ACTIVITY REMAINS UNCHANGED FROM FY 2008.Only minor narrative updates have been made to

highlight progress, achievements and a transition plan as highlighted in the narrative. The funding for this

activity has been reduced by 10% to support EGPAF Pediatric Treatment.

MAINTAINING EXISTING SITES:

This activity relates to EGPAF/CIDRZ (#9000). The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF)

and the Center for Infectious Disease Research in Zambia (CIDRZ) supported government sites have

enrolled 154,237 adults and children and started 97,978 on antiretroviral therapy (ART) as of the end of

June 2008. Presently, 62 ART sites in Lusaka, Eastern, Western, and Southern provinces are being

supported. EGPAF/CIDRZ has trained 1,648 health care workers in adult and pediatric ART delivery.

CIDRZ has presented 48 abstracts and published 36 papers related to these activities. EGPAF/CIDRZ

plan to maintain the existing programs at the joint Government of the Republic of Zambia (GRZ) sites.

There are six proposed components to this track 1.0 funded activity, including: (1) continued support for

existing services at 68 sites in 22 districts; (2) a continued focus on women's health care with the cervical

cancer screening program; (3) pilot integration of HIV care and outpatient department treatment services,

(4) a continued focus on improved quality of care, (5) expansion of community activities to prevent loss to

follow up on patients enrolled and (6) ongoing Laboratory services to support the program.

1. EGPAF/CIDRZ will continue the support of 68 sites in 22 districts throughout FY2009. To keep up with

the increasing numbers of patients renovation projects will be carried out at selected clinics.

2. Cervical cancer screening program: Since the inception of the "See and Treat" Cervical Cancer

Prevention Program, in FY 2006, over 20,000 women have been screened, services in 14 clinics have been

established, five Zambian doctors and 14 Zambian nurses have been trained, 32 Cervical Cancer Peer

Educators have been hired and three Data Associates have been employed. The importance of the

Cervical Cancer Prevention Program is evident in the very high rates of intervention required among women

who present for screening. Of 14,000 women on whom data are presently available, 40% have required

either immediate treatment with cryotherapy or referral for biopsy and/or surgery. Also of significance are

the very high rates of microinvasive cancer (58% of all cancers) detected through screening. These lesions

are associated with very high rates of cure but if not detected and treated they progress to cancers that

have lower cure rates and considerable morbidity.

During FY 2009, we will continue supporting the present clinical and service infrastructure and will expand

services to five more clinics and will screen 10,000 additional patients. We will also focus on developing

the following aspects of the program:

1.Quality Control: In order to improve the quality of services rendered and evaluate their impact we will

create a quality control unit in our administrative infrastructure.

2.Administrative Oversight: We will hire a Program Director who's primary responsibility will be to organize

and lead the administrative operations.

3.Data Management: The data unit will be reorganized to improve its efficiency and output with the goal of

generating information that can be utilized by GRZ staff to aid in the development of national cancer

prevention strategies.

4.Health Promotion and Advocacy: A health promotions and advocacy unit will be added to the

administrative infrastructure of the program.

5.Information Technology: An information technology unit will be developed with the primary purpose of

adapting cost-effective mobile technology to cervical cancer screening activities.

6.Training and Education: We will provide advanced training on methods of screening and treating cervical

cancer in low-resource environments to medical students, Obstetrics and Gynecology residents and doctors

at the university.

7.Surgery: We will develop a radical surgery training program at University Teaching Hospital (UTH) and

Monze Mission Hospital in collaboration with UTH and Ministry of Health (MOH) doctors.

3. Pilot integration of HIV care and outpatient department treatment services: Currently, all EGPAF/CIDRZ

supported sites provide ART services in clinics dedicated to the care of HIV-infected patients. This is a

common model throughout Zambia despite discussion of service "integration". Most conditions such as

pregnancy and diseases such as tuberculosis are managed in a vertical fashion, often without knowledge of

the HIV status or optimal linkage between departments. This model may have worked well in the past to

support ART scale up, but as increasing numbers of HIV-infected patients are identified and the availability

of ART increases there is an urgent need to integrate patient care. In addition, HIV is a confounding factor

in the presentation of virtually any disease or condition and continuing the vertical approach to patient care

may affect patient outcomes. Care integration is occuring through the following activities: 1) outpatient

department (OPD)/ART integration pilot (described below), 2) provision of HIV testing in TB clinics and

strengthening referrals between TB and ART clinics (funded through a different mechanism) and 3)

ensuring that, where feasible, new clinic implementations incorporate an integrated OPD/ART care model.

