Activities for Track 1 and Track 2 funding at site level overlap, therefore the narratives for the two tracks of funding are the same. AIDSRelief (AR) aims at providing durable comprehensive quality care to persons infected with HIV/AIDS. AR strategic program implementation components are developed toward increasing the sustainability of quality HIV care. AR currently serves in 8 provinces and at 19 treatment facilities, primarily in rural Zambia, with target populations that include HIV exposed and infected children, HIV infected adults and pregnant women, alcohol and substance abusers, and prisoners. Our HIV services wrap around a family centered care approach that is strongly linked to the community and integrated with monitoring and evaluation strategies, designed to integrate the family in health decisions including prevention strategies, adherence, and family testing. Our activities and strategic plan can be divided into six major components: 1) community based treatment services (CBTS); 2) medical care including adult and pediatric anti-retroviral therapy (ART), TB and STI management, maternal child health and early infant survival, palliative care, training and professional development; 3) Nursing Care; 4) Outcomes and Evaluation (O&E); 5) Laboratory services; and 6) Health Systems Strengthening (HSS). AR program components are focused on integrating prevention as the primary means to reduce new HIV and TB infections. Our plans for transitioning and sustainability are incorporated into each of these areas of focus and Local Partner Treatment Facility (LPTF) support is accomplished by multi-disciplinary teams with members representing each of the above categories. These teams provide regular on-site support to address critical issues and ensure that necessary components for quality care are developed and maintained. The sites are taking ownership of a comprehensive care delivery model that has been reinforced through mentoring and site visits. Smart Care data and patient outcomes information is regularly fed back to sites to strengthen data use for continuous quality improvement at site level.

Our medical component works closely with the Ministry of Health (MOH) in implementing HIV care and treatment at the site level, conducting trainings accredited by the MOH, plus providing significant assistance in developing antiretroviral therapy (ART), opportunistic infections, prevention of mother to child transmission of HIV (PMTCT), TB, and Pediatric guidelines and training materials. We have partnered with the University Teaching Hospital (UTH), University of Zambia (UNZA) and the MOH in implementing the HIV Diploma Course that trains providers as HIV experts. We have partnered with the General Nursing Council and other implementing partners (University of Alabama/Center for Infectious Disease Research Zambia and Zambia Prevention, Care, and Treatment) in the pilot HIV Nurse Practitioners Diploma program in efforts to task shift and decentralize care to be closer to the patient. AR serves with the Medicine Council of Zambia (MCZ) to develop accreditation of treatment facilities and also certification of ART providers. AR O&E component ensures sites understand quality assurance and develop strategies to implement treatment efficiencies, plus capture key indicators to streamline technical support to areas of identified need. Our HSS component focuses on developing plans to decentralize HIV care to the community through satellite clinics, and task shifting some care responsibilities to trained health care workers. Our CBTS team incorporates the community into each aspect of the HIV care and treatment continuum. Developing integration of health care services at the site level so that TB/HIV, PMTCT/ART, pediatrics and STI efforts harmonize with the community based programs improves cost efficiencies and has lead to an overall program lost to follow up of less than 2% and an overall retention rate of 85%. The management team is also investing in assisting sites with budget development to ensure cost effective strategies to provide sustainable quality programs.

AR focuses on frequent onsite support as a means of disseminating information, initiating new strategies, building linkages, and addressing prevention interventions. Key priorities for CY 2010 focus on prevention with positives, encouraging couple/family counseling and testing, early infant diagnosis and treatment, ensuring all HIV+ pregnant women have access to counseling, testing and ART at all levels, and increased linkages with facilities performing male circumcision. Our CBTS team performs community based pediatric training focusing on identification of infants at risk and the importance of early treatment, as well as strengthening community capacity for couples counseling, and using prevention for positives strategies and prevention counseling for HIV negative clients. Strong linkages with existing home based care facilities strengthen this capacity.

Our transition and sustainability plan encompasses coordinating site support with the Churches Health Association of Zambia, plus scaling up Chreso ART Center for direct funding. AR will coordinate technical support with the MOH, UTH, and UNZA.

AR cannot meet the demand for ART scale up and ensure the same quality of care with level funding, but we will continue to evaluate and implement cost-efficiencies through strategies, such as performance based funding that will allow some scale up of ART.

