April 2009 Reprogramming: Updated Mechanism and Prime Partner from TBD

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS: Activities for FY 2009 have shifted in focus

away from diagnostic counseling and testing (DCT) to clinical care training, enhanced case finding, linkages

between TB and HIV care programs and infection control in 11 districts of Lusaka, Western and Southern

provinces. Narrative changes include updates on progress made in FY 2008 and description of new

activities planned for FY 2009. The mechanism for these activities ended in FY 2008 and has been listed as

to be determined (TBD) for FY 2009.

Activity Narrative:

The funding level for this activity in FY 2009 will remain the same as in FY 2008.

This activity relates to the following activities:

HIV in sub-Saharan Africa has greatly increased the incidence of HIV-related tuberculosis (TB). Data from

2005-2008 show that 60-70% of TB patients in Lusaka District are HIV-infected and 80% meet eligibility

criteria for immediate antiretroviral therapy (ART).

When the Ministry of Health (MOH) began opening ART clinics in 2004, the overwhelming demand for care

hampered the ability to integrate HIV care with other services. As a result, two vertical systems exist within

health facilities for TB and HIV care and many co-infected patients do not receive the coordinated care they

need. Encouraging TB patients to learn their HIV status, improving TB screening at ART clinics and linking

patient care services is essential to improving patient outcomes and the primary focus of CIDRZ TB/HIV

activities.

In 2005, Tulane University through it's sub-partner, the Centre for Infectious Diseases Research in Zambia

(CIDRZ), partnered with the Lusaka District Health Office (LDHO) to pilot TB/HIV integration activities at one

clinic. All TB patients were requested to undergo provider-initiated diagnostic counseling and testing (PICT)

with follow-up to ensure that HIV-positive patients enrolled in HIV care. This was successful in identifying

and linking patients to HIV care and has been expanded to 22 Lusaka District clinics and 45 clinics in

Chongwe, Luangwa, and Kafue districts as of July, 2008. Our data shows that 85% of TB patients who

underwent counseling accepted an HIV test and 63% of those tested were HIV-infected.

In addition to DCT, CIDRZ activities include: (1) training in TB diagnosis and clinical management of TB/HIV

co-infected patients; (2) establishment of referral and communication systems between TB and HIV clinics;

and (3) systematic monitoring and follow-up of activities.

In FY 2007, the USG funded CIDRZ to work in Lusaka District. In FY 2008, CIDRZ was funded to scale-up

activities to Eastern, Western, and Southern Province with continued technical support to Lusaka District. In

an effort to coordinate services among USG partners, CDC-Zambia and the Provincial Health Offices

(PHO's) have requested that TBD focus activities in 2009 on selected districts in Western, Southern, and

Lusaka Provinces. Activities will expand to a further 128 health centers (for a total of 195) in coordination

with PHO's, DHO's and CDC-Zambia in order to build-upon prior activities. In FY 2009, as DCT is

established throughout Zambia at this time, TBD will shift its focus from DCT to TB diagnosis in HIV-infected

persons, clinical management of co-infected patients, linkages between TB and HIV programs, and bringing

TB services closer to rural populations. Based upon discussion with PHO's and CDC-Zambia, TBD will

concentrate FY 2009 services in the following eight districts:

•Lusaka Province: Lusaka district

•Western Province: Kalabo, Lukulu, and Kaoma districts

•Southern Province: Mazabuka, Choma, Gwembe, and Kalomo districts

All USG TB-related funding for the eight districts listed above will come through TBD, while the other

districts in these provinces will receive USG support through their PHO. The priorities in TBD-supported

districts will be:

1.Clinical training in TB diagnosis and management of co-infected patients

2.Strengthening patient referral and sputum courier systems between TB treatment centers, TB diagnostic

centers, and ART clinics

3.Establishment of microscopy centers

4.Bi-annual district data review meetings

5.Monitoring and evaluation of activities to improve systems operations

6.Community sensitization to decrease TB and HIV stigma and encourage uptake of health services

7.Support to strengthening District TB/HIV Coordinating bodies and establishment of Health Centre bodies

