The Zambia Emory HIV Research Project (ZEHRP) is the leader in offering Couples HIV Counseling and Testing (CHCT) in Zambia. ZEHRP has counseled and tested Zambian couples since 1994; as of July 2009, ZEHRP supported CHCT services at 14 sites throughout Lusaka and the Southern Province. This project aligns with PEPFAR II's increased emphasis on HIV prevention since CHCT has proven to reduce HIV transmission within couples. Joint testing and counseling decreases transmission of HIV by more than 60% within discordant couples, and reduces sexually transmitted infections and unplanned pregnancies in all couples. The PEPFAR goal of preventing 12 million new HIV infections must incorporate prevention strategies targeting the population at highest risk cohabiting African couples. Moreover, the legislation authorizing PEPFAR II specifically recognizes the significance of discordant couples, who can most effectively be identified through CHCT. Implementation of prevention strategies within these couples is most effective when they receive HIV results and counseling together; although as a result of inadequate counselor training some programs continue to separate men and women during post-test counseling.

Comprehensive goals and objectives of this project include the following:

1. Offering and promoting CHCT throughout Lusaka and Southern Provinces, primarily at government clinics. Couples receive appropriate risk reduction messages and advice for healthy living based on couples' HIV test result: concordant negative, concordant positive or discordant. 2. Partnering with other USG funded organizations to ensure national level expansion of CHCT. 3. Actively following-up and referring HIV-positive individuals for care and treatment All HIV-positive, pregnant women identified at CHCT are referred for PMTCT, unless the woman is already enrolled. All HIV-positive clients are referred for Antiretroviral Therapy assessment, unless already on ARVs or under assessment. 4. Long-term follow-up of discordant couples ZEHRP's clinic provides discordant couples with additional counseling, condoms, direct links to male circumcision services, family planning (including long-term birth control methods that are unavailable at their local clinic), and screening and treatment for syphilis. In Southern Province, where there is no ZEHRP clinic, discordant couples are invited to return to CHCT sites for a follow-up visit to receive additional risk reduction counseling and condoms. 5. Testing children under five attending CHCT with parents Pediatric testing makes CHCT a more family oriented approach and will capture children that may be missed by other pediatric testing programs. Because both parents consent to testing and hear the child's results, adherence to pediatric ART can be expected to improve for those children. Positive children identified at CHCT are referred into the pediatric ART programs at the clinics.

Geographic coverage and target population: ZEHRP supports CHCT services in Lusaka and Southern Province for all couples - married, cohabiting, engaged, or dating. While the majority of couples tested to date have been cohabiting, ZEHRP is ensuring the promotion of CHCT services to premarital couples. ZEHRP supports CHCT in clinics throughout Lusaka such that all couples within the city should have access. In Southern Province, a much larger geographic area, CHCT is offered in urban towns of Kafue, Mazabuka, and Monze with mobile units that can travel to nearby villages. Support for cross-cutting/key issues: At CHCT, all couples receive family planning information and referrals as needed for family planning services at the clinics. During follow-up visits with discordant couples in Lusaka, ZEHRP offers IUD and implant, and long-term family planning methods that are often unavailable elsewhere. CHCT increases gender equity in HIV/AIDS activities and services, requiring equal participation for women and men, thus incorporating more men into HIV/AIDS prevention activities.

Contributions to health systems strengthening: By integrating CHCT into standard VCT services within clinics, ZEHRP has improved the scope and comprehensiveness of clinic services. ZEHRP trains clinic counselors in CHCT counseling, which requires special arbitration skills, especially when dealing with discordant couples. Cost-effectiveness: Partnering with the District Health Management Teams to integrate CHCT into government clinics maximizes use of existing facilities and leverages PMTCT with prevention of heterosexual transmission when pregnant women and partners are jointly tested. The DHMTs offer free space and clinic counselors are recruited to provide CHCT in their own clinics. ZEHRP will continue to train and mentor clinic counselors to take on management responsibilities for CHCT programs.

Monitoring & Evaluation: ZEHRP will continue to collect age, cohabitation status, testing history, and HIV test result for tested couples; clinic counselors have been trained to use these tools. Promotions are tracked using individual invitations (personal invitations have proven to be an effective means of encouraging couples to attend CHCT) and a Public Endorsement Report Form to capture larger events including health talks at clinics, churches, and work places.

Zambia Emory HIV Research Project (ZEHRP) will offer HIV counseling and testing to cohabitating and non-cohabitating couples. ZEHRP has also extended CT services to children between the ages of 6 weeks and 5 years who have accompanied their parents to Couple HIV Counseling and Testing (CHCT) and have an HIV-positive mother. This encourages the family-based approach to CT services.

ZEHRP counselors provide couples with the prevention messages of Be Faithful, Male Circumcision or consistent condom use depending on their HIV test result; concordant positive, discordant, concordant negative. Couples are also linked to appropriate care and clinical services such as PMTCT and ART. ZEHRP offers IUD and implant, long-term family planning methods, to all tested couples and provides discordant couples re-testing at regular intervals and access to condom,

CHCT will be offered mainly in government clinics in Lusaka and Southern Provinces. ZEHRP offers CHCT on the weekends at government clinics so that working individuals (especially men) are available. In addition, clinic space and clinic staff time are available on weekends. ZEHRP will continue to promote CHCT services in the community to increase demand and decrease stigma.

ZEHRP staff will monitor and evaluate the quality of CHCT services through site visits and evaluations. ZEHRP staff will review all data collection tools for errors on a weekly basis. ZEHRP staff will continue to hold monthly meetings with government clinic counselors to address any programmatic changes and M&E. A staff member with counseling experience will be present to address any counseling issues that may arise. In addition, a staff counselor will be assigned to each clinic as the point person for government clinic counselors. Quality Assurance of HIV testing procedures at field sites will be supervised and evaluated by a trained laboratory technician with plans to incorporate ZEHRP staff into the National External Quality Assurance Program.

ZEHRP aims to test 8,300 couples from the general community along with the previously mentioned 1,700 couples in PMTCT/ANC settings and prevent 60% of incident HIV infections in discordant couples between October 2010 and September 2011.

Between January 2008 and June 2009, Zambia Emory HIV Research Project (ZEHRP) tested 1201 pregnant women, of which 410 were referred for PMTCT because they were not already enrolled. Couple HIV Counseling and Testing (CHCT) will continue to capture pregnant women that are not already enrolled in PMTCT. Pregnant women already enrolled in PMTCT are referred to the clinic based ZEHRP weekend service sites and retested as a couple to help with disclosure and ensure involvement of the father. By counseling men and women together on the importance of PMTCT, CHCT can encourage adherence to prevention methods under PMTCT. Both partners will understand the means of preventing transmission to the child and can openly talk about how they can prevent transmission and re-infection in their situation.

ZEHRP aims to test 1700 pregnant women and their male partners between October 2010 and September 2011. We will be in communication with CDC Zambia to readjust target number of pregnant women tested and their male partners with CHCT in PMTCT and ANC settings pending funding.

PMTCT one time plus-up funds are being added to support: an evaluation on partner HIV testing. Developing and building programs that improve and expand confidential testing and counseling and PMTCT is critical for achieving overall primary prevention of HIV in Zambia. Overall, 11.2% of cohabiting couples are discordant for HIV, including 6.6% of couples where the man is positive and woman negative, and 4.6% of couples where the woman is infected. While over 80% of pregnant women were tested in 2008, only about 10% of their male partners were tested. Partner testing can reduce incident infection in pregnant women and their infants through identification of male-positive discordant couples. More information is required on why partner testing is low.