In FY 2012, AIDSRelief-Transition (AR-T) aims to strengthen the capacity of Zambian health care institutions to provide quality HIV/AIDS prevention, care and support, and treatment services. AR-T will provide HIV/AIDS prevention, care and support, and treatment services initiated under AIDSRelief (AR) and technical and capacity development support to local organizations to progressively assume responsibility for implementing activities in the 19 ART sites. To achieve this, two local partners (LP), CHAZ and Chreso Ministries (Chreso) join CRS, IHV, Futures, and CAF to form the AR-T consortium. AR-T will use the AR model of care to build local partner treatment facility (LPTF) and LP capacity. AR-T will apply five strategic methods to service delivery and capacity-building. Capacity Building: AR-T will incorporate widely accepted best practices to build HIV/AIDS clinical and managerial competence within its program. Clinical Teams: The medical, nursing, laboratory, Continuous Quality Improvement (CQI), and Community-Based Treatment Supporters (CBTS) expertise, will provide LPTFs with training, mentoring, and technical assistance. Data Demand and Information Use (DDIU) for continuous quality improvement: AR-T, in collaboration with MOH and CDC, will ensure facilities have adequate equipment and staff to support and manage SmartCare. Grant Management: AR-T will continue with activities started under AR to strengthen the grant management capacity of LP and LPTFs with emphasis on strengthening cost efficiencies at all levels of the program. Linkages: AR-T will work closely with the MOH at all levels and with community leaders and other stakeholders. AR-T will coordinate all activities with the LP awards.

AR-T will continue the AR family centered approach in the provision of quality HIV care, treatment and support services. AR-T will fully implement the 2010 treatment guidelines in addition to other strategies to ensure the needs of PLWHA across the continuum of care regardless of treatment status are addressed.

AR-T will continue to work with LPTF to promote early diagnosis of HIV infection and engagement into care. AR-T will train and mentor providers to appropriately manage and follow up pre-ART patients ensuring timely clinical visits, OI screening, prophylaxis and management, and CD4 monitoring while addressing their psychosocial needs with an overall goal of timely and safe engagement into HIV treatment services. We will collaborate with other partners and the community to improve retention and reduce loss to follow up (LTFU) in this patient population.

AR-T will work with LPTF to ensure structured treatment preparation and on-going adherence counseling, aimed at improving retention in care and adherence to treatment reducing overall program LTFU.

AR-T will address the care and support needs of patients on ART recognizing the importance of addressing physical, psychosocial and spiritual needs in perceived stable clients which may impact treatment success. AR-T will continue to mentor staff trained in palliative care on pain management, end of life care and support to the bereaved conducting training as need arises. CBTS will continue to work with LPTF in strengthening and ensuring access to existing support groups with formation of special support groups based on a needs assessment for vulnerable and special populations among our clients. AR-T will encourage a peer to peer approach such as PMTCT mothers, parents with HIV positive children, discordant couples and will support linkages between the ART clinic and CBTS. This will allow PLWHA access education and psychosocial support services.

CBTS will continue to work with CHW through LPTF to ensure community linkages and dual referral systems are fostered. AR-T will also establish the necessary linkages and referrals to other organizations with care and support services including nutrition and in turn support other organizations and GRZ systems.

AIDSRelief-Transition (AR-T) will aim at providing quality TB/HIV services by increasing access to testing and treatment for HIV and TB; building capacities to provide and monitor quality services; strengthening relationships and coordination among HIV and TB stakeholders; and collection, reporting, and analysis of relevant data. The laboratories and care, support, and treatment program areas will complement these efforts.

AR-T will screen for TB in all HIV positive clients, appropriately manage including appropriate use of isoniasid and co-trimoxazole prophylaxis and provision of antiretroviral therapy for all HIV/TB co-infected patients regardless of CD4 count while building capacity in providers through approved national trainings and mentorship. AR-T will ensure that all TB patients are screened for HIV. AR-T will build capacity of TB clinicians in ART management through training and mentorship. In this way AR-T will ensure that TB patients testing positive for HIV receive prompt assessment for ART eligibility facilitating early initiation of treatment. AR-T will conduct nutrition assessment for all TB clients with appropriate referrals for management. AR-T will ensure infection prevention at facility level through triaging and at community level by promoting early case detection.

