The overall goal for Eastern Provincial Health Office (EPHO) CDC support is the implementation of programs to improve the management of care for HIV/AIDS, sexually transmitted infections and tuberculosis in the Eastern Province of the Republic of Zambia under the PEPFAR

The Eastern province with a population of over 1.7 million and divided into eight districts will in the Country Operational Plan (COP) FY 2010 continue to work with CDC support to strengthen and scale up TB/HIV activities through capacity building, technical support supervision, meetings and trainings. EPHO will focus on strengthening existing programs through linkages to other potential partners. Infection control programs will cut across all budget codes

The TB/HIV programs' goal is to reduce the burden of tuberculosis among HIV infected patients. The EPHO and Districts will facilitate the implementation of counseling and testing of TB patients for HIV infection, screening of HIV patients for TB infection, strengthening partner notification, TB/HIV coordinating bodies at all levels. Monitoring and evaluation will be strengthened in all program areas through integrated TB/HIV review meetings, systems strengthening through technical support supervision quarterly at EPHO and quarterly at monthly levels. With low TB notifications, emphasis will be placed on intensified case finding, community participation and awareness creation through radio programs.

Prevention of Mother to Child Transmission (PMTCT) services will be strengthened through capacity building, integrated quarterly review meetings, technical support supervision and mentorship. To strengthen PMTCT uptake focus will be on male involvement through community participation and sensitization on radio programs.

EPHO will strengthen early infant diagnosis by training health workers in Paediatric ART services to increase uptake to at least 10%. Provider initiated counseling will be strengthened to increase access to counseling services .EPHO will Improve courier and referral systems for quality management.

Adult antiretroviral services will focus on improving the quality of service provision through training of staffs, mentorship, meetings and infrastructure renovations. Mobile ART services will be strengthened in geographically constrained areas. Monitoring and evaluation will be conducted in partnership with cooperating partners.

EPHO will continue to build sustainable laboratory capacity at both provincial and local levels through training and providing support for laboratory activities in PMTCT, HIV/AIDS and VCT, Pediatric and Adult HIV care and treatment.

Focus will be on accreditation of laboratories, so laboratories can be recognized by World Health Organization (WHO).This is a long term program and two centers will be piloted. Quality control program in TB and HIV/AIDS, monitoring tests such as CD4, full blood count (FBC) and chemistry will be included.

EPHO will also organize and conduct a training of 20 laboratory staff in laboratory management, computer and laboratory information systems. Other training activities will include Rapid HIV testing for TB/HIV, PMTCT and VCT counseling and testing program areas.

Other preventive activities to mitigate and prevent the spread of STIs, HIV and TB will through behavioral change communication through partnerships and community involvement and evolve on community driven innovations like drama and income generating activities for the youth. National and World Commemoration days will be used to create mass awareness and disseminate messages through the local media, educative games, modeling, poetry and role plays.

In line with the national male circumcision strategy and implementation plan 2010 2020 focus will be on Increasing the number of health facilities providing safe male circumcision services as an integrated approach for male reproductive health and the fight against HIV/AIDS (HIV infection prevention) in three districts; Chama, Mambwe and Nyimba, Increasing the skill and quality of service providers through appropriate training, sensitization of communities on the importance of MC as an important component in the package of HIV prevention strategies, complement the services being provided by other partners Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) in Chipata district (Chipata General and Mwami mission hospital).

Strategic information adds value to monitoring and evaluation through comprehensive information communication and technologies to yield better health information systems. The objective is to improve and sustain quality data management systems and information archiving and sharing for aided decision making. EPHO will continue capacity building and provision of technical support in the data collection, storage, retrievals, sharing, analysis, auditing and use. EPHO will ensure maintenance of the strategic information (SI) infrastructure through procurement and repairs of soft and hardware for the security of information including procurement of internet and local area network services. EPHO is to strengthen existing operational, HMIS and other Health Systems mechanisms and governance arrangements at Health Facility, District and Provincial levels

In areas where there are no qualified staff EPHO will recruit and continue supporting those on contractual employment to sustain continuity and smooth implementation of activities

The EPHO will strengthen and expand the ART services in the province in line with national objective "to halt and begin reducing the spread of HIV/AIDS by increasing access to quality HIV/AIDS services".

