The overall objective of the UTH HIV and AIDS Program (UTH-HAP) is to provide expert HIV care and treatment, specialized laboratories services, leadership role in the development of training materials, training and mentoring of health workers, and provision of technical support to the Ministry of Health and its partners.

The UTH-HAP PEPFAR supported priorities for FY2012 will be aligned with the GRZ national policies and strategic plans. The UTH-HAP aims will be achieved through training of a critical mass of Master Trainers in advanced HIV/AIDS prevention, care and treatment; mentorship and clinical evaluations of HIV and AIDS programs; strengthening capacity and rehabilitation of UTH laboratories to support HIV/AIDS services; active participation in national HIV/AIDS technical working groups; strengthening of continuum of care by consolidating linkages between the UTH- PMTCT, pediatric and adult HIV/AIDS services as well as with Lusaka primary health facilities.

The UTH-HAP is a wraparound program emphasizing prevention, care and support, treatment and laboratory infrastructure and has multiple indicators.Monitoring and evaluation: Enabling the collection, aggregation and transmission of core indicator data from service delivery points to inform clinic and program management decisions at all levels is an important goal of the health management information system (HMIS). In 2012, UTH-HAP will strengthen and adhere to the overall purpose and components of an M&E system as outlined in the Organizing Framework for a Functional HIV Monitoring and Evaluation System (UNAIDS in 2008), also known as the 12 Components Framework, whose purpose is to have a fully functional, unified, national M&E system.

Context and Background: Adult care and support is a continuum of care for HIV-infected adults and their families aimed at extending and optimizing quality of life. Some adult patents on ART have complications such as arthritis and nerve complications resulting in weakness in the limbs and nerve pain that may be secondary to HIV, Opportunistic Infections (OIs) and/or HIV related tumors.

Physiotherapy: Given the current shortage of physiotherapists in the country the Physiotherapy in Palliative Care Program (PPCP) will continue to train Physiotherapists in palliative care in order for them to adequately manage clients with HIV/AIDS in their various communities. Further, final year Bachelor physiotherapy students will be trained in out reach palliative care, because community rehabilitation is a compulsory module taken over a period of six (6) weeks. This cohort of paraprofessionals will reinforce the existing workforce of physiotherapists by providing physiotherapy services for HIV/AIDS patients wherever they are posted around the country.

The training of community based rehabilitation workers will be ongoing as they supplement the work of trained physiotherapists. Given that this cohort belongs to the communities, capacity is being built that will provide physiotherapy services by people with an understanding the general populace and the geography of the peri-urban areas. Capacity will also be built in patients so that they are able to take responsibility for their health i.e. not requiring physiotherapists to watch over them as they conduct their exercises daily.

Primary prevention of disability associated with chronic illness and reduced mobility will remain a key goal that needs to be sustained and embraced by physiotherapists, community rehabilitation workers and communities at large. The purchase of physiotherapy equipment and accessories for treatment modalities, and M&E the quality of care and support services, program evaluation to advance program approaches and fill-in gaps in knowledge in priority care and support issues will be ongoing.

Context and Background: Tuberculosis represents a significant threat to health. HIV infection increases the susceptibility to infection with M. tuberculosis, the risk of rapid progression to TB disease, and reactivation of latent TB.

The diagnosis of TB in children is quite challenging, and in 2010 the PCOE in conjunction with the International Centre of AIDS Care and Treatment Program (ICAP) and the MOH National TB program developed a screening algorithm to diagnose TB in HIV infected children and adults to intensify case identification. This tool was piloted in the pediatric ART clinics, was found useful and will be disseminated to other sites.

The UTH-HAP TB/HIV program incorporates provision of laboratory services for the diagnosis of TB and multi-drug resistant tuberculosis (MDR TB) as well as TB screening in the Department of Paediatrics and the UTH-TB Clinic. As a reference laboratory it also oversees an external quality assurance (EQA) program in TB diagnosis and infection prevention program in three provinces.

In COP 2012 and 2013, MOH policy is to expand and strengthen TB/HIV integration by intensifying TB case identification, expanding Isoniazid Prevention Therapy (IPT) by extending IPT to all HIV positive individuals and systematically implementing TB Infection Control (TBIC) measures. At every clinic visit, all HIV-infected infants and children will continue to be evaluated for contact with a TB source, and those presenting with poor weight gain, recurrent cough or fever will be evaluated for TB and those with active TB disease placed on treatment. All HIV-infected infants and children exposed to TB through household contacts, but with no evidence of active disease will be commenced on IPT. Adult screening for TB is contained in Co-Ag number U2G/GH000078.

