Integrated Support for ART & PMTCT (ISAP) is a new program with a goal of supporting local partner treatment facilities (LPTFs) and local communities to expand their capacities to respond to HIV/AIDS-related needs. ISAP will support 15 sites in eight provinces, expanding to four additional AIDSRelief sites, and will focus on three elements, including 1) PMTCT services for several faith based health facilities; 2) Health Systems Strengthening (HSS) activities at Macha Mission Hospital (MMH) to increase nurse training capacity; and 3) Strategic Information activities with LinkNet to connect rural hospitals to better ICT services. ISAP will develop and implement activities to support capacity building in the provision of comprehensive PMTCT care and treatment services to beneficiaries in collaboration with the Ministry of Health (MOH). ISAP will implement a fully integrated PMTCT and ART care and delivery service by establishing high quality, comprehensive ART care for pregnant women and their families. ISAP has two main objectives: 1) Pregnant women's access to high quality PMTCT activities; and 2) LPTFs use of information communication technology (ICT) to expand human resources and health communication capacities.

Under the first objective, ISAP will work in strong coordination with AIDSRelief, the HRSA/CDC-funded PEPFAR project that currently supports ART programs at the same LPTFs, to ensure comprehensive care and treatment. ISAP will 1) build capacity of LPTFs to effectively manage comprehensive PMTCT programming and successfully link PMTCT services to ART services; 2) encourage pregnant women and their families to seek comprehensive treatment with an emphasis on adherence; and 3) provide pregnant women with effective ART and prophylaxis. To ensure that communities surrounding LPTFs actively participate in PMTCT services, ISAP will sensitize community members on the benefits of HIV testing and treatment during pregnancy; engage male partners in PMTCT, including education related to male circumcision; provide training or retraining to medical staff, including traditional birth attendants (TBAs) caring for pregnant women; and partner with other local organizations to provide enhanced ART and MCH outreach for families in rural areas. Comprehensive HIV/AIDS treatment for pregnant women and their families will include linkages between ante-natal clinics (ANC) and ART clinics to ensure that positive pregnant women receive an effective combination of ART. In addition, ISAP will provide infants with a comprehensive package of support, including monitoring and care for 18 months to include early infant diagnosis (EID), Septrin prophylaxis, growth monitoring, treatment of pediatric illnesses and, as necessary, ART administered by a pediatric-trained health care worker. Finally, ISAP will provide an evidence-based effective combination of ART and prophylaxis to pregnant women with a focus on adherence, even to those started on HAART. ISAP will prioritize CD4 counts for pregnant women, training health care workers accordingly to provide technical assistance (TA) to ART providers, while also training ANC midwives to provide ART care, counseling on infant feeding, disclosure counseling and family testing. For all of these activities, ISAP will implement MOH guidelines to provide TA to LPTFs on patient tracking, update core curriculum in PMTCT, and enhance linkages between PMTCT and maternal child health facilities

Under the second objective, ISAP will build capacity at selected LPTFs, starting with MMH, to leverage ICT for health, including maintaining uninterrupted access to SmartCare, making distance learning course available for enrolled nurses, and training and certifying local staff in standard computing courses. These activities will be based around the nurse training school (NTS) and the local public/private venture LinkNet, both of which are affiliated with MMH. Through support to the NTS, ISAP will focus on alleviating the human resource burden at the NTS, while supporting the necessary intake expansion in close collaboration with the MOH and other partners. ISAP will work closely with the NTS and other stakeholders (including Clinton Foundation) in piloting a distance learning adapted version of MOH curriculum for enrolled nurses. We will be able to train LinkNet cohorts in A+ and the graduates will again be trained in basic SmartCare and as network administrators. The trained staff will be deployed to LPTFs to support and monitor SmartCare.

ISAP will rigorously monitor and evaluate program activities. Using in-country networks and available technology, ISAP will build strong patient monitoring and management systems that are used to collect data and track strategic information from the LPTFs through the ongoing AIDSRelief program. Strategic information includes indicators from PEPFAR, other United States Government (USG) agencies, and the MOH. This collective information supports the provision of high quality PMTCT services within broader public health care and, specifically, HIV/AIDS care and treatment ensures drug availability, tracks patient and program progress, and provides accuracy in reporting to both the USG and MOH. ISAP will also work with existing service providers and networks to provide comprehensive PMTCT to pregnant women and their families. ISAP will build on institutional partnerships between the GRZ, private hospitals, AIDSRelief, and the Churches Health Association of Zambia to provide these comprehensive services.

Through existing in-country networks and available technology, ISAP will build strong patient monitoring and management systems to collect data and track strategic information from the LPTFs. This collective information will support the provision of high quality PMTCT services within broader public health care and, specifically, HIV/ AIDS care and treatment, ensure drug availability, track patient and program progress, and provide accuracy in reporting to both the USG and MOH. ISAP will also build capacity among LPTFs to use data to enhance activities.

ISAP in collaboration with LinkNet will support LPTFs in the management of SmartCare and providing useful feedback to MOH and SmartCare programmers for better use of data at local, district and national level. The LinkNet activity will continue to bring the fight against HIV-AIDS to some of the harder-to-reach districts in Zambia. This activity improves the quality of HIV Care, Prevention, and Treatment by establishing locally sustained deployment of the essential health communications, Electronic Health Record (EHR) Systems, and other Health Management Information Systems needed for sustaining quality care in poorly connected remote locations. The LinkNet activity leverages both the SmartCare urban success and the success of the LinkNet proof of concept for community sustainable ICT rural hospital projects in Macha and Mukinge and in other similar project sites in rural Zambia, to help in the national deployment and linking of this new national health information system.

LinkNet will provide specific monitoring and evaluation, training and technical assistance in trouble shooting, networking, anti-virus management, reporting and reports in SmartCare, raw based security and merge functions within SmartCare at LPTFs.

Every effort will be made to preserve all HIV and other clinical testing information and all clinical services and treatment information in the SmartCare electronic health record system, from all program areas, whether obtained via VCT, provider initiated testing and counseling, PMTCT, door-to-door testing, or medical history obtained via general outpatient clinical services.

PMTCT one time plus-up funds are being added to support: Analysis and dissemination of information using Next Generation PMTCT indicators to assess program effectiveness including the impact of COP funding increases for operational costs and one-time plus-up funds.

CRS will focus on the PMTCT sites within the mission network throughout Zambia. CRS will use these funds to strengthen existing monitoring and evaluation systems throughout the mission network and ensure that timely usable data is collected from the covered PMTCT sites.

HSS will form the basis for long-term sustainability of comprehensive HIV programming. At the national level, ISAP will build on established relationships with various departments of the MOH to collaborate on the revision and dissemination of national guidelines and development of curricula and educational materials. At the district level, ISAP will strengthen health care systems through community programming and ensure that sub-grantee programs are aligned with annual operational plans. ISAP will engage sub-grantees in identifying health systems gaps, placing particular emphasis on development of human resources and staffing, operational policies and procedures, and internal financial controls. Specifically, starting with MMH, ISAP will leverage ICT for health, including maintaining uninterrupted access to the SmartCare electronic health record system, making distance learning courses available for enrolled nurses, and training and certifying local staff in standard computing courses and in the use of SmartCare. Technical systems strengthening will focus on using the electronic health record to strengthen referral systems between various providers across the continuum of care, using the SmartCare EHR to provide M&E capacity that will allow data to be used for decision-making, and to establish standard operating procedures that will allow for stable quality service provision including ongoing maintenance of patient electronic health records.

ISAP will implement a fully integrated PMTCT and ART care and delivery service by establishing high quality, comprehensive ART care for pregnant women and their families. To accomplish this, we have three main strategies: 1) Communities surrounding LPTFs actively participate in PMTCT services. ISAP will sensitize community members on the benefits of HIV testing (re-testing in late pregnancy) and treatment during pregnancy; engagement of male partners in PMTCT, including education related to male circumcision; provide training or retraining to medical staff, including traditional birth attendants (TBAs) caring for pregnant women; and partnering with other local organizations to provide enhanced ART and MCH outreach for families in rural areas; 2) Pregnant women and their families are engaged in comprehensive HIV/AIDS treatment. This requires linkages between ante-natal clinics (ANC) and ART clinics to ensure that positive pregnant women receive an effective combination of ART. In addition, ISAP will provide infants with a comprehensive package of support, including monitoring and care for 18 months to include early infant diagnosis (EID), Septrin prophylaxis, growth monitoring, treatment of pediatric illnesses and, as necessary, ART administered by a pediatric-trained health care worker; 3) Pregnant women receive an evidence-based effective combination of ART and prophylaxis to pregnant women. ISAP will prioritize CD4 counts for pregnant women, with appropriate referral to HAART for those eligible, training health care workers according to provide technical assistance (TA) to ART providers, while also training ANC midwives to provide ART care, counseling on infant feeding, disclosure counseling and family testing. ISAP will support dual and triple therapy prophylaxis.

PMTCT one time plus-up funds are being added to support: the renovation of maternity units and staff houses and the provision of solar panels.

Many antenatal and maternity facilities are improvised and not appropriate for delivery services and lack private space for HIV testing and PMTCT counseling. Further some facilities have provision only for antenatal care, without any delivery rooms. In many rural facilities, staff housing for PMTCT staff is limited or substandard to attract qualified staff. Facility deliveries are low due to long distances and lack of transport. Many sites lack electricity and proper water supply affecting quality of delivery services. These would require solar power and boreholes to improve service delivery.

CRS will construct, upgrade, remodel or refurbish antenatal clinics, maternity units, MCH and laboratory facilities within the mission network to improve efficiency in PMTCT services. The MOH and ZDF will assist in site selection based on a criteria that places emphasis on prioritizing facilities with poor infrastructure and potential impact.