The Zambia Prevention, Care and Treatment Partnership II (ZPCT II), started in June 2009, and supports the Ministry of Health (MOH) to scale up, strengthen and sustain clinical HIV/AIDS services in Central, Copperbelt, Luapula, Northern and North-Western Provinces. Key legislative issues for the project include TB/HIV, increasing gender equity in HIV/AIDS activities and services and addressing male norms and behaviors.

The first component supports the National HIV/STI/TB Council (NAC) and the Government of the Republic of Zambia's (GRZ) MOH policies to expand and strengthen HIV/AIDS clinical services using an integrated approach in program areas of testing and counseling (TC), prevention of mother to child transmission (PMTCT), basic care and support, antiretroviral therapy (ART) and male circumcision (MC). Activities include: strengthening the health system through provision of essential clinical and non-clinical equipment, facility renovations, monitoring and evaluation, laboratory and pharmacy support (including strengthening the specimen referral system and the polymerase chain reaction (PCR) laboratory), and capacity building of health care workers (HCWs) and volunteer cadres of lay counselors, community PMTCT counselors, and adherence support workers. Project staff will mentor HCWs and volunteers to ensure maintenance of quality performance standards. This year ZPCT II will expand to an additional 59 facilities and two districts for a total of 41 of the 42 districts and 330 of the 588 GRZ facilities in the five provinces. Among the 330 facilities that provide TC and basic care and support, 319 will provide PMTCT, 130 will provide ART and 30 will provide MC. Prevention activities will include prevention for positives, couples counseling and follow-up for PMTCT mother/infant pairs.

The second component is designed to strengthen district referral networks to and from the clinic and community and work with the district health management teams (DHMTs) and district AIDS task forces to build the capacity of the GRZ structures to manage the partner linkages. These activities will emphasize gender equity and male involvement in health, HIV/AIDS clinical services education, prevention education for both HIV positive and negative, mobile TC, the importance of PMTCT and adherence to ART for those on treatment.

The third component will work with GRZ facilities, to establish a sustainable program by building program management capacity through training of managers, and facilitating joint planning and budgeting including estimating and costing human resources required to run HIV/AIDS programs; promoting active involvement of key GRZ management officials in monitoring, supportive supervision and in quality assurance/quality improvement (QA/QI) assessments; developing/improving strategic information and analytical tools to enhance monitoring and evaluation (M&E) system strengthening, and data ownership and utilization by provincial medical offices (PMOs), DHMTs, and health facilities to improve service provision and logistics management and reporting. To insure sustainability, program activities will be included in MOH action plans, at all levels.

The ZPCT II monitoring and evaluation system ensures data quality from the facility to the province through built-in checks, quality assurance mechanisms and quarterly data audits. The system documents and disseminates program results, achievements, and lessons learned to the MOH, NAC, and USAID. The new indicator targets are estimates and will be confirmed as data is collected.

This year 11 well performing districts will be graduated, using approved QA/QI tools, from intense project technical support, for a total of 42 by project end. Graduated districts will be monitored by the ZPCT II technical teams through PMOs and DHMTs to ensure quality standards are maintained. PLWHAs will be used as additional human resources for clinic and community level activities.

The fourth component will identify six additional private sector facilities to bring the total supported to 12. The technical support on TC, basic care and support, PMTCT and ART given to the private sector will be replicated to ensure services are of the quality mandated by the MOH. Private facilities will be linked to the MOH reporting systems.

In the final component, ZPCT II will contribute to the policies and guidelines through the MOH and NAC technical working committees. In addition, ZPCT II will facilitate referrals and linkages to other clinical services to integrate services such as family planning, malaria, sexually transmitted infections and TB.

Working with the PMOs and DHMTs, ZPCT II will support routine evaluations of lessons learned from treatment interventions to identify and scale up best practices and to develop appropriate training and service delivery packages to increase access to treatment services in public and private health facilities. The process will include: identifying critical activity areas that require evaluation and conducting evaluations as needed; substantive involvement of policy makers, managers, service providers, and other stakeholders involved in the response to HIV/AIDS including building sustainable links between key players, from identification of evaluation questions, conducting training in evaluations, doing evaluations, and documenting, disseminating, and utilizing evaluation results in program implementation.

ZPCT II will strengthen and expand clinical adult care services, following the MOH protocols for ART/OI and STI management and the PEPFAR adult preventive care package, reaching an additional 59 clinics this year for a total of 330 facilities in 41 districts and support the district health management teams in quality assurance for eventual program graduation.

ZPCT II will provide technical support ensuring quality services, and building district capacity to manage HIV/AIDS services. Activities include management of opportunistic infections and pain management within health facilities; prevention for positives interventions; moderate renovations as needed; improved data management; increase referral linkages within and between health facilities and communities working through local community leaders and organizations and other USG projects; participate in and assist the MOH and the NAC to develop strategy, guidelines, and standard operating procedures; and increase program sustainability with the GRZ.

