Since 2004, DAO Lusaka under the leadership of the Defense Attaché Office has partnered with the Zambia Defense Forces through the Ministry of Defence to implement prevention, care and treatment programs.

In addition to the overall management and oversight of the DOD PEPFAR Program, DAO Lusaka has been implementing system strengthening and infrastructure improvement programs in the Zambia Defense Force from as far back as 2005. This continues to be an integral part of the overall DOD PEPFAR program implemented by the other partners such as Project Concern International (PCI), Jhpiego, Society for Family Health (SFH), JSI Logistics and American International Health Alliance.

The program has grown from strength to strength and programs have been expanded and scaled up to all the 54 military health facilities situated on the ZDF bases. This has been necessitated by the fact that the military have health facilities run and managed independently from the Ministry of Health. The health facilities are under the auspices of the three service: Zambia Army (ZA), Zambia Air Force (ZAF) and Zambia National Service(ZNS).

The direction of the program is to focus on capacity building for improved service delivery, leadership development for sustainability, system strengthening and infrastructure improvement for quality in service delivery.

The military in Zambia works closely with other uniformed services and benefits of the PEPFAR program tend to spill over to other services such as the Zambia Police Service that are also involved in peace keeping and other mobile operations through their paramilitary units. Separation of provision of services tend to be difficult and are provided to best meet the needs of all uniformed officers.

Improvement of infrastructure includes renovations of existing spaces to make them user friendly for HIV/AIDs service provision while expansion includes new construction to increase rooms for the purpose of providing adequate space for additional HIV/AIDS services which will assist in scaling up the interventions to meet the health needs for the ZDF, their families and vulnerable population living in these areas, which at many sites are predominantly civilians (non ZDF dependants) who rely on access to Defense Force Medical Services (DFMS) for all routine clinical care.

Funding constraints coupled with increasing demand due to population increase has left the DFMS with substantial infrastructure deficit, which has been compounded by the remote location of many of the 54 DFMS clinics, as well as lack of other donor support and inadequate Ministry of Health (MoH) support for the DFMS activities. Health facilities on these sites need extensive renovation to enable them qualify for the national HIV program where free test kits, ARV and other HIV related drugs become available and will serve as model sites for the ZDF medical staff in the regions to rotate through for training in prevention for mother to child transmission (PMTCT).

HIV/AIDS unit coordinators as well as medical officers from ZDF sites have already been provided adequate training for HIV/AIDS prevention, care and treatment. However despite this support, most of the remaining 31 ZDF sites are still having challenges to deliver effective HIV/AIDS services due to poor infrastructure and lack of laboratory equipment. There is need therefore for support in equipment and infrastructure improvement in order to make service delivery improvement in HIV/AIDS a reality.

FY 2012 activities will focus on continuous strengthening of the ZDF labs in outlying areas and monitoring performance of sites already improved. This activity will link to SCMS to ensure laboratories have reagents and sustainable service. Works on renovations to the HIV/AIDS secretariat will also continue and this will also include provision of furniture and equipment.

The DoD will further support improvement of service delivery in HIV/AIDS care, treatment and testing through infrastructure improvement and expansion on five (5) ZDF sites and provision of equipment. Improvement will include renovations to infrastructure while expansion will include new construction to add more space for additional HIV/AIDs activities. This is to ensure availability of testing facilities on site for women under the PMTCT program and ART clients for initiation and disease monitoring. In addition, to improved service provision, capacity building efforts will involve training staff in HIV Lab Techniques and Good Laboratory Practices, Lab Management and Trainers of Trainers course.

The goal of the DOD over the past four years has been to assist in achievement of sustainable HIV/AIDS services after conclusion of the program through provision of quality systems. DOD has been and will continue establishing a sustainable program by working with DFMS while improving infrastructure and equipment and implementing facility level quality assurance/quality improvement program and improved laboratory equipment systems.

The ZDF has 54 sites spread across the country most of which are in outlying areas. These facilities provide HIV/AIDS services including counseling and Testing, PMTCT, palliative care and ARV delivery, and HIV/AIDS laboratories to the ZDF, their families and vulnerable population living in these areas, which at many sites are predominantly civilians (non ZDF dependants) who rely on access to Defense Force Medical services (DFMS) for all routine clinical care. However inadequate staffing with trained medical personnel coupled with attrition impacts negatively on the overall HIV/AIDS service delivery. Often trained personnel are deployed on operations leaving inadequate staff at the health facilities to cope with the demand.

The ZDF established a School of Health Sciences with a view to train Military Medical Assistants to mitigate the impact of inadequate trained personnel. The initial enrolment capacity for the school was 24 students at a time which is not adequate to cope with the ongoing improvement of health facilities and the subsequent growing demand from the ZDF and the surrounding communities. Over the last few years, the Hostel facilities of the school were expanded by 30 rooms including furniture to increase the bed space to 84. Activities also included short term courses, workshops and twinning activities. Further expansion and construction additional classrooms, demonstration room, library, auditorium, computer room, offices, dining facilities and Kitchen and construction of the additional classrooms, demonstration room, library, auditorium, computer room, offices, dining facilities and Kitchen at the Defense School of Health Sciences.

The program will contribute to improved sustained overall HIV/AIDS service delivery in the ZDF in counseling and Testing, PMTCT, palliative care and ARV delivery, and HIV/AIDS laboratories through training of additional medical personnel and information sharing. Additional FY 2012 activities will focus on equipping the Defense School of Health Sciences, continued training through short courses, workshops and technical assistance efforts from the Defense HIV/AIDS Prevention Program (DHAPP). Capacity building efforts will revolve around leadership training and engagement with the ZDF; training of ZDF health providers in various HIV/AIDS courses.

Due its core strength the agency has been asked to support the Government of Zambia system strengthening efforts highlighted under the Global Health Initiative strategy developed. FY 2012 activities aim to mitigate poor HIV/AIDS health service delivery in other Ministries arising from poor health infrastructure and inadequate staffing:

1. Ministry of Health for renovations of the 5 training schools and recruitment of Clerk of works, improving staff housing through renovations2. Ministry of Home Affairs by renovating run down facilities.3. Ministry of Community Development Mother and Child Health to renovate and improve existing health infrastructure under the Zambia Agency for Persons with Disability (ZAPD) centers by including VCT facilities at Kangonga ZAPD Centre in Ndola, Linda ZAPD Centre in Livingstone and Fisenge Blind Centre in Luanshya.

In an effort to support national efforts to scale up male circumcision activities, the military program will also scale up its activities through programs implemented by its partners. The USG team in country is increasing its budget and activities to meet approximately 40% of the national targets. The ZDF is strategically located to provide VMMC due to the positioning of its health facilities. The DAO Office through DHAPP will support these efforts and facilitate for procurement of mobile tents, travel for DOD urologists to support high season campaigns and also procurement of surgical kits. This will go towards complementing and strengthening partner efforts to scale up and meeting the national targets. These funds will also go towards procurement of equipment such as surgical beds and minor renovation works required on site.

In the country plan, HIV prevention has been identified as priority. However lack of appropriate delivery facilities for expecting mothers in the Zambia Defense Force (ZDF) sites coupled with poor staffing and long distances to alternative referral centers have negatively affected HIV prevention through PMTCT. Generally infrastructure is poor and there is no accommodation for the facilities to be able to attract trained personnel. Most facilities have no running water, power supply and disposal facilities for bio waste.

Because of poor facilities and lack of privacy, most mothers are not keen to report for antenatal while those who can afford opt to report to distant referral centers. As a result the facilities have low antenatal HIV testing, unable to provide early initiation of treatment for positive mothers and post exposure prophylaxis during birth. The lack of proper facilities also results in low male involvement in couple testing while the long turnaround time for the dry blood spot (DBS) PCR results from alternative centers has also negatively impacted on initiation of treatment. The net effect of the poor infrastructure has been failure to comprehensively prevent mother to child transmission of HIV.

Improvement of infrastructure includes renovations of existing spaces to make them appropriate for deliveries and PMTCT service provision while expansion includes new construction to provide space for deliveries and PMTCT which will assist in scaling up the interventions to meet the needs for the ZDF, their families and communities living in the surrounding areas.

In FY 2010 with PMTCT plus up funds the ZDF identified 5 for expansion of the health facilities to include delivery facilities so as to enhance and improve prevention of HIV through MTCT. This included provision of equipment and training of staff by JHPIEGO

In FY 2011 while continuing to support the sites identified in FY 2010, 5 additional sites were identified for improvement and expansion of the facilities to include space for deliveries and PMTCT activities.

FY 2012 activities will focus on continuous strengthening of PMTCT facilities in the ZDF sites in outlying areas and monitoring performance of sites already improved. This activity will link to activities of PCI and JHPIEGO to ensure effective community sensitization and capacity development.

The DOD will further support improvement of PMTCT services on five (5) ZDF sites through improvement of existing facilities and expansion to provide appropriate space for deliveries and provision of equipment. Improvement will include renovations to infrastructure while expansion will include new construction to add appropriate space for PMTCT services.