Adult care and support services are largely centered on the work of the Community Based Treatment Services (CBTS) that focuses on incorporating the community to extend and optimize the quality of life for people living with HIV. In FY 2010 the CBTS specialists will work with adherence staff, community health workers (CHW), and treatment support groups to provide training on treatment preparation, support, and reducing transmission of HIV infection; they will continue tracking patients on care and ART for adherence to prophylaxis and treatment. CBTS will provide messages on prevention to those in care and on ART and ensure clients have access to support groups. In addition, they will help to ensure that clients in care remain linked to the clinic and receive follow up CD4, and preventive health care including cotrimoxazole prophylaxis, insecticide-treated nets, nutritional assessment, prevention assessment, education about clean water, and treatment of diarrhea and other acute illnesses. CBTS will also train staff and CHW to utilize the patient as a window into the family and strengthen the relationship with HIV positive family members not yet on ART. The CBTS team will also help to identify HIV positive individuals at risk for poor adherence including, but not limited to, substance abuse and mental health issues. CBTS will work closely with the networks of local home based care providers and services that are integral parts of our strategic task shifting plans. The CBTS team will support linkages between the ART clinic and the community based support groups including palliative care services.

Another component of Adult Care and Support is training on palliative care provided by palliative care specialist on regional teams. Their training focuses on pain as the 'fifth vital sign', recognizing and addressing provider burn out and stress in the workplace, pain and symptom management in relation to OI, mental health including end of life care, and understanding supportive care for women and children. AIDSRelief (AR) will continue this activity in FY 2010

AR will integrate prevention for positives (PWP) into the standard of care in FY 2010. We will work with the MOH to integrate PWP into national treatment and care guidelines.

In FY 2010 AIDSRelief (AR) will focus on strengthening the quality and delivery of ART services. One of the center pieces of the AR program is our commitment to on-site training and mentoring. During regular site support visits we conduct Ministry of Health (MOH) sponsored trainings for sites in a particular region, and incorporated into all of these trainings is mentoring opportunities in both the out and in patient setting. During these visits indicators are collected and assist in determining site needs and to identify gaps. In FY 2010 AIDSRelief will continue with these activities. In conjunction with the MOH, University of Zambia (UNZA), and the University Teaching Hospital (UTH) a fully UNZA accredited 12 month HIV Diploma course was initiated for advanced training of physicians. The course is taught by a combination of faculty from the University of Maryland and the UTH. The first graduation will include 13 residents. This diploma course will produce the next generation of HIV educators and decision leaders in Zambia. In FY 2010 AR will continue supporting this course.

Nursing is the pivot point for effective task shifting and addressing the ever increasing human resource crisis in Zambia. The nursing strategic plan centers around three stages of task shifting: level one focuses on shifting basic nursing care and triage to community health workers, level two on preparing nurses to triage and refill prescriptions on stable patients, and level three on developing a cadre of nurses to become Nurse Practitioners. The nursing team focuses on providing appropriate MOH approved trainings for nurses, and continues to work closely with General Nursing Council of Zambia (GNC) to teach and mentor nurses as ART prescribers and providers. In FY 2010 AR will continue supporting and strengthening the Nurse Practitioners Diploma program.

We shall conduct nutrition assessment for all clients before commencement of ART for appropriate nutritional interventions. The outcomes and evaluation team have been working with clinical teams to support the use of data for program improvements at site levels

AIDSRelief (AR) will aim to improve uptake of counseling and testing (CT) by increasing the availability of CT in rural areas through routine provider initiated testing and counseling (PITC) in the health facilities and community outreach with home testing service. This will be achieved through training of staff and strengthening linkages with other services. These activities will be followed by regular supervision and follow up visits and participation of testing sites in the national External Quality Assessment program for rapid HIV testing.

PITC will be offered to in-and-out patients, all TB patients, pregnant women, and patients diagnosed with STIs, as well as family members of persons living with HIV/AIDS (PLWHA). We will offer CT services at the community level and home testing for families of PLWHA and work with outreach teams to ensure referrals and follow-ups are done for all positives.

