The community-based prevention, care, and support program will be a three-year program (2010-2013) that receives funding across multiple budget codes. Exact targets and outputs will be finalized during negotiations with the awardee, and entered into COPRS once the program has been awarded.

The twin goal is to support more effective prevention as the main priority in PEPFAR Phase 2, during the three years of program implementation, while developing more sustainable care and support for the intended target populations, which include Orphans and Vulnerable Children (OVC), at-risk youth, and People Living with HIV (PLHIV), as well as affected families and communities across Zambia. A new target group are those who are most at risk among the 85% of Zambians who are HIV-negative.

The objectives are to: 1) Ensure access to high-quality prevention, care, and support; 2) Strengthen the continuum of care and the integration of services; and 3) Improve efficiency, sustainability, and build local capacity of HIV/AIDS related services, including links with the private sector. One aim is to increase the scope and coverage of prevention efforts nationwide. The geographic target is to reach at least 80% of districts nationally, with quality community-based HIV prevention, care and support interventions. Primary target populations include OVC, PLWHA, at-risk youth, other vulnerable groups (such as the uninfected spouses/partners of PLWHA), and their families and communities. A new focus is targeting the 85% of Zambians who are HIV-negative as well as the 15% who are HIV positive.

In each PEPFAR program/technical area, the project will adhere to applicable guidelines. For Prevention, the project will adhere to and support the 2009 Zambian National HIV/AIDS Prevention Strategy, as well as PEPFAR ABC guidelines and FY 2010 technical considerations. In particular, the project will incorporate new PEPFAR guidance on Prevention with Positives (PWP). In HBHC, the project will adhere to national minimum standards for home-based care, as well as PEPFAR guidance. The project will continue to promote comprehensive and holistic care and support, comprising pain relief and nutrition support wherever possible. For OVC, the project will support Zambian strategic plans, as well as PEPFAR guidance. A key strategy is to link and integrate activities and clients across technical areas, from Prevention to TC to PMTCT to OVC to PDCS to HBHC, and onward to ART as well.

New emphasis for OVC include a focus on health care for children under five, and closer links to PMTCT mothers and infants, to: 1) ensure continuity of care for HIV-positive and HIV-exposed infants; and 2) reduce/eliminate loss-to-follow-up among PMTCT mothers and infants. Nutrition support, where provided, will adhere to Zambian Nutrition and HIV guidelines, as well as to draft national guidelines on Food by Prescription.

Contributions to Zambia health system strengthening include closer linkages between community-based volunteer caregivers and clinic based health professionals, in order to provide care and support that is coordinated and of better quality. One aim is to attach caregivers formally to the health system so that they operate with official status under the auspices of the GRZ. Cross-cutting program elements include: limited emphasis on food and nutrition; economic strengthening; water; and gender. More details on the cross-cutting aspects are found below.

The strategy to become more cost efficient includes: combining two previous care and support programs into one to eliminate redundancy; reducing the investment in initial training of volunteer caregivers; retaining as many of the clients and caregivers from the previous programs as possible, in order to speed that start-up and avoid interruption of services, and to save the expense of identifying and training all new caregivers and registering all new clients. This follow-on effort will receive help from the two preceding programs to transition clients and caregivers, so that there is little or no loss of existing client and caregiver "assets."

In addition, the emphasis on linking to the private sector and increasing sustainability implies that these activities will require less external donor funding in the future and be community-owned to a greater extent. This project will link closely to a Zambian-led, community-based prevention contract, as well as to other USG Zambia projects, to optimize use of USG resources.

Monitoring and evaluation plans include: greater integration with national M&E plans and structures as well as greater focus on outcome and impact measures.

This program was initially identified in FY 2008 as a single procurement. However, it has subsequently been determined that it will be more appropriate to develop two separate but closely integrated procurements to meet the full needs of prevention, care, and support.

The project will provide quality care and support to 100,000 PLWHA per year, of whom up to 90% will be adults. Services will adhere to national standards, including national minimum standards for home based care, as well as PEPFAR Adult/Pediatric care and support. All clients will receive the adult or child preventive care package, including cotrimoxazole prophylaxis. It would also assist with food and nutrition assessment, counseling and support. Where nutrition support is provided, it will adhere to national Nutrition and HIV guidance, as well as adopting the draft national Food by Prescription strategy to diagnose and treat malnutrition among PLWHA. All community-based care and support activities will link to and integrate with available clinic-based services, including VCT, PMTCT, OVC and ART.

Any training activities that are required will be planned and conducted in coordination with Ministry planning timetables, and under Ministry auspices, in order to conserve resources, to minimize absence of staff and disruption of services, and ensure that trainees are linked to and recognized by relevant Ministries.

