The high HIV prevalence rate in Zambia (14.3%) has sent a strong message on the need for implementation of comprehensive HIV prevention strategies. At the same time, PEPFAR has said that prevention must be strengthened to reduce the numbers needing treatment, so that treatment needs do not outstrip the available resources. IntraHealth has joined National AIDS Council (NAC), Ministry of Health (MOH) and PEPFAR II in prevention strategies through intensified preventive counseling and testing (CT), Prevention for Positives and prevention for HIV negative people from getting infected.

IntraHealth has partnered with Ministry of Health and other non-governmental organizations in increasing access and uptake of quality CT in poor, remote areas of Zambia through the use of lay counselors. The CT offered is focused on couples' counseling and families as these are the entry points for treatment, prevention and care. Strengthened linkages between the community and health centers have been created through the project's referral system. The clients testing HIV positive are referred for Prevention of Mother to Child Transmission (PMTCT) services, antiretroviral therapy, treatment of opportunistic infections and support groups formed by People Living with HIV/AIDS infection. An ongoing issue subject to considerable discussion among the MOH, CDC, and PEPFAR II is how to help HIV+ persons access ART services in these rural areas.

IntraHealth International is now operating in four districts of Zambia with the first two initiated in July-August 2008: Luangwa district in Lusaka Province, population of 27,100 with 11% HIV prevalence, and Namwala, population 131,000 with 13% HIV prevalence. In May-June 2009, counseling and testing was scaled up to Gwembe district, estimated 45,000 population with 13% prevalence, and Siavonga, 84,000 population with a prevalence of 14.2%. Intrahealth plans to scale up to Kalomo and Sinazongwe district, also in Southern Province in FY 2009 for a total of six districts and 83 sites.

In FY 2010 IntraHealth will scale-up preventive counseling and testing to Itezhi- Tezhi district in Southern Province. Itezhi-Tezhi has an estimated population of 46,357 and 8 % of HIV prevalence rate. We will hire a district coordinator to supervise and ensure quality assurance of services provided at the community level. In FY 2010, Intrahealth intends to operate in 94 sites.

IntraHealth is contributing to health systems strengthening by task shifting of HIV counseling and testing, which was previously facility-based and provided by the health care personnel. In all the districts where IntraHealth is working, services provided by the community lay counselors have lightened the burden of already over-stretched care providers in health facilities.

IntraHealth will partner with the Young Women's Christian Association (YWCA) in post HIV test gender based violence (GBV) counseling. In FY 2010, IntraHealth will augment counseling and testing training of lay counselors with specialized training in couples counseling skills. We will also incorporate Prevention with Positives (PWP) training into their work, drawing from our new PWP initiative. IntraHealth will provide information at community-based discussions with traditional leaders and lay counselors to give an insight into gender equity in communities. Those who test HIV positive will be referred to HIV support groups for emotional support, nutritional and economic strengthening activities such as income generating programs spearheaded by the Network of People Living with HIV/AIDS in Zambia.

IntraHealth will ensure that the quality of confidential CT offered is not compromised, by offering continual supervision of lay counselors by the IntraHealth District Coordinators, and by health care providers in the absence of the District Coordinators. IntraHealth will assure that District Laboratory staff will work closely with District Coordinators to ensure high quality and accurate HIV test results are delivered by the lay counselors. At the community level, traditional leaders will ensure that the services provided do not infringe upon culture and norms of the community.

IntraHealth's monitoring and evaluation (M&E) system requires monthly data reporting by lay counselors on numbers of clients counseled and tested and the number of HIV positive clients referred to a health facility for clinical or non clinical care. These results are submitted to the District Coordinators who in turn submit them to IntraHealth's office in Lusaka. An M&E specialist from Chapel Hill visits annually to conduct annual data accuracy checks using the IntraHealth data quality control format.

In FY 2009, IntraHealth embarked upon a new Prevention with Positives initiative. Its aim was to assist the MOH to implement training in PWP in four provinces, Eastern, Lusaka, Southern and Western provinces of Zambia. In FY 2010, the project will continue to provide preventive training packages. These training programs will be conducted to incorporate treatment, HIV counseling sites and communities. This will be done through collaboration with the Ministry of Health (MOH), Provincial Health Offices (PHO), District Health Offices and partnership with other stakeholders in the selected provinces. IntraHealth will continue these activities, training district level providers and holding community workshops with HIV+ persons.

IntraHealth will partner with Ministry of Health and other non-governmental organizations to increase access and uptake of quality counseling and testing in poor, remote areas of Zambia through the use of lay counselors. IntraHealth International is operating in six districts: Zambia, Luangwa, Namwala, Siavonga, Gwembe, Sinzongwe, and Kalomo. All are in Southern Province except Luangwa, which is in Lusaka province.

In FY 2010 IntraHealth will scale up preventive counseling and testing to Itezhi-Tezhi district through the training of 22 lay counselors. Itezhi-Tezhi has an estimated population of 46,357 and 8 % HIV prevalence rate.

IntraHealth will provide specialized training to the lay counselors in couples counseling skills. We will also incorporate Prevention with Positives (PWP) training into their work, creating synergy with our new PWP initiative. Those who test HIV positive will have prevention messages reinforced and those who test negative will be have personal risk-reduction strategies developed. We will collaborate in Itezhi-tezhi with Christian Health Association of Zambia, which is doing home based care.

IntraHealth will assure the quality of confidential counseling and testing by offering continual supervision of the lay counselors by the IntraHealth District Coordinators, and by health care providers in the absence of District Coordinators.

IntraHealth will intensify follow- up of all the clients who tested HIV positive and have not reached the health centers to access ART and treatment for prevention of opportunistic infections. Re-testing will be done for those who initially tested negative and are at high risk, like pregnant women, discordant partners, STI clients or commercial sex workers.

IntraHealth district coordinators will work closely with district laboratory staff in coordinating and ensuring the quality of rapid HIV testing offered by lay counselors. We will provide refresher training courses of rapid HIV testing for our testers according to the national training standard, provide essential supplies, job aids, and tools to perform HIV testing, provide supervisory and follow up visits, and participate in the national EQA program for HIV rapid testing

PEPFAR II emphasizes prevention as a key intervention to reduce treatment costs. In FY 2010 IntraHealth will collaborate with the University of Zambia School of Medicine (SOM) to initiate Prevention with Positives (PWP) activities through a behavioral intervention designed to prevent transmission and re-infection and promote healthy living among HIV positive men and women. IntraHealth will work in four provinces, Eastern, Western, Southern, and Lusaka. Two IntraHealth staff (PWP Program Coordinator and one current staff) will be trained as trainers to work with the provinces and other partners.

IntraHealth will work with local agencies to conduct workshops for those who test HIV positive with a focus on strategies for prevention of transmission and re-infection and healthy living. The workshop trainees will subsequently be requested and commissioned to conduct similar community-based discussion. The prevention strategies will be directed toward HIV positive individuals and those who do not know their status. IntraHealth will work with the PHO to hold additional trainings on PWP counseling at each district hospital in the four provinces, targeting a total of 50 providers.

We will provide PWP training to lay counselors in seven districts under the separate VCT program, so that they can offer these messages to people in their communities. IntraHealth will also continue to organize community workshops for HIV+ persons to re-enforce prevention messages around disclosure to partners, family planning, reproductive health counselling, risk reduction, alcohol abuse, importance of timely follow-up for those in care and adherence to ART for those on treatment. IntraHealth will reach 30,000 persons with PWP messages. Links between community and clinical services will be maintained, especially with increasing mobile services.

IntraHealth will work with PEPFAR, government and other partners to capture data on relevant end points.