In order to comply and effectively support the national policy, the TB Laboratory will strengthen and implement all three components of the EQA program. This will ensure that there is quality at all stages in the diagnosis of TB. The lab will expand its TB diagnostic capabilities by increasing the number of competent staff, acquiring more laboratory equipment to meet the increasing demand for TB diagnosis, and intensify its supervisory support to other laboratory facilities that it oversees under Co-Ag number U2G/GH000078.

Context and Background: Patients on ART may develop complications that may be secondary to HIV itself, to opportunistic infections (OIS) and/or HIV-related tumors. We aim to extend and optimize quality of life of pediatric clients and their families throughout the continuum of illness.

Accomplishments since last COP: 75% of admitted HIV exposed infants are provided confirmatory tests for HIV infection for early infant diagnosis (EID) and those with definitive diagnoses are enrolled into care and treatment. Cotrimoxazole prophylaxis is provided for all HIV exposed/infected children from 4-6 weeks of age together with access to pharmaceuticals, ITNs, MCH and related laboratory services. Nutritional assessment is ongoing in the department of Paediatrics. Together with the FSU, psychosocial, spiritual and prevention services are provided, including those for adolescents addressing their special needs e.g. support groups and adherence counseling.

Community Based Intervention Association (CBIA): Children with HIV may develop complications such as developmental delays and various types of disabilities. Early intervention can ward off secondary conditions and dramatically improve quality of life. As part of palliative care, UTHHAP works with CBIA to support young children with disabilities to recover some degree of function and have an improved quality of life through pain and symptom relief.

Strategies for 2011: Continue to extend and optimize the quality of life for HIV-infected children and their families through the provision of physiotherapy and education to children with various challenges. To extend the provision of services to districts outside Lusaka, Livingstone and Sinazongwe. Training of caregivers in home based pediatric palliative care which integrates physiotherapy and pain management as well as home based education and feeding techniques. Educate caregivers in child rights, sexual and other abuses, HIV/AIDS prevention and treatment. Continue to distribute ITNs for malaria prevention.

Mobile clinic: In 2012 will continue providing pediatric ART to under privileged children in underserved hard to reach communities with the goal of increasing the number of children receiving care and treatment. In concert with our Co-Ag U2G/GH 000078, the outreach team will overtime become multidisciplinary to include an internist and OBGY specialist to also reach adults will also start serving adults

Context and background: UTH is the national referral hospital in Zambia, and the Department of Pathology and Microbiology provides laboratory services to the hospital and other facilities countrywide with the overall objective of providing quality but cost effective laboratory services to the hospital and the country.

The various laboratory units will continue to support the HIV intervention strategies. The UTH Virology Laboratory (UTH-VL) will continue to provide quality control supervision by performing randomized blinded retesting of some of the specimen collected from the wards. In cases of discrepant results the lab will provide a tie-breaker test based on antigen detection rather than antibody detection.

At a national level UTH-VL will continue to pioneer the HIV proficiency testing program. Once established, this program will feed into the national public health laboratory program. For monitoring of HIV infection the laboratory will continue to expand the national CD4 enumeration quality assurance (NEQAS) program.

The Microbiology (Bacteriology) Laboratory will continue to provide diagnostic services. In COP 2012 & 2013 the lab will further build on its diagnostic capacity for opportunistic infections (OIs) including sexually transmitted infections (STIs) and work towards conforming to international standards for a clinical and national reference laboratory. The lab will also expand on its quality assessment program by recruiting more sites and improving their microbiology diagnostic services through training of personnel in diagnostic procedures.

TB laboratory: will ensure that AFB smear microscopy reagent consumables are available and when lacking provide back-up supplies. UTH will continue supporting the expansion of EQA activities for acid fast bacilli (AFB) outside Lusaka including.

The UTH Virology Laboratory (UTH-VL) works in collaboration with the Immunology Unit of Tropical Diseases Research Centre (TDRC), in collecting epidemiological data on HIV infections on behalf of MOH, the Directorate of Policy and Planning, Monitoring and Evaluation Unit. The specific activities included are

1) Implementation of the 2012 HIV/Syphilis Sentinel (HIV SS) survey: these surveys are conducted every two years by UTH-VL and TDRC. In FY 2012, data will be collected from 24 sentinel sites in all nine provinces of the country. Fourteen of these sites are in the southern zone for which the UTH has oversight. It is planned that data collected be compared to routine PMTCT data to assess the possibility of using PMTCT data only in the future. This comparison of sentinel surveillance and PMTCT data began in 2011 but a migration to complete reliance on PMTCT data may take time thus the need to continue with ANC surveillance in 2012.

