The Zambia Prevention, Care and Treatment Partnership II (ZPCT II) supports the Ministry of Health (MOH) to scale up, strengthen and sustain HIV/AIDS services in Central, Copperbelt, Luapula, Northern and North-Western Provinces. The project will be working in 42 districts, 370 facilities, including 24 private sector facilities, by the end of this COP period.

ZPCT II has five objectives:

First, it supports the National HIV/STI/TB Council (NAC) and the Government of Republic of Zambias (GRZ) MOH policies to expand and strengthen HIV/AIDS clinical service, including testing and counseling (CT), prevention of mother to child transmission (PMTCT), basic care and support, antiretroviral therapy (ART) and male circumcision (MC). Second, the project focuses on the community through strengthening the district referral systems, grants to community based organizations (CBOs) and support to neighborhood health committees.

The third objective builds capacity in GRZ facilities, by strengthening technical and management capacity. Key to the third objective is a formal graduation process, where well performing districts, as defined by a rigorous QA/QI system, transition to MOH management and require and receive less technical support from ZPCT II. The fourth objective enlists private sector facilities to engage them in CT, basic care and support, PMTCT, ART and MC in accordance with National Standards. Finally, the project contributes to the national policies and guidelines for the MOH and NAC through active participation on national technical working groups and steering committees (PMTCT, CT, MC, adult ART, pediatric ART, gender, laboratory and pharmacy) and the generation of knowledge.

This mechanism will receive additional Partnership Framework funding.

ZPCT II will continue to strengthen and expand clinical adult care services. Support will be extended to an additional 21 new health facilities during this planning cycle for a total of 370 facilities during this planning cycle.

ZPCT II will continue to support the management of HIV as a chronic condition including strengthening screening for diseases such as diabetes, hypertension as well as nutritional deficiencies. Clients will be counseled and appropriate referrals made. For example, for nutritional issues ZPCT II will collaborate with USAID-supported nutrition projects, UNICEF or the World Food Program.

ZPCT II will continue to strengthen prevention with positives activities, including assessment of sexual behavior and risk reduction counseling with provision of condoms; partner testing, assessment and treatment for STIs, family planning counseling and provision of contraceptives. In addition, ZPCT II will continue to advance its gender strategy including screening for gender based violence (GBV) and referral of victims to appropriate services. Other activities include management of opportunistic infections and pain management; improved data management; increase referral linkages within and between health facilities and communities working through local community leaders and organizations and other USG projects; participate in and assist the MOH and NAC to roll out or disseminate technical strategies, guidelines, and standard operating procedures; and increase program sustainability within the GRZ.

HCWs will be trained and on-site mentorship and supportive supervision provided in ART/OI using a GRZ curriculum that provides guidance on the provision of cotrimoxazole prophylaxis, symptom and pain assessment and management, patient and family counseling, management of adult and pediatric HIV in the home setting, and provision of basic nursing services. The project will liaise closely with the USAID/Deliver and SCMS on forecasting OI and other drug supply requirements. As with all technical areas, ZPCT II will monitor the quality of care and support for all adult care and support services, and services will be considered for graduation in the context of the districts performance.

ZPCT II will continue to strengthen and expand TB/HIV services in 370 public health facilities and 24 private sector facilities in 42 districts. ZPCT II will screen 65,343 HIV positive patients for TB in the next 2 years. In addition, the project will: harmonize TB/HIV trainings and service delivery protocols; train health care workers and lay counselors in TB/HIV co-management to facilitate cross referral between TB and HIV programs. ZPCT II will strengthen health facility and community referral. The project will also strengthen and expand quality DOTS programs, and increase community involvement and awareness of TB.

Once approved by the National TB Program, ZPCT II will adopt state of the art technologies such as the latest Xpert molecular diagnostic assay. In addition, ZPCT II will strengthen routine laboratory diagnosis of tuberculosis through training and facilitating the capture of multi drug resistance clients and ensure facilities enroll on TB laboratory external quality assessment programs and through lab strengthening efforts and the provision of X-ray boxes.