Health care workers will be trained in ART/OI GRZ curriculum that includes provision of cotrimoxazole prophylaxis, symptom and pain assessment and management, patient and family education and counseling, post exposure prophylaxis for victims of rape and violence, management of adult and pediatric HIV in the home setting, and provision of basic nursing services. Pharmacy staff will be trained in data collection/reporting, ordering, tracking, and forecasting of HIV-related commodities to ensure availability of critical medical supplies and drugs. The project will liaise closely with the USAID/DELIVER project and the Partnership for Supply Chain Management Systems on forecasting drug supply requirements.

Through these efforts, the project will aim to improve access to quality clinical adult care services; promote the use of evidence-based practices and share lessons learned in project implementation; and support the revision of national adult care guidelines and protocols in accordance with GRZ policies.

ZPCT II will support antiretroviral therapy (ART) services in an additional nine clinics this year to reach 130 facilities in 41 districts and support the district health management teams in quality assurance for eventual program graduation.

ZPCT II will expand and strengthen sustainable ART services by providing comprehensive support to strengthen ART facilities and services which includes: training and mentoring health care workers and adherence support workers in the approved ART/OI GRZ curricula; supporting task shifting of ART prescribing to nurses; implementing quality assurance mechanisms; renovating ART clinics and pharmacies, and providing essential equipment; expanding implementation of the ART outreach model; participating in and supporting the Ministry of Health and the National HIV/STI/TB Council's ART Technical Working Group to develop, update and disseminate training materials, protocols and policies; participating in and supporting the USG/Zambia food and nutrition strategy; assisting in the shift to client focused food by prescription approaches; and implementing the gender strategy as it applies to the ART services. ZPCT II implements the MOH case management protocols to follow individual clients and with SmartCare will be able to determine individual client outcomes.

ZPCT II will work with other USG partners to strengthen referral linkages and community outreach efforts aimed at creating awareness of and demand for ART services (including post exposure prophylaxis for case of rape and gender violence), supporting treatment adherence among ART patients including the use of cell phones for tracking, and reinforcing prevention for positives messages. The project will collaborate with the GRZ, USAID/DELIVER, and Partnership for Supply Chain Management Systems in the distribution of ARVs, including pediatric formulas, and training of health facility staff in logistics management to ensure timely ordering and uninterrupted supply of ARVs. Support will further reduce stigma and discrimination associated with ART by working with community leaders and key stakeholders regarding the importance of testing and counseling and availability of ART.

ZPCT II will support TC services in an additional 59 new clinics this year to reach 330 Government of the Republic of Zambia (GRZ) facilities to enhance commodity management and provide quality TC services; ensure same day test results; provide technical assistance to community/faithbased organizations to expand access to TC via mobile services; strengthen linkages to ART and promote routine, targeted TC with maternal child health, PMTCT, family planning (FP), tuberculosis (TB), sexually transmitted infections (STI), MC and ante-natal care services; promote couple, child and youth TC; expand and strengthen inter-facility and community referral systems; promote follow-up services for negative clients; address gender disparities and violence that hinder access to TC services; and, support the DHMTs in quality assurance for eventual program graduation.

ZPCT II will refurbish facilities, train and mentor health care workers and lay counselors, increase quality assurance, and improve data quality and systems for tracking patient flow. Facilities and DHMTs will be supported to maintain site accreditation. In collaboration with the GRZ, USAID/DELIVER, and Partnership for Supply Chain Management Systems, pharmacy, laboratory, and counseling staff in the supported facilities will be trained and mentored in data collection and reporting, ordering, tracking, and forecasting of TC related commodities including HIV test kits.

Linkages with partners through the district referral networks will increase the number of people reached with TC services and avoid duplication of services. ZPCT II will work in the communities surrounding TC sites to increase demand and acceptance of services and target discordant couples. HIV-infected individuals will be referred to services including prevention for positives, PMTCT, ART, MC, FP, STI, and palliative care including TB.

At the national level, ZPCT II will provide technical assistance to the national Counseling and Testing Technical Working Group to develop, revise, and disseminate training materials, protocols, and policies.

ZPCT II will strengthen and expand pediatric care and support services by providing technical support, ensuring quality services, and building district capacity to manage sustainable pediatric HIV/AIDS services in an additional 59 clinics this year to reach 330 GRZ facilities and 12 private sector facilities. Support includes: strengthening management of opportunistic infections and pain management within health facilities; training and mentoring of health care workers (HCWs) and adherence support workers; facility renovations; provision of cotrimoxazole for exposed infants; increasing referral linkages within and between health facilities and communities working through other USG partners, local community leaders, and organizations; and participating in the ART Technical Working Group and the USG Palliative Care Forum to assist the MOH and the NAC to develop and strengthen policies, guidelines, and standard operating procedures.