2) BED Capture Enzyme Immuno-Assay (BED-CEIA) Testing: HIV incidence studies establish the number of new HIV infections in a given population over a given period of time and offer critical information for targeted HIV prevention planning and for measuring the impact of HIV prevention programs. The BED-CEIA is a newly developed assay for the detection of recent HIV infection in resource-constrained settings. With BED-CEIA testing it is anticipated that recent HIV infections will be captured. This information will feed into the national HIV prevention strategies.

3) HIV Drug Resistance Survey: this survey will examine the magnitude of drug resistant HIV transmission in a subpopulation of young women attending antenatal clinics (ANC) in Lusaka at the four sentinel surveillance sites in Matero, Chilenje, Chelstone and Kalingalinga. Data collected for this survey will help to define the extent of transmission of drug resistant HIV strains. Genotyping of samples will be done at a WHO accredited laboratory. These activities will also continue to prepare the UTH-VL for accreditation as an HIV genotyping laboratory.

PUBLIC PRIVATE PARTNERSHIP (PPP) FUNDS: As part of a Public Private Partnership, CDC Zambia will support Georgian and Sorenson Foundations through the UTH lab Cooperative Agreement to enables healthcare, forensic and police professional from the Republic of Zambia to engage in practical training programs in the United States. This training and exposure to forensics with transfer of skills will enable the Zambian staff to prepare and plan for a forensic laboratory that will work towards improving a complete medical examination for sexual abuse, collecting and maintaining a tight chain of evidence and performing forensic testing in Zambia.The Georgian Foundation has initiated the Experience Exchange Fellowship Program (EEFP) which enables healthcare, forensic and police professional from the Republic of Zambia to engage in practical training programs in the United States.The UTH Child Sexual Abuse center sees on average 100 cases of sexually abused children every month. The children and their families are provided with prompt psychosocial counseling, supportive medical treatment, HIV counseling and testing, post exposure prophylaxis and emergency contraception (this is not through PEPFAR funds) if eligible. However the prosecution rates are very low (less than 1%) due to the lack of adequate forensic evidence, limited colposcopy and digital imaging skills, and many of the victims are too young to provide any meaningful evidence in court.This PPP will help to improve forensic diagnosis for protection of women and children; strengthen on-going work within CSA program; provincial roll-out to all 9/10 provinces; training of rapid molecular diagnosis related to rape and child abuse; increase the rates of prosecution and raise the profile on Gender Based Violence in Zambia.

The Pediatric Centre of Excellence in 2009 commenced two weekly ART clinics specifically targeted at HIV positive adolescents, both male and female. The Adolescents, aged 10 to 19 years, are provided with age appropriate health education sessions facilitated by the Adolescent Coordinator and peer educators who were trained by the Centre. The health education sessions address the importance of disclosure, prevention of high risk behavior, adherence to treatment, and sexual and reproductive health. Many are youths who were infected perinatally and are now entering their teenage years and facing unique challenges. In FY 2010 the PCOE completed guidelines and curriculum on adolescent friendly services for health care providers and peer educators as well as training materials in collaboration with Columbia University and MOH. The guidelines address the specific needs of adolescents inclusive of sexual prevention (abstinence), delay of sexual debut and related social community norms. These will be disseminated in FY2011 and training will be conducted to enable health workers better address at national level specific issues pertaining to adolescents.

Clinic-3 provides health education sessions and PITC to all their clients suffering from sexually transmitted Infections (STI) and skin diseases. In FY 2010 3,066 patients attended such sessions which addressed high risk behaviors and endeavored to impact good behaviors, including promotion of abstinence, secondary abstinence, fidelity, reduction of multiple and concurrent partners. Interactive methods are used such as condom demonstrations using male and female condoms to empower clients to initiate safer sex, as well as distribution of condoms and IEC leaflets Clinic 3 carters to all ages, but these messages are mostly directed at adult patients.

2012: We will consolidate the adolescent trainings/communication messages as well as mentorship on life skills based HIV education; on abstinence, condom promotion and distribution and increasing services for STIs.