An enhanced focus on TB Infection Control (IC) will: support trainings on environmental control (improved natural ventilation and use of fans), administrative control (reduced duration of HF patient visit, cough etiquette) and respiratory protection and facility risk assessment; DMOs and health facilities will develop IC action plans and support measures to manage drug resistant TB and TB burden among HCWs. ZPCT II will continue to adhere to WHO recommendations for Intensified Case Finding (ICF) (current cough, weight loss, fever and night sweats) which have since been adapted in the Chronic HIV Care (CHC) checklist.

ZPCT II will continue to support and strengthen routine provider initiated counseling and testing for HIV for TB clients, with emphasis on reducing stigma and discrimination associated with TB and HIV. For those testing HIV positive, immediate CD4 assessment will be done within the TB services before referral to the ART clinic. Using the revised HIV/TB national guidelines and indicators, ZPCT II monitors all activities in all 349 sites, and contributes to the deliberations of the technical working group.

ZPCT II has reached over 15,245 HIV infected children with care and support services. In two years, the project will reach an additional 21,879 children through 370 GRZ and 24 private sector facilities.

Support includes strengthening management of pain and opportunistic infections; training and mentoring of HCWs and ASWs, and increasing referral linkages within and between health facilities and communities working through other USG partners, local community leaders and organizations. Staff will be trained in data collection/reporting and ordering, tracking, and forecasting HIV-related commodities to ensure uninterrupted supplies in close collaboration with USAID Deliver and the Partnership for Supply Chain Management Systems (SCMS).

ZPCT II will support placement and mentorship of lay counselors in pediatric wards to provide routine counseling and testing to inpatients. Where feasible, the identified HIV positive child will have their laboratory investigations completed and started on cotrimoxazole prophylaxis and linked to treatment prior to discharge. In addition, ZPCT II will participate in and support the USG/Zambia food and nutrition strategy and collaborate in the provision of the Ready to Use Therapeutic Foods (RUTF) for malnourished children and supplementary feeding for children on ART in the 10 sites under this program through collaboration with CHAI and MOH. In supporting the family centered approach, the child will be the index case to reach the family with HIV TC with an emphasis on prevention for those found positive and as well as the negative. Where possible care, including ART, will be provided at family centered clinics. Support to establish and strengthen existing adolescent clinics will be provided especially in all high volume sites. As part of strengthening turnaround time of HIV results for children tested through the EID program, ZPCT II will continue to employ and test the use of sms technology to expedite the process of obtaining results from the PCR lab. Once results have been received, parents/guardians of these children will be notified of the availability of the PCR results at the facilities.

ZPCT II will continue to provide technical support, ensure quality services, and build district capacity of laboratory diagnostic and monitoring services in 124 public and 12 private health facilities in 41 districts. During this planning cycle the project will strengthen 10 additional laboratories.

ZPCT II will continue to support internal and external quality control, and the accreditation process for selected labs. Laboratories will be strengthened to perform HIV, CD4 and lymphocyte tests; laboratory diagnosis of TB through training refurbishment and procurement and maintenance of essential equipment in accordance with GRZ guidelines and policies (including point of care CD4 once approved by MOH, hematology and chemistry analyzers, autoclaves, centrifuges and microscopes as needed).

Antiretroviral therapy (ART) clinics and PMTCT clinics without access to CD 4 testing will be linked to nearby ART facilities through specimen referral system. ZPCT II will continue to support the early infant diagnosis polymerase chain reaction (PCR) laboratory in Ndola and ensure the functionality of the DBS referral system including the strengthening of web2sms delivery of results. This work will be closely coordinated with the Centers for Disease Control and Prevention (CDC) and collaborate with the Clinton Health Access Initiative.

