugs were purchased directly by AIDSRelief, in a system parallel to the Ministry of
Health (MOH). However, in the spirit of supporting the "Three Ones" principle and in order to ensure the
development of a sustainable system, beginning in FY 2006, AIDSRelief agreed with the MOH that new
patients initiated on treatment in the AIDSRelief-supported sites would receive first-line and second-line
generic drugs through the Medical Stores Limited (MSL) logistics supply system. The U.S. Government
through John Snow Institute (JSI) Deliver has strengthened the central logistic procurement and supply of
ARV medications.
In FY 2009, all AIDSRelief-supported sites will have access to government supply pipeline of drugs.
AIDSRelief will keep $100,000 for ART drug supply as a buffer stock and to secure certain ARV drugs
unavailable on occasion through MSL. This backup is intended to help avoid emergency stock-outs as the
Government of the Republic of Zambia (GRZ) stock reporting and drug forecasting systems are being
strengthened. As of June 2008, approximately 3,636 patients (adults and pediatrics) were on second-line
and/or drug combinations containing second-line ART. Churches Health Association of Zambia (CHAZ) will
continue to store the buffer stock and will also distribute drugs in FY 2009. AIDSRelief will provide ART for
nearly 30,000 patients at 19 faith based hospitals and other clinics including the maintenance of over
20,000 patients from 2008 and the expansion of ART to an additional 10,000 patients in 2009-2010.
Targets set for this activity cover the period ending February 28, 2010.
Continuing Activity: 15611
15611 12066.08 HHS/Health Catholic Relief 7200 3007.08 AIDSRelief- $212,000
12066 12066.07 HHS/Health Catholic Relief 5249 5249.07 Track 1 ARV $1,615,895
Resources Services
Services
Program Budget Code: 16 - HLAB Laboratory Infrastructure
Total Planned Funding for Program Budget Code: $18,300,000
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
Quality laboratory services play a crucial role in public health in both developed and developing countries they provide reliable,
reproducible and accurate results for disease detection, diagnosis and follow up of treatment. Reliable laboratory results are
important aspects of prevention, care, and treatment of HIV/AIDS, TB and opportunistic infections (OI's). Quality laboratory
services require comprehensive coordinated support programs to establish, maintain, and document ongoing testing procedures,
and must include effective systemic mechanisms for monitoring, collecting, and evaluating information. Accurate patient
diagnosis and monitoring requires Good Laboratory Practices (GLPs), adequate facilities, infrastructure, skills, human resources,
management supervision, equipment that is maintained, sufficient lab commodities, waste management, and a user friendly
system of data recording and reporting.
The U.S. Mission in Zambia began providing laboratory support to the Government of the Republic of Zambia (GRZ) in 2002. To
rapidly expand and improve the quality of laboratory services in Zambia from 2002-2008, the U.S. Mission in Zambia supported
five major initiatives. The first was the provision of automated CD4, hematology and chemistry laboratory testing systems which
are now operating in most districts throughout the country.
The second initiative established three laboratories to provide early infant diagnosis, using the polymerase chain reaction (PCR)
technology. Two laboratories are located in Lusaka -- one at the University Teaching Hospital (UTH) Pediatric Center of
Excellence and the other at the Centers for Disease Research of Zambia (CIDRZ) in Kalingalinga -- and a third laboratory is
situated in the Arthur Davison Children's hospital in Ndola.
The U.S. Mission in Zambia's third initiative involved strengthening the national TB laboratory network, consisting of 160 GRZ
laboratories in 72 districts. Nine provincial hospital laboratories support district and rural health center laboratories. The U.S.
Mission in Zambia supports the National TB laboratory, Chest Disease Laboratory (CDL), the UTH TB laboratory in Lusaka, and
the regional TB reference laboratory at the Tropical Diseases Research Center in Ndola. These three institutions act as referral
and reference TB laboratories provide services in TB culture, drug susceptibility testing, and sensitive TB AFB smear microscopy.
They also disseminate material supporting the national quality assurance (QA) program for TB and AFB smear diagnosis to the
Zambia laboratory network.
The fourth U.S. Mission in Zambia initiative was to strengthen bacteriology laboratory services in Zambia. In FY 2006-2007, CDC
placed the semi-automated blood culture system at six laboratories in UTH, Arthur Davidson Children hospital, and provincial
hospitals. An additional three district hospitals receive lab reagents for blood culture.
The fifth and final initiative involved assistance to the Ministry of Health (MOH) and other partners to develop a national QA plan to
improve the quality of rapid HIV testing in Zambia through a national trainer of trainers, laboratory infrastructure and services
training, provision of QA/QC (quality control) support, specimen transportation, renovation where required, equipment and supply
procurement, and provision of equipment services agreement.
The U.S. Mission in Zambia has been providing laboratory reagents and supplies to PEPFAR-supported laboratories since
PEPFAR's inception through the Supply Chain Management Systems Project and the national (MOH) Medical Stores Limited. A
national laboratory logistics system to track laboratory stock, inventory and the use of laboratory testing records was introduced in
FYs 2007 and 2008. The logistics system is in the pre-pilot phase in three provinces. A national roll out is planned (with
involvement of CDC trained staff), in FY 2009. This activity will ensure the competent and sustainable laboratory management of
test kits, reagents and supplies and full documentation of all occurring transactions.
In FY 2009, the U.S. Mission in Zambia will continue to support activities as described above. In addition, the U.S. Mission in
Zambia will provide both financial and technical support to assist the MOH in several activities including: 1) strengthening national
QA laboratory program in rapid HIV testing, CD4, and TB by working in close collaboration with other partners such as Zambian
Prevention Care and Treatment, UTH, Japanese International Corporation Association (JICA) and the Centre for Infectious
Disease Research in Zambia; 2) developing a national external quality assessment scheme (EQAS) for HIV testing, CD4, and TB,
to include monitoring and evaluation through management supervision; 3) developing a national laboratory information system
that would interface with the established SmartCare system in order to retrieve patient records as well as laboratory data; 4)
developing a new five-year national laboratory strategic plan (the current national laboratory operational plan covers the period of
2006-2008) to ensure that continual and sustainable measures are implemented; 5) improving energy supply for laboratories in
Zambia to offer a stable and continuous system of supply; and 6) providing technical assistance to plan and design a national
public health laboratory in coordination with other partners, (at present, Zambia does not have a national public health laboratory).
A national public health laboratory would offer a sustainable resource for continual national quality management and supervision.
QA for HIV testing began in FY 2008 in collaboration with UTH, the national HIV reference laboratory.
Furthermore, in FY 2009, the U.S. Mission in Zambia will provide more direct technical support to Provincial Health Offices
(PHO's) using a systematic approach in order to improve the quality of laboratory services in all provinces. The U.S. Mission in
Zambia will support setting up an early infant diagnosis (EID) laboratory at Livingstone General Hospital to serve the population in
the Southern Province where HIV prevalence is as high as 30%. The U.S. Mission in Zambia will also offer technical assistance
for the expansion of the EID services at Maina Soko Military Hospital, which is financially supported by the Department of Defense
(DOD). DOD will also expand its services in six military-based hospitals in several provinces.
In FY 2009, the U.S. Mission in Zambia will also continue to build local human capacity by providing professional training of
laboratory personnel at both in-service and pre-services levels. The U.S. Mission in Zambia will encourage participation in
training courses, continued education, skill transfer, hiring and training of local staff, and attendance of conferences and
workshops related to laboratory issues. One of the U.S.-planned trainings will be a Good Clinical Laboratory Practice (GCLP)
course. The curriculum will include QA/QC, ARV laboratory services, equipment maintenance, supply chain management, lab
safety, waste management (sharps and biological), and review of Standard Operating Procedures (SOPs). Furthermore, the U.S.
Mission in Zambia will assist the MOH in reviewing the curriculum of laboratory technologists in collaboration with the Clinton
Foundation, as need arises.
Furthermore, linkages between the Laboratory Infrastructure and Biomedical Injection and Blood Safety program areas will be
established. Technical assistance from the CDC Zambian Laboratory staff to the Biomedical Injection and Blood Safety programs
will be provided.
The U.S. Mission in Zambia will continue to coordinate activities and share information with other donors such as the Global Fund
to fight AIDS, Tuberculosis, and Malaria, President's Malaria Initiative, TB CAP, and JICA to ensure smooth operations and avoid
duplication of resources and effort. With a focus on the missing gaps in strategic laboratory infrastructure interventions including
strengthening the national QA program for laboratory testing at both central and regional levels, improving laboratory
infrastructure (energy), training, provision of laboratory commodities and technical assistance, the U.S. Mission in Zambia is in an
excellent position to further improve the quality and sustainability of laboratory services in Zambia.
Table 3.3.16:
ACTIVITY UNCHANGED FROM FY 2008.
This activity relates to: EGPAF SI (3709.08), JHPIEGO SI (3710.08), Ministry of Health (MOH) (3713.08),
Technical Assistance - Centers for Disease Control and Prevention (CDC) (3714.08), and SmartCare
COMFORCE (9692.08)
Constella Futures leads the monitoring and evaluation (M&E) component for Catholic Relief Services (CRS)
AIDSRelief Zambia. Using in-country networks and available technology, Constella Futures has built strong
patient monitoring and management systems that are used to collect data and track strategic information
from the Points of Service (POS). Strategic information (SI) includes indicators from the President's
Emergency Plan for AIDS Relief (PEPFAR), other United States Government (USG) agencies, National
Ministry of Health (NMOH) in conjunction with the Ministry of Health (MOH), and AIDSRelief specific project
indicators. This collective information supports the provision of high-quality HIV/AIDS care and treatment,
ensures drug availability, tracks patient and program progress, and provides accuracy in reporting to both
the USG and NMOH (former Central Board of Health). While reporting on indicators to donors and
governments is an essential secondary objective, the primary aim of collecting SI is to assist clinicians and
clinic managers to provide high quality HIV/AIDS care and treatment, assist in chronic disease
management, monitor viral resistance, and ensure durable viral suppression.
With the MOH rolling-out SmartCare electronic medical record (EMR) application as the national standard,
having migrated all AIDSRelief supported sites on to SmartCare. Constella futures will concentrate on
providing support in SmartCare, ensuring that all sites are working efficiently in SmartCare programme.
Systematic site mentoring, exchange visits, and in house evaluations will be used to enhance local partner
treatment facilities (LPTF) use and understanding of SmartCare.
The program will ensure that site using new SmartCare to produce accurate reports through data validation,
cleaning and analysis at site level.
In FY 2009 the SI team will continue to focus their efforts on maintaining the standardized national M&E
systems that will be used across all AIDSRelief sites. This will include the mentoring of already trained as
well as training of new facilities in using the forms and software adopted at national level.
Constella Futures will develop an in-house M&E course for LPTF data management staff in collaboration
with CDC, The University of Zambia and MOH.
Constella Futures provides training and on-site technical assistance to LPTFs in order to build in-country
capacity and enhance paper-based and automated HMIS. Focusing efforts on capacity building activities
will ensure that LPTFs are skilled in comprehensive data management, including data collection, validation,
analysis, and reporting. LPTFs will also develop an understanding of the minimum data requirements for
donor purposes and high-quality clinical management. It is Constella Futures's intent to ensure that
accuracy in data management is understood at all levels at the LPTFs because it is an essential component
of monitoring patient progress and ensuring accuracy in reporting.
In year 2009/10 Constella Futures will carry-out more evaluations, which will cover program implementation,
outcome, and impact assessments. The evaluation will incorporate the findings from Quality
Assessment/Improvement (QA/QI), Quality of Life Analysis (QLA) and Life Table Analysis (LTA). The focus
of these will be to bring out the best practices, lessons learned and promising lessons that will come out of
the evaluations and reviews of the AIDSRelief Zambia program.
Continuing Activity: 15618
15618 3711.08 HHS/Health Catholic Relief 7200 3007.08 AIDSRelief- $960,000
8828 3711.07 HHS/Health Catholic Relief 4951 3007.07 AIDSRelief- $450,000
3711 3711.06 HHS/Health Catholic Relief 3007 3007.06 AIDSRelief- $150,000
Estimated amount of funding that is planned for Human Capacity Development $190,000
Table 3.3.17:
