This mechanism includes both tuberculosis and neonatal male circumcision activities. In FY 2012 CIDRZ TB program will build on the progress in FY 2011 to reduce TB morbidity and mortality by improving diagnosis and co-management of TB and HIV in co-infected patients and decrease the spread of TB, particularly in HIV clinics. Overall TB program goals are to:1. Improve clinical screening, TB case detection, and management of TB/HIV co-infected patients in HIV, TB, outpatient, and maternal-child health clinics and strengthen linkages to HIV care and other programs.2. Improve TB diagnostic capacity through improved microscopy services including smear quality assurance and supervision of specimen referral systems.3. Support infection prevention/control activities though training and provision of IPT.4. Provide technical support to the Zambian MOH TB program and support its surveillance and training initiatives.5. Improve community knowledge of and demand for TB screening and HIV testing through outreach activities.Zambia, with high HIV/AIDS burden 14.3% but low MC adoption rates 13% (Zambia DHS, 2007) has been selected by WHO to expand MC service delivery. The Zambian MOH issued a national implementation plan, with goals to reach 80% uptake of Neonatal Male Circumcision (NMC) by 2020 (Zambian Ministry of Health, 2009). Between 2008 and 2011, CIDRZ conducted a PHE to determine the acceptability, feasibility, and acceptability of NMC in Zambia. The PHE showed that NMC was safe and highly acceptable with rates of more than 90%, however, service uptake was only 11%. The overall goal of the CIDRZ NMC Program is to provide technical assistance and support to the GRZ to implement the scale-up of NMC in Zambia with that target of 80% uptake of NMC by 2020.

CIDRZ TB program has adequate staff to carry out the proposed activities which will be sustained through skills transfer to MOH staff. Activities of this project will include:1. Improve clinical screening, TB case detection and management of TB/HIV co-infected patients:a) Clinical training and mentoring in the diagnosis and management of TB including chest x-ray interpretation, and intensified case finding for 110 district and prison health staff. Train district staff to become mentors in TB screening, diagnosis and management as part of the transition of activities. We will also provide mentoring to district staff on the monitoring and evaluation of TB screening and diagnosis in HIV care settings.b) Scale-up integration of TB screening into antenatal clinics to a further 3 clinics in Lusaka District based on the 2011 pilot evaluation.c) Scale-up integration of ART provision into TB corners to a further 3 clinics in Lusaka District based on the 2011 pilot evaluation and support linkages to long term HIV care through referrals.d) Facilitate HIV diagnosis in TB patients we will continue to support Peer Educators that conduct HIV counseling and testing and provide training in provider initiated testing and counseling (PITC) for 50 new health staff.e) Build capacity in MOH staff to supervise the PITC program through training as trainers for 30 district staff in our target districts and continue supporting semi-annual data review and TB/HIV coordinating body meetings.2. Improve TB diagnostic capacity:a) Continue quarterly support for the national quality assurance system in Southern and Western Provinces.b) Continue supervision of the referral systems through supportive visits in each of our target districts.3. Support MOH-led initiatives:a) Train 50 health workers in the Infection Control guidelinesb) Train 75 health workers in the IPT guidelines and management in collaboration with the HIV program4. Support the national MOH TB program:a) Support the HIV program in the provision of guidelines on IPT provisionb) Participate in national guideline review committees and other national TB/HIV coordinating body committeesc) Provide technical support to our target districts through supportive supervision meetings5. Improve community knowledge and demand:a) Continue community sensitizations through meetings with community leadersb) Conduct evaluations of the impact of the community TB interventions

Traininga. Support development of guidelines and training programs for NMC. To date CIDRZ has supported the GRZ to adapt the WHO NMC training manuals to national standards; we plan to finalize development of the adapted manuals in FY 2012. This will ensure standardization, quality and coordination of in-service training.b. Our already established experienced team of trainers will conduct training for:- 25 health workers in NMC surgical skills- 50 lay persons in NMC counseling skills- 50 health workers in NMC benefits, risks, post-operative care and management of complicationsAs such, facility capacity will be built and the health system strengthened. This will positively impact our FY 2012 targets through increased capacity of health workers to perform high quality NMC.c. CIDRZ will support sites with non-consumable supplies for NMC.

The Objectives and Activities of the CIDRZ NMC program include:1. Scale-Up NMCa. Recruit 2 additional dedicated NMC providers to perform NMC, train providers in the public sector and provide support supervision at our sites in order ensure maintenance of high quality services.b. Increase accessibility of NMC services by increasing the NMC sites from the current seven (UTH, Matero Reference, Chipata, George, Kanyama, Kafue, and Chongwe (the last two to be started by the end of FY 2011)) to a total of 10. Three clinics will be started in Copperbelt (Two) and Eastern (One) provinces. Kafue and Chongwe clinics will be run as monthly mobile outreach sites.c. Perform at least 3,000 neonatal circumcisions.d. Monitor and evaluate the NMC scale-up program and provide technical guidance to GRZ on potential scale-upe. Continue to use peer educators for demand creation and follow up of clients missing their review dates; in this regard, hire 6 more peer educators to cover the proposed new sites.2. Enhance community awarenessOur experience has shown that cultural issues are a major barrier to uptake of NMC; as such for FY 2012, community sensitization will be key to improving NMC uptake and eventual program success.a. Participate in annual GRZ campaigns to promote NMC, including child health weeks and national male circumcision campaignsb. Hold meetings with neighborhood health committees, community-based organizations, community leaders to gain program acceptance from the community, dispel myths about NMC, improve community awareness, and build NMC demand.c. Print and distribute Information, education, and communication (IEC) materials tailored to address community concerns.d. Pilot integration NMC sensitization activities in MNCH activities in order to enhance referrals, increase demand, improve retention, and offer a comprehensive package of prevention services to clients. This integrated model may not be applicable to all sites and locales; it will work best where NMC and MNCH clinics are co-located.e. Continue to use peer educators for demand creation and follow up of clients missing their review dates; in this regard, we shall hire 6 more peer educators to cover the proposed new sites.