A model integrating the vertical ART services with regular OPD services was developed between November

2007 and April 2008 in collaboration with Lusaka District Health Officials and clinical staff from two Lusaka

health centers. The model constitutes a comprehensive integration of clinical services, registry systems

and patient flow and introduces provider-initiated counseling and testing for all patients who do not know

their HIV-status. Patients not enrolled in ART are screened using a new short-visit form developed to

encourage greater consistency in clinical screening practice and medical record keeping, and to prompt

screening for common opportunistic infections. Patients found to be HIV-infected will be counseled and

booked for enrollment in the ART program but, under the integrated system, clinical ART services are

provided at the same physical location and by the same providers.

A pilot to test this model in the first of two clinics was initiated in July 2008 with the second anticipated to

start in October. Monitoring and evaluation of the two pilot sites will continue for a twelve month period

from the date of implementation and formal evaluation of the efficacy of the model in the pilot sites will

provide the basis for decisions about future scale-up of integrated ART and OPD services in Lusaka clinics

Activity Narrative: and provincial locations.

4. Continued focus on improved quality of care: In FY 2008, based on projections, approximately 32,000

new patients will be enrolled and 22,000 new patients will be started on ART. Comprehensive patient

support was continued for all enrolled patients including support for all protocol-required laboratory testing in

Lusaka-supported sites and lab instruments, back-up reagents and technical support in provincial sites. In

addition CIDRZ pharmacy services continue to provide oversight in drug distribution, storage and back-up

supplies for ART and drugs to treat and prevent opportunistic infections. EGPAF/CIDRZ will continue to

play a role in national supply chain meetings informing quantification for antiretroviral drugs (ARV) and

opportunistic infections (OI).

Comprehensive quality assurance programs continue to operate in all clinics monitoring improvement in

patient quality of care including the utilization of the SmartCare System to identify treatment failure and

gaps in implementation of patient care protocols. The CIDRZ quality assurance/quality control (QA/QC)

staff also supports the development of clinic based QA teams. Monitoring is achieved by teams of QA/QC

nurses overseeing patient care, based on QA/QC tools and patient care protocols. In addition, there is a

QA/QC team specifically dedicated to monitoring diagnosis and treatment of TB. Weekly clinical meetings

are convened in each ART clinic to discuss and present cases and medical officers work as mentors with

clinic staff to improve care.

In FY 2008 the quality assurance team has been working with the clinical care specialists in all provinces to

build capacity for them to assume responsibility for QA/QC issues; this is evidenced by joint trainings. The

goal is transition of these tasks over time to MOH staff. Similar activities are occurring in pharmacy,

administration, and planning. These activities will continue and expand in FY 2009.

In FY 2009, Project HEART will focus training on more advanced ART management (treatment failure,

second line therapy, drug resistance, STI diagnosis and treatment) for both adults and peds and provide

technical assistance to the provincial health offices to allow them to assume responsibility to conduct basic

ART management trainings. In addition, Project HEART will continue to provide regular quality assurance

and improvement assessments. These are presently being done by CIDRZ teams in collaboration with

local and provincial health staff. In 2009, the MOH district and provincial teams will be encouraged and

supported through technical assistance to conduct independent quality assurance and improvement

assessments.

5) Expansion of community activities: In FY 2009 we plan to pilot a program to follow up newly enrolled

patients who have not yet begun ART in an attempt to stem the default rate of this cohort. We will continue

the existing follow up of all ART patients missing pharmacy visits in Lusaka through the network of support

group workers engaged in this activity and will identify home based care (HBC) groups and other potential

partners for collaboration in the provinces to assist with follow up of patients in these areas.

