In coordination with other partners, the Zambia Behavioral and Social Change Communication Program (ZBSCCP) will improve the health of Zambians at-risk for, living with, and affected by HIV through promoting positive and sustained changes in health behaviors, gender, and other socio-cultural norms. ZBSCCP contributes to health improvement by building sustained capacity of the health system and other stakeholders to design, implement, manage, and evaluate effective communication activities for greater coverage of target groups, retention of key messages, and adoption of healthy beliefs and practices. These activities include the development of national campaigns, materials, and other approaches/interventions featuring actionable messages, aligned with national strategies, informed by formative research, and pre-tested with the intended audience(s) for linguistically and culturally appropriate content. Proper implementation of all activities entails training and supportive supervision on the use of materials and dissemination of messages. As an integrated program, ZBSCCP will receive only a minority of PEPFAR funding for HIV/AIDS-related activities. It will also receive malaria, family planning/reproductive health, and maternal, newborn, and child health funding to address behavioral and social change communication from a holistic perspective.

Aligning with the proposed Partnership Framework, ZBSCCP will contribute to the goal of intensifying prevention by focusing messages on risk reduction and that of enhancing Zambian leadership and management by developing the human and institutional capacity on health communication.

Several sub-groups will be targeted with tailored messages and approaches to meet their needs. Activities to prevent sexual transmission and promote testing and counseling (TC) will target youth (ages 15-24) and adults (older than 24) across Zambia. Male circumcision (MC) activities will target HIV-negative men and their female partners; they will also provide information for parents/guardians on neonatal circumcision. Improving quality and emphasizing prevention in treatment services will target clinical staff, lay health workers, adult and pediatric clients, and their families in the five northern provinces supported by the Zambia Prevention, Care, and Treatment (ZPCT II) Partnership (Central, Copperbelt, Luapula, Northern, and North-Western) and all nine provinces supported by the Zambia Integrated Systems Strengthening Program (ZISSP).

To strengthen health system communication activities, ZBSCCP will establish a resource center in the Ministry of Health (MOH) to collect and disseminate materials to provincial health offices, district health management teams, and the private sector. ZBSCCP will support a technical expert in the MOH to coordinate establishment of the center, oversee development of national campaigns, and transfer skills to appropriate counterparts. Representatives from ZBSCCP will participate in the national technical working group on health communication to coordinate activities with other partners.

Activities will feature one cross-cutting dimension and address two sets of key issues. To implement the cross-cutting gender strategy of reducing violence and coercion, ZBSCCP will develop prevention messages that emphasize positive male norms, such as men acting as responsible providers to dissuade them from alcohol abuse and build their skills in constructive problem-solving that preserve their family and community relationships.

ZBSCCP will also implement two strategies under the key issue of gender by developing messages to increase health-seeking practices, especially among men (e.g., couples TC, family-centered services). To address the key issue of health-related wraparounds, communication activities will couple messages on HIV prevention with those on family planning/reproductive health (FP/RH), especially to promote MC for greater involvement in RH and to reduce the level of unmet need among HIV-positive women. Activities will also couple messages on HIV prevention and treatment with those on child survival, targeting clients of prevention-of-mother-to-child (PMTCT) services and post-natal and pediatric care as part of family-centered services. These coupled messages will highlight the importance of providing the basic care package and additional services, depending on the HIV status of the infant/child.

To achieve greater cost efficiencies over time, ZBSCCP will coordinate the dissemination of messages between the MOH and media entities (e.g., print publications, radio, and television) in the public and private sectors. Such coordination should increase their collective responsibility for public interest in the national HIV/AIDS response.

As part of the monitoring and evaluation (M&E) plan, ZBSCCP will assess participation in activities, exposure to messages, and changes in knowledge and behaviors by conducting standardized population-based surveys and other studies as needed. Data from these studies shall meet PEPFAR and USAID reporting requirements and contribute to Zambia's Health Information Management System and HIV/AIDS M&E Framework.

ZBSCCP aims to improve the health of HIV-positive adults, their partners, and families by enhancing services and integrating prevention messages through communication and training activities, in coordination with ZPCT II, ZISSP, and other projects that support treatment provision. These activities will target adult clients and staff in facilities in the five northern provinces (Central, Copperbelt, Luapula, North-Western, and Northern) supported by ZPCT II and all nine provinces supported by ZISSP.

To enhance the quality of services, ZBSCCP will implement a structured adherence intervention, adapting evidence-based approaches and standardized materials. For adult clients, this intervention will include communication activities with actionable messages on adherence and related healthy practices (e.g. maintaining proper nutrition, monitoring CD4 counts). Complementary training activities for staff, especially lay adherence support workers in facilities and communities, will build their skills to reinforce these messages in follow-up counseling sessions and other discussions with clients.

