To accelerate and intensify prevention in order to reduce new HIV infections by 50% while scaling up treatment, care, and support in Chama, Chadiza, Petauke and Chipata districts of Eastern Province. In FY 2011, CARE International supported 23 clinics in Chama, Chadiza and Petauke districts and in FY 2012 will scale up to 58 clinics to include some in Chipata. In FY 2013, coverage will expand to 97 clinics covering all sites in Chadiza, Chama and Petauke and 50% of the sites in Chipata. Integrated Tuberculosis AIDS Program (ITAP2) will focus on strengthening community responses and linkages with the MOH, CIDRZ and Zambia Integrated Systems Strengthening Program (ZISSP) to create demand for TB/HIV/CT and PMTCT services.

Program Priorities: Increased PMTCT coverage and effectiveness. ITAP2 will work with TBAs, Safe Motherhood Action Groups (SMAGs) and other community based volunteers (CBVs) to implement Social Analysis Action (SAA) and BCC activities to reduce barriers and create demand for PMTCT and family planning services and better linkages with MCH services. ITAP 2 will continue integrating TB and HIV in all its activities including intensified TB case finding and referral of PLHWA for IPT. TB/HIV coordinating bodies will be supported. Knowledge of HIV serostatus will be promoted. ITAP2 will work with Lay counselors to scale up sensitization and referrals of HIV infected individuals and HIV sero-discordant couples for care and support. ITAP 2 will network with the USAID funded, A Safer Zambia (ASAZA) program to reduce gender inequalities and gender-based violence by prioritizing and integrating gender activities in all programs. M&E Plan

- Monthly data collection and reporting by CBVs:

- Program reviews and joint technical supervisory field visits

TB patient notification has continued to decrease in Eastern Province with 2,814 patients notified in 2009 and 2,623 in 2010. This contrasts with national-level trend which increased from 48,591 in 2009 to 48,616 in 2010. Treatment success rate improved from 81% in 2008 to 85% in 2009 in line with WHO target of 85%. TB patients testing for HIV increased from 83% in 2009 to 89% in 2010 above WHO target of 80%. HIV positive TB patients on cotrimoxazole prophylaxis therapy (CPT) and those initiated on ART increased from 41% in 2009 to 67% in 2010 and from 43% in 2009 to 46% in 2010 respectively (EPHO NTLP Bulletin 2010).

ITAP2 will improve case notification in targeted underserved areas by intensifying active TB case finding in densely populated areas with high TB prevalence among the general population including PLWHA. Strength community sensitization activities to promote early recognition of signs and symptoms of TB and the benefits of TB screening among TB/HIV co-infected individual. HIV positive individuals and TB patients will be referred for TB/HIV services and IPT will be given to HIV positive individuals. ITAP2 will update and engage CBVs to implement infection control and prevention protocols at community-level. In addition, focus on on-site mentorship and coaching of CBVs during technical support visits to ensure program quality and efficiency. ITAP 2 will leverage collection and transportation of sputum with partners such as Riders for Health in Chadiza and local companies such as Dunavant in Chipata, Petauke and Chama while CBVs will use bicycles to transport sputum to diagnostic centres. ITAP2 through CBVs will conduct mass campaigns, facilitate submission of follow up sputum for examination, follow-ups of TB patients on treatment, contact and defaulter tracing during special events and house to house visits. Activities will be monitored through technical supportive supervision and quarterly review meetings with stakeholders at all levels to ensure quality and efficiency.

Activities:

- Strengthen youth involvement (both in and out of school) in TB/HIV by including TB information in existing anti-AIDS clubs

- Intensify active TB case finding by through community sensitization activities on key signs and symptoms of TB through public address system and drama and networking with other partners involved in TB screening such as MOH and CIDRZ.

- Train treatment supporters in latest TB/HIV management, infection control, and prevention and conduct quarterly technical supervisory support visits

- Integrate TB infection control, and prevention sensitization messages during HTC house to house visits to reduce cross infection in the community.

- Facilitate contact and defaulter tracing of TB patients and strengthen referral network to screen TB contacts and put TB defaulters back on treatment

- Facilitate airing of 12 TB/HIV anti-stigma radio programs

- Support special events such as TB world day by facilitating satellite sensitization campaigns on early detection, infection control and prevention and benefits of TB screening among PLWHA.

- Facilitate involvement of key stakeholders such as treatment supporters, PLWHA , MOH, and traditional leaders in planning, implementation and program review meetings to improve ownership and leveraging of resources.

HTC remains an essential component to Zambias HIV prevention program. Although Zambia has expanded provision of HTC services country wide, the percentage of people that have tested for HIV and know their status still remains low at 15.4% with more women (18.5%) reported to have received the HIV test and know their results than men at 11.7% (ZDHS, 2007). In FY 2011, CBVs supported by ITAP 2 referred 825 individuals for HTC from 23 health centres in the three districts and 53% clients among the general population were counseled out of 8,000 targeted and 6% tested HIV positive. 89% of the TB patients were counseled and tested and received their test results from the TB clinic. A total of 3,395 were reached and 947 were counseled and tested for HIV and 41 tested HIV positive during World AIDS Day.