Funding under this activity will support the cost to conduct community-level testing and use systematic task shifting strategies to train lay counselors in CT. To accomplish this activity hospital staff will be trained and updated to provide CT (including PITC and couples counseling). Supervisory staff at the hospital will ensure that minimum quality standards of services are met both in health facilities and in the community. Since many AR sites are in remote locations, a variety of personnel must multi-task to accomplish goals. The final component will be to strengthen and expand linkages to ensure continuity of care for all persons accessing CT through AR. Engaging people who test positive into comprehensive HIV care and specific prevention messaging regarding behavior change, disclosure, alcohol abuse, family planning etc, is the cornerstone of our CT approach. We will accomplish this through strong linkages with community-based tracking programs, evidence-based counseling, and enrolling and retaining people into ART program. Linkages will be formed with other HIV-related activities including palliative care, orphans and vulnerable children projects, social, psychological, and legal support services conducted by local organizations and CHAMP.

The AIDSRelief (AR) strategy to further close the gaps in pediatric care and support is anchored by a focus on early infant/childhood survival and includes six target areas to be addressed across all 19 sites: mother-to-child transmission; pediatric HIV testing and counseling for infants, children, adolescents, and their families; comprehensive; care of exposed infants and their HIV+ mothers, including provision of co-trimoxazole (CTX) prophylaxis for exposed and infected children, as well as a comprehensive preventive care package for exposed, infected, and affected children; treatment of infected children, including ART, OI treatment, infant feeding and nutrition assessments, palliative care, and psychosocial support services; care for families; and outcomes and evaluation.

AR will continue to focus on diagnosis and turnover of results for Early Infant Diagnosis to ensure timely initiation of all infants confirmed positive. AR will also provide oversight and ongoing training of staff in correct Dried Blood Spots methodologies. Training to ensure prompt recognition of developmental delays, failure to thrive, TB, and recurrent infections will be emphasized at the provider and community levels. All HIV exposed infants will be enrolled in care through their second birthday to ensure ongoing Septrin prophylaxis, prompt diagnosis, routine vaccinations, and support for maternal health. ART and OI treatment is discussed in Pediatric Treatment.

Family involvement is a key to supporting best outcomes for HIV+ infants and children, and emphasis on male involvement is incorporated into pediatric care messages. Providing strategies for ART clinics to see all family members on the same day helps promote this endpoint.

AIDS Relief (AR) is committed to ensuring the long term health of all HIV-infected children through the provision of comprehensive quality care and treatment. At the site level, ongoing technical support will be provided in 3 key areas: determining eligibility; treatment initiation, monitoring and follow up; and practical pediatric treatment challenges.

Treatment initiation begins with early diagnosis of pediatric HIV infection. As guidelines for treatment initiation continue to change based on available evidence, the local clinical staff will be oriented to the new guidelines through training and mentorship. This will include current information on which regimen to use for children with a known history of NNRTI exposure in Zambia, there is now agreement that all NVP exposed infants will be started on a boosted PI regimen. Providers will also receive ongoing training and mentoring in recognizing and treating ARV-related toxicities; treatment failure; OI treatment and prevention; and nutrition recommendations for infected children on treatment. Additionally, ongoing, on-site training and mentoring in the recognition and management of key clinical conditions HIV-TB co-infection, Pneumocystis Carinii Pneumonia, HIV encephalopathy, growth failure, nutrition assessment and others which render a child eligible for ART treatment will be provided. We will link with DHMTs for the provision of Food By Prescription services.

Third, providers, adherence counselors, and pharmacy staff will be trained and updated in practical issues which can create specific challenges for pediatric ART care, such as treatment preparation, disclosure counseling, adolescent issues; treatment support, storage and administration of ARVs, and when and how to re-dose ARVs.

AR will provide both central and local training and mentoring in the MOH Pediatric HIV Care Training Course for staff and providers that have not yet received it. In an effort to both decentralize care and strengthen district-level capacity, providers from rural health centers affiliated with our local partners, as well as those from the associated district-level facilities, will be included in these trainings.

Futures Group International, LLC (Futures) is leading in the Strategic Information (Monitoring and Evaluation and health management information systems-HMIS). Futures will work with the Ministry of Health (MOH), Centers for Disease Control and Prevention and other partners to consolidate and bring to fruition the intended results of SmartCare which will be used to collect and track data from the various local implementing partners.

A total of 120 health personnel in 19 treatment sites will be trained in data management and information usage for improved health outcomes. Futures will produce accurate, monthly, quarterly, semi-annual and annual reports for the AIDSRelief program to meet all reporting and programmatic requirements at all levels.