AR-T will distribute information education and communication materials on TB/HIV with supervision of individuals.

AR-T will continue with Directly Observed Therapy, contact tracing and TB/HIV screening. AR-T will improve laboratory microscopy diagnostic capacity. AR-T will build technical capacity through collaboration with chest diseases laboratory, the university teaching hospital TB laboratory staff as necessary ensuring good clinical and laboratory practices and standard operating procedures are observed.

AR-T will participate in national-level meetings through TB/HIV Technical Working Group and the quarterly TB/HIV centre for disease control-supported partners meeting, ensuring clear coordination and complementarities of TB and HIV activities across Zambia. AR-T will participate in the national calendar activities. AR-T will collaborate with MOH in MDR-TB surveillance.

AR-T will facilitate process of information sharing between local partner treatment facility and district health management teams through regular meetings, and discussion of reports of the TB/HIV coordinating bodies.

AR-T recognizes the dependence of successful pediatric HIV care on the existence of a solid family structure and will thus continue AR family centered approach to care extending this to a special emphasis on male involvement. AR-T will ensure HIV care where applicable for caregivers of HIV exposed and infected children. AR-T will ensure full implementation of the new (2010) pediatric antiretroviral therapy management guidelines. We will care for HIV exposed children ensuring national recommendations on frequency and duration of monitoring, HIV testing, infant and young child feeding, and that OI and antiretroviral prophylaxis are adhered to. AR-T will promptly engage HIV infected children into antiretroviral services once meeting criteria with caregiver education and treatment preparation. AR-T will conduct screening and management of OI particularly TB, growth monitoring, and nutritional assessment, counseling and referral. AR-T will ensure all children follow the national immunization schedule. AR-T will promote linkages to support groups and other care and support services of both children and care givers. Recognizing the threats on adherence, AR-T will promote disclosure, addressing this from time of engagement into care. AR-T will support youth friendly and adolescent services recognizing the special psycho-social needs of this population. AR-T will address childhood illnesses through health talks, IEC material on prevention as well as first aid tips and will network with relevant organizations for the provision of insecticide treated bed (mosquito) nets and safe water interventions. AR-T will mentor providers on the importance of comprehensive assessment and management of pain in children addressing not only physical, but psychosocial and spiritual forms of pain which sometimes are over looked in this population.

AR-T recognizes the importance of well established laboratory services in the provision of quality HIV services and will build on AR achievements in addition to new innovations. AR-T will ensure laboratories have the necessary physical environment, technical capacity and systems to achieve quality services. AR-T will support laboratory refitting as needed towards a physical environment conducive for delivery of quality laboratory services. Onsite mentoring on good laboratory practices, use of SOP including equipment maintenance; sample collection, preparation and storage, and infection prevention will be conducted. AR-T will address quality assurance, participating in the national and international external quality assurance program while adhering to the existing on site internal quality control measures. AR-T will continue the technical collaboration with MOH and participate in the technical working group activities. AR-T will be involved in the PIMA field study and other activities where possible. AR-T will work towards ensuring laboratories have MOH approved equipment for standardization. This will facilitate easier equipment maintenance; reagent logistics management system, and is sustainable. Refresher trainings on different chemistry, hematology and diagnostic tests on needs basis will be conducted by AR-T with continued collaboration with MOH and chest diseases laboratory to build capacity of laboratory staff.

AR-T will complete the process of installation of cavidi viral load equipment begun under AR at five sites and subsequently compare its performance against that of the gold standard polymerase chain reaction. AR-T will strengthen systems through technical assistance in the area of laboratory management information systems ensuring accurate data, reporting and subsequent quantification helping prepare capacity to use of a fully electronic system. AR-T will conduct trainings on laboratory management for lab managers building their capacity to be more independent and to supervise other facilities. AR-T will strengthen MSL collaboration to facilitate effective communication on commodity status and allow advance planning for any deficits.

AR-T will ensure that all 19 LPTF have adequate equipment and trained staff to support and manage SmartCare. AR-T will continue collaborating with MOH and CDC to ensure data managers SmartCare Certification. Sixty LPTF staff will be trained or retrained in SmartCare. The LPTF will synthesize PEPFARs quarterly reports using DDIU approaches to guide program monitoring and quality improvement, adjusting program activities as appropriate. AR-T will strengthen capacity of CQI committees at the LPTF to use the data they generate to inform program activities. In addition AR-T will conduct periodic data audits which will be undertaken at the LPTF to continuously track data quality. These strategies will ensure accurate, valid, and timely reports which will be used to monitor overall AR-T successes and challenges in patient management and overall project outcomes. AR-T will produce monthly, quarterly, semi-annual, and annual progress reports to inform program planning.

