Partner will support the ZDF to improve overall clinical prevention, care, and treatment services around the country throughout the three branches of the military service Zambia Army, Zambia Air Force and Zambia National Service. The partner will work closely with other partners implementing the MCH program, SMGL, as a component of the PMTCT program. The goal of the project is to develop sustainable training, supervision, and M&E systems to rapidly expand HIV/AIDS services to additional clients served by the ZDF. This includes strengthening management and planning systems to support PMTCT and HIV/AIDS care and treatment services, with the appropriate integration, linkages, and referrals to minimize transmission of HIV.Our program objectives are:Objective 1: Increase clinical capability by supporting ART, TB/HIV, and PMTCTObjective 2. Integrate HIV counseling and testing into Palliative Care and STI services through PITCObjective 3: Strengthen STI diagnosis and management services within the ZDFObjective 4: Strengthen Male Circumcision services within the ZDFObjective 5: Work with ZDF and other partners to strengthen systemsThe Defense Force Medical Services (DFMS) supports health facilities at 54 of the 68 ZDF sites, with the remaining sites relying on military medical assistants and outreach support. These health services are dispersed across hard-to-reach areas around the country and serve both ZDF and local civilian populations. In addition, given the mobile nature of the ZDF, it is often the first responder to medical emergencies and disasters throughout Zambia. The partner will support services in a total of 14 sites focused in three provinces: Eastern, Southern and Western.

In order to expand integration of Counseling and testing (CT) in TB/STI and other Services, there is need to continue strengthening service providers knowledge in the new protocols and guidelines for provider-initiated testing and counseling (PITC), as well as in documentation and reporting of comprehensive care provided to identified positive clients. In collaboration with ZDF, the partner will conduct two trainings in PITC for general service providers, with on-site follow-up by ZDF trainers. The partner will further support a mentorship program at 14 sites in Eastern, Western and Southern provinces, working through case studies with service providers. The partner will facilitate effective monitoring and evaluation of service delivery through improved indicators and the provision of client registers. Site strengthening at the 14 sites will be done through purchasing of equipment and supplies. M and E systems shall be strengthened through trainings, supervisions and holding feedback meetings.

The revised National Provider Initiated Testing and Counseling (PITC) Training Package will be utilized for all provider trainings. This package, adapted from CDCs counseling protocols and training materials by Jhpiego, MOH and partners, takes a no lost opportunities approach to prevention, effectively integrating PICT with TB care and treatment and linking it to identification and treatment of other common co-infections, such as STIs and other opportunistic infections. PITC is a key component of the diagnostic work-up for patients who present with TB and/or other symptoms and signs that could be attributed to HIV. Through training, providers are not only equipped with the knowledge and skills needed to provide HIV/CT services, but gain an appreciation for the importance of provider-initiated CT that is essential to effective implementation of this service. It further reinforces the delivery of a comprehensive and continuous package of services that does not end with a positive HIV test or initiation of ART. Prevention with positives will be integrated in this comprehensive care through screening of sexual activities, condom distribution, gravindex testing and STI management.

The partner will strengthen TB/HIV collaborative activities within ZDF in three provinces (Eastern, Southern and Western Provinces). The partner will train 25 health care providers in these provinces, including doctors, nurses, clinical officers, and other health cadres, in diagnosis and management of TB and TB infection control. Intensified TB Case Finding (ICF) in clinical settings (ART, PMTCT and OPD) in ZDF facilities will be enhanced through screening of attendees presenting at various clinics using a symptomatic screening tool. Linkages with the district health management teams will be strengthened as these will provide materials for the diagnosis and management of TB.

The partner will support the establishment and accreditation of 5 additional TB diagnostic centers in ZDF in the three provinces. The partner will support referral of prepared slides (fixed and stained) rather than referring clients to diagnostic centers in facilities that will not be designated as diagnostic centers. The partner will strengthen laboratory networks within ZDF in the three provinces. 20 laboratory assistants and technicians will attend AFB refresher training conducted by the national Reference laboratory. Working with PCI, community participation in TB programs will be strengthened in the three provinces by supporting TB treatment supporters. A total of 80 community TB treatment supporters will be trained to strengthen community linkages.

The Zambia Defense Force has established a School to train health care providers in order to alleviate the shortage of skilled manpower in ZDF health facilities. The partner will support the training of 48 Military Medical Assistants (MMAs), 24 Laboratory and 24 Pharmacy Assistants. The trainings respond to the needs of the ZDF health facilities in their quest to provide quality health care to their clients. The partner will also support the school to follow up all the 96 students trained during the year.

TBD will build on the support provided to the school by ensuring that the DSHS clearly defines the cadres of health care providers that will be trained by the school, assist the school prepare a staff establishment required to provide the necessary trainings. Jhpiego will work with the school to develop sustainable systems for students, lecturers, and suitable clinical training settings where students will practice.

The partner will continue to provide training skills updates to all staff teaching at the school. A total of 20 lecturers will be targeted.

The partner will assist the school to develop/update training curricula for all the training programs that are provided by the school ensuring that such curricula are in line with good governance principles and the regulatory bodies (Health Professions Council, General Nursing Council and Pharmacy Regulatory Authorities of Zambia). The partner will work with DFMS to ensure that plans are developed that will sustain operations at the school and ownership.

As in many health areas, the Zambian military lags behind the MOH in implementing MC activities. Currently, five ZDF sites (ZNS Chiwoko, Arackan Barracks, Zambia Air Force (ZAF) Mt Eugenia, Luena Barracks, Maina Soko Military Hospital (previously supported with CDC funds) are providing Male circumcision (MC) services to military personnel and surrounding civilian communities, which comprise approximately 80% of clients. The demand for MC services among military staff and their families is ever-increasing.

During the past year, the partner began implementation in new sites within Eastern, Western and Southern routes. In 2012, the number of sites will increase to eight. Jhpiego will also increasingly support mobile/outreach MC services in ZDF facilities. This would involve purchase of the vehicles, equipment, supplies and consumables needed, as well as training additional clinicians who would be able to support the MC services in these sites. These units would support outreach MC services as well.

To overcome the shortage of health care providers in ZDF, Jhpiego will engage DHMT MC providers to support military sites. These providers will be engaged on part time basis and paid an allowance for their time. Jhpiego will support strengthening of demand creation through use of community support groups trained by PCI. The partner will engage community mobilizers trained by PCI to help generate demand for MC services. The quality of MC services provided will be ensured by employing quality improvement tools, monitoring, supervision, refurbishments of MC sites and procurement of MC supplies and commodities.While facilities will be providing MC services on a routine basis, past experience has shown that such efforts are well-complemented by MC campaigns. The partner will thus support four campaigns during the year, during which facilities will make a special effort to raise community awareness of and demand for MC, and Jhpiego staff will provide on-site technical support. All sites supported will provide the minimum package of services, including HIV testing and counseling and age appropriate pre and post-op sexual risk reduction counseling, including condom use. All clients will be screened for STIs and provided prompt treatment, as required. Client counseling on abstinence during wound healing and post-operative care will also be provided. It is expected that with all these efforts 3750 men will be reached with MC services.

The sexual prevention activities are closely integrated with the palliative care PITC activities. Members of the military are at particularly high risk of HIV and STIs. These populations are away from their families for extended periods. Prevention of HIV transmission and acquisition is dependent upon early and effective treatment of STIs using the syndromic approach of STI case management, which is a key component of comprehensive HIV management. Offering STI treatment and partner management at the HIV positive clients first visit mitigates re-infections as well as prevention of drug resistance.

Forty (40) providers will thus be trained in application of the syndromic management approach to STIs in the delivery of ART, TB, PMTCT and other outpatient services. Training will emphasize the syndromic approach to STI management, risk assessment and risk reduction counseling. The standard available training materials will be used for these trainings. Targeted interventions contribute to the overall goal of reducing STI prevalence and slowing HIV transmission.

The partner will engage five ZDF STI/HIV trainers to provide follow-up and mentorship in all 14 sites in Eastern, Western and Southern provinces. Improved monitoring will be facilitated by updated indicators and registers. ZDF staff will be encouraged to take the lead in providing all technical support and monitoring, including assessing service delivery and addressing gaps. Using this methodology the partner will work toward sustainability in the continuing education initiatives that the Zambia Defense Forces need to undertake to keep their health service providers up-to-date on the best practices in STI syndromic case management as well as other areas of health care.

Drawing on lessons learned and the call for the virtual elimination of pediatric HIV, TBD will continue to strengthen the use of more efficacious regimens in PMTCT. The partner will work closely with the other partners in PMTCT to ensure that HIV positive women eligible for HAART are able to access this service. To maximize the effectiveness of HAART, the partner will implement a nutritional assessment tool for providers to use in assessing all positive pregnant women; women determined nutritionally deficient will be referred to other organizations for food supplementation. Early infant diagnosis will continue to be strengthened. Also, the partner will ensure that SML initiative is incorporated into the PMTCT program, in the districts where there is overlap between the partners.

