This program continues to strengthen, support, and expand the Ministry of Healths sustainable response to the HIV/AIDS epidemic in the Republic of Zambia. The intent of this program is to complement and continue the current public health activities of the Ministry of Health (MOH) in Zambia.The Ministry of Health (MOH) headquarters is responsible for the overall leadership in the delivery of health services in the country, including policy, planning, and coordination and supervision of all sub-national structures as well as implementing partners.

This project will support a sustainable response to the national HIV epidemic in the Republic of Zambia by assuring that direct support provided to the MOH is used to effectively and efficiently support the implementation of comprehensive integrated HIV/AIDS and healthcare interventions in general.

This program primarily provides support in the areas of Prevention of Mother to Child Transmission (MTCT), Antiretroviral Treatment for both Pediatrics and Adults(PDTX and HTXS), Tuberculosis (HVTB), Strategic Information (HVSI), other prevention (HVOP-STI), Cancer registry, Laboratory (HLAB), counseling and testing (HVCT) and Health system strengthening (OHSS).

Using COP12PMTCT PLUS UP funds $400,000, the MOH will continue to provide leadership in implementing priority strategies intended to accelerate the prevention of mother-to-child transmission (PMTCT) program toward reaching the goal of elimination of HIV MTCT by 2015. In addition to providing strong leadership and coordination of all stakeholders, MOH will implement one-off activities intended to strengthen the base of the national PMTCT program for a more effective MTCT elimination drive...

Narrative (3,500 characters)

The National TB control Program (NTP) will continue to support and strengthen access to quality TB and HIV care services in Zambia through strengthening of TB/HIV collaboration and coordination at all levels of care. The program will continue to support key staff at the central unit. Continue to strengthen TB/HIV collaboration through regular and scheduled meetings with all stakeholders. Continue to develop and update guidelines. The program will also continue to strengthen programmatic management of MDRTB.

The program will continue to build capacity in Provider Initiated Testing and Counseling (PITC) in order to increases surveillance of HIV among TB patients as well as the provision of ART and CPT in the TB clinics. This will be achieved through the upgrading of the current training packages to include the new WHO recommendations. This will further be strengthened by conducting On the Job Training (OJT), mentoring, and technical support to the provinces.

The program will expand the TB/HIV services into the prisons though capacity building, mentoring, and patient and client care.

To reduce the burden of TB among the HIV positives the program will build capacity in the provision of Isoniazid Preventive therapy (IPT) and intensified case finding (ICF). IPT/ICF guidelines are already being developed and a training package will be developed. TB Infection Control will also be enhanced.

Program monitoring and evaluation of the TB/HIV activities will be done through capturing of TB/HIV data elements and holding of data review meetings. The NTP will support the quarterly National and Provincial TB/HIV coordinating body meetings.

NTP will also strive to increase access to both TB and HIV diagnosis by strengthening the TB laboratory network efficiency in the country. The program will support the courier system to improve the surveillance of drug resistant TB.

National Reference Laboratory (NRL) will focus on providing specialized TB laboratory diagnostic services to all healthcare facilities. These will be new diagnostics and will include; Hain test, GeneXpert, and iLED fluorescent smear microscopy for improved smear sensitivity and turnaround time. NRL will procure adequate laboratory supplies and reagents for TB culture and microscopy centers. Establish service for TB laboratory equipment.

The NTP will provide technical support through supervision and during the holding of bi-annual national data review meetings, provincial and district review meetings.

To increase on awareness to the public Information, education and Communication (IEC) materials will be developed, printed and distributed to all the health facilities in the country.

The NTP will conduct the National TB prevalence survey to estimate the prevalence of TB through population based surveys.

Pediatric care and support will ensure increased number of infants and children identified early in care and support by expansion of the Early Infant Diagnosis (EID) program and routine Provider Initiated Testing and Counseling (PITC). This will be done through trainings and mentorship activities which will include PMTCT, pediatric counseling and testing, infant and young child feeding, EID, palliative care and management of pain, and anthropometric measurements in children and early identification of malnutrition.

Co-trimoxazole prophylaxis for all HIV exposed and positive children will be provided in maternal neonatal and child health (MNCH) settings as well as all the follow up care and support service points. Loss-to-follow up on co-trimoxazole prophylaxis will be addressed by improving links between health facilities and communities.

The newly developed adolescent guidelines, which address disclosure in all children in a staged approach, adherence and sexual and reproductive health issues in the pediatric population particularly in the adolescent age group will be rolled out to all sites. Research and evaluations will be directed towards these emerging concerns. In order to address these issues, standard tools will be developed to be able to collect data systematically.