EPHO will train 30 staff in Adult ART management; provide mentorship support and technical support supervision monthly through clinical care teams in eight districts and Quarterly by PHO team to the districts. The EPHO will facilitate holding of quarterly clinical symposiums in all the districts and bi-annual provincial clinical symposia at the two level two hospitals. The EPHO will integrate prevention for positives (PwP) as part of standard care in all ART sites and will train adherence counselors in PwP. The programme will also strengthen adherence and retention of patients on treatment through holding of quarterly community drug and therapeutic committee meetings in the districts. The community drug and therapeutic committee will be strengthened through technical and supportive supervision by the province and district teams. The province will spearhead monitoring and evaluation through support to district quarterly HIV/TB review meetings, technical support supervision to all the districts and review of monthly reports. The provincial quarterly technical review meetings with the districts will be integrated with other programs e.g. TB. EPHO and the districts will participate in the commemoration of World AIDS day with support to health support.

The major objective of the program is to provide counseling, testing and care in all health facilities of the province. This serves as the entry point and linkage to care, antiretroviral service provision and prevention activities. However, the counseling services will be strengthened for prevention of the positives and negatives through quarterly meetings and sensitizations on strong messages of abstinence, faithfulness to one partner in relationships and use of condoms. In view of diagnostic counseling and testing as opposed to voluntary counseling and testing, provider initiated counseling and testing will be strengthened in all health facilities in the province.

Mentorship in counseling and testing services will be done as an integrated activity. The Province will train 40 health workers (20 per district, Nyimba and Mambwe) in child counseling. To enhance counseling services and also address the issue of discordance, couple counseling will be strengthened by training 60 health workers in the province.

The districts will conduct Sensitization meetings for 50 community leaders in couple counseling and training of 80 lay counselors in finger prinking for HIV testing for three days. The province will conduct monitoring of counseling and testing services quarterly to the districts and monthly through the districts to health centres. Quarterly counselors meetings will be held to share experiences and review progress in implementing planned activities. The Province will facilitate commemoration of World VCT day in the two districts, Nyimba and Mambwe.

$75,000 is provided to help assure quality training and oversight for SmartCare CT module implementations, at all sites providing this service. Workstations and smart cards will be supplied via EGPAF or MOH.

The EPHO will ensure that at least 10% of patients on ART are children by strengthening and scaling up Pediatric ART services. Training of 50 staff in pediatric ART management, 50 staff in pediatric mentorship, providing mentorship support monthly through clinical care teams in eight districts will work toward achieving the objective. The province will provide mentorship on quarterly basis. During mentorship the teams will look at ART management, DBS, PITC, and child counseling, follow up of exposed children and septrin prophylaxis. Clinical symposia will be integrated with the Adult treatment symposia. Quarterly HIV/TB review meetings for eight districts and the technical review meetings by PHO will be integrated with other programs and will act as a monitoring and evaluation tool. The EPHO will also support scale up of mobile ART service to Chama, Chadiza, Nyimba and Mambwe which are the most disadvantaged districts. The trained community lay counselors in drug adherence will play a major role in ensuring that clients adhere to treatment and follow up visits to the facilities for reviews and counseling are adhered to. In order to keep the lay counselors abreast with new information, quarterly meetings will be held at district level. EPHO will join the rest of the world in commemorating WOLRD AIDS DAY. Mass community sensitization through the media and other forum will take place. Production of IEC materials on HIV/AIDS/TB/PMTCT to reinforce prevention interventions will be printed

The EPHO main goal and aim is to strengthen existing operational, Health Management Information System (HMIS) and other Health Systems mechanisms and governance arrangements. The approach includes implementing and maintaining internet connectivity in all the eight districts, district and 2nd level referral hospitals and Provincial Health Office, with a viable Local Area Network (LAN) to facilitate data processing and information sharing for informed decisions.

SmartCare deployment and capacity building, as part of the national HMIS, will be scaled up to all the eight hospitals, two 2nd level referral hospitals and the remaining 10 health facilities that are on National Zambia Electricity grid. Currently 34 computers with SmartCare have been deployed for ART, PMTCT, maternity and or antenatal services. During 2010, electronic health records will be used for all clinical services in clinics with electricity. SmartCare (SC) data will be aggregated from all SC facilities to the district, every month, at the same time as HMIS data, then from district to province and to MOH..

Technical support at all levels in data management will involve periodic data audits, quarterly data review meetings. The EPHO will conduct an initial end user training for District and PHO managers in data audits and data quality assurance. Capacity will be built in 32 District and eight Provincial Health level managers in data quality and data quality self assessment with a view to roll out the trainings to health facilities. Supportive supervisions to the eight districts will be on-going, to ensure quality of care and reliable data. Data associates in strategic areas will be maintained with wages or salary support, and will intervene expeditiously when any facility has difficulty using its electronic health record system.