The project will focus on strengthening the capacity of CBVs to provide information and refer community members for counseling and testing services through community mobilization approaches such as drama performances, door to door counseling and during special events or campaigns such as the World AIDS Day, VCT, and TB Day. Emphasis will be placed on Couples HTC, PWP, family based counseling, involvement of local leadership, CBOs, and capacity building of key partners such as traditional leaders, CBVs and Lay counselors. Partners will promote community mobilization and increase utilization of HTC in hard to reach areas through mobile and home based services by involving them in planning, implementation, and program review meetings.

ITAP2 will also ensure that CBVs are equipped with information to refer individuals to other programs such as MC and family planning, while those who test HIV positive will also be referred for treatment, care and support services.

Key activities:

- Facilitate community awareness activities through participation in national events such as World AIDS Day, VCT and TB Day, and drama, public address (PA), community radio programs, SAA, and distribution of IEC materials to promote demand for HTC among the general population

- Train and retrain 60 lay counselors in latest HTC manual and couples CT.

- Update 97 health centre focal point persons in latest HTC manual and couples CT and on effective community mobilization strategies that will promote utilization of HTC services by the community.

- Engage and train traditional leaders, traditional initiators, religious leaders and other community volunteers in the family centered approach including couple counseling, disclosure and partner notification to promote HIV testing.

- Strengthen linkages with health facilities and other organizations to provide mobile HTC services in hard to reach areas

- Facilitate house-house HTC sensitization visits by CBVs to promote utilization of HTC and availability of follow up services such as treatment, care and support services at health facilities.

- Facilitate radio programs to sensitize the community on couples CT, MC and family planning by involving influential and role models such as traditional leaders and PLWHA.

- Facilitate semi-annual planning and program review meetings with 120 local partners such as traditional leaders, lay counselors and local CBOs leaders in the four districts to promote program ownership.

- Strengthen data collection system on referrals of couples counseled and tested from ANC, curative and other preventive services by improving documentation at health facilities and community level.

In FY 2011, ITAP2 contributed to increased demand for PMTCT services in 23 clinics in the three districts. 1,206 pregnant women were referred for antenatal care by CBVs although 600 were targeted while 4,145 women received ANC. Of these 96% were counseled and tested for HIV and received their test results. Five percent tested HIV positive and out of these, 89% received dual ARV prophylaxis. In FY 2012, ITAP 2 will scale-up to 58 clinic catchment areas out of a total of 118 in four districts including Chipata district and will add an additional 39 clinic catchment areas in FY 2013.

ITAP 2 will continue to support community mobilization activities to promote utilization of PMTCT services by strengthening community to clinic referral networks and vice versa. ITAP 2 will promote access to PMTCT services by strengthening referral networks at all levels and scale-up quality PMTCT interventions, PITC, use of more effective ARV regimens, access to CD4 testing, retention and adherence of mother-infant pair, linkages and referral to treatment care and support services . ITAP 2 will advocate for community-level HTC of couples through the CBVs during door to door campaigns and during community drama performances. CBVs will also provide health education to discordant couples on family planning and linking HIV positive clients to family planning providers and also for ART for prevention purposes. Male partners who test HIV negative will be referred for MC services. CBVs will participate in following up mother-baby pairs so as to minimize on loss to follow up. In addition, ITAP2 will strengthen CBVs to utilize drama and engagement of role models like prominent persons in society to promote male involvement and couples CT.

Key activities:

- Orient 600 CBVs including traditional birth attendants in updated PMTCT guidelines to equip them with latest information to use during community awareness activities and household visits.

- Train 150 CBVs in prevention with positives and provide them with relevant materials in five health centers with high HIV prevalence.

- Facilitate establishment and/or strengthening of 97 SMAGs or PMTCT support groups through information sharing fora and participation in events such as National VCT Day, World Breastfeeding Week and World AIDS Day.

- Continue to strengthen community awareness activities through drama, engagement of role models like prominent persons in society, religious leaders and traditional leaders in order to promote male involvement and couple counseling and testing.

- Facilitate linkages on PMTCT services with PHO, CIDRZ and Zambia Integrated Systems Strengthening Program (ZISSP).

- Continue strengthening and capacity building of existing community structures through training and retraining, improved coordinated efforts of 600 CBVs, 120 FBOs, local leadership, and health care providers in order to decentralize PMTCT services.

- Facilitate and support referral system that will promote integration of PMTCT with routine maternal child health, reproductive health services such as family planning, adult and pediatric treatment services and referral of HIV positive for TB screening as well as linking them to existing food and nutrition programs.

- Facilitate quarterly joint planning and program reviews with stakeholders at, provincial, district and clinical site level to promote coordination, collaboration, leveraging of resources and improve program quality.