AR-T will roll out a second round of the Site Capacity Assessment (SCA) at the LPTF. This will follow on the first round of the assessment conducted in FY 2010 and FY 2011. AR-T will support the LPTFs to develop and implement capacity-building action plans to address identified gaps using the SCA and CRSs Holistic Organization Capacity Assessment Instrument (HOCAI). AR-T will participate in national technical working groups for SmartCare and M&E convened by the MOH, CDC and other partners. AR-T will continue to mentor counterpart staff of the LP to build their M&E capacity in all areas and will work closely together to ensure the smooth and progressive handover of patient numbers and reporting from the second year of the award.

AR-Ts model of implementing a successful care and treatment model and re-enforcing that model through site visits and mentoring creates ownership at the local site level of the care model and increases care and cost efficiencies. Integrating care components into one team that can address all HIV related concerns at the site level promotes identification of gaps before they create system breakdowns. Integrating care services such as TB/HIV, PMTCT/ART, and STI/HIV that interface with HIV positive individuals streamlines care and fills gaps in service provision. AR-T will continue to build on this model with increased transfer of site mentoring and evaluation to the LPTF. AR-T will continue with the roll out of the SCA at LPTFs. AR-T has created budgeting templates for each LPTF that assists them in creating a budget that supports a sustainable HIV care and treatment program. AR-T will meet with each LPTF to create work plans and budgets that increase local ownership of the program and transfer important management skills to the site level.

AR-T will continue to work with CHAZ and Chreso in the areas of workforce planning, management and leadership development, and finance and compliance. We have provided support to the MOH and provided medical technical expertise with a Zambian AR Infectious Disease Specialist to support the National ART Coordinator. At the local partner treatment facility level we are supporting task shifting for CDEs in basic nursing skills to improve patient flow and shorten waiting times, providing intensive program assessment and quality improvement programs, and assisting with needed renovations and laboratory restructuring including replacing older failing equipment. Finally, we will continue collaboration with the Health Professional Council of Zambia, and other regulatory boards.

Circumcision has been shown to reduce the risk of HIV transmission up to 60% in men. Zambia has initiated several centers for circumcision and is expanding training. AR has linked with partners directly implementing male circumcision programs to ensure community members of AR sites have access to this service. AR-T will continue to work with implementing partners to ensure that each site knows how to access circumcision services locally, and is training in supporting patients post-circumcision care. Training with educational messages to persons considering circumcision will be provided to ensure correct information about benefits and recovery is provided.

AR included a bio-medical prevention component addressing the promotion of male circumcision. Eight LPTFs offer on-site MC supported by AIDSRelief, JHPEIGO, Mopani Mines or CHAZ. The others refer to near-by hospitals or Society for Family Health carefully following up on the referrals and tracking the circumcised clients. The promotion of male circumcision will be an integral part of the LPTF community-based educational program, and AR-T will develop gender sensitive messages indicating reasons for MC, service location and what MC entails. We will include male circumcision messages in ANC as part of the male involvement campaign. The project will help each LPTF develop and finalize standard operating procedures (SOP) that outline referral networks for circumcision for negative men. AR-T will monitor the number of males provided with comprehensive male circumcision services that include counseling and testing (CT), surgical male circumcision and linking those who test positive to ART services.

AR-T will address injection safety by promoting good clinical and laboratory practices. Through training and mentoring, AR-T will promote standard universal precautions and infection prevention practices including safe phlebotomy, proper waste management and disposal, and use of protective clothing. AR-T will re-enforce messages on occupational post exposure prophylaxis (PEP) and work with LPTF to ensure steps to be taken by an injured member of staff are clearly outlined and are known, and that PEP drugs are available immediately eligibility for PEP has been established.

AR-T will promote good logistics and commodity management to ensure sustained availability of the necessary blood drawing materials.

