Context and Background. The PEPFAR program and other donors complement and feed into the activities of the national HIV program

UTH Profile: The University Teaching Hospital (UTH) is situated in Lusaka. About 50% of the population is children aged less than 15 years, while women childbearing age constitutes about 20% of the total population. Lusaka has 30 primary health facilities run by the Lusaka District Medical office, eleven of which have delivery (labor) suites, and nine offering ART. Referred patients to UTH access most services free of charge, but cost share for specialized investigations. The Lusaka HIV prevalence at 21% is much higher than the national average.

The UTH is the national tertiary referral hospital, but also provides primary and secondary care to Lusaka residents, and contributes to surveillance endeavors. The UTH Mission statement is "To provide affordable, quality health care, function as a national reference center, train health care providers, conduct research to help resolve existing health problems and for the development of Science".

Main Objective: To turn UTH into a regional HIV Centre of excellence through the provision of expert HIV care and treatment, specialized laboratories, reclaim its leadership role in the development of training materials, training and mentoring of health workers, and provision of technical support to the Ministry of Health and its partners.

Methods: Providing a continuum of HIV care, by building on what has already been achieved locally and elsewhere to turn the tide of global HIV/AIDS. The above aim is being achieved through the 1) training of a critical mass of Master Trainers in advanced HIV/AIDS prevention, care and treatment, mentorship and clinical evaluations of HIV and AIDS programs. 2) Expansion and strengthening of new and old service C&T outlets, Family Support Units (FSU), pediatric ART and those providing palliative care, 3) domestication and timely revision of HIV and AIDS related international guidelines and training manuals 4) active participation in all HIV and AIDS related technical working groups (TWG) to help guide government policy based on evidence based medicine 4) strengthen and support the national mentoring program 5) and, continue contributing to HIV/AIDS related surveillance activities. HIV/AIDS is a mammoth challenge to the health care delivery system that requires innovative ways of getting more people on HIV/AIDS preventative strategies and ART.

2010 Project Strategy

The program will continue building on the UTH national mandate; to offer expert tertiary health care, train health care workers (HCW) and conduct research. For this application we will continue to concentrate on three major areas: 1) achieving primary prevention of HIV infection through the PMTCT, MC programs and adult ART, 2) improving the care and treatment of HIV/AIDS and related conditions and 3) strengthening laboratory support for surveillance, diagnosis, treatment and disease monitoring. The guiding principle in the design of this program lies in the comprehensive application of existing best practice, expansion, capacity building, task shifting, sustainability and community mobilization.

Additionally, in FY 2010, UTH seeks to continue implementing different surveillance activities in HIV/AIDS/STI/TB important in enhancing GRZ's response to the HIV/AIDS/TB pandemic. HIV prevalence and incidence data are critical in assuring that the program activities are responding to state of the epidemic, as well as informing and guiding policy and interventions. UTH will contribute to the development of a survey protocol for estimating the prevalence of HIV in children less than five years olds. UTH will seek to estimate the HIV incidence for recent infection using the BED-CEIA testing strategy. HAART has been scaled up to most health centers in Zambia. It is important that surveillance and monitoring of HIV Drug resistance (HIV DR) is part of HAART programs. UTH will seek to use specimens from the 2010 HIV SS in ANC to evaluate the burden and extent of transmitted HIV drug resistance in Zambia.

Expected Outputs in 2010 (are outlined in the table on page 9). In essence UTH-HAP is a wraparound program; [prevention, care and support, treatment and laboratory infrastructure with multiple indicators).

Monitoring and evaluation: Enabling the collection, aggregation and transmission of core indicator data from service delivery, district, and national levels, including reporting to USG, to inform clinic and program management decisions at all levels is an important goal of HMIS. It involves data quality, data transmission and data exchange formats, and security and confidentiality. In 2010, UTH-HAP will adhere to the overall purpose and components of an M&E system as outlined in the "Organizing Framework for a Functional HIV Monitoring and Evaluation System", published by UNAIDS in 2008, also known as the 12 Components Framework, whose purpose is to have a fully functional, unified, national M&E system. We will also Build on UTH-Hap capacity to conduct program evaluation and operations research. (4,948)

Context and Background: Adult care and support is a continuum of activities for HIV-infected adults and their families aimed at extending and optimizing quality of life through the provision of clinical, psychological, spiritual, social, and prevention services. At UTH HAP, clinical care includes; prevention and treatment of OIs (excluding TB) and other HIV/AIDS-related complications including malaria and diarrhea (providing access to commodities such as pharmaceuticals, insecticide-treated nets and related laboratory services, pain and symptom relief, and nutritional assessment and support).