Specific sensitization messages will be improved upon to focus explicitly on enrollment into the ART

program and the importance of maintaining clinical follow-up before and during ART initiation and

continuation. Through the various information, education, and communication (IEC) materials (drama,

radio, print, video) the community team will emphasize the importance of maintaining regular clinical follow-

up for those enrolled to ensure initiation of ART at the appropriate time.

6. Ongoing Laboratory services to support the program: The EGPAF/CIDRZ ART and prevention of

mother to child transmission (PMTCT) activities are supported by a Central Laboratory at Kalingalinga

District Clinic. The Central Laboratory performs multiple assays designed to provide clinical support for the

service programs and the ongoing projects at CIDRZ. The laboratory performs assays on clinical

specimens for hematology, clinical chemistry, clinical microbiology, coagulation, HIV diagnostics, molecular

biology diagnostic, serology, specimen archiving, and HIV monitoring (CD4 counting and HIV viral load).

All assays, are enrolled in international quality assurance programs and blinded specimens are received

throughout the year for testing and comparison with other labs in a similar peer group. Clinical specimens

are transported to the laboratory from various clinics and hospitals throughout Lusaka and Zambia via a

dedicated specimen transport system. All specimen records are managed with a computerized laboratory

information system, which is interfaced with the high-throughput instruments in the laboratory. Complete

client test results reports are generated for each specimen received and distributed to the appropriate clinic

by the dedicated specimen transport system.

Currently, the Central Lab is performing approximately 11,000 CD4 tests, 10,500 complete blood counts

(CBC's), 11,000 chemistry (liver and kidney function tests), and 2,000 syphilis tests per month for the ART

Service and PMTCT programs. The number of molecular biology tests performed is increasing to

approximately 7,000 HIV RNA viral loads and 600 HIV DNA polymerase chain reaction (PCR) infant

diagnostic tests per year.

The laboratory plans to participate with the Lusaka District Health Management to augment the capacity of

four sub-district labs in the Lusaka Urban District to provide testing of selected tests, such as Full Blood

Counts, CD4 and Liver and Renal function chemistry tests for the HIV and care treatment program. These

MOH laboratories will add capacity in the district system and relieve the pressure on the CIDRZ Central

Laboratory. Additionally, CIDRZ has implemented a utilization control process to reduce or eliminate

needless testing. This process has already significantly reduced testing volume in the ART program.

We will ensure gender equity in provision of ART services, through community based sensitization

programs aimed at encouraging both males and females to access ART services

Transition:

Increasing program sustainability with the GRZ, Project HEART will work with the monitoring and evaluation

technical working group and the care and treatment technical working group to build on the quality

Activity Narrative: assurance activities started in FY 2008. In FY 2009, in collaboration with the GRZ, Project HEART will

work with district and provincial health offices to increase numbers of staff on their teams and to increase

capacity of staff to assume responsibility for various program components (laboratory, pharmacy, QA/QC,

data, clinical care, community etc). In conjunction with MOH timelines for capacity building, partial and

then complete transition of program responsibility will be agreed upon.

Over the next few months meetings will be held with the MOH, district health management teams and

provincial health offices to discuss a detailed transition plan. This will include maintenance and expansion

activities, both clinical and community. This plan will have a timeline and bench marks that must be met

over the coming years. The details of this transition plan will be included in the PY6 reapplication

(FY2009/10).

TARGETS HAVE HISTORICALLY BEEN UNDER ART SERVICES EXPANSION TRACK 2.0

New/Continuing Activity: Continuing Activity

Continuing Activity: 15517

Continued Associated Activity Information

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

System ID System ID

15517 4549.08 HHS/Centers for Elizabeth Glaser 7171 5250.08 Track 1 ARV $15,764,509

Disease Control & Pediatric AIDS

Prevention Foundation

9003 4549.07 HHS/Centers for Elizabeth Glaser 5250 5250.07 Track 1 ARV $15,764,509