AR-T staff and community leaders will develop or adapt new evidence-based handouts on abstinence, delay of sexual activity, fidelity and partner reduction. CBTS and the community health workers (CHW) will distribute these at community meetings, home visits, and for existing community radio prevention programs. They will provide materials for LPTF to deliver to youth in-school HIV prevention programs. They will provide technical assistance (TA) and evidence-based materials on how to form youth friendly corners and youth support groups for boys and girls, both in and out of school linking with, for example district AIDS task forces, and youth alive in Lusaka. All materials will be gender sensitive and in the local vernacular. AR-T trainers will address particular needs of adolescents by training health workers (HW) in youth/adolescent counseling focusing on prevention for both HIV-free and young PLWHA, and on the different problems and perspectives of males and females. AR-T will assist LPTF identify adolescent sexual reproductive health services that will provide these services, and set up a well-documented referral system.

CBTS will engage community opinion leaders to encourage wide spread counseling and testing, and endorse prevention strategies such as delaying sexual debut, reducing multiple and concurrent sexual partners, and reducing trans-generational sex in their catchment areas. CBTS will conduct community trainings and build linkages to the ART center as part of their prevention efforts. AR-T will focus on providing regular prevention counseling for all patients regardless of treatment status. AR-T will target AB prevention activities and messages to adolescents, individuals in both steady and less committed sexual relationships, and to both HIV positive and negative individuals. Trainings and outreaches providing prevention messages will take place in all 19 LPTF. AR-T will measure the targeted population reached with AB preventive interventions.

AR-T will conduct a needs assessment, measuring community involvement in HIV testing activities, access to testing services, number of counselors and testers, and other implementing partners providing this service within LPTF catchments. AR-T with LPTF will then develop an implementation plan. CBTS are responsible for the LPTF outreach program promoting CT through CHW.

We will train and update hospital staff to provide CT (including provider initiated testing and counseling (PITC) and couple counseling). Supervisory staff at the hospital will ensure minimum quality standard of services both in health facilities and in the community are met. As many AR-T sites are in remote locations, a variety of personnel must multi-task to accomplish goals. AR-T will strengthen and expand linkages to ensure continuity of care for all persons accessing CT through them. AR-T will develop and incorporate HIV prevention and treatment messages for the general population, MARP, PHDP, and ANC settings into trainings for CT staff; provide current information to clinical staff who train CHW, develop a CME module for HW consistent with national guidelines for pre-ART counseling and advice, and provide TA to clinical staff and CHW to create and document a plan for monitoring pre-ART patients.

AR-T will strengthen LPTF capacity to link services such as PMTCT and exposed baby care to expert HIV care making suggestions for improving them and or establishing linkages to programs that provide them, communicating with implementers providing PMTCT and Early Infant Diagnosis for HIV-exposed infants and working together for a solution if these linkages are not functioning well. AR-T will monitor the outcome of CT by the number of people who receive CT services and get results, the number of individuals who receive couples counseling and testing for HIV and get their test results, the number of health care providers trained in CT, and the number of CHW trained in community and home-based adherence counseling and support for people on ART.

Most at risk populations (MARP), positive health dignity and prevention (PHDP) populations, and other at risk but poorly recognized populations are often lost to linkages to care and consistent, tailored prevention to address their particular situation. Targeted prevention activities serve to keep pre-ART patients in the ART system. AR-T will; develop and incorporate HIV prevention and treatment messages including information education and communication (IEC) for PHDP into trainings for counseling and testing staff, provide current information, through in-service training for clinical staff who train CHW, develop a continuing medical education (CME) module for HW consistent with national guidelines for pre-ART counseling, and provide TA to clinical staff and CHW to create and document a plan for monitoring all at-risk clients. Prevention activities will focus on MARP, PHDP, Discordant Couples, and HIV negative women who are at increased risk of HIV acquisition identified in antenatal clinics (ANC).

AR-T specialists will review LPTF experience in prevention messages development to at risk populations, ability to understand and oversee behavior change communication service implementation, and ability to evaluate the impact of these interventions. AR-T will then develop a training and mentoring plan with targeted training and mentoring throughout the five years of the project to build capacity. In collaboration with district health management teams (DHMT), community leaders, and other stakeholders, AR-T and LPTF will develop a unified HIV prevention action plan for each LPTF for at risk population in their catchment area, organized and owned by community leaders. They will facilitate meetings between LPTF programs and other active prevention programs in the community to assess resources, gaps and ways of synergizing activities. They will also facilitate meetings between LPTF and community leaders to assess local leadership and approaches to promoting HIV prevention, specifically male leadership in prevention and opposition to gender violence, involvement of girls and women, and community-based PLWHA support groups.