8.System strengthening through infrastructure renovations to facilitate TB/HIV activities and promote TB

infection control

Within Lusaka Province, TBD's primary focus will be Lusaka District, while Lusaka PHO will concentrate on

the remaining three districts. However, TBD and Lusaka PHO (in consultation with CDC-Zambia) decided to

allocate certain activities to each organization to conduct for all four districts in the province. TBD will

concentrate on clinical trainings for health center staff, while the PHO will conduct community health worker

trainings in all four districts. The PHO will also support district and health center coordinating bodies and

data review meetings while TBD will support training of lay microscopists and strengthening of patient

referral and sputum courier systems in all four districts. Working with monitoring and evaluation staff at

CDC-Zambia, indicators have been divided between the two organizations to avoid double-counting.

TBD will hire two TB/HIV Officers; one in Western Province and one in Southern Province to work with the

TBD provincial teams. These TB/HIV Officers will provide local activity coordination and follow-up. They will

work closely with the TBD provincial teams, PHO's, DHO's, and the TBD Lusaka team. The TBD Lusaka

team will provide oversight for TBDTB programs in Lusaka Province.

Activity Narrative: We anticipate providing clinical training to a total of 390 medical officers, clinical officers, and nurses from

the targeted districts. They will be trained in diagnosis of TB in HIV-infected persons (whether diagnosed or

presumed) including symptom recognition, diagnostic investigations, chest x-ray interpretation and clinical

management of co-infected patients. In addition, ART clinic staff and staff from referring TB treatment and

diagnostic centers will come together for workshops to develop patient referral and sputum courier systems.

To aid TB case finding, 16 lay microscopists will be trained and microscopes provided (where needed) to

create rural microscopy centers and/or provide additional staff in urban labs. New microscopy centers and

sputum courier systems will decrease the distance that patients have to travel for smear microscopy as this

impedes completion of the diagnostic process. Lastly, communities will be sensitized through meetings with

community leaders, drama performances and distribution of brochures and posters in Western and

Southern Provinces (this will be covered by Lusaka PHO in Lusaka).

At this time, TBD does not plan to incorporate Isoniazid or co-trimoxazole preventive therapies into

integration models as both are under evaluation at pilot sites run by the MOH and other partners. Should

the MOH advocate scale-up of these programs, TBD will incorporate them into our activities. All TB/HIV co-

infected patients are targeted in integration activities including men and women, children and adults.

A major challenge encountered in FY 2007 and 2008 was the shortage of health care staff. Larger clinics

do not have enough nurses to provide DCT to and ensure ART follow-up for all TB patients. Thus, we

developed a pilot TB/HIV peer educator program at two Lusaka clinics. This program will run through

February 2009, with on-going monitoring and an evaluation at the end. Following evaluation and

consideration of program benefits and sustainability, the MOH will decide whether the program should be

scaled-up to other Lusaka clinics.

Infrastructure was another challenge in FY 2007 and 2008. As of August 2008, renovations to increase

counseling space and reduce nosocomial transmission are underway or have been completed in 10 Lusaka

District clinics, with eight more budgeted for in the remainder of FY 2008. We anticipate that renovations

will be required in an additional four clinics during FY 2009.

A significant strength of the CIDRZ program is intensive follow-up, monitoring, and evaluation to help

ensure that activities continue as intended with quality maintained. With expansion to provincial sites in FY

2008, follow-up was decentralized through collaboration with DHO's. At the request of the MOH, data

collection shifted from CIDRZ-developed forms to reliance on routinely-collected MOH data to minimize the

burden on health center staff. CIDRZ has worked with Lusaka District to modify their forms to capture vital

TB/HIV data. In FY 2009, TBD will continue monitoring through MOH program data, with data strengthening

activities focused on regular discussions with DHO's and PHO's and bi-annual data review meetings with

district staff to enhance their ability to produce and monitor high-quality program data (this will be supported

by Lusaka PHO in Lusaka Province).