Physiotherapy: Some adult patients on (ART) have complications such as arthritis and nerve complications resulting in weakness in the limbs and nerve pain that may be secondary to HIV itself, opportunistic infections (OI's) or/and HIV-related tumors. As part of palliative care, these patients are rehabilitated in order to recover to some degree of function and have an improved quality of life. The success of this program in 2010 will be achieved through building on what has already been achieved and expansion of the palliative care programs (increase the number of service outlets) to more communities. Program emphasis will be on training of HCW and CCW, community mobilization and sensitizations, community based workshops and task shifting, collaboration with community and national stakeholders to advocate for continued services for people with special needs through out the country. Target population: both male and female adults. Our goal is: To provide physiotherapy in Palliative Care services through Physiotherapists and community based care givers, expand and saturate Physiotherapy in Palliative Care (PC) services to all communities in Lusaka and beyond,

Strategies for the coming year: In 2010, we hope to improve and consolidate prevention services which will include ?prevention for positives behavioral counseling and counseling and testing of family members.

Context and Background:

In keeping with the UNAIDS and WHO goals of universal access to HIV prevention, care, and treatment, there is now considerable advocacy to universal access to HIV C&T, with the goal that all persons should know their HIV status. The UTH HAP has three C&T programs that aim to Identify those in need of HIV care and treatment and to provide specific prevention education and counselling based on knowledge of HIV status.

Provider initiated counseling and inpatient testing program (PITC): has been ongoing at UTH since 2005, in 2010 we aim to provide, consolidate, and maintain high levels of PITC on all in patient wards. PMTCT and STI clinic.

Family Support Unit (FSU): was set-up in 1992 and continues to be the VCT arm of UTH-HAP, in 2010, we aim to coordinate & expand FSU within & outside Lusaka to provide psychosocial support & supportive counseling services and continue to build the national psychosocial C&T capacity by offering a menu of training interventions; offer intensive adherence information, education and counseling, orientation of HBC groups in Pediatric HIV care, provide outdoor/mobile VCT at community events i.e. "world AIDS day, VCT day, continue with Kids'-club activities for enrolled Pediatric clients, continue to host community, sensitization/educational activities to increase awareness of pediatric HIV issues, including availability of treatment, orphans and HIV. Continue to offer house- hold VCT to clients unable to access health facilities for various reasons. The unit will target over 100 households. This will also involve partnering with the Child sexual abuse unit and community schools who have these gaps.

Zambia Voluntary Counseling and testing Services (ZVCTS); Is tasked by MOH, to identify and set -up VCT centers and accreditation of ART centers in hard to reach under serviced rural areas. In 2010, about 100 rural sites in 12 districts will be identified and established. Baseline activities will include meetings with the District management staff to identify new sites with appropriate basic requirements for provision of C&T in rural areas. Available IEC materials will be translated into local languages and distributed to enhance social marketing of VCT service in rural areas. Rural counselors will be trained in HIV rapid testing and refresher courses for the service providers in the provision of VCT services in already existing sites will be conducted on the newly revised testing algorithm. ZVCT will participate in national events such as Worlds AIDS, VCT Days and other public gatherings. All new sites will be followed up with supervisory visits in conjunction with the district management, to assure quality of services.

Context and Background: Zambia is faced with a generalized HIV epidemic that contributes to difficulties in identifying children and reaching paediatric treatment goals. The Zambian paediatric ART guidelines have adopted a public health approach to virologically test HIV exposed infants at six weeks supported by a confirmatory HIV rapid test at 18 months of age. GRZ has strengthened policies to remove barriers to access i.e. the recording of maternal and infant HIV status on the under five card for easy identification of HIV exposed/infected infants and children. Several paediatric ART trainings have been carried out country wide, to ensure an adequate cadre of health workers is equipped to deal with the special needs of children.

Accomplishments since last COP: UTH HAP provides PITC to >95% of children admitted into paediatric wards, confirmation of HIV exposure with a DNA positive test is done on over 75% of admitted HIV exposed infants, ART (as soon as a definitive diagnosis of HIV is made in infants), cotrimoxazole prophylaxis (all HIV exposed/infected from 4-6 weeks of age), and

Integrated treatment programs (MCH, TB, malaria and Nutrition).

Community Based Intervention Association (CBIA): Children with HIV may develop complications such as developmental delays and variable types of disabilities. As part of palliative care, UTH HAP works with CBIA to support young children with disabilities to recover to some degree of function and have an improved quality of life.

Strategies for 2010: Extension and optimizing the quality of life for HIV-infected children and their families throughout the continuum of illness through the provision of appropriate clinical, psychological, spiritual, social, and prevention services. We will also work on achieving gender equity in services and support for service providers. Mobile clinic; provision of pediatric ART to under privileged children in underserved hard to reach communities. Back-up supplies; providing access to commodities such as pharmaceuticals, insecticide treated nets and related laboratory services, pain and symptom relief, and nutritional assessment and support. Expansion of CBIA activities to other districts to reach 100 children in 5 communities with educational and developmentally stimulating activities, train caregivers in home based pediatric palliative care and integrates physiotherapy with pain management.

The UTH -PCOE contains the most comprehensive program elements and organisational structure. It provides care and treatment to HIV exposed/infected infants and children and there are cumulative > 8,000 children in care and about half of these are on ART. We hope to continue providing and demonstrating exemplary best practices of care and treatment for HIV infected and exposed children, so as to increase the number of children engaged in care and receiving antiretroviral therapy inclusive of prophylactic therapy with Cotrimoxazole, and to achieve a notable reduction in the number of severely malnourished HIV infected children >18 months, in Misisi, Chawama, Kuku and Kanyama;

UTH - PCOE will support current and expansion activities by building on its core programmatic elements. We will continue partnering and collaborating with ICAP and offering technical support to the MOH in the development of pediatric HIV related guidelines and training manuals, capacity building of HCW in the care and treatment of children with HIV/AIDS, will support the expansion of pediatric ART in the Southern Province as well as down referral to district sites that filter into local hospitals. The PCOE mobile ART clinics will continue to serve the under privileged children in underserved areas of peri- urban Lusaka. In 2008 the PCOE established the "Misisi: Community Nutrition/HIV Care Program". This is a community model piloting the effectiveness of early detection of malnutrition in infants and young children, and a comprehensive application of existing best practice with community participation that enhances sustainability. UTH will also buy into the food by prescription program. This was recently drafted in Zambia and will provide for clinically malnourished pre-ART and ART children. From 2009, Zanelic and the nutrition program will be supported with a weekly mobile ART services

In 2010 we hope to increase service outlets providing pediatric ART: Together with the Southern province provincial office (PMO) UTH-PCOE have identified districts in need of new pediatric outlets, preparation of the sites will include; training and mentoring MDT on site and work to achieve more children newly initiating pediatric ART, who ever received ART and increase the number of children currently on ART. In the nutrition program we hope to achieve a notable reduction in the number of severely malnourished HIV infected children >18 months, in Misisi, Chawama, Kuku and Kanyama; through community mobilization, sensitization, outreach activities and active community participation, monthly audits.

The early infant diagnosis lab (EID): will continue testing DBS for DNA PCR for UTH, Southern Province and CHAZ supported health facilities. The lab will work on improving its diagnostic capability through infrastructure development, regular maintenance and certification, and support for extra staff.

In FY 2010, UTH seeks to continue implementing HIV surveillance activities, and expanding the laboratory capacity in the following areas: (1) dissemination of information from the 2008 HIV sentinel surveillance (HIV SS); (2) implementation of the 2010 HIV SS survey in the 27 sentinel sites; training field staff, perform sample analysis, data management, analysis and report writing; (3) estimation the HIV incidence using the BED-CEIA testing strategy; (4) UTH will continue in estimating the extent of the emergence of transmitted HIV drug resistant strain in sentinel surveillance sites; (5) As HIV prevalence data among children is lacking, UTH plans to contribute to development of a protocol for estimating the prevalence of HIV in this category, and implementation in selected sites.

CSA: The UTH - PCOE one stop centre for sexually abused children intends to consolidate the development of systems, and guidelines in the management of CSA. The centre will continue to lead in the prevention and management of sexually abused children. By 2010; children completing a 28 day PEP course will increase from 64% to 75%, two sites in Kafue and Mazabuka will be established to offer services to sexually abused children, 100 individuals will be trained on the recognition, reporting and prevention of child sexual abuse, will continue to enlist community support through the radio, electronic media and giving education messages to youth organizations.

ZANELIC is a local NGO which provides emergency shelter to abused children and strives to create an environment where children are safe from all forms of abuse and promotes the rights of children in Zambia. Its main objective is "To provide shelter, basic health, education, care and psychosocial counseling and support to physically and emotionally abused children, HIV testing services to sexually abused children and ensure that 90% of these children become emotionally stable and prepared for reintegration". In 2010 UTH-HAP will continue partnering with ZANELIC and will support its consolidation and expansion of current activities to the Southern Province.

Clinic -3: In 2010 clinic 3 will continue consolidating its various activities, and in line with PEPFAR goals to link STI clients to HIV diagnosis, treatment and care, and screening of HIV positive clients for STI, Clinic 3 will continue running its VCT centre and offering PITC to all patients referred to the clinic. It will continue educating patients on the transmission, complication, prevention and the link between STIs and HIV. Patients will continue to be empowered on how to use condoms through videos, DVDs, and penile and vaginal model demonstrations, and taught how to negotiate safer sex. At the end of each session condoms and IEC materials in various local languages will be distributed to all patients.

UTH activities in FY 2010 will remain in line with the five year plan submitted with FY2009: UTH will assist the MOH to assure the accuracy of HIV test results generated by all facilities conducting rapid HIV testing in Zambia (C&T, PMTCT, and care and Treatment programs) as well as TB AFB smear microscopic results.

At the UTH Virology Laboratory, we will continue managing the National QA program in collaboration with CDC . It will oversee and provide technical assistance to provincial laboratories, PMTCT, and VCT sites to establish QA for rapid HIV testing. UTH Virology laboratory staff will coordinate training of trainers (TOTs) and roll-out training sessions of rapid HIV testing. UTH will prepare HIV proficiency panels using dried-tubes specimens methods, continue to conduct the national External Quality Assessment Scheme (EQAS) for rapid HIV testing, and perform supervisory visits. In addition, UTH will continue to establish a national EQAS for CD4 testing.

TB laboratory: We will ensure that AFB smear microscopy reagents consumable are always available and when lacking provide back-up supplies. UTH will continue supporting the expansion of EQA activities for acid fast bacilli (AFB) outside Lusaka including: training, on-site evaluation, proficiency testing, AFB smear microscopy blind rechecking, and feedback to the laboratories and building human resource for challenges in tuberculosis laboratory management. UTH will provide EQA data and feed back to the national TB reference laboratory (Chest Disease Laboratory).

Microbiology laboratory: We will strengthen the diagnosis of bacteremia/septicemia and other bacteriological identification and testing. The microbiology laboratory will improve its diagnostic capability through staff training, infrastructure development, regular equipment maintenance and certification, and supply chain management. We will establish internal and external quality assurance program for microbiology in two district hospitals in Lusaka province.

Furthermore, UTH will co-ordinate, and support regular meetings with CDC and other partners, to allow dissemination of activity and improve collaboration to avoid duplication of activities and encourage feedback.

Context and Background: Tuberculosis is one of the infectious diseases which pose a challenge in HIV infected persons and earlier detection of active TB in HIV infected patients helps in the management of the disease. The UTH Tuberculosis laboratory has the capacity for relatively quicker diagnosis of TB and drug susceptibility testing of Mycobacterium tuberculosis isolates. These services if properly utilized will play a big role in the management of TB patients and HIV/TB co-infected patients. The provision of quality assured results is one important aspect of the DOTS strategy. The continued monitoring of internal quality control systems at diagnostic centers and use of external quality Assessment tools cannot be over emphasized in the fight against tuberculosis. The laboratory uses approved Ministry of Health laboratory registers and forms.

The PCOE will work closely with the International centre of AIDS care and treatment program (ICAP) and the Ministry of Health National TB programme to develop practical screening algorithms to diagnose TB in HIV infected children and adults as well as training materials to improve TB diagnosis.

TB Laboratory: UTH laboratory examined 12,931 sputum smears in 2008 and 2,303 were smear positive. There were 12 MDR isolates in the same year. The laboratory provides diagnostic services and release results in the shortest possible time for patients in Lusaka, Eastern and Western provinces. Where need arises, technical staff will be sent for training in new methods and of particular importance i.e. in FY 2010, in the performance of DST on second-line drugs. We will receive samples from UTH and from provinces under our jurisdiction for culture, identification and drug susceptibility testing to both first line and second line anti-tuberculosis drugs, consequently contributing to the diagnosis and management of MDR and XDR-TB.

Monitoring and Evaluation: All activities will be monitored by way of on the spot checks, meetings, monthly, quarterly, semiannual report and annual reports. Data bases will be created for data collection purposes.

Funds for this activity will through Columbia University. (ICAP)