The Zambian Educational Partnership for Advanced Care and Training (ZEPACT) is a collaborative effort led by the University of Zambia School of Medicine (UNZA-SOM) in partnership with the University of Maryland (UM), Centre for Infectious Disease Research Zambia (CIDRZ), University of Alabama (UAB), and Vanderbilt University. ZEPACTs primary objectives address 3 main areas: 1) Training healthcare workers and community health workers in HIV care and treatment, 2) Improving clinical care for complex HIV patients and 3) Strengthening HIV drug resistance surveillance (HIVDRS) in Zambia. Using COP12 base funds, HIV specialty training will include continuation and enhancement of ongoing Masters-level training for doctors, to be strengthened by a new program to send up to two(2) UNZA-SOM/UTH faculty to UM for short term clinical attachments. The Lusaka Advanced Treatment Center (ATC) will continue to serve as a training center for advanced HIV care while providing treatment for complex HIV patients. The implementation of ZEPACT programs will incur additional costs from year 1 related to increases in personnel and resources for: 1) the new diploma-level HIV training program which will begin enrolling nurses and clinical officers; 2) expansion of the HIV nurse provider training program into all 9 provinces; 3) enhancement and expansion of the HIV mentors program; 4) provision of training and mentoring for HIV-specific components of the MOH Community Health Worker program; 5) development and resourcing of two additional ATCs in Ndola and Livingstone based on the model of the new Lusaka ATC; and 6) significant expansion in the ability to process HIV resistance testing and compile both primary and secondary resistance data for the HIV DRS.

The Advanced Treatment Centers in Lusaka, Livingstone, and Ndola will be responsible for the care and treatment of complex HIV positive patients, most of whom will require testing for virologic failure and antiretroviral resistance. Viral load and genotype testing will be conducted at the Pediatric Center of Excellence (PCOE) laboratory at UTH, with support from the CIDRZ research laboratory. The viral load and genotype test results will be entered into the HIVDRS database. The cost for improvements to the resistance assays and for the general infrastructure upgrades are incorporated into the HTXS and HSS budgets.

During year 1 ZEPACT personnel will have been incorporated with the active Ministry of Health (MOH) HIVDRS working group and developed plans for synergies and priorities. During year 2 ZEPACT will support the strategy established for primary HIV resistance sentinel surveillance by the CDC and WHO. ZEPACT will also support the establishment of HIV Resistance laboratory testing capacity, as described above, and linkage of the data to the HIVDRS program. Critical to the management of HIV over the next decade will be a comprehensive understanding of the resistance implications from first and second line treatment failure and the effectiveness of third line regimens based on the detected resistance patterns. The linkage of the ATC and the HIVDRS program will be critical for the development of this information and incorporation into a data base that allows high level analysis. The quality of laboratory resistance testing will be essential to reliable data sets, and significant investment in internal and external quality control systems will be developed. With expanded needs at the ATC for resistance testing there will be increasing needs for qualified trained laboratory personnel.

National HIV medical experts/MSc in HIV Medicine: The training of highly skilled HIV specialist medical officers will continue as in Year 1 as UNZA-SOM capacity is built through the secondment of Infectious Disease faculty for training purposes and introduction of UNZA faculty participation in the International Physician Exchange Program through UM. Yearly curricula revision will continue. The MSc HIV Med graduates will provide clinical leadership at new Advanced Treatment Centers (ATC) and MSc candidates will receive increasing mentorship at the ATC for advanced training. Eight doctors and will be enrolled in the second year. By the end of year two, 40% of training responsibilities for the MSc HIV Med course will be provided by local faculty.New Diploma/MSc HIV Care Program for Nurses and Clinical Officers: During Year 1 MSc HIV curricula was revised and approved by UNZA. In the second year, the adapted MSc curriculum for training of Nurse tutors and clinical officer lecturers will be implemented. Four nurse tutors and two clinical officers will be enrolled in the Diploma/MSc course in HIV Medicine at UNZA. Working in conjunction with General Nursing Council and Chainama College will build sustainability in the goal. The training of nurse tutors and clinical officer lecturers will ensure that appropriate HIV instruction is integrated into the pre-service training of nurses and clinical officers in Zambia.Revision, Expansion, and Transition of HIV NP program: During Year 1 the program coordinator has evaluated the existing program and consulted with key stakeholders including MOH, GNC, and other partners to identify sites for program expansion. In year 2 ZEPACT will train a total of 60 NPs 15 at Lusaka School of Nursing, 15 at UNZA SOM, and 15 at each of 2 Enrolled Nursing schools identified in Year 1. Training will consist of an initial 6 week NP training, followed by 10 months x32 hours per month of in-situ mentorship in their respective HIV clinics and 5 days of intensive mentoring every 3 months at a provincial ART clinic. The training of the mentors will be integrated into the HIV mentorship program described below. During year 2, if funding is available, ZEPACT will assume primary financial and administrative responsibility for the continuation of the Nurse Prescribers program to build this essential cadre of health care providers for effective and quality ART service delivery.Development of qualified HIV mentors for provision of training in HIV care and treatment:In year 2 an additional 8 new clinical mentors will be trained. A needs assessment for the program will be conducted in conjunction with the MOH to determine continuing training needs. The MSc HIV Med and (MEPI-sponsored) MMED-ID programs will incorporate training modules on clinical teaching and mentoring so that those graduates can be incorporated into the mentorship program. Mentoring of 200 health care providers will take place at clinical sites. Review and revision of consensus performance indicators for quality improvement in partnership with the MOH and CDC SmartCare team will occur yearly.

The University of Zambia School of Medicine, will continue to contribute towards the acceleration of the Ministry of Health (MOH) prevention of mother-to-child transmission (PMTCT) program specifically through human resource capacity development for improved quality and coverage of PMTCT services. UNZA SOM will implement one-off activities intended to increase the out-put rate of trained nurse prescribers.

The provision of quality care for patients with advanced treatment failure and complex HIV related disease will be required as the number of ART experienced persons increases with a maturing epidemic in Zambia. Mishandling of these patients could undo years of careful planning to support a manageable HIV care and treatment program in Zambia. During year one the first model Advanced Treatment Center (ATC) will be opened at UTH in Lusaka. In the second year of the grant, the ATC opened in Lusaka in the first year will continue to operate. An expected 500 patients will be cared for in the Lusaka ATC. In addition, two new sites will be opened in Ndola and Livingstone. The Ndola ATC will be expected to have 250 people in care and the Livingstone ATC will be expected to have 250 people in care. MSc HIV students will spend at least 4 weeks per year on rotation through an ATC, and nurse and clinical officer tutors enrolled in the Diploma/MSc HIV Care course will also spend 4 weeks rotating through an ATC. MMED-ID students will spend 4-8 weeks each year rotating through an ATC, and clinical medical students will spend at least 2 weeks with exposure in the ATC. The supervision in the ATC for these cadres will be from ID Specialist, HIV Specialist, or designated UNZA-SOM faculty. During year 2 additional ATC will become operational in Ndola and Livingstone, and data collection integrated into the National program. The opening of these centers will require the addition of an HIV Specialist, Nurse Prescriber, and advanced Community Based Treatment Specialist full time at each site, plus an office to support their activities. Significant cost for providing care in ATC will be required for resistance testing and increased viral load monitoring. The ATC will also be responsible for addressing complex OI treatment issues resulting in diagnostic laboratory studies outside the normal scheme. Results of resistance testing will be provided to the HIV Drug Resistance Surveillance program for the development of a comprehensive HIV drug resistance data base. The ATC in Ndola will be closely aligned with the Copperbelt University medical school, which is supported by the UNZA SOM through the MEPI initiative. The ATC in Livingstone will be aligned with the ongoing UNZA MEPI activities at Livingstone General Hospital as well as existing CIDRZ support for adult HIV treatment.