ZPCT II will support in-patient pediatric lay counselors to provide TC. If positive, the child will have their laboratory investigations completed before being discharged and referred for the appropriate treatment, either ART or cotrimoxazole prophylaxis. HIV positive children will be referred, through the district referral network, to community programs such as CRS/SUCCESS and RAPIDS, for home based care services. The child will be the index case to reach the family with TC with an emphasis on prevention for those found positive and negative. Where possible, care, will be provided at family-centered clinics. Through dried blood spot testing, infants under 18 months will have access to polymerase chain reaction laboratory to determine their HIV status.

ZPCT II will mentor health care workers to increase their ability to monitor pediatric HIV clients including management of nutrition and food by prescription, child rape victims and gender violence. 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 in close collaboration with the USAID| DELIVER and the Partnership for Supply Chain Management Systems on forecasting required drug supplies.

ZPCT II will assist the GRZ and private facilities to provide ART for pediatric patients in an additional nine ART sites in the 41 districts reaching 129 of the 130 ART facilities. The project will provide technical support, ensuring quality services, and building district capacity to manage pediatric HIV/AIDS services for eventual program graduation. ZPCT II will link to the adult ART program to strengthen ART facilities and services; expand implementation of the ART outreach; ensure injection safety; strengthen community referral linkages and improve service integration to increase demand for ART services; support the national ART Technical Working Group; and provide technical assistance and mentoring to health care workers, including adherence support workers (ASWs) and pediatric lay counselors. ZPCT II will integrate innovative approaches to pediatric ART case management, including mentoring, on-site training, and strengthening basic ART/opportunistic infections (OI) pediatric management, with special attention to routine provider initiated counseling and testing, timely initiation of ART, nutritional support, post exposure prophylaxis for rape, child sexual abuse management, and cotrimoxazole prophylaxis. The project will support ASWs to assist families in addressing ART adherence and other challenges to effective pediatric case management.

ZPCT II will strengthen linkages with PMTCT services and under-five clinics to ensure eligible HIV positive pregnant women receive ART, and infants of HIV-infected women are tested for HIV at nine and 18-months as per the revised National PMTCT and ART Protocol Guidelines. Dried blood spot specimens from infants under 18 months will be sent to the polymerase chain reaction laboratory for early infant diagnosis. ZPCT II will scale-up early childhood diagnosis through integration with in and outpatient child health services, couples and child counseling, and promotion of male involvement in PMTCT services. The project will continue to provide pediatric ART case management mentoring, on-site training, and strengthening basic ART/OI pediatric management. ASWs will assist families in ART adherence and other challenges to effective pediatric case management.

ZPCT II will establish and scale-up male circumcision (MC) activities in 14 health facilities in the five provinces adding to the 16 sites established last year for a total of 30 sites in 20 districts in four provinces. Program activities and site selection will be carried out in consultation with the Government of the Republic of Zambia's MOH MC technical working group and in collaboration with U.S Government (USG) programs for social marketing, behavior change, Partnership for Supply Chain Management Systems, Elizabeth Glazier Pediatric AIDS Foundation (EGPAF), and other non USG funded MC including the Gates program with Society for Family Health and JHPIEGO Gates Foundation program. Program activities will indirectly coordinate with USG implementing partners for AB activities. The project will also link with other HIV and health related areas that will increase demand for and access to MC services.

In partnership with the University Teaching Hospital MC unit, ZPCT II will increase access to safe, high quality MC services integrated with TC, HIV prevention for both positive and negative, male reproductive health services, and STI services and will create linkages to male circumcision services through maternal and child health services. Health care workers will be trained to provide MC using the World Health Organization (WHO) materials and WHO supplemental counseling training materials. ZPCT II will provide supportive supervision using international performance standards. ZPCT II will work with community groups and other partners including traditional leaders, using communication messages approved by the MOH through the MC technical working group, to create awareness and demand for MC services as part of the prevention strategy which will also educate men on gender based violence and the needs of their female partners.

At the national level, ZPCT II will support the MOH MC technical working group and the National HIV/STI/TB Council preventions of sexual transmission to develop policies, protocols, guidelines, and training and education materials to enhance national scale-up of quality MC services.

ZPCT II supports the MOH to strengthen and expand PMTCT services in 57 new clinics for a total of 319 facilities in 41 districts of the five provinces. ZPCT II will promote PMTCT service delivery through provision of technical support and training for health care workers, community cadres (including traditional birth attendants (TBAs), community PMTCT and lay counselors); facility renovations; provision of essential equipment including point of service hemoglobin testing to provide more efficacious HIV prophylaxis regimens; strengthen the national external quality assurance program; and support the district health management teams to facilitate program graduation.