UTH-HAP will promote couple counseling at all counseling sites (PITC & VCT); will strengthen linkages between STI, TB and ART clinics to promote PwP by offering ART to sero-discordant HIV positive spouses and sero concordant spouses not yet on ART. The key focus areas will be promotion of sexual abstinence among youth, faithfulness in marital and stable unions, and condom use to protect against HIV and other STIs.

There is considerable advocacy to universal access to HIV C&T (HCT), with the goal that all persons should know their HIV status. The UTHHAP has three HCT programs.

Provider initiated testing and counseling (PITC): has been ongoing at UTH since 2005. We aim to maintain high levels of PITC on all pediatric and adult in-patient wards, PMTCT and STI clinic, and outpatient departments. Targets for PITC coverage are >95% of all eligible/available children provided with counseling and testing in pediatric inpatient wards, 8,000 adults in the adult PITC entry points, and 100% of all STI patients. In the FY2010, 97.9% of pediatric inpatients were reached with PITC; 7,539 clients in the adult inpatient wards and 100% of STI patients with unknown HIV status. All clients who test HIV positive are linked to treatment and care, nutritional assessment is ongoing. In COP 2012 emphasis will be placed on ensuring successful referrals and tracking of HIV positive individuals as well as partner/couple counseling.

Family Support Unit (FSU): was set-up in 1992 and continues to be the VCT arm of UTH-HAP. In COP 2012 we aim to strengthen activities in Lusaka and Livingstone PCOEs to provide, among other things, HCT, psychosocial support/ supportive counseling services, training/cross-cadre mentoring, orientation of HBC groups, mobile VCT at community events, sensitization/educational activities and house-hold VCT to clients unable to access health facilities. The unit target is to reach over 100 households; 1,757 households were reached in FY2010. In COP 2012 FSU will intensify partner and family C&T especially in identification of sero-discordant couples.

Zambia Voluntary Counseling and testing Services (ZVCTS): is tasked by MOH, to identify and set -up VCT centers and accreditation of ART centers in hard to reach under serviced rural areas. Training of counselors is based on the Zambian testing protocols, data and logistics management and quality assurance programs. In 2012, refresher courses will be conducted in VCT centers on a regular basis to ensure quality of service and support supervision will be conducted for all new and existing VCT/PMTCT sites in collaboration with the District Health Management Teams.

The Child Sexual Abuse (CSA) Program and Zambia Child New Life Centre (ZANELIC) will continue to engage in awareness campaigns directing attention to HIV/AIDS and social and community norms that impact the disease in the communities in which they operate.Target Population Approx. Dollar Amount Coverage number to be reached by each intervention component ActivityVictims of CSA 250,000.00 80% by 2012 PEP, supportive counseling, referral to care and treatmentWomen, Men, Vulnerable Children (Zanilec) 125,000 1,380 men, women and children Capacity building/transit home for abused childrenSTI/skin clinic clients USD50,000.00 2880 individuals C&T, promotion of condoms, STI management, messages/to reduce risks of persons engaged in high-risk behaviors.Gender Mainstreaming1. One stop CentreVictims of CSA and their families, communities, teachers, police men, reporters 250,000.00 2,500, professionals and men, women and children Training of HC workers, police officers, teachers on GBV, male care givers on masculinity. Printing of training manuals & brochures2. ZANILECWomen, Men, Vulnerable Children 100,000.00 1,000 men, women and children Educational support, skills training, community sensitization. Strengthening of food security3. FSU: Women, Men, Vulnerable Children and families 100,000.00 5,000 men, women and children Household VCT, school debates, educational tours, childrens and caregivers workshops, training of male care givers, legal rights and protection of women & girls, printing of IEC materials, educational support

CSA: Aim: To increase the number of children completing PEP from the current 70% to 80%. This will be achieved by setting up task forces of influential networks in identified areas. These teams will be trained to sensitize and educate communities as well as offer support to families where CSA has occurred. A social worker will be utilized to help set educational programs in schools as well as bridging the gap between the One Stop Centre and the task force teams. The training manual on medical guidelines and management of CSA will be reviewed and updated to keep in line with changes that have occurred in recent years and distributed to relevant organizations.ZANELIC: is a local NGO providing emergency shelter for abused children. In 2012 ZANELIC will enhance their focus on Gender issues, with the aim of increasing womens capacity to prevent and respond to Gender Based Violence (GBV) and improve the quality of life for women and girls and to enable communities to secure the rights of women and their children. This will be achieved by the Women in Prison and Community Based Women Empowerment project through capacity building, training on HIV/AIDS and GBV for men and women, nutritional support for children with HIV/AIDS.

