We will provide a minimum package of prevention for positives by:

1. Training peer educators to assess sexual activity and provide prevention counseling.

2. Training nurses to assess family planning needs and provide counseling.

3. Including prevention modules in existing trainings.

We will support pre-antiretroviral treatment (ART) clinical care by:

1. Providing routine prevention counseling and ensuring condom availability.

2. Procuring select opportunistic infection drugs if needed.

3. Strengthening technical capacity at the district, provincial, and national levels.

4. Participating in technical working groups and providing technical support for guidelines and training packages.

5. Supporting 50 community sensitization drama performances.

We will support peer educators and treatment supporters by:

1. Recruiting and training 40 new peer educators and supporting 160 peer educators.

2. Providing ongoing mentoring and support to all peer educators and treatment supporters.

3. Conducting 12 trainings with treatment supporters and Neighborhood Health Committees on prevention for positives.

4. Disseminating prevention information, education, and communication materials.

5. Providing technical support for task-shifting guidelines and training packages.

We will pilot follow up of pre-ART patients for repeat ART eligibility screening by:

1. Analyzing program data to understand missed opportunities.

2. Assessing the feasibility of using methods such as text messages, phone or home visit reminders.

3. Reviewing the impact and operational demands of increased pre-ART patient follow-up.

We will support integrated HIV screening and care in 14 outpatient (OPD) wards by:

1. Providing ongoing monthly clinical mentoring at integrated sites.

2. Training 15 clinic staff in five new sites.

3. Recruiting and training 10 lay counselors.

We will provide comprehensive women's health clinical services by:

1. Providing 19 sites with trained personnel, equipment, and supplies.

2. Creating effective linkages through trained clinic-based peer counselors.

3. Conducting ongoing mentoring and quality improvement systems.

4. Supporting ongoing health promotion and advocacy.

5. Training staff and students at the University of Zambia School of Medicine.

We will support quality clinical care at existing antiretroviral treatment (ART) sites by:

1. Training 80 health care workers in advanced clinical management. (All trainings in-service)

2. Developing capacity in Zambian Ministry of Health (MOH) clinicians to conduct ongoing quality improvement (QI). Outcomes monitored are via SmartCare electronic medical records system

3. Supporting 20 Nurse Practitioner trainees.

We will improve the capacity of MOH staff to provide oversight and training by:

1. Training 40 MOH staff in clinical mentoring.

2. Conducting QI activities jointly with MOH staff.

3. Integrating with provincial strategic plans.

4. Supporting MOH provincial trainers to conduct four basic ART trainings.

5. Developing MOH capacity to assess training and mentoring needs and capacity.

6. Developing MOH capacity to assess and improve logistics management.

We will improve adherence to treatment and reduce loss to follow up by:

1. Training peer educators to address treatment failure and address causes of loss to follow up

2. Providing counseling for assisted disclosure to partners and family.

3. Continuing adherence counseling for all pharmacy visits and follow up of late patients.

We will provide ongoing laboratory support by:

1. Providing diagnostics for clinical monitoring of HIV.

2. Ensuring quality assurance (QA) of dried blood spot testing.

3. Providing good clinical laboratory practice training.

4. Procuring limited essential new equipment within national guidelines.

5. Supporting national lab QA plans.

6. Developing MOH capacity to assess equipment needs and provide logistics management training.

7. Increase links between districts and vendors and hand over maintenance contracts.

We will provide technical support to MOH by:

1. Participating in MOH HIV treatment technical groups.

2. Participating in efforts to improve the national inventory stock management system.

We will integrate ART in clinic and community-based comprehensive primary health care in three districts by:

1. Providing technical assistance to promote integrated services.

2. Supporting training in ART management.

3. Supporting district-based clinical QI staff.

Target population is all HIV-positive adults and children.

We will support clinical pediatric antiretroviral treatment (ART) care by:

1. Supporting provincial teams conducting trainings in pediatric HIV care and treatment (one training per province; 30 participants per training). Trainings support current WHO/Zambian guidelines to treat all HIV-infected infants.

2. Training clinical mentors at the provincial and district level to mentor clinic staff in pediatric ART, and providing ongoing support to trained mentors.

3. Training clinic, district, and provincial pediatric mentors in the use of pediatric clinic performance reports and the development, implementation, and assessment of quality improvement activities.

4. Providing quarterly supportive supervisory visits by the CIDRZ clinical team.

5. Piloting the use of viral load monitoring in children on ART.

6. Using pediatric patients as entry points for testing parents/guardians in order to improve parent/guardian health and consequently child survival.

7. Training clinicians to identify sexually transmitted infections in adolescents and manage or refer appropriately.

We will provide pediatric adherence counseling and psychosocial support by:

1. Implementing adolescent support groups at eight sites.

2. Training 16 peers to identify high risk sexual practices and provide age appropriate counseling including safer sexual practices.

3. Training 40 peer educators to provide adherence counseling of children on ART.

4. Training 80 peer educators in disclosure counseling for children as a way of improving adherence.

5. Strengthening referrals and access to community awareness programs on child sexual abuse and the availability of HIV prevention strategies for abused children.

We will provide technical support to the MOH by:

1. Participating in MOH pediatric treatment technical working groups and actively supporting the review of guidelines and development of training materials, clinical algorithms, and forms.

SmartCare is a continuity of care assurance system selected in program year 3 by the MOH as its national electronic health records system. The MOH is the lead member of the SmartCare project; the MOH and its partners use this national system for reporting to the GRZ and donors on HIV programs.

In FY 2010, the MOH will receive direct support from CDC and continue to receive technical support from the SmartCare project, enabling it to take on more and more of the project's management and responsibility toward successful transition.

To strengthen the MOH's ability to monitor and evaluate projects, EGPAF will continue to provide seconded staff, equipment, and logistical assistance to SmartCare.

EGPAF/Zambia will continue to oversee contracts, software design firms and consultants as needed to continue SmartCare development and deployment. Funds will be used for staffing, training, consumables, equipment maintenance and transport as well as supervisory support to sites.

The program will also invest is central staff to support infrastructure (help desk, report writing, development of distance learning materials as well as trainers who can institute the SmartCare Competency Certification program.

SmartCare Stations will be purchased and configured with SmartCare and other supporting software and distributed to health posts, rural health centers, urban health centers and hospitals. Clinic staff will receive training on SmartCare and the data will be uploaded to the District Health Offices, which will then be reported to the MOH. The MOH will also continue to receive, as needed, equipment and hardware which they will manage. The District and Provincial Health Offices as well as the MOH M&E staff will receive IT stations as needed.

Lastly, the SmartCare program will continue to work with a variety of partners including MOH, provincial health offices, JHPIEGO, CIDRZ, LinkNet and CRS/AIDSRelief to strengthen collaboration for improved M&E infrastructure, operation and analyses.

PMTCT one time plus-up funds are being added to support: Analysis and dissemination of information using Next Generation PMTCT indicators to assess program effectiveness including the impact of COP funding increases for operational costs and one-time plus-up funds.

EGPAF will focus on PMTCT sites within the Lusaka Province of Zambia. EGPAF will use these funds to strengthen existing monitoring and evaluation systems throughout the provincial network and ensure that timely usable data is collected from the covered PMTCT sites.

We will continue to support integrated services at 301 sites by:

1. Providing routine opt-out HIV testing.

2. Re-testing HIV-negative women in antenatal and labor wards and managing incident infections.

3. Increasing infant testing by promoting disclosure and linking testing to cotrimoxazole prophylaxis.

4. Improving turnaround time for dry blood spot test results for early infant diagnosis.

5. Supporting 150 peer educators, lay counselors, health care extenders and traditional birth attendants.

6. Providing ongoing quality improvement through on-site supportive mentoring.

7. Supporting MOH guidance on infant feeding in the context of HIV and resource constraints.

8. Supporting MOH revision of PMTCT guidelines in line with WHO updates.

9. Promoting male involvement, partner testing, and condom use (district supplies).

We will increase the uptake of more efficacious regimens by:

1. Increasing sites providing dual therapy by training 100 health care workers.

2. Expanding diagnostics for antiretroviral treatment (ART) eligibility screening and hemoglobin (providing microcuvettes).

3. Working with community based organizations and districts for awareness activities.

4. Increasing adherence to repeat clinic visits.

We will increase the enrollment of pregnant women on ART by:

1. Ongoing clinical mentoring in ART for pregnant women.

2. Assessing new sites and supporting comprehensive care including family planning.

3. Training eight health care workers at four new sites.

4. Supporting clinic extenders to identify eligible women.

5. Conducting monthly ART / PMTCT data review meetings.

We will ensure PMTCT is integrated in primary health care in Chongwe, Kafue, and Luangwa by:

1. Providing technical assistance on protocols.

2. Supporting training for trained birth attendants and community health workers.

3. Supporting clinical quality improvement nurses.

We will promote district oversight, and program data monitoring and use by:

1. Expanding use of complex performance indicators.

2. Auditing management of funds.

3. Conducting periodic data review meetings with HMIS staff in supported districts.

4. Training District Health Information Officers in monitoring and evaluation and involving them in data audits and quality control activities.

PMTCT one time plus-up funds are being added to support: Community approaches to improve uptake of highly efficacious PMTCT, the procurement of bicycle ambulances for facilities where appropriate, and the renovation of maternity units and staff houses and the provision of solar panels.

While over 80% of pregnant women were tested in 2008, only about 10% of their male partners were tested. EGPAF will strengthen PMTCT services by using a number of effective approaches to enhance partner counseling and testing.

Increased male partner involvement in PMTCT will ensure that couples access testing where they will know each other's HIV status and receive important preventive services.

Implementing prevention strategies that target couples in PMTCT is most effective when they receive HIV results and counseling together. Thus BU will provide male partners with the opportunity for additional counseling, risk reduction messages, direct links to male circumcision services and screening and treatment for STIs.

EGPAF will reinforce and encourage adherence to HIV prevention methods by counseling men and women together on the importance of PMTCT. Both partners will understand the essence of preventing transmission to the child and will be able to openly talk about how they can prevent transmission in discordant and re-infection in concordant couples.

Many antenatal and maternity facilities in Lusaka Province are improvised and not appropriate for delivery services and lack private space for HIV testing and PMTCT counseling. Further some facilities have provision only for antenatal care, without any delivery rooms. EGPAF will procure bicycle ambulances for facilities in Lusaka Province where it is difficult for pregnant women to reach appropriatefacilities in time for a safe delivery of the baby. Provision of PMTCT at the time of delivery is an important intervention for HIV prevention that can be maximized by the utility of bicycle ambulances to transport expectant mothers to the health facility.

In Lusaka, Western, Eastern, and Southern Provinces, many antenatal and maternity facilities are improvised and not appropriate for delivery services and lack private space for HIV testing and PMTCT counseling. Further some facilities have provision only for antenatal care, without any delivery rooms. In many rural facilities, staff housing for PMTCT staff is limited or substandard to attract qualified staff. Facility deliveries are low due to long distances and lack of transport. Many sites lack electricity and proper water supply affecting quality of delivery services. These would require solar power and boreholes to improve service delivery.

EGPAF will construct, upgrade, remodel or refurbish antenatal clinics, maternity units, MCH and laboratory facilities to improve efficiency in PMTCT services. The MOH and ZDF will assist in site selection based on a criteria that places emphasis on prioritizing facilities with poor infrastructure and potential impact;

The goal of the EGPAF/CIDRZ laboratory team is to improve the availability and quality of district-level Ministry of Health (MOH) laboratory services in Eastern, Western, and Southern Provinces. HIV care and treatment patients in provincial sites receive far fewer baseline diagnostics than those in Lusaka and Kafue supported by CIDRZ Central Laboratory. Baseline lab coverage averages 35% in Eastern Province, 60% in Western, 73% in Southern, and 87% in Lusaka; provincial follow-up diagnostic rates are even lower. District referral laboratories and well-functioning specimen referral services have the potential to decongest overloaded provincial laboratories and expand district HIV prevention and treatment services, in particular the ability of pregnant women to access nevirapine-boosted zidovudine prophylaxis and antiretroviral therapy.

We will support three district referral laboratories in Kapata (Eastern province), Monze (Southern province), and Mongu urban clinics (Western province). We will assess specific site needs and work with the Districts and Provinces to ensure technical staff support, as well as essential equipment are available and in good working order, and to provide minor renovations as needed.

We will support the MOH specimen referral system through an intensive pilot at, at least nine clinics that will fall within the district referral laboratory system. We will assess transport capacity at these nine rural referring facilities, procure motorcycles and cool boxes as needed, and implement a simple specimen tracking log at referral sites. We will also assess existing transport networks, including public systems, to find areas where efficiencies in specimen transport can be increased.

The MOH has developed a national QA/QC strategy to assess the quality of laboratory results. We will support the MOH in preparation, transport, and assessment of quality samples in line with the national strategy.

Good Clinical Laboratory Practice (GCLP) training strengthens the capacity of provincial laboratory staff to run laboratories. We will train 50 laboratory technicians in GCLP.

PMTCT one time plus-up funds are being added to support: Improvements in infrastructure for PMTCT clinical and laboratory services

EGPAF through it's subpartnership with CIDRZ will conduct district level laboratory assessments with the Ministry of Health, the Lusaka Province Health Office, and other partners and procure equipment as appropriate for maximum cost-effectiveness and coverage for use in facilities in Lusaka Province. CD4 machines for district or provincial laboratories, hematology to measure anemia, and blood chemistry kits and equipment will be procured for the PMTCT sites most in need. In many facilities throughout Lusaka Province, the use of clinical and laboratory equipment is often monopolized by ART patients. EGPAF will use these funds to increase PMTCT patient access to important clinical and laboratory services as PMTCT-specific demand for these services increases with the new WHO PMTCT guidelines.