AR-T will monitor progress of the outlined interventions.

AR-T will continue to work closely with the national program in procurement strategic planning, national quantification exercises, and provides estimates of the cost of approved and proposed ART guideline changes. AR-T will also support logistics systems within our LPTF that report to medical stores limited (MSL) for supplying accurate consumption and stock data. AR-T will work closely with CHAZ to provide some back-up to MSL in case of stock outs. AR sites have experienced stock out of certain ARV in the past year. We are dependent upon the MOH and MSL to ensure adequate supply of ARV drugs. We will continue to update the MOH on potential shortfalls in their logistics and procurement systems.

AR-T will continue to aim at delivery of quality ART services. AR-T will fully implement the 2010 treatment guidelines through MOH certified trainings and on site mentoring of 60 HW. The team will aim at increasing access to treatment of positive partners in discordant relationships, all TB patients, eligible patients co-infected with hepatitis B and those meeting CD4 criteria for treatment ensuring appropriate first line regimens as per national guidelines are utilized. We will encourage active OI screening prior and at the time of ART commencement and will address the challenges related to the peri- ART commencement period- promotion of early diagnosis of HIV and of early detection for ART eligibility, continued OI screening and management to prevent the immune reconstitution syndrome, screening for and management of adverse events, psycho-social support, and adherence counseling. We will address quality care for patients on ART for longer periods through; regular clinical and CD4 monitoring with emphasis on attention to signs indicating a viral load, ongoing adherence support, OI screening and management, management of co-morbidities and monitoring for long term adverse events. AR-T will address the care of more complex cases capitalizing on task shifting of stable clients to the nurse prescribers and working with MOH advanced treatment centers. AR-T will continue with the role begun by AR of involvement in the development of training materials for the roll out of the HIV drug resistance surveillance system including the implementation of early warning indicators AR-T will pay special attention to pregnant women eligible for HAART with measures such as fast tracking of such clients in the ART clinic. AR-T will work closely with the integrated support for ART and PMTCT (ISAP) project in building capacities among maternal child health (MCH) staff in ART management through mentorship and training. This will facilitate prompt assessment for ART eligibility and early initiation of treatment. We will ensure on-going preventive interventions through the prevention with positives approach as per national guidelines. AR-T will conduct nutrition assessments and refer to available services through strengthened linkages and referral systems. AR-T will also strengthen linkages to support groups and care and support services particularly for vulnerable groups.

AR-T will continue aiming at the provision of quality pediatric antiretroviral treatment services with implementation of the new (2010) paediatric ART management guidelines, updating previously trained providers and training and mentoring more providers. Increasing early initiation of antiretroviral therapy will be addressed; mentoring on timing and correct dry blood spot collection with measures to reduce result turn around time, promotion of provider initiated testing and counseling, recommendation for testing of all children of patients in HIV care below the age of 15, and strengthening of linkages between maternal neonatal and child health services and ART services. AR-T will ensure use of appropriate first line regimens particularly the use of a protease inhibitor for nevirapine exposed infants and phase out of stavudine based regimens. The team will adhere to recommended clinical monitoring schedule ensuring dose adjustments are done, adverse events and treatment failure are looked out for and are managed, and nutrition assessment and growth monitoring are conducted. AR-T will establish linkages and referral systems to the countrys advanced treatment services for complex cases. AR-T will promote adherence to treatment through education and treatment preparation of care giver and patient where feasible, use of pediatric formulations and fixed dose combinations, and ongoing adherence support. AR-T will foster linkages with support groups and peer educators to promote retention in care and to address treatment fatigue. AR-T will avail the MOH developed materials for use in pediatric treatment services such as wall, desk and pocket size dosing charts as well as pocket size treatment guidelines. We will address issues of quality through mentoring on completion of medical records with random chart abstraction as means of assessing. AR-T will continue to participate in MOH led technical working groups regarding pediatric HIV care including working on the integrated paediatric, PMTCT and adult ART scale up plan.