The 2010 budget increase is to focus strong and repeated SC in-service, other trainings, and frequent oversight, to assure excellent SC implementations, so that clients receive the full benefit of continuity of care that is possible with readily accessible and complete health records and a system of integrated services and referrals. In 2010 deployments to facilities with alternative but sufficient power will begin.

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.

EPHO will focus on PMTCT sites within the Eastern Province of Zambia. EPHO 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.

In 2009, Eastern Province health office (EPHO will establish comprehensive male circumcision in 5 of the 8 districts of eastern province. EPHO will implement male circumcision as an integrated HIV preventive measure.

We will sensitize the communities (community leaders, Community health workers, and Community based organizations) on the importance of MC as an important component in the prevention strategies. The EPHO activities will complement the services being provided by other partners' e.g. Jhpiego at Chipata general hospital and Mwami mission hospital.

In FY 2010 EPHO will, 1) train 10 health workers in MC in three remaining districts of the province, 2)conduct one day orientation in MC of 30 community based volunteers (10 per district in the three remaining districts),3) will provide supportive supervision to MC sites in the province in combination with other programmes like TB, PMTCT, and antiretroviral therapy services),4) Conduct monitoring and evaluation (M/E) of the MC program as part of the quality assurance process in the three districts, 5) conduct 12 radio programs on the importance of MC in the prevention of STI/HIV, 6)Conduct outreach and mobile MC activities,7) hold quality assurance meetings quarterly with sites doing MC and procure equipment and commodities related to MC. As the funding is limited EPHO's activities will mainly be training, community sensitization, supervision of MC activities provided by Jhpeigo, monitoring and evaluation.

To prevent and mitigate the spread of Sexually Transmitted Infections (STIs), HIV and TB, promotion of positive behavioral change is cardinal and will be reinforced. To achieve this, the Provincial Health Office (PHO) and the District Health Offices (DHOs) will mentor the health workers and youth coordinators. The number of trained peer educators stands at 40 in Chipata district and EPHO will facilitate continued training of peer educators in catchment areas such as churches, colleges where there are no trained peer educators to reach the target of 80 . An integrated approach with other program areas in awareness creation of preventive messages during recreation activities will be used to reach other youths and adults. Pool, bicycle rallies, during biannual youth festivals, school and out of school youths will compete with each other through quiz, songs, poems and educative modeling in the area of TB/HIV/AIDS. Twelve TB/HIV programs on radio station will be aired to reinforce dissemination of health messages including messages for prevention for positives and negatives. Couple counseling will be advocated for to prevent new and re-infections.

Youth coordinators will facilitate community sensitization through monthly and quarterly meetings. Patron and matrons will provide mentorship to the youths on quarterly basis. To enhance youth empowerment and as a way of keeping them away from engaging in vices such as beer drinking, drug abuse and sex work, PHO will work with partners to support skills training in carpentry, tailoring and tie and dye.

One of the major drivers of the HIV epidemic is youth involvement in alcohol abuse which predisposes them to engaging in unprotected sex. Youth friendly activities will stress the dangers of alcohol abuse using behavior change communication strategies. The EPHO will advocate for the strengthening and enforcement of policies and by-laws that restrict persons under the age of 18 from entering drinking places or purchasing alcoholic drinks. This will be done through holding regular meetings and consultations with civic leaders, local authorities, business communities, and other key stakeholders. These activities will be monitored to ensure quality delivery of services.

The main objective of the Prevention of Mother to Child Transmission of HIV infection program for the EPHO is to provide oversight to the scale up and strengthening of the PMTCT services in the eight districts of the province including support to all PMTCT related training. EPHO funds will also leverage with other partners to support combined supervisory visit.

With current low male involvement in health services, EPHO will ensure that male partners not to miss out on important preventive services such as counseling and testing, education on condom use to prevent re-infection, reduction on the number of sexual partners and repeat testing for both mothers and their spouses male involvement will be strengthened in the four districts.

Monitoring and evaluation of programme implementation will be done through technical support supervision, integrated technical review meetings and mentorship at all levels of health service delivery. The use of combination therapy for PMTCT HIV positive clients will be strengthened. To reinforce the quality of monitoring the EPHO will train 30 health workers (supervisors) in order to provide them with updated knowledge and skills in PMTCT. The trained supervisors will then conduct on site re-orientation of trained staff in the use of dual /triple therapy in all the districts where appropriate.