Disease Control & Pediatric AIDS

Prevention Foundation

4549 4549.06 HHS/Centers for Elizabeth Glaser 2998 2998.06 TA- CIDRZ $0

Disease Control & Pediatric AIDS

Prevention Foundation

Emphasis Areas

Construction/Renovation

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:

THIS IS A CONTINING ACTIVTY BUT HAS BEEN PULLED OUT OF THE MAIN HIV TREATMENT

COMPONENT WITH SPECIFIC EMPHASIS ON TREATMENT OF CHILDREN

Activity Narrative:

This activity is related to adult treatment (# 4549.08 and 3687.08), PMTCT (#3788.08), all provincial

pediatric treatment activities (# NEW SPHO, EPHO and WPHO) and a number of public health evaluations

that are ongoing.

The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) and the Center for Infectious Disease Research

in Zambia (CIDRZ) propose to maintain existing and expand the antiretroviral therapy (ART) service support

to the Government of the Republic of Zambia (GRZ). All EGPAF/CIDRZ supported sites offer pediatric

services. The EGPAF/CIDRZ program has not yet met the target of at least 15% of ART clients being

children. This is due, in part, to the continued difficulty in diagnosing and recruiting pediatric patients,

especially infants. While the absolute number of children accessing ART care and treatment has steadily

increased, the overall number of children as a percentage of clients accessing treatment has remained

between seven and eight percent. In FY 2009 a number of activities are planned to increase this

percentage: (1) a multi-prong approach to increase the focus on pediatric care, (2) expand the model of

HIV care and treatment for orphans and vulnerable children residing in orphanages and (3) improve

outreach to vulnerable children by using the existing community network to share information regarding

local treatment services available for children.

The EGPAF and CIDRZ-supported government sites have enrolled 154,237 adults and children and started

97,978 on antiretroviral therapy (ART) as of the end of June 2008. Presently, 62 ART sites in Lusaka,

Eastern, Western, and Southern provinces are being supported. EGPAF/CIDRZ has trained 1,648 health

care workers in adult and pediatric ART delivery. CIDRZ has presented 48 abstracts and published 36

papers related to these activities.

(1) Multi-prong approach to increase the focus on pediatric care: The new MOH guidelines recommend the

initiation of ART to all infants with a confirmed (virological) diagnosis of HIV infection, regardless of CD4

percentage. EGPAF/CIDRZ will assist the MOH to scale-up this activity and this should increase the

numbers (and percentage) of children starting ART. EGPAF/CIDRZ will strengthen linkages with PMTCT to

increase enrollment of children into care and treatment. In addition, as requested by the MOH,

EGPAF/CIDRZ will pilot the use of a protease inhibitor (lopinavir) based regimen in children at selected site

(s). EGPAF/CIDRZ supports and advocates for provider initiated counseling and testing (PITC) through a

variety of means. Clinicians are trained and encouraged to advise sick parents to have their children tested

irrespective of age and encourage siblings of children already in care and treatment to be tested as well. In

ongoing pediatric specific training, clinicians review PITC and brainstorm on how more children can be

reached.

EGPAF/CIDRZ will improve psychosocial support offered by pediatric peer educators through a two week

training program for 60 pediatric peer educators called Psychosocial Care and Counseling for HIV Infected

Children and Adolescents (ANECCA/AIDS Relief). The program will also refurbish and equip child-friendly

counseling rooms with basic supplies and will develop appropriate job aids to improve pediatric treatment

literacy. Examples of job aids include guidelines for pediatric dosing, re-dosing, and medicine

administration in laminated or wall chart form. Focus group discussions will be held with pediatric providers

to ensure that the job aids developed or purchased are relevant to the challenges they face. Targeted

supportive supervision and clinic mentoring will be provided to pediatric healthcare providers by pediatric

mentors and information, education and communication (IEC) materials will be shared which focus on

improving parent-provider communication. In collaboration with HCP, we are developing a positive living flip

chart for children which will also assist clinicians and families in initiating and maintaining children on ART.