Of approximately 18,000 new TB patients at TBD sites during FY 2009, we estimate that 55% will receive

DCT over the 12-month period for a total of 10,000 patients. The percentage tested will be greater in rural

districts where there are few TB patients and lower in Lusaka District where significant staff shortage results

in fewer patients tested and where the DHO has requested that TBD not provide staff support in the form of

overtime shifts or lay counselors. This was requested so that programs are sustainable within current district

staffing structures. Of the 10,000 TB patients who are tested for HIV, approximately 70% of them (7000)

will be HIV-positive. It is expected that 50% of the co-infected patients (3500) will receive HIV care.

To align data collection with national systems, TBD will collect copies of MOH facility-level reports from

DHO's each quarter. Thus TBD will be collecting and reporting to CDC the same data that is reported to the

National TB Program through DHO's and PHO's.

All TB/HIV integration activities are designed to be sustainable and operate within current district clinic

structure. CIDRZ works with MOH staff to integrate services within the confines of staff capacity and will

continue efforts to strengthen collaboration with MOH staff. Rather than providing services directly, CIDRZ

trains district nurses, doctors, clinical officers, treatment supporters, and peer educators and helps them

evaluate and re-organize systems for greater efficiency and sustainability. Data monitoring, mentoring and

supportive supervision will be provided in conjunction with DHO's and PHO's. CIDRZ is a member of the

National TB/HIV coordinating body.

Lastly, CIDRZ has a TB laboratory at the CIDRZ Central Lab. Where possible, this facility will collaborate

with the Chest Diseases Laboratory on training and assessing new TB diagnostics. Our lab has capacity for

light and fluorescence microscopy, liquid and solid culture, molecular diagnostics, species identification and

drug sensitivity testing. The lab is currently conducting an evaluation of several lower-cost light-emitting

diode (LED) fluorescence microscopes to determine if they are suitable for TB diagnosis in Zambia. In FY

2009, the lab will provide TB culture, drug sensitivity testing and molecular diagnostics for complicated TB

suspects/cases at CIDRZ-supported HIV clinics including smear-negative TB suspects, treatment failures,

and relapse cases.

New/Continuing Activity: Continuing Activity

Continuing Activity: 15566

Continued Associated Activity Information

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

System ID System ID

15566 3653.08 HHS/Centers for Tulane University 7185 3080.08 UTAP - CIDRZ - $2,074,000

Disease Control & U62/CCU62241

Prevention 0

9037 3653.07 HHS/Centers for Tulane University 5021 3080.07 UTAP - CIDRZ - $1,810,000

Disease Control & U62/CCU62241

Prevention 0

3653 3653.06 HHS/Centers for Tulane University 3080 3080.06 UTAP/Tulane $150,000

Disease Control & University

Prevention

Table 3.3.12:

THIS ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

•Expansion to 3 additional districts in Western Province

•Expansion of VCT mobilization activities in two additional Lusaka communities

•Active integration of CT activities with other HIV-related services, including prevention, PMTCT,

tuberculosis treatment, and ART

•Phase out Livingstone activity

Activity Narrative

This activity is linked to EGPAF HTXS (# 4549.09 and # 3687.08) EDPAF PDTX (# NEW) and EGPAF

HBHC (#17073.08). Other identified partners include: Society for Family Health (# USAID), Kara

Counseling and Training Trust (# USAID) and, Eastern and Western provincial cooperative agreements

under counseling and testing and treatment programs (# EPHO #3669.08, #9751.08 and NEW peds,

WPHO #17817.08, #3792.08 and NEW peds)

Many of the program activities described in this narrative were previously funded under the University

Technical Assistance Program mechanism (Tulane University). Those voluntary counseling and testing

(VCT) and community activities have now been brought under this cooperative agreement.

In 2006, an intensive, coordinated community outreach project started in the Lusaka community of

Mtendere. Nicknamed "Save Mtendere!" this community education project aimed at dramatically increasing

the population tested for HIV through intensive community mobilization, including door-to-door counseling

and testing (CT) for families. This is a critical adjunct to rapidly expanding HIV care and treatment, as

attitudes and perceptions towards HIV begin to change. In the year prior to "Save Mtendere!" just over

1,000 people voluntarily tested for HIV in the Mtendere Health Center. Through the Save Mtendere!