Future, collaborating with Ministry of Health (MOH), will support sites in the management of SmartCare and providing useful feedback to MOH and CDC for better use of data at local, district and national level. They will also provide specific training and technical assistance in trouble shooting, networking, reporting, and reports in SmartCare, raw based security, and merge functions within the national health system.

With the wealth of information accumulated over the past 7 years, Futures will continue to utilize the information for adaptive management to document trends and achievements, best practices, and lessons learned. We will endeavor to disseminate extracted information through quarterly publications of findings and make presentations to such forums as partners forums, programmatic review meetings, and write abstracts/white papers that can be submitted for conferences and/or published in relevant publications. Additionally, through the (Data Demand Data Use) DDIU workshop, Futures will strengthen LPTFs ability to extract, synthesize, and convert data we collect into meaningful information, to share best practices on data use for informed decision making, and to improve the working relationships of the SI and CQI teams to ensure streamlined data use activities.

Futures will collaborate with all partners to realize the vision of the AIDSRelief Sustainability plan.

The program will target discordant couples at all 19 LPTF AR supported sites within the eight provinces in Zambia with other prevention strategies. Promoting prevention strategies among discordant couples that are culturally acceptable and initiating the HIV+ partner on ART as soon as possible will work towards decreasing sexual transmission of HIV among discordant couples. AR onsite and central trainings will incorporate identifying and addressing issues surrounding discordant couples. We will continue to train all cadres of health care workers on prevention strategies and counseling of discordant couples at each encounter to prevent future infections. AR emphasis on family counseling and testing and male involvement will promote initiation of ART when appropriate, regular testing according to risk levels, monogamous sexual relations, and standard prevention interventions at the community level among discordant couples. We will also offer directed counseling to HIV negative clients, particularly women who test HIV negative in ANC programs for comprehensive prevention strategies. Other areas of focused prevention will take place within our LPTF with outreach to incarcerated persons both with Prevention with Positives strategies, and general prevention strategies for HIV negative incarcerated persons in and around Lusaka and Kabwe where selected LPTF have prison outreaches. We will continue to build linkages with STI and TB management into HIV care and treatment programs and increase sexual prevention messages through posters, waiting room videos, and group counseling including couples counseling. Lastly, our substance abuse program will focus on risk reduction particularly for persons with alcohol abuse problems and Prevention with Positives within the support group structure.

AR will continue to work with sites to indicate number of discordant couples tested in SmartCare forums as a methodology for patient tracking. Regular supervisory visits will be conducted to ensure that program activities are implemented according to the guidelines.

In FY 2009, AIDS Relief treated 2,500 HIV (+) clients for TB and trained 100 health staff. AR will enhance laboratory capacity to TB diagnosis, prevent nosocomial infections, strengthen referral linkages to ensure timely diagnosis and treatment, ensuring accessibility to information, on the relationship between TB and HIV to the surrounding communities, enhancing the capacity for the diagnosis of smear negative and extra-pulmonary TB, and reducing the potential risk of nosocomial transmission. AR will strengthen infection control strategies by refitting laboratories in seven LPTFs and training laboratory personnel in Good Laboratory Practices (GLP). AR will ensure partner notification, condom use of co-infected patients, and linkages with support groups of people living with HIV/AIDS for care.

AR will place emphasis on intensified TB case finding, diagnosis, treatment and infection control. AR will make family case finding routine and will screen all HIV (+) individuals for TB. AR will test all TB patients and suspects for HIV infection. AR will strengthen the concept of "Provider Initiated Testing and Counseling." AR will strengthen linkages between the ART and TB clinics and train health workers in the management of TB/HIV co-infection and follow up with on-site mentoring. AR will also equip all the laboratories to perform sputum smear to detect TB and conduct quality assurance and quality improvement activities with nearby reference laboratories. AR will refer smear negative specimens to reference laboratories for culture and ensure that chest X-ray services are available for all sputum-negative individuals. AR will strengthen its communication strategy to sensitize the communities on the linkage between TB and HIV. Support will be provided to the National TB/HIV coordinating bodies at all levels and to TB/HIV data review meetings at the district level, while collaborating with MOH in MDR-TB surveillance. In addition, renovations will be made to infrastructure to maximize TB infection control. AR will support CHAZ (sub partner) to strengthen human resources in TB/HIV activities and provide salary support to the TB/HIV officer, Assistant laboratory Officer and IT officer to carry out TB/HIV activities.