On-site mentoring and supervision will be continued in order to strengthen and improve the quality of health services provided with main focus on palliative care and pain management in children.

The new safe motherhood cards will also take into account the linkage between MCH and Pediatric ART services and once implemented should help address Testing of children during the routine immunization programs and six monthly mass immunization campaigns will be continued.

There has been increased support health care workers and lay counselors t will be trained in DBS collection for EID and the number of EID sites will be expansion from the current 1,470 PMTCT sites.

Laboratory services provide accurate and reliable information to guide decision making for quality health care. In line with this laboratory services have set priority areas that include activities to strengthen laboratory management towards accreditation, the establishment of the National Quality Assurance unit that will oversee both internal and external quality assurance activities and generally the implementation of Quality Management Systems

The Ministry of Health is implementing an accreditation program that will see selected laboratories get international recognition through accreditation. This will be achieved through trainings in strengthening laboratory management towards accreditation (SLMTA), technical support and provision of equipment and supplies.

The National Quality Assurance unit will be established at Chainama Hospital. The unit will coordinate and manage laboratory quality assurance activities for Ministry of Health. It will work with laboratories to implement both internal and external quality assurance activities such as the External Quality Assessment (EQA) programs for Tuberculosis (TB), CD4 enumeration HIV testing among others. The unit will also provide technical support and Continuous Profession Development for laboratory staff. In the initial phase the unit will hire some staff to support the operations with funding from the MOH CDC Cooperating Agreement. To sustain the quality assurance activities and continue building capacity in the management of laboratory activities, Quality Management Systems (QMS) trainings will be conducted.

The National Quality Assurance unit will continue to work with the Chest Diseases Laboratory (CDL) to implement the TB EQA program and other programs that are specific to TB. CDL will continue to strengthen the national QA program for TB smear microscopy to increase the national coverage down to health centers in all the provinces. CDL itself will continue to participate in international EQA programs for microscopy culture and drug susceptibility testing. In addition, CDL intends to introduce the EQA follow up visits for corrective action and will do an assessment of TB Laboratory services versus population distribution.

With the recruitment of ICT Personnel at provincial level and decentralization: support and maintenance can be achieved. This will cement ownership of the system to the lower levels of the MOH hierarchy and is more sustainable.

It is also envisaged that with training in data use, the demand for SmartCare generated standard and adhoc report will increase thereby making data entry mandatory at the various levels of the ministry.

The target activities for SI program will encompass:

Capacity building in ICT Skills for MOH HQ and Provincial staff

Decentralize SmartCare Training and Technical Support visits

Conduct bi-annual national-wide QA/QC visits for SmartCare deployments

Build capacity to support data use at all levels of the MOH hierarchy HQ, provincial and district levels

Scale up SmartCare to another 500, mostly PMTCT sites

Upgrade current SmartCare deployments with OPD module

Capacity building at Ministry of Health headquarters for continued SmartCare software development

The Zambia National Cancer Registry

The Zambia National Cancer Registry (ZNCR) is currently a hospital based registry and the data obtained does not reflect the cancer burden in the country. Strengthening CR at the provincial level will continue in COPs 12 & 13. In the ZNCR goal of strengthening the data management for policy formulation, the registry recognizes the urgent need and plans to do the following:

Establishment of the ZNCR structure with the appointment of a Registrar

Appoint information officer that will be collecting cancer data and completing the notification forms.

Strengthen data analysis and reporting capabilities through CANReg training.

Hire and train data analyst(s)

Notification of all cancer cases by the hospitals, cancer clinics, and pathology laboratories.

Capacity building for Information Officers at the 9 Provincial hospitals

Monitoring and Evaluation

The MOH will conduct joint field monitoring, supportive supervision, assessment of status and quality of services, data quality checks and verifications at all levels with program managers. The ministry will also be Reviewing the existing data collection for male circumcision, condom distribution, PMTCT, ART and HIV/TB integrated services and develop a user-friendly Guidelines/ Protocol on how to complete registers/log books and keeping raw data/information and reporting on number of people receiving services. This will require the ministry to undertake a country-wide evaluation in a representative sample of facilities to determine the effectiveness of program, identify and address common inaccuracies and identify and transfer good practices. M&E Guidelines will be developed for Supervision of HIV and AIDS programs at Health Facilities by all level to strengthen M&E and quality assurance of all facilities.