Program in Mtendere, George, Kalingalinga, and Livingstone, the project has supported the provision of CT

for more than 48,000 community members and reached more than 450,000 through door-to-door outreach

activities to date. In 2007, we continued activities within the Mtendere community, and expanded the

program using lessons learned from Mtendere to two additional communities; one in the Lusaka District -

Kalingalinga - and one in Livingstone, the capital of the Southern Province. Provincial settings pose very

different challenges for community outreach and require effective community mobilization messages and

methods.

In FY 2008, we have continued activities in Mtendere, Kalingalinga, and George communities in Lusaka and

have increased our coverage within Livingstone district to cover both Maramba and Dambwa areas. Also,

in FY 2008, 75 community mobilizers were trained in rapid testing to initiate "in-home" testing for those

community members requesting immediate testing. We have also begun initial site assessments and

community health worker training in Mongu (Western Province), in preparation of full implementation of

similar activities in 2009.

To improve access to VCT, in 2007, we began a prevention focused VCT program in rural Western

Province, Shangombo District. This is a three-pronged approach providing VCT in static local health facility,

in the community (i.e. door-to-door), and via mobile units. In 2008, these activities expanded to Lukulu, and

with moderate scale-up in Kalabo.

In 2009, we will continue these two initiatives - the "Save the Community!" initiative (as it is now termed

following expansion outside of Mtendere) and the rural VCT program - with CDC support. The proposed

activities for each are as follows:

1.For the "Save the Community!" initiative, we will expand to two additional communities in Lusaka: Bauleni

and Matero Reference. These were chosen based on catchment area and geographic location. We will also

implement "Save the Community!" door-to-door sensitization campaigns in the Western Province capital of

Mongu.

Plans will include training all community mobilization volunteers and clinic-based coordinators, who will

monitor their activities and ensure consistency of messages. These coordinators will provide a central link

between volunteers and members of the community. To continue with the success of "in-home" testing, 60

community mobilizers will be trained in rapid testing. The clinic-based messages and activities will be

coordinated with other United States Government-funded organizations conducting community outreach as

well as various local partners (Society for Family Health - New Start (USG funded - Lusaka); Kara

Counselling and Training Trust (Local - Lusaka), YWCA (Local - Western, Lusaka). We will continue to

identify and collaborate with partners in each of the districts noted for expansion.

We will continue to focus on community mobilization and development of innovative, community-based

modes of communication, including an official campaign launch in Mongu - like we have done in both

Lusaka and Livingstone previously - to be coordinated with the Provincial Health Office. Local VCT centers

within the district clinics and stand-alone sites will be consulted to measure the impact of these activities.

Monitoring the demand for VCT before and after implementation of community outreach will provide a crude

measure of effectiveness.

We will perform a needs assessment for similar activities in the Senanga District of Western Province and

initiate training of community health workers, with an anticipated program launch later in the year. In order

to consolidate our VCT efforts in Western Province, we will work to turn over the "Save the Community!"

program to other CDC partners in Livingstone.

2.In 2009, we will scale-up activities within sites in Kalabo District, with a focus on increased access to VCT.

In addition, we will expand VCT support to three new districts in Western Province. Taking advantage of the

infrastructure developed for the "Save the Community!" in Mongu, we will support door-to-door VCT

services. Later in the year, we also plan to expand to Senanga and Kaoma. This program will seek close

collaboration and linkages with ART PMTCT, TB programs in the districts covered. The mobile unit will

collaborate and schedule community visits with PMTCT, ART and TB so that mobilization done covers all

Activity Narrative: these areas. The program will seek to actively engage local leaders in mobilization activities and work with

them to build their capacity to continue to share prevention messages at all community gatherings and to

promote open parent child communication regarding prevention. We will then train community health

workers / lay counselors, local leaders and integrate them into the mobile unit- and facility-based VCT

activities. This will lay the groundwork for the door-to-door activities.

New/Continuing Activity: Continuing Activity

Continuing Activity: 19501

Continued Associated Activity Information

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

System ID System ID

19501 19501.08 HHS/Centers for University of 8701 8701.08 UAB $340,000

Disease Control & Alabama,

Prevention Birmingham

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $250,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14: