In FY 2010 Boston University Center for International Health and Development, through its local Zambian NGO, Boston University Center for International Health and Development Zambia (BU-CIHDZ), will continue to expand the national prevention of mother-to- child transmission (PMTCT) program in the 8 districts in Southern Province (SP) in which it has been working to date. The primary objective will continues support of efforts by the GRZ in scaling-up and sustaining quality PMTCT and early infant diagnosis (EID) services within maternal, neonatal, and child health programs in accordance with the Zambian national PMTCT strategic objectives.

BU-CIHDZ will implement activities designed to: 1) increase access to quality PMTCT activities; 2) improve quality of PMTCT services integrated into routine safe motherhood activities; 3) increase coverage of counseling and testing services; 4) increase uptake of dual and highly active antiretroviral therapy (HARRT) 5) improve referral and linkages to antiretroviral treatment (ART) for positive women and their families; 6) increase access to an expanded EID program; 7) improve palliative care to HIV-affected children (e.g. provision of co-trimoxazole); 8) improve the use of electronic health records using SmartCare ; 9) implement innovative approaches to reach less accessible rural populations through the use of community health workers (CHWs) and trained traditional birth attendants (tTBAs); 10) continue the promotion of exclusive breastfeeding for HIV-infected children (as per national guidelines); 11) continue to work closely with traditional leaders to increase male knowledge of, and involvement in, PMTCT issues; 12) as requested by the Ministry of Health (MOH), strengthen PMTCT mother-infant follow-up by enlisting tTBAs and CHWs to assist in the scaling-up of the Singazongwe pilot follow-up program throughout all 8 of the BU-CIHDZ supported districts in SP; and 13) continue the strategic development and planned implementation of a clear exit strategy such that the PMTCT program is fully integrated and sustainable in the SP health system by the end of PEPFAR II (2014).

BU-CIHDZ works in 8 of the eleven districts in SP; Mazabuka, Siavonga, Gwembe, Monze, Choma, Kalomo, Kazungula and Livingstone. The ongoing PEPFAR-funded service delivery work of BU-CIHDZ currently supports a total of 165 health clinics in SP; the total catchment population of said supported clinics is approximately 1,227,000.

Current priorities include promotion of disclosure and enhanced male partner and family support, uptake of key PMTCT interventions such as the more efficacious PMTCT antiretroviral regimens, CD4 testing and prompt initiation of HAART for eligible women, adherence to national guidelines on infant feeding methods, improved uptake of infant testing, positive prevention, and linkages to ongoing care and treatment for HIV-positive mothers, infants, and other family members.

The activities to be undertaken in FY 2010 are cross-cutting programs in the categories of Human Resources for Health (e.g. PMTCT and EID Training for health center and district level staff as well as community volunteers) and Food and Nutrition: Policy, Tools, and Service Delivery (e.g. promotion of exclusive breastfeeding in line with the National PMTCT Guidelines). BU-CIHDZ activities also have key issues under the category of Health-Related Wraparounds, namely Child Survival Activities and Safe Motherhood (e.g. collaboration with University Teaching Hospital, Clinton HIV/AIDS Initiative (CHAI), Center for Infectious Disease Research Zambia (CIDRZ), Mothers2Mothers (M2M) and Catholic Medical Mission Board (CMMB) on issues and activities related to PMTCT, EID and pediatric ART uptake), as well as Family Planning (e.g. linking to condom distributors and couples counseling, respectively, Society for Family Health and Zambia-Emory HIV Research Project).

Boston University has a long history in Zambia and will continue in FY 2010 to strengthen partner relations and collaboration in the interest of jointly contributing to improve specific services within the Zambian health care system in an efficient and cost effective manner. Specifically, BU-CIHDZ will continue collaborating with M2M and CMMB in their respective work with HIV-positive mentor mothers and male involvement community groups; also, BU-CIHDZ will work closely with CIDRZ to further identify barriers to pediatric ART and co-trimoxazole uptake, and find innovative ways to address these barriers both at the community, clinic, and national level.

BU-CIHDZ has a monitoring and evaluation plan in place for both its PMTCT and Pediatric Care and Support (PDCS) activities. Using MOH registers and/or SmartCare outputs, data is gathered from each supported health facility on a monthly basis. This data is then analyzed to monitor the performance of individual sites and districts as a whole; technical assistance is dispatched as necessary. PDCS activities (EID) are similarly monitored with additional system checks in place to monitor both the testing commodity and sample/results transport systems to ensure barriers to results being quickly received by families are identified and mitigated when possible. Additionally, the community sensitization program is monitored using qualitative methods which track community engagement (e.g. meeting attendance), and compare PMTCT service uptake at catchment clinics.

In FY 2010, BU-CIHDZ will work closely with MOH and other partners including CIDRZ and CHAI to systematize the EID program in SP and ensure a strong link between PMTCT and ART clinics.

FY 2010 activities in EID will result in the scale-up of infant HIV diagnosis in SP by continued collaboration with the SPHO, University Teaching Hospital, CHAI, CIDRZ and other partners. Activities will focus on building and operationalizing a stronger referral system to ART care and treatment centers. Earlier HIV diagnosis will lead to earlier referral and initiation of antiretroviral therapy at much younger ages.

In partnership with SPHO and the DHMTs, BU-CIHDZ will train 100 health workers in supported facilities in the dried blood spot (DBS) collection. In addition to DBS trainings in a group setting, BU-CIHDZ staff will conduct routine technical support visits to all supported facilities to reinforce the package of care for exposed infants, including perinatal antiretroviral prophylaxis, uptake of co-trimoxazole, ongoing nutrition assessment, and repeat testing after breast feeding cessation. Emphasis will also be on provider initiated testing of older children in the maternal and child health clinic, prompt referral to care and treatment for identified positive children, and appropriate infant and young child feeding practice.

FY 2010 activities will also include working with MOH to find more efficient systems to deliver EID results to the very rural areas of SP. Some of the inherent logistical difficulties surrounding EID in SP stem from delays in promptly returning DBS results to the rural health facilities. In partnership with the MOH, BU-CIHDZ proposes to implement a DBS online laboratory database system which will allow results to be accessed both via internet as well as through direct cell phone SMS communication to the facilities where they were collected. Confidentiality will be ensured by using only patient identification numbers. SP DHMT and PHO can then access the database securely via the internet to get immediate results. Concurrently, rural and urban healthcare facilities with cell phone access (a majority of facilities in SP even in remote locations) will be sent batched DBS results for their specific facility via SMS messages.

PMTCT one time plus-up funds are being added to support: Cost-benefit analysis comparing the additional costs of earlier HAART for pregnant women or complex PMTCT regimes based on pediatric cost data. Cost information on pediatric HIV/AIDS care and treatment is limited, though Boston University (BU) has already used several approaches for adult care and treatment. BU will continue to enhance the understanding and document the reasons and cost of PMTCT failures. This will assist in advocacy for improvements in coverage.

In FY 2010, through collaboration with the SPHO and district health management teams (DHMTs), BU-CIHDZ will directly support PMTCT services in 8 districts of SP. In partnership with SPHO and the DHMTs, BU-CIHDZ will train 100 health workers in supported facilities in the National PMTCT training package. BU-CIHDZ will continue to focus efforts on training health workers on data management, ensuring all facilities are correctly completing MOH registers, using SmartCare (SC) according to MOH procedures and reporting complete data to the district health offices monthly. These facility- to-district reporting strengthening activities include instituting operations to ensure that the SC merge is routinely and correctly done between facilities and districts, and that key skills in clinical use of SC information for improved care are established. In addition to the national training package, BU-CIHDZ staff will conduct routine technical support/mentor visits to emphasize technical areas such as provider initiated counseling and testing, retesting of HIV negative pregnant women, couples testing and condom promotion during pregnancy and lactation.

BU-CIHDZ will continue to support provincial/district efforts to develop networks and referral systems for pregnant women to better access health services such as family planning and ART services. These networks are critical for linking HIV positive pregnant women to ART services and developing an approach where all HIV positive women are referred for baseline CD4 counts and ART services. BU-CIHDZ will also support the provision of counseling on appropriate feeding options for infants born to HIV positive women and those of unknown status.

To address the health center staffing shortfalls which affect PMTCT service delivery (e.g. counseling and testing, mother-infant follow-up, community engagement of male involvement), BU-CIHDZ will continue supporting a cadre of community lay counselors and work towards better incorporating a focus on male involvement into their community outreach.

Master level students from Boston University School of Public Health will continue to be recruited to work with the PMTCT activities in Southern Province on six month rotations.

PMTCT one time plus-up funds are being added to support: Community approaches to improve uptake of highly efficacious PMTCT.

While over 80% of pregnant women were tested in 2008, only about 10% of their male partners were tested. Boston University (BU) will strengthen PMTCT services by using a number of effective approaches to enhance partner counseling and testing.

Increased male partner involvement in PMTCT will ensure that couples access testing where they will know each other's HIV status and receive important preventive services.

Implementing prevention strategies that target couples in PMTCT is most effective when they receive HIV results and counseling together. Thus BU will provide male partners with the opportunity for additional counseling, risk reduction messages, direct links to male circumcision services and screening and treatment for STIs.

BU will reinforce and encourage adherence to HIV prevention methods by counseling men and women together on the importance of PMTCT. Both partners will understand the essence of preventing transmission to the child and will be able to openly talk about how they can prevent transmission in discordant and re-infection in concordant couples.

PMTCT one time plus-up funds are being added to support: the assessment and development of courier system.

Boston University will conduct district level laboratory assessments with Ministry of Health (MOH) and other partners and assess and strengthen courier systems for facilities without full laboratory services. A courier system is in place to link ANCs with the 131 laboratories with CD4 capacity, but this has not succeeded in providing timely results on a consistent basis. The use of specimen tubes with fixative to allow stable CD4 measurement for 7 days rather than the current 2 days is being validated at this time in Zambia. This will allow the expansion and improvement of the courier system for centralized testing, in order to provide CD4 services to the most remote ANCs.