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: 2007 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
•Fifteen percent of FY 2008 funds have been placed into the Pediatric Treatment and Care & Support
program areas.
•Narrative has been updated to describe the activities associated with only Tract I funding.
This activity relates to CRS (#8827).
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.
New/Continuing Activity: Continuing Activity
Continuing Activity: 15612
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
15612 4548.08 HHS/Health Catholic Relief 7199 5249.08 Track 1 ARV $156,799
Resources Services
Services
Administration
8829 4548.07 HHS/Health Catholic Relief 5249 5249.07 Track 1 ARV $2,582,819
4548 4548.06 HHS/Health Catholic Relief 3007 3007.06 AIDSRelief- $0
Resources Services Catholic Relief
Services Services
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
* Reducing violence and coercion
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.09:
The five sites supported from Tract I funding are St. Francis Mission Hospital, St. Theresa Mission
Hospital, Mtendere Mission Hospital, Wusakile Clinics, and Chreso ART Center Lusaka. These sites by
February 2008 accounted for 13,259 patients on ART. The high enrollment at these sites has created
emergency level capacity challenges in the areas of human resources and infrastructure. While these sites
have been receiving AIDSRelief support and enrolling patients the longest, they also have had high staff
turn over requiring increased technical assistance. They have also created the need for increased effort
directed toward task shifting and decentralization with satellite clinic development.
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 prevention of mother to child HIV transmission (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.
7.Community Based Treatment Services (CBTS) focuses on utilizing the community to maximize health
care outcomes. The CBTS specialists work with adherence staff, community health workers 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. The
magnitude of patient requiring follow-up at these sites has created the need for increased effort in
community worker training and transportation needs through vehicles, motor bikes, and bicycles. These
sites will continue to need greater task shifting efforts to empower community workers to take on a greater
role in the care and treatment team. 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.
8.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 MOH sponsored trainings are often conducted for sites in a particular region, and
incorporated into all of these trainings is mentoring opportunities in both the various out patient clinics and
the in patient setting. In an attempt to address sustainability one of the physicians at Chreso ART Center is
participating in the year long HIV Diploma course at University Teaching Hospital (UTH) to add HIV
expertise to the center. 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.
9.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. These trainings will be
conducted at Chreso ART Center. AIDSRelief has trained over 40 nurses at St. Francis Mission Hospital
and they now provide the bulk of outpatient ART care for this LPTF.
10.The Outcomes and Evaluations (O&E) team have done yearly assessments of viral load outcomes
demonstrating durable quality care at our sites. Formal chart reviews, adherence surveys, and HIV
knowledge questionnaires have been collected since 2005. All of these sites were included in our quality
assurance/quality improvement sampling and survey. 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.
11.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. Three of these sites have had extremely high laboratory staff
Activity Narrative: turn over requiring increased effort at retraining and ensuring quality standards are maintained. Two sites
had upgrades on laboratory equipment to meet increased demand, and three of these sites will have an
investment in viral load capacity during the coming year.
12.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.
During FY 2009 an additional 5,975 patients on ART will be added from these sites. The activities outlined
for all sites in the Pediatric Care and Support, Pediatric Treatment, and PMTCT narratives will also be
incorporated into the work plan for each of these Track I sites.
The activities in this proposal will complement activities in (#8827) and will enhance scale-up and
consolidation of ART services in areas served by AIDSRelief. These services are critical to providing
quality HIV care and treatment, and have been an integral part of the AIDSRelief program since its
inception. This proposal is also contingent upon continued central funding through HRSA at existing levels.
Continuing Activity: 17694
17694 17694.08 HHS/Health Catholic Relief 7199 5249.08 Track 1 ARV $4,198,714
Estimated amount of funding that is planned for Human Capacity Development $756,188
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 FISCAL
YEAR (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 7500 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 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. 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
Activity Narrative: 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:
Health-related Wraparound Programs
* Child Survival Activities
* Malaria (PMI)
* Safe Motherhood
Estimated amount of funding that is planned for Human Capacity Development $150,000
Table 3.3.11:
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.
Activity Narrative
This activity is related to activities under adult treatment (#17694.08 and #4548.08) adult care and support
(# 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)
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. 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
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
program.
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.
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: 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.
Estimated amount of funding that is planned for Human Capacity Development $200,000