To address the needs of clients, the project will provide clinical care to at least 50,000 PLWHA, and continuous PSS to all PLWHA. Care and Support will continue to assist hospice care and advocate for pain relief for PLWHA. Other interventions may include malaria and TB case-finding and control measures. Other efforts will be directed towards increasing ownership and sustainability of care and support, including GRZ accreditation of hospice care facilities to qualify them for public funds and enabling the GRZ to post health professionals at hospice sites.

This will be an extension to the OVC care and support of the RAPIDS project, which seeks to reach 250,000 OVC. It may also incorporate OVC clients and service areas of Track 1 OVC projects, if funding permits. The new project will provide or ensure access to at least a minimum package of critical OVC services and support. New emphases for OVC include a focus on health care for children under five, and closer links to PMTCT mothers and infants, to: 1) ensure continuity of care for HIV-positive and HIV-exposed infants; and 2) reduce/eliminate loss-to-follow-up among PMTCT mothers and infants. As allowed by the GRZ, community caregivers will promote or perform collection of dried blood spots (DBS) for HIV-exposed infants to increase Early Infant Diagnosis (EID).

In contrast to OVC targeting under PEPFAR I, it will be HIV sensitive rather than HIV specific, in order to reduce direct or reverse stigma and discrimination. Interventions may include education, shelter, protection, health security, food and nutrition, HIV prevention, PSS including mental health services, and greater access to livelihoods and economic strengthening.

Where nutrition support is provided, it will adhere to national Nutrition and HIV guidance, as well as adopting the draft national Food by Prescription strategy to diagnose and treat malnutrition among OVC. All community-based OVC care and support activities will link to and integrate with available clinic-based services, including VCT, PMTCT, OVC and ART. In particular, OVC care and support will link closely to PMTCT services to ensure continuity of care and follow up for HIV-exposed infants.

Any training activities that are required will be planned and conducted in coordination with Ministry planning timetables, and under Ministry auspices, in order to conserve resources, to minimize absence of staff and disruption of services, and to ensure that trainees are linked to and recognized by relevant Ministries. This includes volunteer caregivers who should receive their certification from the relevant ministries under whose auspices they will be allowed to operate.

The TBD award will target adult and pediatric PLWHA with ART adherence support. It will provide continuous care and support from time of HIV diagnosis to ART eligibility (CD 4 less than 200 for the general population and less than 350 for pregnant women). Caregivers will encourage timely return to clinic visits for periodic lab tests to confirm CD4 counts. Other screening techniques will rely on visual observation, or questions regarding increasing frequency and severity of illnesses and medical complications, etc.

Caregivers will ensure effective, timely referral of community and home-based care clients to ART and PMTCT sites. The TBD will work with the GRZ and other partners to establish common, simple mechanisms to confirm that clients act on referrals.

Caregivers will link with or attach themselves to ART and PMTCT sites, sharing client information on client progress, problems, and follow up, as appropriate. At clinic request, caregivers will help relocate clients who miss clinic visits. Project vehicles will be used as needed to ensure that ART clients who live far from ART sites reach the clinic for care or for ARV re-supply. Clinics will reciprocate, sharing information that caregivers need.

Caregivers and prevention counselors will participate in early warning mechanisms to detect and report the emergence of ARV drug resistance, so that it can be addressed at the earliest opportunity. They will also screen for and report signs of adverse effects, both short and long term, of ARV drug regimens, to allow for a rapid response by clinicians.

Caregivers and prevention counselors also receive training in nutrition assessment and counseling, as well as pain management. They will provide these services, under clinical supervision, acting in coordination with clinical sites, and reporting on their actions.

The TBD award will promote Positive Prevention as well as a gender balanced approach to care and inclusion of clients. GIPA principles will also continue to play a role in the program and these guiding principles will also be transferred to any takeover parties.

The ultimate goal is to achieve a target of providing adherence support for 100% of PLWHA on ART by the end of project.

The new project will work closely with the TBD Prevention RFP to reach and maintain the level of TC delivery (41,000 clients in the last reporting period) by the two predecessor projects (RAPIDS, SUCCESS) combined. It is expected that the Prevention RFP will provide the bulk of TC design and technical assistance, but provide at most 25% of the TC service delivery. The TBD Prevention, Care, and Support RFA will retain the bulk of volunteer caregivers to deliver the majority of TC services at mobile sites and in homes and other community settings. The new project will link TC clinical and community services much more closely, and arrange to link HIV positive clients immediately to other needed services to improve continuity of care for PLWHA, and to reduce loss-to-follow-up of "pre-ART patients" (PLWHA who are current clients of community/home-based care are often referred to by clinical providers as "pre-ART patients" and described as "lost-to-follow-up" although in reality they are in fact closely followed by community caregivers). Testing and Counseling (TC) will also link the 85% of Zambians who test HIV-negative to intensified prevention and support initiatives to reduce the risk of future HIV transmission.

The new project would link itself to existing TC sites. Counseling and testing would occur primarily in the home and community, which will facilitate couples counseling, follow up of discordant couples, and family counseling. The project could provide direct VCT service delivery in most cases, or in some cases, mobilize communities to help other TC providers. TC will be used as a venue to initiate Prevention with Positives (PWP) messages/activities. Linking project activities to the private sector where possible, and absorbing clients and caregivers from previous projects, are two ways to reduce recurrent costs and increase sustainability. To the extent that donor and private sources increase, these activities will require less external donor funding in the future, and be "community-owned" to a greater extent than at present.

The project will provide quality care and support to 100,000 PLWHA per year, of whom 10% or more will be children. Services will adhere to national standards, including national minimum standards for maternal and pediatric care, and for home based care, as well as PEPFAR Pediatric care and support. As allowed by the GRZ, community caregivers will promote or perform collection of dried blood spots (DBS) for HIV-exposed infants to increase Early Infant Diagnosis (EID). All children will receive the OGAC/ GRZ recommended child preventive care package, including cotrimoxazole prophylaxis for HIV-exposed children. Of these, the project will provide clinical care as needed to up to half, and provide continuous PSS to child clients. It would also link with and assist in food and nutrition assessment, counseling and support, following national guidelines.

Where nutrition support is provided to clinically malnourished clients, it will adhere to national Nutrition and HIV guidance, as well as adopting the draft national Food by Prescription strategy to diagnose and treat malnutrition among pediatric PLWHA. When addressing the nutrition needs of infants and young children, the project will follow national Infant and Young Child Feeding (IYCF) guidelines. A goal of infant/child feeding will be to ensure long-term HIV free survival of children.

Other interventions may include malaria and TB screening, case-finding, and control measures. Other efforts will be directed towards increasing ownership and sustainability of care and support, and might include GRZ accreditation of hospice care facilities to qualify them for public funds as well as allow the GRZ to post health professionals at hospice sites. All community-based care and support activities will link to and integrate with available clinic-based services, including VCT, PMTCT, OVC and ART.

Any training activities that are required will be planned and conducted in coordination with Ministry planning timetables, and under Ministry auspices, in order to conserve resources, to minimize absence of staff and disruption of services, and to ensure that trainees are linked to and recognized by relevant Ministries.

All prevention efforts will employ a "combination" approach, comprising biomedical, behavioral and structural interventions, to achieve comprehensive prevention targets and reduce transmission of HIV. The project will also operate in full compliance and coordination with the 2009 Zambian National Prevention Strategy.

The project will ensure prevention efforts are fully integrated and continuous across all program/technical areas. It will avoid artificial divisions between AB/multiple concurrent partner reduction and Other Prevention. The project seeks to ensure that OVC and at-risk youth employ more effective AB and related prevention strategies such as delay of sexual debut and partner reduction. It will aggressively promote reduction of multiple concurrent partnerships. Based on recommendations from an inter-agency (CDC-USAID) Prevention with Positives (PWP) technical assistance visit in August 2009, it will roll out and scale up effective, comprehensive Prevention with Positives (PWP) initiatives, as well as supporting Positive Living Groups and other behavior change efforts for PLWHA, such as reducing intake of alcohol, improving diet and nutrition, and combating gender-based violence. Lastly, it will seek to increase and improve on prevention efforts to protect the 85% of Zambians who are HIV negative. To do this, it will identify those HIV negative individuals who are at the highest risk of infection (for example, those whose spouse or partner is HIV-positive, or who is known or thought to have multiple sexual partners), and provide targeted behavior change activities to enable them to protect themselves better against infection. This could include couples counseling and testing, and/or raising awareness of risky sexual behavior.

All prevention efforts will employ a "combination" approach, comprising biomedical, behavioral and structural interventions, to achieve comprehensive prevention targets and reduce transmission of HIV. The project will also operate in full compliance and coordination with the 2009 Zambian National Prevention Strategy.

The project will ensure prevention efforts are fully integrated and continuous, and will avoid artificial divisions between AB and Other Prevention. Implementing partners will include a full range of "other prevention" strategies and interventions, such as reduction of risk behaviors ranging from alcohol and other substance abuse, to gender-based violence, and behaviors such as soliciting or providing transactional or trans-generational sex in exchange for money or goods. Partners will also include condom promotion and distribution, if they have no objection under the conscience clause. The activity will also link closely to AB and STI prevention, and to other related GRZ and USG efforts. Funding for Other Prevention in this community-based prevention project is modest. The intent is to integrate prevention in other technical areas such as HKID and HBHC. The project will receive significant technical assistance for the design and implementation of prevention activities from another community-based -prevention TBD contract mechanism.