Western Province is a predominately rural province with a projected population of 1,015,753 in 2010, consisting of 480,888 males and 504,257 females. The geographic composition of this area consists of savannah woodlands and plains, traversed by the Zambezi River; deep sandy terrain and flood plains not only make communication and food production extremely difficult, but also makes it tough to access health services. Most areas of the province can only be reached by 4x4 vehicles year round and some parts only by canoes and speed boats during the rainy season. The challenging terrain makes delivery of logistics and health services difficult and the cost much of providing health services much higher, than most provinces in Zambia. By FY 2010, the province will have 12 hospitals and 148 rural health centers (total of 160 health facilities). The vastness of the province and low population density also make it difficult to make services easily accessible and is compounded by low staffing levels and insufficient infrastructure.

In FY 2010, the Western Province Health Office (WPHO) will focus on hard to reach areas that are cut off by seasonal floods, areas with high population density, high HIV and TB prevalence as well as special vulnerable population groups (e.g. such as pregnant women, children and people living with HIV/AIDS).

The HIV prevalence in Western Province according to the 2007 Demographic Health Survey has increased from 13.1% to 15.2% and therefore the WPHO's overall goal in the next 5 years is to prevent new infections while improving health delivery to people living with HIV/AIDS/TB in the province. This is expected to significantly contribute to the attainment of the health-related Millennium Development Goals.

WPHO will increase access to and utilization of services, improve quality of services in all technical areas through supportive supervision, and mentoring of health care workers. We will ensure availability of logistics and support transportation of specimens and outreach services from hard to reach areas.

WPHO will put in measures to strengthen the referral system and coordinate all services provided in all technical areas by other partners working in HIV/AIDS and other fields. WPHO will strengthen community participation, promote sustainability, and monitor performance in all technical areas. WPHO will intensify HIV prevention activities through a combination of strategies that include Male Circumcision (MC), promotion of condom use including among positives and discordant couples, PMTCT, and Behavior change communication (BCC) and strengthening of prevention messages for those testing HIV negative, and ensuring that these services are promoted and provided at all HIV testing areas.

PMTCT will be provided with an increased focus on promotion of couples counseling and male circumcision where applicable. WPHO will provide capacity-building to recruited and existing staff to improve their performance. WPHO will refurbish, renovate, and extend chest clinics, laboratories, counseling rooms, two ART rooms, youth friendly corners, and MC operation rooms. This will increase space, strengthen infection prevention, and improve the quality of services provided. WPHO will provide motorbikes and bicycles to selected sites to ease the difficulties of the staff and community volunteers have in transportation of specimens and slides.

WPHO will promote community ownership and active involvement by working with selected community members and groups such as traditional, civic and religious leaders, faith-based organizations, women's and youth groups.

Integration of activities is expected to improve cost efficiencies. Technical support and mentoring will be integrated across technical areas as well as promoting the use of multi-skilled supervising and mentoring staff. WPHO will strengthen health provider skills in data analysis and utilization so that activities are planned and implemented based on evidence and identified need. WPHO will also integrate transportation of specimens (CD4, smear slides, and DBS) across technical areas.

Qualified personnel will be recruited and trained in providing services in all the technical areas in order to ensure that, where feasible, all services are provided under one roof. The staff will also provide health services in areas that are not specifically supported by USG funds. WPHO will enhance provision of health services with gender mainstreaming into perspective.

In FY 2010, WPHO will monitor services in the technical areas through monthly, quarterly, bi-annual and, annual progress reports, data audit reports, performance assessment, and technical support reports.

By end of FY 2009 there will be 34 ART sites in the province (17 supported by USG funds). In FY 2010, Western Provincial Health Office (WPHO) using USG and global funds will scale up to 4 new sites and CIDRZ to 2 more sites resulting in a total of 40 sites. We will continue supporting mobile activities and recruit four more ART providers.