PMTCT and ART services will be linked. Laboratory samples for CD4 testing from PMTCT facilities will be transported to sites with CD4 machines to ensure eligible women are put on full ART. Blood samples taken from exposed children at six weeks, during routine immunizations, will be sent to the polymerase chain reaction laboratory for early infant diagnosis. HIV positive women will be linked with community groups that provide nutritional, legal, and psychosocial support (including support for gender based violence) and encourage male involvement and couple disclosure. TBAs will assist with PMTCT adherence support and follow-up at the community level. Women testing positive will receive prevention for positives interventions, malaria prophylaxis, and will be referred to family planning and ante-natal services. Those who test negative will be referred to comprehensive prevention activities. ZPCT II will track mother/infant pairs through maternal child health clinics to enhance early diagnosis and increased uptake of pediatric ART services.

ZPCT II will support accurate reporting and data collection (utilizing a computer based system where possible) and reliable supplies of ARV prophylaxis. Commodity management will be coordinated with the GRZ and the Partnership for Supply Chain Management Systems. ZPCT II follows national guidelines and provides technical assistance to the national PMTCT Technical Working Group to develop, revise, and disseminate training materials, protocols, standard operating procedures, and policies.

ZPCT II will provide technical support to ensure quality services and build district capacity of laboratory diagnostic and monitoring services in an additional 15 GRZ laboratories reaching a total of 111 laboratories. The project will strengthen the laboratories to perform HIV, CD4 and lymphocyte tests; refurbish laboratories; procure essential equipment in accordance with GRZ guidelines and policies (including CD4, hematology and chemistry analyzers, autoclaves, centrifuges, microscopes, and refrigerators); improve laboratory quality assurance mechanisms, information systems, and personnel capacity; provide training of laboratory technicians and ensure consistency in laboratory supplies through the national logistics system; provide the Good Clinical Laboratory Practices training; and participate in national laboratory groups in the development or review of policies, guidelines, standard operating procedures, and training manuals.

ART clinics without access to CD4 testing will be linked to nearby ART facilities through the specimen referral system. ZPCT II will continue to support the early infant diagnosis polymerase chain reaction PCR lab in Ndola and ensure transportation for dried blood spot samples. The project will also coordinate with activities supported by the Centers for Disease Control and Prevention (CDC) and collaborate with the Clinton Foundation HIV/AIDS Initiative.

ZPCT II will work with the GRZ and CDC to strengthen laboratory quality assurance mechanisms, information systems, and laboratory personnel's capacity to ensure adherence to GRZ's recommended laboratory standards. ZPCT supports the Medical Council of Zambia ART accreditation process which includes the evaluation of laboratories. In addition, as the MOH identifies an accreditation process, ZPCT II will assist with the implementation. Finally, ZPCT II will continue to train laboratory staff in commodity management and lab-related activities. Assistance for this second component will be coordinated with USAID/DELIVER, the Partnership for Supply Chain Management Systems, CDC, and GRZ to avoid duplication of efforts and to ensure that facility-level forecasting and procurements eliminate stock-outs of essential commodities.

ZPCT II will support the GRZ to strengthen and expand TB/HIV services in an additional 59 facilities this year to reach 330 facilities in the 41 districts and 12 private sector facilities. The project, working with other U.S. Government (USG) and non USG) programs, will harmonize TB/HIV trainings and service delivery protocols; train health care workers and lay counselors in cross-referral for TB/HIV and other opportunistic infections; provide microscopes and laboratory reagents; renovate TB laboratories; strengthen and expand TB services among HIV-infected individuals, including TB microscopy and treatment; and support initiatives for TB infection control and intensified TB case finding in the facility and the community. The project will also strengthen and expand quality direct observed treatment short course programs, and increase community involvement and awareness of TB as well as work through the district referral networks to link the community to the clinics. ZPCT II's monitoring and evaluation system includes HIV/TB indicators and uses the Ministry of Health approved data collection tools.

In order to increase the capacity of the MOH, ZPCT II conducts the approved MOH training programs in ART/OI, pediatric HIV and adherence support reaching 630 service providers (which include health care workers and adherence support workers) in FY 2009 and will reach an additional 700 in FY 2010.

Provider initiated testing and counseling for HIV will be offered to the TB clients and their family, with emphasis on reducing stigma and discrimination associated with TB and HIV. In addition, TB diagnosis among all HIV-positive patients will be conducted to reduce the incidence of TB Immune Reconstitution Syndrome and to ensure appropriate TB and/or ART services.

ZPCT II will work at the national level with the National TB and ART Technical Working Groups, to ensure that policies and guidelines are optimal for TB/HIV linkages at all levels of the health care system. In particular, ZPCT II activities will support the National TB strategic plan and will be coordinated with the newly formed TB coordination bodies at national, provincial, district and community levels.