Clinic-3: Continue to link STI clients, both male and female, to HIV prevention, treatment, care and support and to screen HIV clients for STIs. Continue to strengthen provision of PITC to all patients referred to the clinic and empowerment of clients in the use of condoms and negotiation of safer sex (purchase and distribution of condoms). The Clinic will introduce a new outreach training entitled Applying behavioral theory to STI/HIV prevention aimed at equipping service providers with a better understanding of behavioral science and introducing them to behavioral theories on STI/HIV prevention.

The National PMTCT program has set up a high level of commitment towards improving maternal and child survival in its PMTCT plan the Virtual Elimination of MTCT of HIV and Provision of care and Treatment for Paediatrics HIV. In 2009 the Department of Obstetrics and Gynecology (OBGY) started to offer PITC in its antenatal clinics (ANC). There was a notable enhancement in sustainability and increase in the uptake of women into the program. From 2010 the Department took up leadership of the PMTCT program at UTH and will continue partnering with other partners to scale up PMTCT programs and coverage.

This Co-Ag supports only preventive PMTCT activities. Since October 2010, 179 UTH nurses, were trained using the PMTCT national and/or the revised set of PMTCT guidelines which reflect the WHO 2010 guidance. During the first half of FY 2010, 97.7% of women with unknown HIV status and eligible for C&T were tested. Six hundred and thirty-two women were tested for Syphilis. Fifty three spouses were counseled and tested for HIV. There is a large potential to scale up couple counseling in OBGY wards as well as in the ANC.

Over 2012 & 2013, UTH-HAP is determined to enhance the quality of provision of PITC and couple counseling in ANC, labor and post-natal wards; PMTCT to all HIV positive pregnant women; roll out C&T to previously HIV sero-negative pregnant and postnatal mothers to capture sero-conversions. Under UTH-HAP Co-Ag No. U2G/GH000078 ART will be offered to all pregnant women with absolute CD4 counts of <350 in an ANC setting. Referral linkages will be strengthened between the ANC and the adult ART Program to treat sero-discordant HIV positive husbands as well as sero concordant husbands not yet on ART to enhance prevention with positives (PWP). These activities will be integrated with provision of family planning as well as infant and young child feeding counseling (IYCFC). Nutrition assessment counseling support (NACS) will be integrated in the ANC and wherever an HIV infected person is seen. The department will continue to work closely with MOH, NAC and ZVCT to scale up VCT/PMTCT services and make it universally accessible to the rest of the Zambian population primarily by providing a training pool for Zambia.

UTH-PCOE, established in 2005, contains the most comprehensive program elements and organizational structure for pediatric treatment. There are a cumulative total of > 10,000 children ever enrolled into care and about 4,000 ever commenced on ART. There are currently 2,082 pediatric patients on treatment. UTH-HAP will continue to provide and demonstrate exemplary best practices of care and treatment for HIV infected and exposed children so as to increase the number of children engaged in care and receiving ART inclusive of prophylactic therapy with Cotrimoxazole, and to offer technical support to the Ministry of Health (MOH). In COP 2012 we will aim for 600 children newly commenced on treatment.

In 2012, To address the challenge of clients lost to follow-up and improve overall retention on treatment, we will need to incorporate the Smartcare system and continue to strengthen linkages with local clinics. In efforts to improve adherence, a family centered approach will be taken and adolescent activities will be enhanced to provide specific services including support to facilitate transitioning to adult services. The EID lab and the PITC program will continue to support early detection of HIV in infants and extend efforts for CD4% and viral load monitoring of children pre-ART or on ART. The PCOE mobile ART clinics will serve the under privileged children in underserved areas of peri-urban Lusaka. The Smartcare system will greatly improve data collection, monitoring, and analysis

In 2009 the Misisi Community Nutrition/HIV Care Program was established. This is a community model piloting the effectiveness of early community identification and care of HIV infected and uninfected undernourished children against a backdrop of high case fatality rate (30-45%) among children admitted to UTH with severe malnutrition mainly due to late presentation and complications of HIV infection. Children enrolled into the program are supplied therapeutic supplemental food and those with complicated severe acute malnutrition are referred to UTH for stabilization then enrolled into the Outpatient Therapeutic Program (OTP) upon discharge. HIV infected children and caregivers are referred for care at UTH/local clinics.