In FY 2012, the USG will support MoH to strengthen access to quality TB and TB/HIV care services through strengthening of TB and TB/HIV collaboration and coordination at all levels. The program will support key staff at the central unit, strengthen TB/HIV coordinating bodies and data review meetings at national and provincial levels, provide mentoring and supervision, develop and update guidelines (IPT/ICF), develop IEC materials and programmatic management of MDR-TB.

The program will build capacity in Provider Initiated Testing and Counseling (PITC) in order to increase surveillance of HIV among TB patients as well as the provision of ART and CPT in the TB clinics. To reduce the burden of TB among the HIV positives the program will build capacity in the provision of Isoniazid Preventive therapy (IPT), intensified case finding (ICF) and TB infection control (TB IC). MoH will strive to increase access to both TB and HIV diagnosis by strengthening the TB laboratory network efficiency and support the courier system to improve the surveillance of drug resistant TB.

National Reference Laboratory (NRL) will focus on providing specialized TB laboratory diagnostic services. These new diagnostics will include; Hain test, GeneXpert, and iLED fluorescent smear microscopy for improved smear sensitivity. NRL will procure adequate laboratory supplies and reagents for TB culture and microscopy and establish service for TB laboratory equipment.

In FY 2012, the USG will support MoH to measure progress towards the national targets in the control and prevention of TB by conducting a national TB prevalence survey. This survey will be population based and will estimate the prevalence of TB for baseline and an assessment to be held after five (5) years to measure the impact. The survey will be conducted in 80 selected clusters with a sample size of approximately 60,000.

The objective of this survey is to estimate in a nationwide representative among adults who are 15 years and above the prevalence of bacteriological confirmed pulmonary TB (PTB) both by sputum and culture positive, estimate the prevalence of symptoms suggestive of bacteriological confirmed pulmonary TB in suspects, estimate the prevalence of radiological abnormalities suggestive of bacteriological confirmed PTB, determine the health seeking behaviour of TB suspects and the prevalence of HIV among TB suspects. The USG funding will support to procure the necessary equipment, reagents and other supplies, transport, hiring and training of staff, data management, laboratory quality assurance, advocacy and social mobilization, monitoring visits and technical assistance. Due to limited knowledge and skill in conducting such a massive survey, the planning, monitoring, evaluation, data management and technical support through supervision will provide capacity to the health staff and will ensure sustainability. The M&E unit of the MoH will continue to take the lead in the areas of data quality and use under the Epidemiology and Data user Training Program. This will enable staff at national, provincial and district levels to scrutinize data, improve data quality and produce quarterly and annual PEPFAR progress update reports as well as epidemiological profiles for their jurisdictions.

During the COP12 implementation period, MOH will continue to provide overall leadership including coordination of implementing partners towards attaining the national goal of circumcising 2.5 million men by 2015, with an aim of contributing towards the national objective of reducing HIV incidence by 50% from the current 1.6 to 0.8 by 2015. Whilst USG implementing partners will separately receive funding dedicated to service delivery, the MOH will use part of the COP12 funding from the CDC Co-Ag to continue strengthening coordination with a new focus on the provincial and district levels. The MOH will under-take targeted capacity building for identified MC program focal point staff in the Provincial and District Medical Offices in order to ensure that the overall MOH strategy and operational plan is effectively translated into service delivery at these levels. Capacity building will also focus on developing effective leadership at provincial and district level for the coordinated deployment of demand creation activities and improving the monitoring of the program at these level. The MOH will also use part of these COP12 funds to provide a coordination platform for the development of a national standardized MC counseling package, and development of MC messages aligned to the national communication strategy. Additionally, the MOH will dedicate a portion of the COP12 MC funds to support supervision and mentoring, training of trainers in the districts as well as covering attendance of regional MC meetings by MOH staff.

In 2012, the Ministry of Health (MoH) will continue to support increased access to HIV Counseling and Testing through training of health workers in Provider Initiated counseling and Testing (PICT) and in couple CT. Facility based CT services will continue to be offered at static sites. HIV CT will reach out to adolescents through the provision of Youth Friendly Corners at the Health facilities.

MOH will support door to door CT services in hard to reach areas by providing training to lay counselors/community based volunteers who will promote a family centered approach. Health care workers will also be trained in child counseling to ensure that more children have access to counseling. The lay counselors will be supervised by Health care providers to ensure high quality CT services.

The communities will be mobilized and encouraged to know their HIV status; and those testing positive will be linked to ART services. In discordant relationships the positive partner will be initiated on HAART regardless of CD4 count or clinical status in line with national ART guidelines. MoH will ensure that linkages between CT and ART services are strengthened to minimize lose to follow up. The HIV negative persons will be given information on how to maintain their negative status.