ZPCT II will work with the GRZ and CDC to strengthen laboratory quality management systems, information systems, and laboratory personnels capacity to ensure adherence to GRZs recommended laboratory standards. In addition, laboratory staff will continue to be trained in commodity management and good clinical laboratory practices. This will be done in collaboration with USAID/Deliver, the Partnership for Supply Chain Management Systems, CDC, and GRZ to avoid duplication of efforts and to ensure that facility-level forecasting and procurements provide constant supplies of required commodities. As with all ZPCT II activities, our lab efforts operate within the MOH structure and graduation plans for the post ZPCT II period are applied.

ZPCT II will continue to support the information needs of the GRZ, USAID/Zambia and PEPFAR and ensure that supported sites produce quality data through training and onsite mentoring. All activities support the national MOH M&E strategy, adhere to the principle of the Three Ones and build local capacity to serve the long term M&E needs of the MOH.

HCWs are trained in data collection and reporting, and receive on-site mentoring as needed. ZPCT II will continue to support the roll out and upgrade of the Smartcare system for both the ART and PMTCT programs including capacity building of HCWs, technical support to the facilities and procurement of hardware and consumables, and supporting data entry clerks. In addition, ZPCT II will continue to conduct semi-annual data audits in all five provinces in collaboration with the MOH data management specialists.

At provincial level, ZPCT II will continue to collaborate with MOH partners in the use of specific QA/QI tools. This process builds partners capacity to 1) utilize data for decision-making, 2) measure progress toward reaching targets, and 3) improve quality of care according to national standards. This element is central to the ZPCT IIs efforts to foster country ownership. Based on the QA/QI system, the project will continue to identify and graduate districts that have met the criteria for graduation.

At national level, as part of the M&E TWG, ZPCT II will continue to participate in the MOH Epidemiology for Data Users (EDU) Training of trainers and provide technical assistance implementation at provincial level. The project will construct a Geographic Information System database for all ZPCT II sites in collaboration with USG partners. Finally, the project will increase its focus on implementation science and evaluation research over the next two years, to assure that we are extracting the lessons learned across all technical areas and from the significant experience in capacity building, scale up, facilitating and standardizing government ownership through the graduation process.

ZPCT II will continue to work with Ministry of Health in strengthening key components of Zambias national health system that affect delivery of HIV/AIDS and other services. Indeed, ZPCT II is designed to build capacity in the MOH, and ensure solid country ownership of all activities. In this planning cycle, the project will continue to build the management capacity of MOH officials and employees within the Provincial Medical Office and District Medical Office through 59 implementation agreements known as Recipient Agreements (RAs). RAs provide funding to support a mutually agreed on scope of work with PMOs, DMOs and sites. Transfer of full responsibility for program activities to the MOH is built into these agreements through a performance-based sustainability plan that allows health facilities and ultimately districts to graduate from intensive technical assistance when MOH-approved quality standards are met and maintained. The plan is based on ZPCT IIs QA/QI tools, which are under review by the MOH (covering all technical areas). Successful facilities must demonstrate sustained ability to meet quality standards in four areas, technical, commodity management, data management and human resource management, across all services. Districts graduate when 80 percent of facilities meet the required standards. Even after these districts are graduated they continue to receive ZPCT II and provincial MOH support at reduced levels through jointly developed post-graduation management plans.

ZPCT II will continue to fully integrate the QA/QI tools into the Ministrys daily operations as the foundation for a successful transition to complete MOH control. In addition, ZPCT II will enhance MOH capacity to use data for performance improvement, and provide new technical, supervisory and other management training for provincial, district and facility managers.

During this reporting period, there will be continued focus on the capacity building, including an initiative to build specific skills and systems to strengthen HR, planning, financial management and governance within the MOH at the provincial and district levels

ZPCT II will support high quality voluntary medical male circumcision (VMMC) services for the targeted 15-49 age group. A total of 50 MC sites will be established. Regular outreach and mobile MC activities will increase uptake during school holidays and traditional ceremonies; the project will contribute an additional 13,242 MCs over the next 2 years.

All VMMC activities will be carried out in consultation with GRZ MOH MC technical working group and DMOs in collaboration with US Government (USG) and Bill and Melinda Gates Foundation (BMGF) supported programs. ZPCT II model sites will be equipped and supported to become high volume MC facilities within the MOH structure, following WHO guidance on implementation models for optimizing the volume and efficiency of MC services in HIV prevention (MOVE).

In partnership with the University Teaching Hospital MC unit, ZPCT II will facilitate training of HCWs using the national training package. MC services will be integrated with CT, HIV prevention counseling and messages for both positive and negative, and linked to other male reproductive health and STI services. Supportive supervision, using national and international performance standards, will be incorporated. Through its community mobilization unit and linkages with other partners at national and local levels including traditional leaders, ZPCT II will amplify efforts to create awareness and demand for MC services. We will promote MC as part of a total prevention strategy that seeks to increase gender equity. At national level and in support of the Health Professional Council of Zambia (HPCZ), ZPCT II will collaborate with other partners to finalize the MC accreditation guidelines and support preparation of all supported sites for the accreditation process.

FHI 360 will continue to work at the global level to test and develop improved MC techniques. A soon to be completed randomized controlled trial (RCT) in Zambia of a new MC device (Shang Ring) holds promise for accelerating acceptance of a tool that can make the provision of MC more efficient. Additional efforts to generate knowledge through implementation science around MC scale up in Zambia will be identified as well.

ZPCT II will expand to reach 370 public health facilities in 42 districts by the end of this planning cycle. In the last 9 months, ZPCT II counseled and tested over 513,660 individuals, and will reach an additional 1,473,948 individuals over the next 2 years.

The project works through the provincial and district medical offices to provide high quality CT services with effective linkages with other service areas, assure commodity flow and availability, and adhere to good data collection and reporting requirements. In collaboration with the GRZ, USAID/Deliver, and SCMS, pharmacy, laboratory, and counseling staff in supported facilities are trained and mentored in data collection, reporting and ordering, tracking and forecasting of CT commodities. During this reporting period, ZPCT II will refurbish facilities, train and mentor HCWs and lay counselors, increase quality assurance, improve data quality and systems for tracking patient flow and facilitate site accreditation.

Integration of CT with other services will be strengthened, including FP, STI, TB and MC using an opt out strategy whenever practicable. The project will promote couple as well as youth CT through both the static as well as through mobile CT services, and meet the needs of pregnant women in all appropriate settings. All CT services will include a focus on risk assessment and risk reduction, as well as the provision of condoms and follow up for those testing negative. Prevention with positive interventions will be provided, including immediate referral for HAART for the positive partner in a discordant couple. ZPCT II will address gender disparities that hinder access to CT and support district medical offices in quality assurance for eventual program graduation.

Linkages with partners through the district referral networks will increase the number of people reached with CT services and avoid duplication of services. ZPCT II will work in the communities, and other partners, surrounding CT sites to increase demand and acceptance of services and target discordant couples. HIV-infected individuals will be referred to services including, PMTCT, ART, MC, FP, STI, and palliative care as needed.

ZPCT II will support PMTCT services in 359 public health facilities in 42 districts. 344,682 pregnant women have been reached with PMTCT services; an additional 445,088 pregnant women will be served over the next 2 years. The per client costs of PMTCT is approximately $30. Options for lowering these costs include: graduation, technology and economies of scale

PMTCT services are strengthened through the provision of technical support and training for HCWs, community volunteers, facility renovations and provision of essential equipment. M&E and QA/QI systems permit regular measurement of progress towards numeric targets and adherence to quality standards. ZPCT II assures effective commodity management through continued training and mentoring in accurate reporting and data collection and close coordination with GRZ and Supply Chain Management Systems (SCMS).