ZBSCCP will also implement communication activities on prevention with people living with HIV (PLHIV). Key messages in these activities include the disclosure of HIV status to partners; TC for partners and children; counseling on sexual risk reduction (including abstinence, mutual monogamy, partner reduction, and correct and consistent condom use), responsible alcohol consumption, and FP/RH options; screening for and treatment of STIs; and MC for HIV-negative male partners. The development of these messages will follow guidelines on PLHIV in facility-/community-based settings issued by the U.S. Centers for Disease Control and Prevention (2003) and World Health Organization (WHO, 2008), and involve the target audience(s) in formative research and pre-testing.

ZBSCCP will provide training and supportive supervision for clinical staff and adherence support workers to incorporate PLHIV messages in all interactions with clients. Through all communication and training activities, ZBSCCP shall contribute to improvements in the quality of life for adults on treatment and prevention of new infections among their partners.

ZBSCCP will implement the communication and social mobilization activities on TC, in coordination with ZPCT II, ZISSP, social marketing, and other projects that support TC service provision. These activities will focus on sexually active and high-risk youth (ages 15-24) and adults (older than 24), with tailored approaches and messages for different sub-groups. All activities will emphasize the importance for individuals to know their HIV status, generating demand for services in diverse settings (i.e. boosting voluntary TC) that complement the provider-initiated approaches in facilities and increase the overall uptake of TC.

Contributing to the prevention of new infections (92 percent of which will likely occur among partners in casual as well as low-risk heterosexual relationships), ZBSCCP will promote couples TC, especially in HIV and FP/RH services to reinforce healthy sexual practices and minimize HIV risk among sero-discordant and concordant negative couples. Integrating with the delivery of preventive health services, ZBSCCP will promote TC for males and couples among potential MC clients and for children among PMTCT clients.

ZBSCCP will incorporate these promotional messages into activities and materials advocating comprehensive prevention through appropriate channels (e.g. peer outreach, mass media). It will also support the delivery of TC services through a national telephone hotline and campaigns, including national and local TC events.

While ZBSCCP will adapt materials and messages from existing resources (e.g. PEPFAR-supported toolkit for TC events), the development of innovative interventions (e.g. promoting couples TC in various circumstances and settings) will involve target audience(s) in formative research and pre-testing. ZBSCCP will implement all activities with training and supportive supervision.

Through these activities, ZBSCCP shall promote TC as a "gateway" for follow-up services that reinforce the responsibilities and capabilities of individuals, couples, families, and communities to prevent HIV spread.

ZBSCCP aims to improve the health of all infants and children, focusing on those exposed to or infected with HIV, by enhancing services and integrating prevention messages through communication and training activities, in coordination with ZPCT II, ZISSP, and other projects that support treatment provision. These activities will target parents, guardians, and staff caring for pediatric clients in facilities in the five northern provinces (Central, Copperbelt, Luapula, North-Western, and Northern) supported by ZPCT II and all nine provinces supported by ZISSP.

To enhance the quality of services, ZBSCCP will develop job aids and other materials for training and supportive supervision of clinical staff to provide the pediatric basic care package and additional services, depending on the HIV status of the infant/child. Likewise, ZBSCCP will develop convenient flip charts and other materials that PMTCT motivators and other lay health workers can use to raise awareness of and generate demand for high-quality services.

The messages in these materials will emphasize prevention in two main ways. First, they will reinforce messages in PMTCT activities primarily for pregnant women to avoid infection and prevent perinatal transmission. Second, the messages will link with child survival activities to promote adoption of high-impact interventions to prevent the onset of childhood illnesses and malnutrition through diarrheal and respiratory disease management, exclusive breastfeeding, immunization, nutritional assessment and supplementation, and safe water/hygiene/sanitation, among others.

The development of all messages will follow guidelines issued by WHO (2008) and involve the target audience(s) in formative research and pre-testing. ZBSCCP will work with ZPCT II, ZISSP, and other projects for effective use of materials and dissemination of key messages through training of trainers and service providers. Through these communication and training activities, ZBSCCP will contribute to improvements in the quality of life for pediatric clients and prevention of new infections among infants and children.

ZBSCCP will implement the communication and social mobilization activities in MC, in coordination with ZPCT II, ZISSP, social marketing, and other projects that support comprehensive MC service provision and in alignment with the national MC strategy that MOH launched in June 2009. In order to reduce male HIV incidence (which has stabilized around 1.2 percent since 1995), ZBSCCP will focus on boys and men, while some activities will raise awareness of MC among female partners and parents of male infants.

All activities will cover target groups across Zambia, with special attention to two provinces with relatively higher rates of MC: Northwestern (71%) and Western (40%). In these provinces and other communities that widely practice MC for cultural reasons, ZBSCCP will engage traditional providers through documentation of techniques used and complications experienced, and promotion of comprehensive MC services (i.e., building on the healthy socio-cultural norm of MC to increase the acceptability and use of services in facilities).

Developing activities that follow the guidance and adapt the toolkit produced by the United Nations agencies, ZBSCCP will enable boys, men, and parents to make responsible decisions on MC, based on knowledge of their HIV status and information on the benefits and risks. For clients, ZBSCCP will reinforce the messages on remaining abstinent during wound healing and avoiding high-risk sexual practices thereafter to minimize the risk of complications and HIV acquisition. Messages for women will emphasize the benefits and risks of MC to them and their roles in the decision-making process on MC for their male partners and children.

ZBSCCP will implement a national MC campaign and other activities, with materials and messages informed by formative research, pre-tested among target audiences, and delivered through appropriate channels (e.g., mass media), and with training and supportive supervision components for proper implementation. Through these activities, ZBSCCP will promote MC as part of comprehensive prevention that includes messages on healthy sexuality and relationships, and links with other services.

ZBSCCP will target sub-groups of youth (ages 15-24) and adults (older than 24) with tailored activities to meet their unique needs. Complementing school/community-based efforts, activities for general youth aim to delay their sexual debut by empowering them around their values, aspirations, and expectations. Activities for sexually active and high-risk youth will promote secondary abstinence. For these youth as well as adults, activities will also address sexual risks (e.g., multiple and concurrent partners), behavioral triggers (e.g., alcohol abuse), and harmful gender norms.

Activities under this component include campaigns, materials, and other interventions with actionable messages delivered through appropriate channels (e.g., peer outreach, mass media). These messages aim to prevent HIV acquisition from casual and low-risk heterosexual sex the predominant modes of transmission.

While ZBSCCP will cover youth and adults across Zambia, the focus of interventions will vary by sub-group. The intent of these activities center around sustaining behavioral change among urban males, contributing to a further decrease in HIV prevalence that declined between 2002 and 2007. ZBSCCP will intensify efforts targeting urban females and rural residents to prevent new infections and reduce HIV prevalence, which did not change significantly in these sub-groups between 2002 and 2007.

Most activities will adapt evidence-based interventions with standardized messages. However, to address emerging needs, ZBSCCP will develop innovative interventions through formative research and pilot testing to determine appropriate approaches and content for effective uptake of key messages. All activities will include training and supportive supervision for proper implementation.

ZBSCCP will promote abstinence, mutual monogamy, and partner reduction as part of comprehensive prevention, which incorporates messages on correct and consistent condom use and MC, and facilitates linkages to community/facility-based services, including TC.

Adapting standardized population-based surveys and other methods, ZBSCCP will assess participation in activities, exposure to messages, and changes in knowledge and behaviors.

ZBSCCP will target sexually active and high-risk youth (ages 15-24) and adults (older than 24). Activities will promote correct and consistent use of condoms, screening and treatment for sexually transmitted infections (STI), responsible consumption of alcohol, and other actionable prevention messages. These messages will address relevant sexual health and gender issues, such as the risks of dry sex, sexual cleansing, initiation ceremonies, and gender-based violence and communication skills for healthy, equitable relationships. ZBSCCP will incorporate messages into campaigns, materials, and other interventions delivered through appropriate channels (e.g., peer outreach, mass media). These activities aim to prevent HIV acquisition from heterosexual sex, with special messages for extramarital, age/wealth disparate, and other transactional relationships and sero-discordant couples.

ZBSCCP will cover youth and adults across Zambia. While addressing the needs of urban males to sustain changes in behavior and the decline of HIV prevalence that occurred between 2002 and 2007, ZBSCCP will focus on urban females and rural residents, in conjunction with other efforts, to achieve the same results.

Most activities will adapt evidence-based interventions with standardized messages. To encourage changes in harmful behavioral patterns and social norms (including gender) inadequately addressed by past efforts, ZBSCCP will develop innovative interventions with key messages, informed by formative research and pre-tested with the target audience(s) for better uptake. Implementation of all activities will include training and supportive supervision.

ZBSCCP will support comprehensive prevention and link with the ZPCT II, ZISSP, social marketing, and other projects to generate demand for and facilitate access to condoms, STI management, and alcohol abuse treatment, in addition to MC and TC.

Adapting standardized population-based surveys and other methods, ZBSCCP will assess participation in activities, exposure to messages, and changes in knowledge and behaviors.