During the fiscal year 2012, Chreso will support four sites in three provinces of Zambia. The Community based treatment services (CBTS) will comprise of HIV testing both onsite and mobile, out patient referrals, home based care, and support groups. Medical care will comprise both adult and pediatric prevention, care, support and anti-retroviral therapy (ART) services, TB and STI management, maternal child health (MCH) and early infant survival, training and professional development.Chreso will monitor retention levels by continuing regular updates of retention data by the use of Data Demand and Information Utilization (DDIU). In order to continue building and strengthening the capacity of the M&E team, Chreso will strengthen the current Continuous Quality Improvement (CQI) teams to have monthly plans that will create a sense of ownership to achieve the goals of the programs, train more members of staff in SmartCare (to encourage understanding of individual patient care). Chreso will also strengthen ties with other ART clinics and AIDSRelief to monitor those patients who are lost to follow.Chreso will also ensure that the health systems are strengthened in order to execute functions as expected by all stakeholders. Capacity strengthening will continue in the technical department, the programs department, finance and compliance and strategic Information. Chreso will continue to be a subscribed member with the National External Quality Assessment Scheme in all laboratory sections to ensure quality health care delivery through proper and effective diagnosis.

The activities proposed under the budget codes below will all be done in collaboration with AIDSRelief Zambia team.

Chreso will deliver quality comprehensive care to PLWHA by employing approved national guidelines. Chreso will provide psychosocial support to those on ART and pre-ART. Adherence counseling will be a very important component of care. Adherence to ARVs is crucial to a patients treatment success because nonadherence puts patients at risk of viral resistance to their current regimens. Chreso will ensure treatment preparation programs teaching on the importance of adherence, how to deal with side effects of ARVs, and how to maintain good nutrition to ensure medications work properly. Once they begin therapy, patients enter adherence support programs in which health workers, close friends, or family members also educated on ART conduct follow-up visits to see if the patient is taking his or her medication correctly, maintaining a balanced diet, and avoiding opportunistic infections.

Chreso will also refer patients to sources of socioeconomic support as well as referring for human rights and legal support to clients that will include PLWHA participation, stigma and discrimination reduction and succession planning. Chreso will also provide medical and nursing care in form of counseling and testing, preventive therapy, OI treatment and prophylaxis and some level of palliative care plus referrals. Chreso will expand patient education on HIV prevention; home hygiene interventions; and provision of basic health and OI prevention commodities. Chreso will strengthen management of pre-ART clients, ensuring appropriate monitoring, strengthen follow ups and retentionChreso will strengthen current referral networks for all types of patients, including: HIV expert consultation for complex patients and specialized counselors for pediatric adherence. Chreso will encourage clients in care to remain linked to the clinic so as to receive follow up CD4, and preventive health care and have an opportunity to join support groups. Chreso will provide training to health workers in collaboration with AR-T in standard didactic sessions using the national ART curriculum and on-site mentorship at sites by a multidisciplinary team of experienced HIV care providers and OI trainings.

Chreso will ensure that 100% of HIV-positive clients are screened for TB and fast-tracked to appropriate treatment using national guidelines if co-infected and are provided with co-trimoxazole prophylaxis, entering the ART system if they are positive. Chreso will continue to strengthen TB diagnosis based on sputum examination quality TB/HIV testing and treatment services and through TB and TB/HIV messages used for outreach, delivered via community gatherings such as drama programs, government-supported public address systems, and information, education and communication materials. Chreso will conduct quarterly meetings with TB treatment supporters and provide technical support supervision to volunteers who will support patients on treatment and refer community members and adult patients with a chronic cough, fever, or other TB symptoms to facilities.

Chreso will enhance laboratory capacity for TB diagnosis; sputum exam, LED microscopy and facilitate prevention of nosocomial infections among health care workers; strengthen referral linkages between Chreso facilities and the government TB (DOTS) sites. As part of the TB/HIV component, Chreso will include nutritional assessment. And for those with TB, their families will also be tested through contact testing and family case finding.

Chreso will ensure that laboratories and other work areas are conducive for infection prevention and control while ensuring that personnel in the laboratories have sufficient trainings provided in collaboration with AR-T. This collaboration will also see other health workers receive trainings in case detection with prompt treatment and screening. These trainings will also ensure that health workers are trained in the new management of TB/HIV co-infection through MOH approved guidelines.Chreso will also be working to strengthen linkages with other organizations and District Health clinics that are providing care to TB patients. These linkages will be useful for conducting Quality assurance and quality improvement activities and ensure that feedback is given. Chreso will also collaborate with DHMT in areas of MDR-TB surveillance while advocating to be attending TB MDR data review meetings.

Chreso will deliver quality comprehensive care to HIV positive children not yet on ART, to those initiating ART and to those already on ART by employing approved National Guidelines. Chreso will provide Psychosocial Support to clients, both on ART and pre-ART for them to access quality counseling, spiritual support, follow-up counseling and community support. For those on ART and those about to start ART, adherence counseling will be a very important component of care. Chreso will ensure that patients adhere to therapy. Adherence to ARVs is crucial to a patients treatment success because nonadherence even taking less than 95 percent of the medication puts patients at risk of viral resistance to their current regimens. Once individuals are determined through clinical evaluation to be eligible for ART, they will enter treatment readiness programs. These programs educate patients/ caregivers on the importance of adherence, how to deal with side effects of ARVs, and how to maintain good nutrition to ensure medications work properly. Adherence to ARVs is often challenging because the side effects. Chreso will in collaboration with AR-T train healthcare providers in child and adolescent counseling and will ensure that counseling for infants, children, adolescents and their families is available. Chreso will ensure prompt infant diagnosis, treatment and follow up according to National Guidelines and will use the family centred approach for continued care. Chreso will ensure that Nevirapine and Septrin prophylaxis is given according to National Guidelines and that infant feeding options are clearly given to the mothers. Chreso will also ensure growth monitoring and nutritional assessment at each visit and will ensure that immunizations are upto date. Chreso will link mothers to Insecticide Treated Nets and malnourished children to programs that provide nutrition and also teach basic home hygiene and prevention of diarrhea.

Chreso will ensure that all sites laboratories have more reliable energy sources, MOH-approved equipment, and personal protective equipment. Standard Operating Procedures Manuals (SOPs) (according to national guidelines) for equipment maintenance, cleaning, and personal safety will be updated, governing workload management, and suggesting safety and hygiene for appropriate specimen collection areas and infection prevention and control.

Chreso will improve site laboratory capacity through linkages to Chest Diseases Laboratory. Using the MOH laboratory training manual Chreso, in collaboration with AIDSRelief Transition, will train both professional and lay staff in HIV testing to facilitate task shifting, as well as to build the capacity of laboratory assistants and technologists to 1) apply good clinical practices for diagnostic quality and infection prevention; 2) conduct hematology and chemistry tests, CD4 counts, TB diagnostics including conversion from conventional to WHO recommended acid fast bacillus and fluorochrome acid microscopy, and tests for other OIs, including cryptococcal meningitis and malaria; and collection and storage of samples for EID. We will also ensure that transport is available for transportation of specimen to reference laboratories. Chreso has had a Cavidi viraload machine installed at its Lusaka site which AIDSRelief-T will be conducting at the site in collaboration with Chresos own staff.

Chresos current laboratory capacity has passed all accreditation requirements. Additional capacity would a) enhance scale up requirements and participate in the national External Quality Assurance (EQA) program; b) establish and strengthen a Quality Assurance (QA) program for local laboratories; c) improve supply chain management; and d) facilitate online capacity by improving the laboratory management information systems (LMIS).

Chreso, with AR-T, will train and mentor laboratory managers in management skills, and decentralize Technical Assistance (TA) by preparing laboratory staff to provide quarterly TA, mentoring, and supervisory roles within sites. Chreso will provide continuous professional development through trainings to help laboratory staff maintain individual certifications.

Chreso Ministries will guarantee that all facilities have trained staff, adequate equipment to manage SmartCare. Chreso Ministries will collaborate with AIDSRelief Transition (AR-T) to ensure implementation of a monitoring and evaluation system for valid, accurate and timely reporting. Thirsty LTPF staff will be trained and certified In SmartCare. Chreso Ministries will ensure that all sites have CQI/DDIU commodities that will synthesis aggregate quarterly reports for evidence based decision making and programme guidance. Chreso will conduct periodic data reviews to ensure and guarantee good quality data capture and analysis throughout the project lifespan. Chreso will produce monthly, quarterly, semi-annual and annual progress reports as required by MoH and CDC. At national level, Chreso will participate in M&E technical working groups. Chreso will collaborate with AR-T for the handing over of sites and technical support to staff LTPF in the first and second year of the programme award. Chreso Ministries will collaborate with PHOs and DHMTs for better program management at local levels.

Chreso will continue working with AR-T to enhance its organization systems and those of Chreso sites. Chreso in collaboration with AR-T will administer the Site Capacity Assessment tool and the Holistic Organizational Capacity Assessment tool to identify gaps. Chreso will address the identified gaps to strengthen systems at HQ and site level. Chreso will continue its partnership with AR-T, CDC, and the GRZ to strengthen project Clinical Oversight, Strategic information, Grant Management as per USG compliance regulations and Supply chain. Chreso will train relevant staff to provide technical assistance and onsite mentoring. These will serve as start up activities necessary for a phased out transitioning exercise.

Chreso will escalate new information in HIV treatment in partnership with AR-T Zambia and according to national treatment guidelines to all clinical and medical staff for better service delivery. Chreso will continue with regular meetings for training, and compliance related updates. Refresher courses and training opportunities shall be provided to staff at HQ level and site levels.Chreso will continue working with the MoH of health taking advantage of the already signed Memorandum of understanding to advocate for MoH supported medical and clinical staff as occurs in other faith based institutions.

Chreso will collaborate with national training institutions willing to utilize Chreso facilities for training and exposure of clinical and nursing staff to practical ART service provision skills for an enhanced and better skill base in line with the sixth national development plan that highlights the need for improvement of the availability and distribution of qualified health workers in the country. Chreso will train Community health workers in adherence and patient follow up, counseling, patient monitoring, and reporting for HBC efficiency.

Chreso will continue the promotion and provision of male circumcision in all its sites and use community based educational programs, and gender sensitive messages developed by AIDSRELIEF Zambia about the benefits of MC and service locations, provided in local languages. Chreso will start by renovating the existing infrastructure, and building capacity of the clinic staff and community health workers; to ensure acceptance, stronger community participation through community mobilization and sensitization. To avoid stigma and encourage speedy of services, Chreso will integrate MC services as part of routine health services and create linkages between HIV prevention, MC, HIV CT and ART sites and a strong referral system for those testing positive for early access to ART services.

Chreso will ensure that in order for MC activities to succeed, an effective management system will established to oversee the provision of these MC services and ensure that necessary medicines, supplies, equipment, and environment at the facility are available for providing safe MC services of good quality Qualified and competent providers are availableInformation and education on HIV prevention and MC provided to clients. Chreso will use single use needles, and where instruments such as scalpels are used, there will be an autoclave machine at each site to sterilize such instruments in order to prevent and control infectionsChreso will continue to regard Monitoring and evaluation as an important component of every activity and hence, MC will be subjected to thorough documentation and record keeping and reporting.

Chreso Ministries will continue to use disposable single use syringes and needles. Chreso will promote the use of safety boxes as part of infection control. Chreso will, in line with the National Guidelines, also continue to promote and implement the PEP policy guidelines. In order to ensure Commodity security, Chreso Ministries will continue to access single-use syringes and needles, lancets and blood drawing equipment, safety boxes, gloves, and other accessories through the Ministry of Health supply chain pipeline managed by Medical Stores of Zambia.Chreso will strengthen the activities of the infection control teams as a way of Integrating of injection safety and waste management into HIV services.

Chreso will strengthen community based treatment support (CBTS) through community sensitization as well as build capacity for community based treatment through trainings, skill building, role plays, drama, and community action plan development. Chreso will promote delay of sexual debut or secondary abstinence, fidelity, partner reduction and related social and community norms as part of a balanced prevention message approach, with elements of abstinence and be faithful programs done in tandem with condom social marketing where appropriate.

Chreso will intensify HIV prevention services targeting young people through youth based life-skills training, and promotion of overall Adolescent Sexual Reproductive Health services.Chreso will have deliberate activities targeted at the most at risk people (MARPS) such as transportation workers, uniformed servicemen and other vulnerable individuals and groups including victims of rape/abuse, prostitutes and children. Chreso will also conduct monitoring and evaluation activities in the community by having quarterly meetings to strengthen relationship with the community. Chreso will continue to strengthen partnership and linkages with other organizations offering preventive care in the district by attending monthly and quarterly meetings for District AIDS Task Force and District Referral Network Associations and encouraging partner notification through disclosure of HIV results by educating communities and couples seeking counseling and testing services. Chreso will strengthen its position of advocating for abstinence for the unmarried and its benefits as one way of prevention while respecting and supporting other preventions as well.

Chreso will consider counseling and testing as a key component of the entire program. Strategies will include PITC, VCT, couples and family testing, mobile CT, door-to-door CT, and PCR for early child diagnosis. In the fiscal year 2012, Chreso will utilize PITC across all entry points and particularly to reach women outside ANC clinics, and additional effort will be given to support women tested in MCH clinics for improving access to longer-term HIV services. In addition, we will test family members of patients in care through targeted community based testing. Chreso will ensure that HIV counseling and testing is offered and available to all patients and will also ensure that appropriate HIV testing techniques and approaches that meet required national standards are utilized. Chreso will strengthen and support VCT as an integral component of HIV/AIDS/STI/TB prevention, control and care as well as support appropriate training in VCT in collaboration with AR-T. Chreso will continue to make use of the available VCT guidelines for children, including disclosure and will promote community-based and family-based counseling and testing. Chreso will use existing guidelines for peer educators and counselors trainings. To ensure commodity availability, Chreso will ensure timely forecasting, quantification, procurement and distribution of HIV test kits.

To increase the uptake of CT, Chreso will continue to use onsite VCT, PITC and mobile CT in rural areas and prisons. Chreso will ensure those clients that test negative be reviewed after 3 months and through the family centred approach will be tracked and followed by the CBTS teams.

Couple counseling and testing will be a major component of both family based testing and PITC. Testing only one partner in a couple does NOT result in HIV risk reduction. Couples Counseling and Testing (CCT) decreases transmission of HIV within discordant couples. CCT has been proven to be an effective, important strategy in the prevention of HIV and leads to increased condom and long acting contraceptive use and reduction in HIV transmission, sexually transmitted infections (STIs), and unplanned pregnancies.

Chreso will continue its strategy of conducting mobile couple counseling testing clinics targeted at Neighborhood Health Committee zones and targeted community referral points, during which males are encouraged to be involved in PMTCT programs by accompanying their partners to antenatal care clinics. Chreso will also establish a couple counseling testing program targeted at community events E.g. World VCT day, International Womens Day, Lab our Day. During all these events awareness talks on partner disclosure and notification in homes will be conducted through public address and distribution of Information, Education and Communication materials. In working with AIDSRelief, Chreso will ensure that counselors are trained in couple counseling and program design.

Chreso will run community activities and trainings in collaboration with AIDSRelief-Transition (AR-T) to promote abstinence, including delay of sexual activity or secondary abstinence, fidelity, partner reduction and related social and community norms as part of a balanced prevention message approach, with elements of abstinence and be faithful programs done in tandem with condom social marketing where appropriate.Chreso will intensify HIV prevention services targeting young people through youth based life-skills training, and promotion of overall Adolescent Sexual Reproductive Health services.

Chreso will improve the care and treatment of STIs by improving STI diagnostic and management capacities and strengthen community education on STI prevention, partner notification and treatment compliance. We will train health workers from the facilities in syndromic management of STIs. The trainings will be according to National Guidelines.Chreso will have deliberate activities targeted at the most at risk people (MARPS) such as transportation workers, uniformed servicemen and other vulnerable individuals and groups including victims of rape/abuse, prostitutes and children.

Chreso will, in collaboration with AR-T, train CHWs and support integration of issues of gender violence into HIV community prevention activities with PLWHA support groups, home visits and counseling sessions. Chreso will engage male community leaders to mobilize men in behavior change activities opposing domestic violence. Chreso will further link with other programs such as YWCA and Victim Support Unit (VSU) addressing cultural norms which engender male violence against women. Chreso will care for its health care providers by following National Guidelines on issues of post exposure prophylaxis (PEP) and will ensure psychosocial care is provided as well.

Chreso will sensitize communities on the dangers and effects of alcohol and drug abuse in relation to ART. Chreso will further strengthen linkages with other organizations, like DEC, Alcohol and Drug abuse department in Chainama College, the City Council and have regular meetings in relation to prevention of drug, alcohol and other substance abuse in the community.

CHRESO will continue to scale-up PMTCT services building upon the work that was done during year one of this grant as outlined in COP11. Based on the MOH national protocol guidelines and PMTCT scale-up plan, CHRESO will implement programs intended to contribute towards the countries attainment of the HIV MTCT elimination goal by reducing the proportion of HIV exposed babies becoming infected to <5%. In order to achieve this, CHRESO will focus on optimizing the quality of PMTCT services whilst sustaining coverage of HIV counseling and testing within its ANC services at 95% and above. CHRESO will provide CT across all entry points to integrate HIV prevention, care and treatment services, including maternal and child HIV care and PMTCT, family-centered services with partner and family testing as part of treatment expansion. Chreso plans to ensure that 75% of its primary level facilities have integrated ART and PMTCT services by end of the COP12 period. This is expected to result in at least 80% of HIV+ pregnant women receiving a complete course of efficacious ARV regimens as per National guidelines. By the end of the same period, CHRESO will work towards implementing integrated Family Planning and CT services for prevention of pregnancy for all HIV+ and those of unknown status in up to 70% of its HIV CT facilities. As part of efforts to establish a complete four pronged PMTCT program, CHRESO will continue to scale-up integrated youth friendly sexual and reproductive health service delivery with PMTCT to reach 20% of its supported facilities as a strategy for primary prevention of HIV. To ensure that quality of services is improved and all targets are met, CHRESO will delivery supportive supervision and mentoring on a quarterly basis to 100% of its supported sitesAs a critical component for attainment of the elimination goal, CHRESO will implement evidence based interventions aimed at curtailing the huge loss-to-follow up and will target to retain no less than 65% of mother-baby pairs in care and treatment services including EID up to 18 months postpartum; and for Nevirapine prophylaxis in breastfeed babies up to cessation of all breastfeeding.Based on the new evidence regarding treatment as prevention and the known additional risk of MTCT incident HIV infection in pregnant women, CHRESO will implement interventions intended to ensure that >80% of ANC attendees receiving couple counseling, testing and receiving their results, with 100% of HIV+ partners linked to treatment programs.

Treatment at all levels will be provided in collaboration with AIDSRelief who will be doing technical support with Chreso. Chreso will use the recently approved new National Guidelines in the management of HIV/AIDS for its clients. Chreso will provide laboratory investigations to clients that are eligible for HAART and for continuous monitoring. Chreso will also ensure the appropriate management of side effects of ARVs and in collaboration with AR-T will ensure continued onsite mentoring and training of its staff using MoH packages in the management of ART and OIs and other refresher courses. Chreso will also use monthly clinical meetings as a way of keeping its staff updated on current HIV/AIDS management issues. Chreso will also ensure that clients are reviewed by trained personnel and clinical follow up appointments are given to them.Chreso will further conduct nutritional assessment for all clients before commencement of ART for appropriate nutritional interventions and will facilitate training of health care providers on how to conduct nutritional assessments and refer those who are malnourished to appropriate services. Chreso will ensure that clients are adherent to their medication by giving them regimens that are simple but effective and also ensure that clients do not miss their appointments by actively following them. Chreso will also ensure that psychosocial support is available and will link the clients to organizations that give specialized psychosocial support.

Chreso will use the recently approved new National Guidelines in the management of paediatric HIV/AIDS for its clients. Chreso will provide laboratory investigations to clients that are eligible for HAART and for continuous monitoring. Chreso will also ensure the appropriate management of side effects of ARVs and in collaboration with AR-T will ensure continued onsite mentoring and training of its staff using MOH paediatric packages in the management of ART and OIs and other refresher courses. Chreso will also use monthly clinical meetings as a way of keeping its staff updated on current paediatric HIV/AIDS management issues. Chreso will also ensure that clients are reviewed by trained personnel and clinical follow up appointments are given to them.Chreso will further conduct nutritional assessment for all clients before commencement of ART for appropriate nutritional interventions and will facilitate training of health care providers on how to conduct nutritional assessments and refer those who are malnourished to appropriate services. Chreso will ensure that clients are adherent to their medication by giving them regimens that are simple but effective and also ensure that clients do not miss their appointments by actively following them. Chreso will also ensure that psychosocial support is available and will link the clients to organizations that give specialized psychosocial support. Chreso will strenghthen linkages at all levels namely PHO, DHO and HQ to ensure that there is a constant supply of testing kits e.g. DBS bundles and to ensure that updates on current Pediatric ART information is obtained through the District. Chreso will also collaborate with MOH including participation in different technical working groups.