MoH will undertake supervision and mentoring of primary health care workers in the provinces on a quarterly basis

The national STI response and intervention includes the following areas of emphasis:

1. Improved case management;

2. Enhanced in-service and pre-service training in syndromic management with an integrated approach;

3. Supervision and mentoring of primary health care workers;

4. Strengthening monitoring, evaluation and reporting;

5. Strengthening STI supplies particularly drugs, Syphilis Rapid Tests and female and male condom supplies;

6. Improved community participation in prevention, control and early treatment;

7. Development of synergistic relationships and networks with private sector and stakeholders in STI prevention and control.

In FY 2012, MOH will continue to implement the national STI program by strengthening coordination of partners working in various parts of the country and through regular annual meetings. During FY2011, MOH introduced guidelines for Rapid Syphilis Testing in Zambia. This resulted in introduction of a national strategy for syphilis screening in line with WHO global strategy for elimination of congenital syphilis by 2015. MOH aims to screen all pregnant women for syphilis and increase syphilis screening among other groups at high risk of STIs and HIV infection. The national goal is to integrate syphilis screening into RH, STI, TB and HIV services. With the introduction of Rapid Diagnostic Tests, health care providers will adhere to guidelines for STI management and offer quality health care as clients will be tested on the spot for syphilis. In FY2012 it will be very important to continue implementing these guidelines, including monitoring to assure quality and reliability of test results. There will also be training of frontline health workers-doctors, nurses, medical licentiates and clinical officers.

MOH will strengthen coordinated supportive supervision to provinces to improve quality of routine data collected for HMIS, support routine provider initiated CT among STI clients, provide regular updates on evidence-based practices that feed into national guidelines and improve the monitoring and evaluation of STI programs. Condom promotion and distribution is one of the pillars of the STIs prevention strategy. The MOH will ensure district health officers take stock of how condom programs are working, how many are available, where they are available, who is using them and how they are helping in prevention of new HIV and STIs infections.

MOH will intensify support for HIV prevention services targeting young people through youth based life-skills training and promotion of overall adolescent sexual reproductive health services in all the provinces. MOH will support PMOs and DMOs in improving and strengthening youth friendly services in all the districts and health facilities for out of school youth including supporting the training of peer educators.

MOH will support the delivery of HIV prevention services for people living with HIV (PwP) as part of routine care in community and health facility settings. With high levels of sero-ddiscordancy among cohabiting couples, it will be important to strengthen condom use in PwP. MOH will support the development and coordination of PwP training materials for health care providers and community lay counselors. MOH will support the implementation of Gender Based Violence (GBV) activities and information dissemination at health facilities, community and household levels. There will also be orientation and training of service providers in GBV.

The National PMTCT Program will continue to support and strengthen overall guideline amendments and implementation through all stakeholders; in line with on-going WHO recommendations. The program will also continue to support and ensure capacity building for PMTCT staff at MOH, and will train both inservice and preservice health care providers this is in view of high turnover of skilled staff in Zambia. MOH will strengthen the PMTCT program collaboration through regular and scheduled Technical working group meetings with all stakeholders. The program will also continue to develop and implement M and E tools to build and maintain quality service delivery and programming at all levels and conduct data audits recording and reporting and use for planning. The program will continue to improve service delivery through data use for planning, utilizing population-based analysis, peer review, sharing and documenting best practices and showcasing successes, addressing bottlenecks, giving technical assistance, and optimizing SmartCare use for program planning.

The program continues to coordinate support to training programs both pre-service and in-service to increase coverage of service delivery. This includes new focus on specific prevention messaging, improved community-based efforts to increase male participation in PMTCT, improved links to early infant diagnosis and improving the rates of provision of accurate electronic health records to patients for the purposes of continuity of care and referral linkages. This will further be strengthened by conducting mentorship, support supervision and technical support to the provinces. MOH shall maintain quarterly data audits and population based review interactive meetings involving all districts, provinces, the Center, and partners in the health sector. Using COP12PMTCT PLUS UP funds, the MOH will continue to provide leadership in implementing priority strategies intended to accelerate the prevention of mother-to-child transmission (PMTCT) program toward reaching the goal of elimination of HIV MTCT by 2015. In addition to providing strong leadership and coordination of all stakeholders, MOH will implement one-off activities intended to strengthen the base of the national PMTCT program for a more effective MTCT elimination drive. MOH will implement activities designed to specifically: facilitate the establishment, deployment, and institutionalization of standardized QA/QI systems for PMTCT in Zambia; continue to provide leadership in order to facilitate roll-out of smart-care for PMTCT to all PMTCT sites, including provision of technical and logistics support to districts in deploying of smart-care; conduct a national PMTCT impact assessment in collaboration with implementing partners, and; undertake comprehensive and robust data quality audits and host an annual PMTCT review meeting towards the elimination goal.Using the COP12 PMTCT PLUS UP funds ($170,000), MOH will implement one-off activities intended to strengthen the base of the PMTCT program in the province. These activities will be designed to: Increase health worker retention in rural facilities; Increase utilization of maternity; continue to expand integration models for ANC and ART; Support development of integration models for PMTCT, pediatric HIV care, and routine MNCH services such as EPI, growth monitoring, nutritional support and post natal services; Continue to expand sustainable intra-district laboratory sample courier systems.

