Sustainability Through Economic Strengthening, Prevention, and Support for Orphans and Vulnerable Children, youth and other vulnerable populations program (STEPS OVC) is a three-year USAID-funded grant from July 2010, providing standardized and sustainable HIV prevention, care, and support services, through seven organizations: Africare, CARE International, Catholic Relief Services (CRS), Expanded Church Response (ECR), the Futures Group, The Salvation Army (TSA) and World Vision International (WV)-lead partner. In FY 2013, STEPS OVC will scale up quality, comprehensive care and support to 320,000 orphans and vulnerable children (OVC) and 115,000 people living with HIV/AIDS (PLWHA), reach 50,000 individuals with confidential HIV counseling and testing (HCT) services, and 26,000 households with economic strengthening initiatives. Evidence-based HIV prevention interventions will reach 80,000 beneficiaries. By June 30, 2011, STEPS OVC had provided at least one service to 96,700 adults and children at household by 13,849 trained caregivers. The program will scale up direct HCT services and coordination with PMTCT, ART, MCH, and other social protection programs. STEPS OVC has sub-granted to 244 Zambian non-governmental organizations to expand local capacity and geographic coverage to all 73 districts, and will add another 157 local partners in FY 2012. STEPS OVC will address recommendations from the baseline evaluation report and the data quality assessments and map the way forward for country ownership by finalizing memoranda of understanding with GRZ offices. New opportunities for public-private partnerships will complement the consolidation and transition process.

STEPS OVC program will provide 115,000 PLWHA with comprehensive care and support, including 10,815 adults reached by 30 June 2011. Identification of beneficiaries will occur through home based care, positive living support groups and health facilities, with emphasis on linkages with PMTCT and ART clinics and expanded access to HCT. STEPS OVC will strengthen referrals between the health facilities and the community caregivers. At the same time, follow up of clients from ART and PMTCT clinics at community level while they are encouraged to maintain check-ups at the health facility. This should contribute towards client retention. Currently, 70% of caregivers are registered at health facilities to ensure caregiver training and provision of quality care and support within MOH guidelines.

Caregivers will provide comprehensive care for asymptomatic, symptomatic, and end-of-life beneficiaries in line with MOH home based care standards. Services include physical, social, psychological, spiritual, and pain management care. Caregivers will provide nutrition assessment, counseling, and support, with improved community-to-clinic level referral of malnourished beneficiaries and linkages to economic strengthening initiatives. Linkages with health structures and community support will strengthen the continuum of care for PLWHA, including HCT for the chronically ill, positive living groups, ART programs for cluster of differentiation 4 (CD4) monitoring and treatment, and hospices for end-of-life care.

Caregivers will hold household dialogues in prevention, including partner disclosure support, adherence counseling, and PMTCT education. STEPS OVC will support government adaptation of prevention with positives toolkits, and will collaborate with ZPI to cascade new prevention interventions reaching PLWHA.STEPS OVC will collaborate with the Palliative Care Association of Zambia (PCAZ) and the MOH to transfer responsibility for caregiver capacity building to local owners, and will pilot client kit distribution in specific districts.

STEPS OVC will monitor and evaluate service provision through a standardized client database as well through routine field visits to provide supportive supervision.

STEPS OVC program will provide 320,000 OVC with comprehensive care and support, including the 85,885 served with at least one service by June 30, 2011. Identification of HIV-positive children will occur through home based care and linkages with PMTCT, ART clinics, referrals for early infant diagnosis, and expanded access to HCT.

STEPS OVC will transfer responsibility for caregiver capacity building to local owners. STEPS/OVC will procure about 2500 bicycles to strengthen the capacity of caregivers and community welfare assistant committee's working with OVCs. Caregivers have been trained in Child Status Index (CSI), Say and Play, Interpersonal Psychotherapy for groups and will continue to provide six components of OVC care and support (education, health, shelter and care, nutrition, child protection, psychosocial care, and economic strengthening), and hold household dialogues in prevention. Caregivers will use the Child Status Index tool to assess vulnerability and will provide nutrition assessment, counseling and support, and improved community-to-clinic level referral for all and especially malnourished children. Specific districts will scale up Positive Deviance [PD] Health.

Linkages will broaden comprehensive support to OVC, including ART programs for care of HIV-infected OVC and legal services for child protection. STEPS OVC will continue to share successes, lessons learnt and best practice through the program technical working group as well as through the USG Care and Support Technical Working Group. STEPS OVC will work with GRZ to reach at-risk youth through youth friendly health corners and resource centers. Collaboration with ZPI will address HIV-prevention needs of vulnerable populations, including the well to do, and will strengthen gender-sensitive OVC programming. STEPS OVC will take part in finalizing standards for OVC care in Zambia for adoption by GRZ.

Sub-grantees will ensure that beneficiaries receive OVC services integrated with basic care and support through direct service provision and by maximizing partnerships. They will lead economic strengthening initiatives to strengthen capacity of households to protect and care for OVC. In order to mitigate the impact of HIV/AIDS and increase access to basic education, STEPS/OVC will provide tuition, educational supplies and other materials for OVC living in 1000 elderly-headed households and train at least 600 OVC in life skills and HIV issues.

STEPS OVC program will provide comprehensive care and support to 20,000 children. Identification of beneficiaries will occur through home based care, positive living support groups and health facilities, with emphasis on linkages with PMTCT, referrals for early infant diagnosis and ART clinics and expanded access to HCT. OVC will be eligible for services prescribed within PEPFAR OVC Guidance of education, health, shelter and care, nutrition, child protection, psychosocial care, and economic strengthening according to need. HIV positive children will also be included in the Interpersonal Psychotherapy for Groups program.

STEPS OVC will strengthen referrals between the health facilities and the community caregivers. At the same time, follow up of pediatric clients from ART and potential clients through PMTCT clinics at community level will occur along with encouragement to maintain check-ups at the health facility. This should contribute towards client retention.

Currently, 70% of caregivers are registered at health facilities to ensure caregiver training and provision of quality care and support within MOH guidelines. Caregivers will provide comprehensive care for asymptomatic, symptomatic, and end-of-life beneficiaries in line with MOH home based care standards. Services include physical, social, psychological, spiritual, and pain management care. Caregivers will provide nutrition assessment, counseling, and support, with improved community-to-clinic level referral of malnourished beneficiaries and linkages to economic strengthening initiatives. Linkages with health structures and community support will strengthen the continuum of care for PLWHA, positive living groups, ART programs for cluster of differentiation 4 (CD4) monitoring and treatment.

STEPS OVC will support government adaptation of prevention with positives toolkits, and will collaborate with ZPI to cascade new prevention interventions reaching PLWHA. STEPS OVC will monitor and evaluate service provision through a standardized client database as well through routine field visits to provide supportive supervision.

STEPS OVC program will reach approximately 8,000 people in FY 2013 with HIV prevention interventions primarily focused on abstinence and/or being faithful (AB). STEPS OVC will implement evidence-based interventions that respond to drivers of the HIV epidemic identified by The National HIV/AIDS/STI/TB Council (NAC). STEPS OVC partners and sub-grantees will identify and link with government and non-government stakeholders to ensure that a combination of behavioral, biomedical, and structural prevention interventions is available to target populations.

STEPS OVC will transfer responsibility for implementation of AB prevention to local owners, including schools, community and faith-based organizations, and churches. Sub-grantees will implement the Safe From Harm curriculum targeting adolescents aged 14-20 and their parents, to increase parent-child communication about reproductive health. Life skills education for in- and out-of-school youth will support healthy decision-making and negotiation skills, and promote delayed sexual debut. Sub-grantees will scale up The Faithful House curriculum, implemented as operations research in FY 2011, which uses a peer education approach to lead groups of married couples through dialogue around mutual fidelity and communication about sexuality in marriage. Using the Stepping Stones approach, the program will also target couples, opening communication around social and gender norms that influence faithfulness. All interventions delivered in a small group setting will target no more than 25 people to enable participation and opportunity for personal appraisal of behavior.Collaboration with ZPI will address HIV-prevention needs of vulnerable populations, including the well-to-do, and will strengthen gender-sensitive AB prevention programming. STEPS OVC will consider cost-effectiveness and scalability prior to implementing new approaches.

Sub-grantees will integrate AB prevention services into OVC and basic care and support services through direct service provision. STEPS OVC will work with the prevention technical working group to ensure quality assurance through standardized approaches and materials as well as through supportive supervision and training. STEPS/OVC also provide and help adolescent pupils appreciate new information on HIV/AIDS, BCC, prevention and life skills training to increase access to quality information about HIV/AIDS and healthy living.

STEPS OVC program will provide HCT services to 50,000 people in FY 2013. Priority target populations for HCT are the chronically ill and household members of STEPS OVC beneficiaries, including sexual partners of PLWHA, young children and pre-adolescents. Caregivers will refer HIV-exposed infants for early infant diagnosis. Additional target groups include couples of childbearing age (emphasizing pregnant women and their partners), youth ages 16 to 24, well-to-do populations and high-risk communities.

STEPS OVC will increase access to HCT services through direct service provision and by maximizing partnerships. Certified lay counselors attached to local health facilities will implement houseto-house HCT. Static and mobile HCT, including workplace HCT, will reach under-served populations. STEPS OVC will follow Ministry of Health (MOH) protocols, standards, and guidelines for HCT. Sub-grantees will coordinate HCT with local stakeholders and will submit timely reports to the government.

Linkages with health structures and community support will strengthen the continuum of care for newly diagnosed PLWHA, including home based care, positive living groups, prevention with positives counseling, and ART programs. Persons testing negative will receive counseling to assess personal risk and identify harm reduction strategies. STEPS OVC will support government adaptation of prevention with positives toolkits, and will collaborate with the ZPI to cascade new prevention interventions linked to HCT.

STEPS OVC will adapt best practices in HCT from Society for Family Health, Zambia Emory HIV Research Project, Corridors of Hope, Comprehensive HIV/AIDS Management Program and Zambia Health Education and Counseling Trust. Specific attention will be on addressing programmatic opportunities and gaps identified through the baseline evaluation report and the data quality assessment visits.

By 30 June 2011, STEPS OVC had reached 659 individuals who had been tested for HIV and given their results.

STEPS OVC program will reach 80,000 people in FY 2013 with HIV evidence-based prevention interventions that respond to drivers of the HIV epidemic identified by NAC. STEPS OVC will reach both adults and youth (15 to 24 years) with prevention messaging to address sexual and other risk behavior such as alcohol and drug abuse. HIV positive individuals (adults) will be the target for prevention with positives (PwP). Linkages will ensure that a combination of behavioral, biomedical, and structural prevention interventions is available to target populations; both male and female youth and adults.

STEPS OVC will transfer responsibility for gender-sensitive implementation of HIV prevention interventions to local owners, including schools, community and faith-based organizations, youth peer educators, youth friendly health corners and resource centers, and churches. Caregivers will hold household dialogues with all members of households, focused on risk reduction counseling and personal behavior change decisions.

Sub-grantees will mobilize community, faith, and youth leaders to reduce stigma and discrimination, using AIDS Alliance stigma toolkit and Channels of Hope. Community Change groups and gender awareness discussion will address socio-cultural practices that influence HIV risk. STEPS OVC will build caregiver skills in disclosure support, assessment of sexual activity, assessment of partner status and linkage to HCT, education on sexually transmitted infections, access to condoms, adherence counseling, fertility choices, and referrals. Linkages to economic strengthening will aim to reduce vulnerability.

STEPS OVC will support government adaptation of PwP toolkits, and will collaborate with ZPI to cascade new prevention interventions to address HIV-prevention needs of vulnerable populations, including the well-to-do individuals. STEPS OVC will consider cost-effectiveness and scalability prior to implementing new approaches including, PLHIV palliative care as prevention, HCT as prevention, support groups for children, youth and adults, PWP, and workplace interventions.

By 30 June 2011, STEPS OVC had reached 14,104 individuals under this intervention area.

At the household level, PLWHA that are on ART will be targeted for household ART adherence. Those that test HIV positive during household CT and are placed on ART will also be encouraged by the caregivers to adhere to treatment. Caregivers will proactively encourage mothers to seek Early Infant Diagnosis (EID) by providing EID education to their communities, referring HIV positive women to health clinics to test their infants and receive the results of the Polymerase Chain Reaction (PCR) test so that HIV positive children that are eligible are put on ART and then be monitored for adherence. STEPS OVC will acquire lessons learned from a pilot with the MOH and the Clinton Foundation, which, through the use of mobile phones, is aiming to reduce the turnaround time on receiving results in the laboratory to getting the results to the healthcare providers. ART and PMTCT clinics will refer clients to caregivers and CHWs, while caregivers will refer clients that are having complications due to ART to the clinics, an activity that will be strengthened through cell phone referral pilots. STEPS OVC will work with ART programs, other CT programs to promote Provider Initiated Counseling and Testing (PICT) among health workers and develop a referral system where all members of a clients household will be linked to PICT services and referred to appropriate interventions and age sensitive services after testing.

Rough estimates indicate that in Lusaka, over 50% of HIV and AIDS care and services are provided by private practitioners. Engaging the private sector through the development of public private partnerships for increased responsibility in HIV prevention and care services and further developing the referral system to include the private sector are key strategies, and fundamental in reaching the well- to-do Zambians.

With the experience of the Futures Group, GIS will be used to link disparate data sets such as facility lists and program coverage areas, service statistics, census counts and road maps to conduct spatial analyses. At the program level, the tracking system identifies areas which are not being served by the treatment sites for intensified promotion and outreach.