An additional 20 health care workers and 20 lay workers will be trained in PMTCT to fill identified gaps using on-site training approach for health care providers and group-based training for lay workers. These lay workers will ensure that there are community linkages between the community and the health facilities. Activities of lay workers will be facilitated by the provision of monitoring and evaluation tools, bicycles, as well as other items, as needed to enhance the mother-child pair follow-ups in the community.

Jhpiego has worked with the DFMS to develop an Integrated Reproductive Health Supervisory tool that encourages an integrated approach to supervision, including PMTCT, as well as focused antenatal care, family planning and other reproductive health services. Furthermore, the SBM-R quality improvement system will continue to be implemented. These two tools support the implementation of PMTCT services post training, identify and address gaps in knowledge and skills and contribute to routine monitoring of the quality and completeness of PMTCT services being provided. Support will additionally be provided in the form of equipment, supplies and commodities.

Supportive supervisory visits will be conducted to service providers in the 14 sites along the Eastern Sothern, and Western routes. This will be done in collaboration with ZDF managers and supervisors in order to develop their supervision skills and use of the supervisory tools. During these visits, providers will also be trained in skills that will enable them to assess the nutritional status of HIV positive mothers (using the above-noted tool) and link them to other organizations that are providing food supplementation.

The partner will continue to support the MOH and provincial health offices while at the same time working closely with other implementing partners such as CIDRZ. The focus is to strengthen the districts ability to supervise and provide quality services. The partner will support two districts in lay worker training, mentorship and supportive supervision in the Eastern and Western provinces of Zambia. The partner will train 40 lay workers (20 per district) and conduct two supportive supervision and mentorship visits (one visit per district).

The partner will build on previous work to support comprehensive HIV/AIDS prevention, care and treatment services in ZDF health facilities. The partner will work with the 14 supported sites to expand quality ART services in the three provinces of Eastern, Western and Southern. During the site visits, orientation of health workers in HIV/AIDS will be done at each of the camps to ensure that senior managers at the camp understand HIV/AIDS programs at the health facility.Group based trainings in ART will be provided to all sites to increase their capability to provide comprehensive HIV/AIDS treatment services with a total of 20 health care providers trained.To support performance improvement of systems and quality adult treatment service delivery, the partner will conduct supportive supervision and mentorship visits to all the facilities in the Eastern, Southern and Western provinces. In order to ensure sustainability, the partner will work within the existing ZDF structures and plans. All the sites will be visited twice per year to document performance standards.The partner will emphasize prevention activities in clinical settings and re-enforcing prevention messages at every clinical encounter with HIV positive clients. A minimum package of care for HIV prevention among clients receiving HIV care will be implemented at all the sites. Collaboration with other partners shall be improved through joint planning, joint supportive supervision and sharing of reports. Community linkages will be strengthened through community ART adherence supporters.

The partner will support ZDF with reaching accreditation standards in some sites to the level required by the Health Professionals Practitioners Council of Zambia.

In FY12, Jhpiego will strengthen Paediatric HIV Treatment in ZDF-supported units by ensuring early identification of infants and children who are exposed to HIV as well as through provider initiated counseling and testing, and timely and effective linkages to appropriate diagnostic facilities. Jhpiego will work to ensure children identified to have HIV infection receive timely initiation of ART and also put on cotrimoxazole prophylaxis. This will be made possible through capacity building of health care providers working in these units. Therefore, health care providers will receive on-the job-training courses.Treatment will also be enhanced through provision of regular hands-on mentorship and supervision to ZDF ART-supported sites by technical persons with knowledge, expertise and experience in management of Paediatric HIV, to ensure sustained provision of quality HIV care to children living with HIV and AIDS.In additional to training of provider in Paediatric HIV treatment, Jhpiego will also support training of providers in child counseling, a skill which many providers lack, thereby missing out on opportunities for early identification and provision of treatment to children who need this service.Key to the success of HIV management is adherence to treatment on the part of the client and care giver (s) and indeed on knowledge and skill in providing adherence education and support to the client and care giver on the part of providers; and so in this regard, Jhpiego will support a training of providers in adherence counseling, in children.Jhpiego will also print and distribute Paediatric ART treatment job aids and national guidelines.