The project will support the operationalization of the revised national PMTCT protocol guidelines, including provider initiated testing and counseling (PITC) by increasing access to CD4 assessment through the use of point of care CD4 machines within MNCH services. HAART will be initiated within MNCH services for eligible clients to increase uptake and contribute to efforts to reduce maternal mortality. The project will strengthen access to contraception and family planning counseling in both MNCH and ART clinics. Referrals between the two services will be reinforced, including access to desired contraceptive methods in the postpartum period. In addition, re-testing after three months for all pregnant women who previously tested negative will be strengthened; sero-converters will be immediately provided with combination ARVs or HAART. Early infant diagnosis will be strengthened by shortening the turnaround time between specimen collection and clients receipt of results. A family centered approach that enhances HIV prevention activities, male involvement and couple T&C within PMTCT will be strengthened. Pregnant women and their partners testing positive will receive prevention for positive interventions, including screening and management of STI, access to condoms and provision of malaria prophylaxis (IPT) for the pregnant women.

ZPCT II will support ART services in 130 MOH health facilities and at least 10 private sector facilities, in 42 districts and support the district medical office in strengthening quality assurance systems that lead to eventual program graduation. In the next two years, ZPCT II will reach another 74,975 individuals.

ZPCT II will support the operationalization of the revised adult and pediatric ART guidelines to include provision of HAART to the positive partner in all discordant couples, TB, and Hepatitis B co-infected patients. The project will strengthen provision of HAART for all eligible HIV positive pregnant women by ensuring access to point of care CD4 and provision of HAART within MNCH services where feasible. Training and regular on site mentoring and supportive supervision of HCWs and ASWs as per current national guidelines will continue as will the emphasis on task shifting of ART prescription to nurses. The project will provide essential equipment as needed and expand ART outreach model. Clinical meetings will focus on patient monitoring, retention in care and treatment failure. Data are reviewed monthly at clinic and project level, and quarterly at PMO and DMO level; technical assistance is focused on observed deficiencies using standardized QA/QI tools.

ZPCT II will participate in the operationalization of the Early Warning Indicators (EWI) for HIV Drug Resistance surveillance with MOH. In addition, ZPCT II will continue to advance its gender strategy in ART services. The project will work to incorporate cell phone sms technology to address adherence and retention issues.

Finally, ZPCT II will continue to work with other USG partners to strengthen referral linkages and community outreach efforts aimed at creating awareness of and demand for ART services. The project will collaborate with the GRZ, USAID/Deliver, and SCMS in the distribution of ARVs and training of health facility staff in logistics management to ensure timely ordering and uninterrupted supply of ARVs. Support will further reduce stigma and discrimination associated with ART by working with community leaders and key stakeholders regarding the importance of HIV CT and availability of ART.

ZPCT II will continue to provide ART for pediatric patients in all the 42 supported districts. Currently, ZPCT II has put over 4,563 children on ART and another 5,787 children will be put on ART in the next 2 years.

The project will continue to provide technical support, ensuring quality services and building district capacity to manage pediatric HIV/AIDS services for eventual program graduation. The program will promote a family centered approach including full integration of pediatric ART services in all supported ART sites. The project will collaborate with the GRZ, USAID/Deliver, and SCMS in the distribution of ARVs including pediatric Fixed Dose Combination (FDC) formula to enhance adherence. ZPCT II will strengthen community referral linkages and increase demand for pediatric ART services; provide technical assistance and mentoring to HCWs, ASWs and pediatric lay counselors.

ZPCT will integrate pediatric ART case management including training and on-site mentoring with focus on provider initiated counseling and testing and timely initiation of ART. ASWs will assist families in addressing unique pediatric ART adherence issues.

Linkages between pediatric ART and PMTCT services will be strengthened through early infant diagnosis, using DBS, and enrollment into care at six weeks. In addition, all infants and children below 24 months that are HIV positive are immediately initiated on HAART. In addition, initiation of HAART on the ward will also be encouraged to reduce loss to follow up. Pediatric ART clients will transition to adult facilities through the establishment of adolescent ART clinics. This innovative approach is considered a model for assuring continuity of care, and will leverage community support groups whenever possible.

ZPCT II will continue to participate in the technical working groups, and will develop a plan for evaluating program data as per the interests of GRZ and the USG. List of questions are being developed, as is an examination of available data sources. These efforts will lead to a better understanding of the overall effectiveness and efficiency of national pediatric HIV program in Zambia.