Currently, over 80% of patients positively respond to ARV treatment, only a small percentage of patients develop drug adverse reactions, immune reconstitution inflammatory syndrome and treatment failure. WPHO supports adherence counselors to assess clients for compliance before initiation of and during treatment; this has reduced default rates and improved clinical outcomes.

We will strengthen quality of ART services by conducting in-service training for health facility staff in adult ART, management of opportunistic infections, and adherence. Staff will assess, prepare, and counsel clients for adherence at each clinical visit. Community adherence counselors will be trained and equipped with the skills to ensure treatment and prophylaxis adherence, counsel and test family members, and promote prevention among positives and discordant couples. WPHO will use the SmartCare system to track and evaluate clinical outcomes through mortality rate, immunological and virological reports. ART site managers will be instructed in logistic management and support maintained for the clinical officers recruited in FY 2009.

We will mentor staff in new sites monthly and old sites quarterly and ensure adherence to ART accreditation guidelines by intensifying supportive supervision, procuring furniture, stationary and motor bikes, and support transportation of specimens to district and provincial laboratories. PLWHA will receive quality laboratory monitoring services. One health center will be refurbished and linkages strengthened between programs and referral systems. WPHO will put in place a record system to monitor and follow-up referrals.

We will increase the number of patients on ART from 830 at the end of FY 2009 to 1830 by end of FY 010.

WPHO will monitor and evaluate the program through technical review meetings, technical support, and progress reports.

In FY 2010, the Western Province Health Office (WPHO) will increase access to Counseling and Testing (CT) by increasing the number of health facilities from 140 to 160. The provision of CT during traditional ceremonies, commemoration days, public functions and conduct TC campaigns at community and educational institutions will be a focus. Demand for CT will be created through the use of drama performances to deliver prevention messages in four districts. WPHO will support sensitization meetings for local leaders (chiefs, civic/church leaders and neighborhood health committee members) in two districts with high risk populations, and the project will collaborated with four radio programs.

WPHO will ensure provision of quality counseling services by training community-based volunteers (CBVs), Classified Daily Employees (CDEs), and training facility staff in couples counseling and testing. Use of laboratory staff in the training and carrying out of quality assurance activities will promote higher standards for HIV testing. Individuals, couples and families are encouraged to know their HIV status; and those individuals testing positive will be assessed for ART eligibility and referred appropriately. Those testing negative will be given information on how to maintain their status and encourage other family members to know their status. WPHO will promote partner counseling and condom use in discordant couples. Services will be integrated into family planning, male circumcisions and blood donor services. WPHO will intensify supportive supervision to ensure adherence to national guidelines. Approximately $75,000 is provided to help assure quality training and oversight for SmartCare CT module implementations, at all CT sites. The retesting policy will follow WHO guidance, emphasizing high-risk groups, pregnant women and STI clients. This mix of strategies will result in 15,000 clients accessing CT services.

WPHO will coordinate all CT services including those provided by other partners (CIDRZ, CHAZ, CRS, and PLWHA) to ensure adherence to national standards through quarterly stakeholders meetings. Monthly reports, quarterly data audit review and, technical supervision reports will be used for monitoring and WPHO will ensure sustainability by encouraging districts to include CT activities in annual plans.

By end of FY 2009 there will be 34 ART sites in the province, of these, 17 will be supported by USG funds. In FY 2010, we will scale-up to 4 new sites and CIDRZ will scale- up to 2 more sites, totaling 40 ART sites in the province.

WPHO will increase access to pediatric ART by supporting outreach activities, intensifying adherence to national guidelines on Provider-Initiated Testing and Counseling, follow-up of PCR positive infants to ensure timely treatment and monitoring of side effects. We will support adolescent peer groups among HIV positives.

In order to ensure quality pediatric ART services, WPHO will train health facility staff in pediatric ART and in management of opportunistic infections, pediatric counselors and community adherence counselors. We will mentor staff in new sites monthly during the first quarter of implementation and quarterly for staff in old sites. Supervision will be provided to all sites on a quarterly basis.

WPHO will put in place a record system to effectively follow up HIV exposed children and follow up referrals to ensure access to services. We will strengthen retesting of all exposed/ negative children as per guidelines. Community participation will involved training of lay counselors and engaging community leadership in developing the terms of reference (e.g., encouraging families/couples and individuals to test and know theirs' and their children's status, carrying out HIV rapid testing and follow-up , and providing messages on prevention focusing on use of condoms and avoiding multiple partners) for lay counselors. We will support meetings with local leadership to increase utilization for pediatric services and formation of treatment support groups.

We will recruit ART providers, procure furniture for ART sites; motor bikes to facilitate transportation of specimens to district laboratories and provide quality laboratory monitoring services.

WPHO will monitor and evaluate the program through quarterly technical review meetings, progress and supportive supervision reports.

WPHO, in collaboration with the DHOs (District Health Offices) will continue to support the implementation of SmartCare through training, limited site readiness preparation, provision of logistical support for the deployment and post-deployment supervisory visits. WPHO will support a systematic and consistent flow of data from SmartCare facilities to the DHOs, then WPHO and finally to the Ministry of Health headquarters for planning and health decision making. WPHO will further provide support, dissemination and supervision of upgrades and other enhancements to SmartCare periodically when changes are made to the system.

To provide enhanced PMTCT and ART services to positive mothers, SmartCare will be deployed in at least 80% of the sites offering PMTCT, which have sufficient electricity.

In order to achieve this objective, WPHO will train at least 2 health workers in SmartCare, per deployed site, and all DHO and hospital program officers in M&E. This will build capacity in the use of health information for effective planning and program improvement. WPHO will also continue salary support to eight data associates to facilitate data collection and analysis at the district and provincial levels. Data Associates will provide technical support to health facility staff on data management and analysis. WPHO will continue to service and maintain SmartCare ICT equipment and internet services in the DHOs.

WPHO will support community sensitization activities focusing on the importance and use of electronic patient health records (Smartcards). WPHO will support Drama performances, meetings with local leadership (Chiefs, civic and church leaders and NHC members) and air radio programs.

WPHO will improve the quality of SmartCare facility data through performance review meetings. We will support DHOs to collect, verify and report to the provincial health office to ensure that old and new health staff are competent to accurately record, analyze, and report health data using SmartCare. WPHO will monitor strategic information activities through monthly and quarterly health information reports, technical review meetings, biannual progress reports, and field supervisory visits reports.

PMTCT one time plus-up funds are being added to support: PMTCT missed opportunities evaluation of program and Provincial PMTCT M&E training on the OGAC next generation indicators.

Cost information on pediatric HIV/AIDS care and treatment is limited, plus-up funds will be used explore missed opportunities for PMTCT and PMTCT failures across the cascade, including the social, cultural, laboratory and clinical factors that contribute to infant infection.WPHO will focus on PMTCT sites within the Western Province of Zambia. WPHO 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.

Western Provincial Health Office (WPHO) in collaboration with CIDRZ will promote and support provision of male circumcision (MC) as one of the HIV prevention strategies in the province. The objective is to contribute to the reduction of HIV transmission in the province and towards meeting the national target of carrying out 100,000 circumcisions in FY 2010.

Some communities of Western Province traditionally practice male circumcision; in these communities, WPHO will focus on safety and infection control. In other communities emphasis will be on raising awareness to increase utilization, safety and infection control. Circumcision will be provided as a package (testing and counseling, condom use, couples counseling and involvement of women, linkages to ART, STI and Family Planning services, infection control) with strict adherence to national guidelines.

CIDRZ will carry out a provider skills training for 4 health facilities in order to equip them with the desired skills, and procure MC equipment for Lewanika General Hospital and selected centers. WPHO will provide the leadership, mentor and provide technical support to the trained staff. Two clinical officers/nurses will be hired and renovation of two rooms will be performed. With the above interventions in place, we aim to perform 700 circumcisions.

The delivery of MC services will increase to four health facilities that will be selected based upon population density, and HIV prevalence. To increase demand, we will support sensitization meetings with the local leadership (Chiefs, civic and church leaders, Neighborhood Heath Committee members, and traditional MC practitioners), communities targeting men and women, and carry out MC campaigns in schools and colleges located within the health facilities catchment areas. WPHO will develop MC Information Education Communication materials in local languages and integrate MC in other technical areas (PMTCT, Counseling and Testing, Sexually Transmitted Infections, TB, and Antiretroviral Treatment) and encourage districts to put MC services high on the district planning agenda.

WPHO will monitor program implementation through performance assessments, technical review meetings, and monthly

Western Province Health Office (WPHO) will strengthen condom and other preventive activities in five districts using a combination of prevention strategies that include PMTCT, MC, community sensitization and prevention for positives. The program will also address issues of harmful social norms, GBV, intergenerational sex, transactional sex, excessive alcohol consumption, and multiple and concurrent partners; youth friendly services will continue (promotion of condom use, life skill, family planning, MC, substance abuse, teenage pregnancy and STI and HIV treatment and support). In addition to targeting women and youth, priority populations such as communities in fishing camps, lumbering camps, men organizing traditional ceremonies, and men's fellowship church groups will be sought after.

WPHO will facilitate sensitization meetings with local leaders (chiefs, civic and church leaders), mobilize communities, support drama performances, and radio programs. The messages will include promotion of the role of men as heads of households in prevention of HIV and STIs. PLWHAs will be engaged in planning, implementation and monitoring support to PLWHAs for carrying out preventive activities to ensure ownership and sustainability of the program

To strengthen health systems and increase service coverage, WPHO will train peer counselors and support the "Youth Alive" group in implementing preventive activities aimed at imparting life skills and encouraging youth to know their status. Anti-AIDS clubs for both in and out of school youth will be offered CT services, and youth friendly corners will be renovated.

The distribution of condoms and efforts to educate on consistence and correct use will intensify. Community sensitization on PMTCT and STI screening will continue as will opportunities for people to know their status as part of the prevention package. WPHO will conduct community outreach activities targeting most at risk populations. Through these interventions WPHO aims to reach 300,000 people with prevention messages and counsel and test 12,500 clients.

WPHO will monitor the program through performance assessments and supportive supervision reports.

The provision of services will scale up from 140 to 160 sites and support outreach activities. Western Province Health Office (WPHO) will support active engagement of community leaders, and NHCs members in promoting PMTCT services which has proved to be a very successful strategy for increasing couples counseling. Area chiefs, civic and church leaders will be engaged in supporting male sensitization meetings and increasing couples counseling within the antenatal clinics.

WPHO will ensure quality of PMTCT services by supporting provision of comprehensive PMTCT services in accordance with the national guidelines. WPHO will orient Classified Daily Employees in syphilis screening and HIV testing, train community-based volunteers (CBV) in finger pricking HIV testing, and health workers in the new PMTCT package, orient health workers in the use of HB machines, training of CBVs, and health workers in the PMTCT. A record system will be developed to facilitate follow-up for both mothers and exposed infants, in addition to use of the revised antenatal and child health cards. HIV negative women will be retested later in pregnancy and or labor to manage incident infections. Further, WPHO will orient staff in selected facilities to follow-up and facilitate linkages to services such ART and TB sites.

In order to ensure uninterrupted supply of HIV and syphilis test kits, procure haemocue machines, and micro cuvettes, bicycles, and cotrimoxazole syrup as back-up supply for prophylaxis, measures to strengthen the DBS courier system will be implemented. This is also expected to ensure timely initiation of infants on ARVs and provide fuel to transport Dried Blood Samples and CD4 specimens.