Four districts will hold biannual follow up meetings with 80 traditional leaders as their influence and involvement in PMTCT services is cardinal to community involvement. The trained tradition leaders together with health center staffs and traditional birth attendants will monitor the effectiveness of the community support groups .e.g. SMAGs, breast feeding groups etc in supporting clients to adhere to treatment and ensure the smooth running of the mother baby follow up programme through meetings. Furthermore 100 community lay counselors will be trained in HIV Rapid test finger pricking technique.

EPHO will conduct mentorship activities quarterly to the districts and monthly by the district to the health facilities and communities. Support to the SMAGs and other support groups will be offered through technical support. The EPHO will ensure early infant diagnosis is supported by ensuring that dried blood spot test on each and every exposed child at all stages.

PMTCT one time plus-up funds are being added to support: the procurement of bicycle ambulances for facilities where appropriate.

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. EPHO will procure bicycle ambulances for facilities 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.

Main Objective: To strengthen capacity, ensure sustainability at the local level and provide support for activities to be conducted by local staff within the province in PMTCT, Pediatric ART, HIV/AIDS, TB and Counseling and Testing

EPHO will initiate the accreditation process of laboratories in the province in collaboration with Ministry of Health and CDC. The accreditation will start in four selected laboratories in the province through training. EPHO will support training of seven staff that will scale up the laboratory accreditations of other laboratories. EPHO and the districts will strengthen internal and external quality control in the laboratories focusing on Rapid HIV testing, CD4 count, blood chemistry and bacteriology. EPHO will train 20 staff in laboratory management, computer appreciation and laboratory information systems. 25 staff will be trained in phlebotomy. EPHO will strengthen the referral system of the specimen from the facilities to the main laboratories in eight selected facilities in Mambwe (three) and Nyimba district (five). This will be through support to the facility by provision of fuel or recruitment of motorbike riders as well as procurement of specimen transportation system. EPHO will sustain an equipment maintenance system in order to have affective working equipment. The laboratory plans to regularly service the equipment so that break down of machinery is reduced. Equipment will include but not limited to five generators, FACS Count Machine, and five refrigerators.

In addition, EPHO received an approval from the MOH to establish an early infant diagnosis testing capacity in the Eastern province. EPHO will support this activity by improving existing laboratory space at its provincial hospital to be suitable for this type of work and train staff.

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

Eastern Province Health Office will conduct district level laboratory assessments with MOH and other partners and procure equipment as appropriate for maximum cost-effectiveness and coverage. 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 clinics throughout Eastern Province, the use of clinical and laboratory equipment is often monopolized by ART patients. EPHO 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.

The goal of the TB/HIV programme is to reduce the burden of TB disease among the HIV infected individuals. Among the important activities, is the screening of TB infected patients for HIV infection and the screening of HIV infected patients for tuberculosis. The EPHO will ensure linkages between counseling and testing services. The TB patients who are HIV positive will be linked to Network of Zambian People living with HIV/AIDS (NZP+) for continued care and support. HIV/ART and TB services will be strengthened including notification of partners and use of condoms for patients with TB/HIV including education on the risk of infection transmission.

With low TB notification rates, emphasis will be placed on intensified active case finding through community involvement, treatment supporters will play an active role in sensitizations on, DOTS and TB/HIV preventive health messages through 15 radio programmes.

Following the formation and operationalisation of the TB/HIV coordinating bodies, it is imperative that these bodies are active and effective at all levels. The TB/HIV coordinating bodies will hold quarterly meetings and technical support supervision.

EPHO will ensure support is provided through quarterly integrated TB/HIV review meetings with partners to monitor the planned and implemented activities. EPHO will conduct integrated technical support supervision at all levels of care. Multi-drug (MDR) and extra multi-drug resistant (X-DR) TB makes TB Infection Control cardinal to the reduction of disease burden. The PHO will support TB infection control trainings of 80 health workers, provide mentorship in DCT, TB infection control and management. The EPHO will continue with renovations to infrastructure to accommodate TB/HIV settings.

EPHO will strengthen staffing in constrained districts by employing eight staffs and continue supporting the District field officers and EPHO TB/HIV officer.

EPHO will attend the CDC- GAP Partners meeting, commemorate the world TB day, and support the transportation of sputum specimens to the diagnostic centres. EPHO will hold training for 20 microscopists and refresher course in sputum examination for 20 staffs.