The ART program plan to carry out the following activities in its effort to achieve its goal to continue to halt and begin to reverse the spread of HIV/AIDS by increasing access to quality ART services:

TB/HIV /PMTCT integration

In order to reduce loss to follow up and improve the management of patients with co-morbid conditions, the program will build the capacity of TB programme to manage the ART records, logistics and ART management for co-infected patients. This will tie in with the focus on Intensified TB case finding, TB infection control and Isoniazid prophylaxis. Tools to capture the patients that are cross referred will be developed and deployed.

PMTCT presents a unique challenge as far as access to ART is concerned. We have more PMTCT providing sites compared with ART sites and CD4 testing facilities are few and far in between, therefore the ART programme would like to build capacity in PMTCT to manage the ART records, logistics and ART management for pregnant women and infant follow up. The procurement and deployment of a reliable point of care CD4 machine will greatly enhance access.

HIV drug resistance (HIVDR)

HIV drug resistance is an emerging problem in ART program. Currently 4% of all patients on ART are on second line treatment. It is important therefore to assess the scale of the problem and identify practices that could promote HIVDR using Early Warning Indicators and HIVDR surveillance for patients initiating ART and those switching from first to second line.

Establishment of advanced treatment centers(ATC) for 3rd line treatment

About 0.008% patients are estimated to be failing 2nd line treatment. Due to lack of guidelines and expertise in managing such patients the program will be commissioning a pilot ATC at University Teaching Hospital. Eventually ATCs will be scaled up to Ndola Central Hospital (NCH) and Livingstone General Hospital (LGH). This will go side by side with building laboratory capacity for HIV Drug resistance testing at UTH; eventually NCH and LGH.

The programme has procured a limited supply of third line drug using funding from Ministry of Health to be given to eligible patients. A referral mechanism will be developed for patients from far flung areas to enhance access.

SmartCare strengthening

This is an electronic patient record management system. It is about 80% deployed countrywide. The SmartCare program still needs further strengthening and improvement. The SmartCare forms needs updating in line with the 2010 ART guidelines. SmartCare needs to be able to generate specific reports as needed for quality improvement using Smart Query.

The Ministry of Health (MOH) has made tremendous strides in scaling up pediatric HIV services country wide. Currently, we have over 25,300 children on ART. The ministry of health hopes to have 27,000 children on treatment in 2012 scaling up to 32,000 by the end of 2013.

In order to maintain quality of care and adherence to National Guidelines, the Ministry of Health will continue healthcare worker capacity building through trainings in pediatric HIV management, on site mentorship and supervision. MOH will print and disseminate the pediatric HIV training manuals Retention of pediatric patients on treatment has been one of the challenges of the National Pediatric ART program. The MOH will train healthcare workers and community supporters on interventions to reduce loss to follow-up and will conduct awareness campaigns on the importance of timely ART for eligible children. The number of sites providing pediatric ART will be increased. Despite the steps gained in Early Infant Diagnosis (EID) program and routine Provider Initiated Testing and Counseling (PITC) there is still need to strengthen these services in order to avoid missed opportunities. Trainings and mentorship activities in EID and PITC will be carried out in selected rural and the SMS technology will be rolled out from the pilot sites to all the EID sites. 6 Viral load machines will be placed in selected districts to improve the monitoring of children in pre-ART or on ART.

The number of children living with HIV and reaching adolescence has increased, therefore Healthcare workers and other support groups need to have the capacity to manage these adolescents, through training, mentorship and supervision. These include training of peer educators in adolescent HIV care, support and treatment and also to assist the facilities establish adolescent friendly ART services. Program monitoring and evaluation of the pediatric treatment activities will be done by capturing of data elements through Smart Care and holding of data review meetings.