WPHO will continue to support PMTCT health providers recruited through this mechanism, support lay counselors to follow- up exposed infants, and Cotrimoxazole prophylaxis. Lay counselors will sensitize communities, test and counsel, and encourage couples counseling; promote use of condoms in general, among positives and discordant couples, as well as during pregnancy and lactation. Postnatal mothers will be linked to family planning services and negative male partners to male circumcision. Program implementation will be monitored through technical review meetings and supportive supervision reports.

PMTCT one time plus-up funds are being added to support the procurement of bicycle ambulances for facilities in Western Province where it is difficult for pregnant women to reach appropriate facilities in time for a safe delivery of their 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.

The goal is to improve the capacity of laboratories to provide effective and efficient quality laboratory services in order to enhance diagnosis and patient monitoring in HIV/AIDS/TB/STI related conditions.

WPHO will support selected laboratories to meet laboratory accreditation requirements, initiate, and conduct the accreditation process with Ministry of Health and CDC. We will support and ensure quality of all laboratories testing including HIV, build capacity of laboratory personnel through various trainings undertaken in collaboration with MOH, CDC and other partners. Laboratory staff (34) will attend in-country training courses in lab management, quality assurance (QA), basic computer skills, laboratory accreditation, phlebotomy, equipment maintenance, and lab information system. WPHO will support TB QA activities in collaboration with the Chest Disease Laboratory and a QA system for laboratory related tests including, but not limited to, HIV rapid test, CD4, and TB smear microscopy will be established from province to district and district to health center. WPHO will procure one CD4 fax count machine for a district laboratory to replace the CD4 guava machine which has erratic supply of reagents. We will procure equipment maintenance services.

WPHO will create an operational logistic system to bring specimens from health centers to district and or provincial laboratories where there is CD4 testing capacity and other clinical lab capacity. We will support specimen referral and transportation systems by procuring motor bikes for ART sites, procure fuel and cool boxes for transporting specimens.

We will monitor services through quarterly technical support, quarterly technical review meetings, and progress reports.

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

WPHO will conduct district level laboratory assessments and procure equipment as appropriate for maximum cost-effectiveness and coverage for use in facilities in Western 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 Southern Province, the use of clinical and laboratory equipment is often monopolized by ART patients. WPHO 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 TB program in Western province has seen marked improvement with the counseling and testing for HIV among TB patients increasing from 38% in 2006 to 82% in 2008. WPHO will increase access to TB/HIV collaborative activities by scaling- up services to 160 facilities; TB diagnostic services will be increased in five new health facilities giving a total of 54 diagnostic sites for the province.

Demand for TB services will be created by strengthening participation of community leaders (chiefs, civic and church leaders including Neighborhood community members) in health sensitization and mobilization, support of drama groups and trained treatment supporters.

We will increase diagnosis of smear positive TB among pulmonary TB patients by training clinical, nursing and laboratory staff and ensuring that all 160 health facilities open TB suspect registers to document people with cough for more than two weeks.

WPHO will support four districts while CIDRZ will support three but the overall responsibility is for WPHO to ensure proper coordination.

WPHO will ensure quality TB services by training staff in the Stop TB strategy, TB/HIV collaborative activities, clinical management and TB infection control. We will support treatment adherence, defaulter and contact tracing to prevent emergence of resistant TB strains. WPHO will recruit a provincial TB coordinator and maintain the laboratory coordinator as well as TB coordinating bodies at all levels. WPHO will encourage TB/HIV co-infected patients to use condoms and notify partners. These patients will be linked to support groups of people living with HIV and AIDS for continued care and support.

WPHO will procure bicycles, umbrellas, gum and boots to facilitate TB treatment supporter's work. Motor bikes will be purchased for transportation of sputum specimens and prepared smears. WPHO will renovate the Sesheke chest clinic. Technical support will be provided quarterly, from Province to District and from District to Health Center and conduct technical data review meetings to ensure consistent and quality data. All seven districts use the government approved data collecting and reporting tools.