Discussions are underway between the CIDRZ, MOH, Lusaka Provincial Health Office, Lusaka District

Health Management Team, the University Teaching Hospital Pediatric Centre of Excellence (PCOE), and

Columbia University, to increase access to care and treatment and provide comprehensive clinical and

psychosocial services under one roof by renovating a large, pediatric community clinic in Lusaka. If support

is gained for this community based Children's HIV referral clinic, clear roles of all the partners involved will

be identified to avoid duplication of efforts including the role of the PCOE in comprehensive training of

health care workers, provision for referral of complicated cases and down referral of stable clients to the

community centre or nearest health facility. This will be a community based Children's HIV referral clinic

and will also be used to improve the skills of the health care workers who treat pediatric patients at the

primary level. This is not meant to duplicate activities of the PCOE. This will be a model clinic for pediatric

care at the primary level.

(2) Expand the model of HIV care and treatment for orphans and vulnerable children: Despite intensive

efforts at the Fountain of Hope Program at Kamwala, this site has not been able to enroll children into care

and this intervention has been closed. Fountain of Hope is no longer housing children on a long-term basis

and has had a number of issues in recruiting and retaining qualified clinical staff.

Instead we have been focusing our efforts to support a local NGO "Tiny Tim and Friends" to provide care

and treatment to vulnerable children. This comprises general medical, as well as HIV care and treatment.

The focus of this program is to stabilize children on initial ART treatment and then refer them back to the

MOH clinics for long-term care. HIV care and treatment has also been initiated at Bwafano Day Care

Centre where 102 children have been enrolled into HIV care and treatment and 40 commenced on ART.

Bwafano also has an established psychosocial support service which can be used as a resource to

strengthen psychosocial support and counseling as outlined above.

(3) Improve outreach to vulnerable children: To improve outreach to vulnerable children a number of efforts

will continue to strengthen community linkages with locally available treatment services. The puppetry

program which explains care and treatment in a child-friendly manner will continue and be expanded in a

controlled manner to maintain high quality performances.

Activity Narrative: We will also strengthen community outreach activities including development and expansion of child and

adolescent peer support groups, community based education campaigns on pediatric ART. Community

outreach will follow up women from PMTCT services for early identification and testing of exposed children

for commencement of ART if found positive. These will occur as a wrap around activities to current child

survival activities such as growth monitoring, expanded program on immunizations and training and support

for intensive follow up of HIV exposed infants.

Other organizations providing services in Lusaka and the Provinces to vulnerable children will be contacted

locally by community outreach workers and information will be provided to them regarding care and

treatment services offered at the EGPAF/CIDRZ supported clinics. Specifically they will be referred to the

clinics where there are pediatric friendly rooms and counselors who can support the vulnerable child and

caregiver.

EGPAF/CIDRZ 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 to consider adopting a common technical approach to food and nutrition

support.

Laboratory Support:

The EGPAF/CIDRZ ART (adult and pediatric) and PMTCT activities are supported by a Central Laboratory

at Kalingalinga District Clinic. The Central Laboratory performs multiple assays designed to provide clinical

support for the service programs and the ongoing projects at CIDRZ. The laboratory performs assays on

clinical specimens for hematology, clinical chemistry, clinical microbiology, coagulation, HIV diagnostics,

molecular biology diagnostic, serology, specimen archiving, and HIV monitoring (CD4 counting and HIV

viral load). All assays, including are enrolled in international quality assurance programs and blinded

specimens are received throughout the year for testing and comparison with other labs in a similar peer

group. Clinical specimens are transported to the laboratory from various clinics and hospitals throughout

Lusaka and Zambia via a dedicated specimen transport system. All specimen records are managed with a

computerized laboratory information system, which is interfaced with the high-throughput instruments in the

laboratory. Complete client test results reports are generated for each specimen received and distributed to

the appropriate clinic by the dedicated specimen transport system.

Currently, the Central Lab is performing approximately 11,000 CD4 tests, 10,500 complete blood counts

(CBC's), 11,000 chemistry (liver and kidney function tests), and 2,000 syphilis tests per month for the ART

Service and PMTCT programs. The number of molecular biology tests performed is increasing to

approximately 7,000 HIV RNA viral loads and 600 HIV DNA polymerase chain reaction (PCR) infant

diagnostic tests per year.

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.11: