Jhpiego will continue to implement the third year of the DOD program through the HIV/AIDS Prevention, Care and Treatment Program: Prevention, Care and Treatment of HIV/AIDS in Foreign Militaries award. Jhpiego will continue its work supporting the Zambia Defense Force (ZDF) in the military's effort to rapidly expand HIV/AIDS services to additional clients (military personnel and the civilian populations near military installations) served by the ZDF by developing sustainable training, supervision, logistics and monitoring and evaluation systems. Jhpiego will continue capacity building and strengthening with the ZDF health services by supporting the provision of quality, comprehensive HIV/AIDS prevention, care and treatment services. These programs will benefit military and civilian clients and patients at all 54 Defense Force Medical Services (DFMS) supported health facilities through capacity building, system strengthening and standardized supervision.

Jhpiego will also support the ZDF in the use of use a Performance and Quality Improvement (PQI) approach in which gaps in services and quality are self identified by central level managers, supervisors, and site level service providers. Over the past decade, Jhpiego has developed and refined our own PQI tool, Standards-Based Management and Recognition (SBM-R), a practical management approach for improving the performance and quality of health services. Using the SBM-R tool, solutions to address and close performance and quality gaps will be identified by the ZDF, ensuring ownership of the activities.

The Goal of this project is to rapidly expand HIV/AIDS services to additional clients and patients served by the ZDF by developing sustainable training, supervision, logistics and M&E systems.

Jhpiego will meet this goal through the following objectives:

1. Increase clinical capability by supporting comprehensive HIV services including ART, cervical cancer screening, TB/HIV and PMTCT services in 54 DFMS medical facilities

2. Integrate HIV counseling and testing into Palliative Care, STI, and Other Prevention services

3. Work with ZDF and other partners to strengthen systems in the ZDF

To ensure sustainability, Jhpiego has worked closely within the existing ZDF structures and plans. Jhpiego facilitates the development and dissemination of appropriate standard guidelines, protocols, and plans. Jhpiego also assists the ZDF with the implementation of a facility-level quality improvement program. The project's goal is to leave behind quality systems to ensure continuity of services after the program concludes.

Jhpiego, as an important partner to the MOH HIV/AIDS programs, supports the ZDF in gaining access to materials, systems, and commodities funded by the U.S. Government, other donors, and numerous technical partners who work with the MOH, and to harmonize services and maximize efficiencies between ZDF and MOH facilities and programs. In FY 2010, Jhpiego will facilitate further collaboration to ensure harmonization and standardization of approaches, tools and materials between the two systems.

To ensure collection of necessary PEPFAR program-level indicators and other output data for project monitoring, Jhpiego will work through the ZDF information systems, when feasible, and directly with health facilities when proper information systems are not in place, especially for new areas such as MC. Jhpiego will use TIMS, the training information monitoring system, to track persons trained and trainers used to facilitate follow-up and record keeping.

To assist in development of a sustainable quality work force, Jhpiego worked with the ZDF to identify one capable institution in order to institutionalize the human capacity building. The Maina Soko Military Hospital and the Defense School for Health Studies in Lusaka were identified in FY 2008 as the future center for capacity building within Defense Forces, and will provide continued in-service training on the number of programs undertaken by Jhpiego during the past years of work with ZDF. In FY 2010, Jhpiego will continue work with the Maina Soko hospital and will provide support and supervision to ensure quality of services and training.

To ensure sustainability, Jhpiego works within the existing ZDF structures and plans. Jhpiego facilitates the development and dissemination of appropriate standard guidelines, protocols, and plans. Jhpiego will continue to strengthen and expand facility-based performance improvement systems, providing increasing opportunities for the trained staff from model sites to lead supervision and mentorship programs, while still mentoring and actively supporting the ZDF sites whenever necessary.

HIV-infected women are at a much higher risk of developing precancerous lesions of the cervix, and have more rapid progression to cancer than women who are not HIV-infected. In addition, women receiving appropriate anti-retroviral therapy are living longer, increasing the risk that those precancerous lesions will progress to cancer. As a result, HIV-infected women should receive cervical cancer prevention services as part of their routine HIV care and treatment.

Currently, cervical cancer screening is available in Lusaka and to a limited extent in two other districts. The "Single Visit Approach" (SVA) is a recognized alternative for low resource setting to the cytology-based model of cervical cancer prevention services. The service is provided by trained healthcare providers at the primary care level ensuring that it is accessible to women.

Jhpiego proposes to build on and complement efforts by the Centre for Infectious Disease Research in Zambia (CIDRZ) and WHO to support the MOH to scale up cervical cancer prevention in Zambia. The proposed activities are a stakeholder meeting, establishment of a technical working group (TWG), development of service delivery guidelines; and development of a framework for scale up. This would be followed by adaption of the training package and implementation of the training program. We would train 40 providers to provide services at six ZDF sites to provide services an average of 35 clients a month for nine months.

The services will be implemented through the ART clinics and referral systems between pre-ART, ART, PMTCT and PwP services would be implemented. A referral system for advanced disease would also be implemented. Services provided would be tracked through client records and periodic supportive supervision to ensure quality services are provided.

In order to leverage resources, Jhpiego proposes to implement this integrated intervention in the six ZDF sites where we will be providing support for MC services. Since most of these sites are not providing MC five days a week, the same space that has already been refurbished with PEPFAR funds could be used to provide cervical cancer screening. The logistics and feasibility would need to be discussed with each site.

Jhpiego will build on previous work to support treatment services in the 54 ZDF health facilities. Jhpiego will target at least 80 providers in ART, including doctors, nurses, clinical officers, and other health cadres. The ART training is a part of the series of trainings on core competencies for these cadres and will also include PMTCT management and diagnosis and management of TB and other OIs, in an effort to strengthen linkages between ART and other HIV/AIDS prevention, care and treatment services to ensure more comprehensive and continuous care for people leaving with HIV/AIDS.

Following the training, supervision visits to the service providers will be jointly conducted by Jhpiego and ZDF using SBM-R and other supervisory tools that were developed in the previous years. To ensure a synergy of the efforts in the process, Jhpiego will deepen our linkages with the MOH, the National HIV/AIDS/STI/TB Council (NAC), and other collaborating partners such as PCI and the Naval Medical Center in San Diego (NMCSD).

Jhpiego will continue supporting the DFMS in conducting workshops using the orientation package for lay workers (e.g., managers, clergy, community leaders, and caregivers) on HIV/AIDS prevention, care and treatment, covering CT, PMTCT, Care and ART as well as linkages to other services such as TB and STIs, to educate them on HIV/AIDS and provide them with accurate and relevant information they can disseminate to more diverse populations.

Jhpiego will work with ZDF to incorporate Prevention With Positives (PwP) principles in clinical care settings for patients receiving ART as these patients frequently visit the clinic, providing an opportunity to deliver prevention messages. Pre-ART patients will also be targeted with PwP approaches during the visits to the facility. As clinical services are an entry point for nutritional care, nutritional status of patients will assessed and malnourished patients will be provided with micronutrient support, therapeutic feeding or be referred to PCI's nutritional support programs in the community. In addition, Jhpiego will link and integrate clinical and community activities to improve early identification of clients, follow up, and retention in care.

Jhpiego will train 60 providers, including doctors, nurses, clinical officers and other health cadres in the management of pediatric HIV using national guidelines. Pediatric treatment is currently available at selected centers where there are specialists trained in pediatric management. This training is a part of the series of trainings on core competencies for these cadres and will also include ART and PMTCT management, in an effort to strengthen linkages between ART and other HIV/AIDS prevention, care and treatment services to ensure more comprehensive and continuous care for people leaving with HIV/AIDS.

Jhpiego will train health care providers in early infant diagnosis using the Dry Blood Spot (DBS) technique and link the ZDF system to the national system of specimen collection and testing. Links to integrate clinical and community activities to improve early identification of clients, follow up, and retention in care will also be ensured.

Following the training, supervision visits to the service providers will be jointly conducted by Jhpiego and ZDF using SBM-R and other supervisory tools that were developed in the previous years.

To support performance improvement systems and quality ART service delivery, Jhpiego will conduct supportive supervision visits to the 24 model facilities. Jhpiego will continue supporting the DFMS in conducting workshops using the orientation package for lay workers (e.g., managers, clergy, community leaders, and caregivers) on HIV/AIDS prevention, care and treatment, covering CT, PMTCT, Care and ART as well as linkages to other services such as TB and STIs, to educate them on HIV/AIDS and provide them with accurate and relevant information they can disseminate to more diverse populations.

To ensure sustainability, Jhpiego works within the existing ZDF structures and plans. Jhpiego facilitates the development and dissemination of appropriate standard guidelines, protocols, and plans. Jhpiego will continue to strengthen and expand facility-based performance improvement systems, providing increasing opportunities for the trained staff from model sites to lead supervision and mentorship programs, while still mentoring and actively supporting the ZDF sites whenever necessary.

Narrative (2250 characters)

ZDF has a program to train a cadre called Military Medical Assistants (MMAs) who form a very important part of the ZDF health services as they are often called on, due to the lack of adequate professional health staff, to work in the health centers in positions as high as that of Ward Masters, a position including administrative and medical responsibilities just below doctors. Jhpiego supports this program and will train 100 MMAs.

Jhpiego will build on experience within the MOH system to support the development of a better system for planning and managing their health and HIV clinical prevention, care, and treatment services. Jhpiego will assist the ZDF in strengthening their planning and management through extensive support of their planning process and develop strategic planning capacity at the DFMS central level.

The SmartCare program employs Electronic Medical Records to enable providers to create and access updated portable records of the patient's medical history and ongoing treatment plans. This system is especially useful for the mobile personnel of the ZDF, thereby assisting with continuity of care and treatment. Jhpiego has supported the rollout of SmartCare in 54 ZDF facilities and will continue to provide minimal technical support to ZDF facilities, providing refresher training as needed. In order to ensure sustainability of the program, the Defense School of Health Sciences will be supported to provide pre-service training in SmartCare to its students.

Jhpiego will continue to work with the ZDF and in-country partners on planning, forecasting, procurement and logistics management to strengthen the medical procurement and logistics systems throughout the ZDF. Jhpiego's partner, John Snow International (JSI) Logistics Services, will assist in the area of logistics support through supportive supervision of the ZDF the 260 ZDF staff previously trained by JSI in procurement, logistics management and forecasting systems, providing refresher training as needed. JSI will also monitor the supply chain system for ARVs and HIV test-kits designed earlier. As a result, the ZDF will be able to plan and manage services as well as avoid stock outs in ARVs, HIV test-kits and commodities.

Jhpiego will provide support to six MC Service delivery sites within the ZDF. This will include orientation of managers, assessment of sites, renovations and refurbishment where necessary, training of providers, provision of equipment and medical surgical supplies and post training follow up and supportive supervision.

The orientation for managers and supervisor is a two days program which provides an overview of MC including site preparedness and supportive supervision. Jhpiego will support the training of MC providers and MC counselors using the UNAIDS/WHO/Jhpiego training package. The MC skills course is a 10 days training that equips providers with the necessary knowledge, skills and attitudes to provide safe MCs. The MC counseling course is a separate training for five days and equips the providers will necessary knowledge, skills, and attitudes to provide counseling for MC including HIV testing and Counseling.

Jhpiego will roll out their recently developed male circumcision simulation to reinforce decision-making skills and improve patient-provider relationships. Jhpiego will promote couple counseling in the MC program to enhance female involvement and will facilitate referral between services linked to MC, e.g. HIV care and PwP programs.

All sites supported will provide the minimum package of services which include:

HIV testing and counseling provided on site

age appropriate pre- and post-operative sexual risk reduction counseling

exclusion of symptomatic STIs and treatment when indicated

provision and promotion of condom use

circumcision surgery in accordance with national standards

Counseling on the need for abstinence during wound healing

Wound care instructions

Post-operative clinical assessment and care

Ongoing support to sites will continue to ensure that they provide high quality, comprehensive MC services, through periodic supportive supervision visits using a standard-based management and recognition approach.

With all these efforts, it is envisioned that 30 providers will be trained in MC, 30 counselors will be trained and 20 managers oriented in MC program; comprehensive MC services will be provided to 2,700 men per site (average 50 MCs per month per site for nine months).

Jhpiego will continue strengthening ZDF service providers' knowledge and skills in STI and HIV prevention counseling working with the ZDF Medical Services to better integrate CT into STI services, adapting a "no lost opportunities" approach to prevention counseling as well as care for HIV infected clients to better STI services. A total of 75 service providers will be trained. The sustainability of this effort is a major focus of the work and is reinforced through using and expanding training capacity already developed within the ZDF Medical Services. ZDF trainers previously developed by Jhpiego will conduct this training, and Jhpiego will support these trainers through co-teaching opportunities and supportive supervision. In addition, STI information will be incorporated into the comprehensive HIV/AIDS orientation package for lay workers. This package will be used to provide prevention education for ZDF personnel. Whenever possible, Jhpiego will also continue to increase gender equity in provision of trainings, by providing learning opportunities to equal proportions of males and females in all the programs.

Jhpiego has supported PMTCT services at 20 ZDF sites, and will expand to an additional four model sites that will be determined. Jhpiego will expand facility-based performance improvement systems and maximize the benefit to ZDF from the model sites by working with ZDF central command and DFMS, as well as base commanders, to develop a system of staff rotation and on-the-job training. Jhpiego will to train ZDF staff in PMTCT (80) and will select 20 high performing PMTCT providers and develop them as trainers and mentors to further develop capacity to expand and support PMTCT services. As needed, previously trained staff will be retrained on QA and EQA to enhance the testing being done in the PMTCT context. The EQA will be addressed during the lay counselors training. The training covers all topics of an effective PMTCT package including effective/efficacious PMTCT regimens, CD4 screening, HAART for HIV+ eligible pregnant women, IYCF, couples counseling and male involvement.

Working with MOH, Jhpiego will continue to implement the mentorship and supervisory tools. This will support the implementation of services after service providers have been trained while addressing any gaps in knowledge and leading to routine monitoring of the quality and completeness of PMTCT services. Jhpiego will work on policy and training to include nutrition assessment for pregnant women to enhance food supplementation for effective prevention from mother to child.

To address sustainability, Jhpiego will identify institutions in two provinces that can be developed to provide ongoing capacity building. Direct assistance to the institutions will be based on initial assessment and will include educational equipment and support to establish training processes. The result is to improve both pre-service training as well as in-service training based on national strategies and guidelines. The implementation of these activities will be coordinated at the central level with MOH.

Jhpiego will train 120 lay workers by targeting at least three lay workers from each of the PMTCT sites in the two selected provinces. Jhpiego will provide mentoring and supportive supervision to these workers to ensure quality and safety of services.

PMTCT one time plus-up funds are being added to support: Development, dissemination and training in the new PMTCT Guidelines. As described, changes in PMTCT guidelines have occurred. The MOH has quickly adopted as policy in Zambia the revised WHO guidelines, and the MOH has committed to change its implementation guidelines to allow nurses to prescribe three ARVs in the PMTCT program. However, roll-out may be delayed without additional resources for training and material development. Mobile teams from ART clinics have assisted, but require short-term funding. In addition, partner testing is recommended, but only a minority of nurses has received such training. One-time funding will be considered for development and printing of new guidelines for PMTCT. Development of curricula, training materials and job aides for nurse prescription of HAART during pregnancy, use of complex regimens including, if recommended, prevention of lactation transmission; and Development and piloting of modules for couple prenatal education that includes couple testing and counseling, male reproductive health, and parenting information.

DOD PEPFAR will support the Zambia Defence Forces to train military medical personnel once the guidelines have been developed. JHPIEGO has been providing training and will be strategically placed to carry out this activity including dissemination. Military health facilities are not part of the MOH service delivery system and as such the activity has to be planned for and budgeted for separately. The military health facilities cater for military members, their facilities and the community surrounding the military bases, this has brought about an overwhelming burden but is an opportunity to reach women and children receiving services from them. An estimated 253, 000 people are being reached through the military bases around the country.

Jhpiego will train at least 40 providers, including doctors, nurses, clinical officers, and other health cadres, in diagnosis and management of TB including intensified case finding and management of other opportunistic infections (OIs). Using the training package developed by the ministry of health, health care professionals in ZDF will be trained in TB infection control. This training is a part of the series of trainings on core competencies for these cadres and will also include ART and PMTCT management, in an effort to strengthen linkages between ART and other HIV/AIDS prevention, care and treatment services to ensure more comprehensive and continuous care for people leaving with HIV/AIDS. Following the training, supervision visits to the service providers will be jointly conducted by Jhpiego and ZDF using SBM-R and other supervisory tools that were developed in the previous years.

Jhpiego will continue to expand the local ZDF capacity by training an additional 12 ART and TB staff as trainers and mentors to support and expand the program. To support performance improvement systems and quality ART service delivery, Jhpiego will conduct supportive supervision visits to the 24 model facilities. Jhpiego will continue supporting the DFMS to conduct workshops using the orientation package for lay workers (e.g., managers, clergy, community leaders, and caregivers) on HIV/AIDS prevention, care and treatment orientation package, covering CT, PMTCT, Care and ART as well as linkages to other services such as TB and STIs, to educate them on HIV/AIDS and provide them with accurate and relevant information they can disseminate to more diverse populations.

To ensure sustainability, Jhpiego works within the existing ZDF structures and plans. Jhpiego facilitates the development and dissemination of appropriate standard guidelines, protocols, and plans. Jhpiego will continue to strengthen and expand facility-based performance improvement systems, providing increasing opportunities for the trained staff from model sites to lead supervision and mentorship programs, while still mentoring and actively supporting the ZDF sites whenever necessary.