The purpose of the Zambia-led Prevention Initiative (ZPI) is to increase utilization of community-level interventions through a targeted approach and provide technical leadership and expertise on comprehensive, effective, community-based prevention efforts aimed at reducing HIV transmission in Zambia. The objectives of ZPI are:

Build capacity in communities affected by HIV/AIDS to access more effective, gender-sensitive, higher-quality HIV prevention programs;

Strengthen the continuity and coordination of effective, efficient, and sustainable HIV prevention;

Design efficient, sustainable, and locally owned responses to HIV/AIDS, including increased engagement with the private sector; and Provide community-based family planning and reproductive health services as an adjunct to effective prevention of HIV/AIDS

In FY 2010, ZPI project focused in five provinces and in COP2012 period will expand to two more provinces. Primary target populations include the 85% of HIV-negative Zambians, especially those most at-risk, OVC and youth, PLWHA and discordant couples, women affected by GBV, and their families and PLWHA in affluent communities. It also targets those at risk of infection increased by abuse of alcohol and other substances, and behaviors influenced by social norms promoting risky sexual activity.

The use of existing trained community volunteers, peer educators, and health workers from STEPS-OVC and other partners will reduce the cost of initial training, and offer an opportunity for leveraging USG funding and a more cost efficient response. In addition, the emphasis on linking to the private sector and increasing sustainability implies that these activities will require less external donor funding in the future and be community-owned to a greater extent.

ZPIs Care and Support strategy and activities is linked primarily to economic strengthening. ZPI will continue its focus through a sustainable livelihood framework that looks at how households can reduce their economic vulnerability. Instead of targeting households based on HIV and AIDS status, ZPI will target households based on their economic characteristics such as skill base, level of poverty and extent of current and past economic engagement. Through both groups and household level interventions, ZPI will support linkages to social assistance as well as support asset growth and protection.

ZPI will continue to roll out self help group savings and credit schemes using the Grass Roots building Our Wealth (GROW) model and other related aspects like financial and market literacy. The trained cadre of staff from ZPI and local partners will roll out EE models to STEPS OVC caregivers, PLWHA and other targeted groups.

Though ZPI is not providing direct social assistance, households requiring such assistance will be referred to identified partners. Referrals will be made at points of contact by ZPI provincial office teams and sub-grantees. Social assistance may include social cash transfers, food aid and food for work. ZPI will support the creation of small savings and credit schemes, facilitate basic business education and create linkages to legal protection services such as upholding womens property and inheritance rights.

ZPI works closely with STEPS OVC on prevention interventions with Orphans and Vulnerable Children. While STEPS is responsible for care and support of OVC, ZPI provides technical assistance and support for the design of evidence based interventions aimed at reaching OVC. In addition, ZPI will be training organizations that work directly with OVC in the areas of participatory methodology. Using Reflect Methodology, ZPI will aim at having vulnerable children identify their own problems and meaningful solutions. ZPI will not target these trainings directly at OVC, but rather the local organizations that work directly with OVC at community level.

Prevention training will incorporate recommendations from joint CDC-USAID technical assistance. OVC prevention efforts will begin at the earliest opportunity in the community, in school settings and elsewhere, in accordance with national guidelines for schools.

PWP efforts will focus on OVC who range from early adolescence to 18 years of age, those who are already sexually active, or those who indicate they may soon become active.

ZPI will wrap around OVC interventions with economic empowerment opportunities for youth. Where ZPI partners are linked with groups of OVCs we will enroll them in EE Grow programs. In addition, we will support Career fairs for in school grade 12 youth. Career Fairs will link youth to potential employment opportunities and job readiness skills.

Strategic information and knowledge management is a key component of the ZPI program. ZPI will continue to focus strategic interventions based on findings from the baseline study. During this period ZPI will conduct two operations research studies to support evidence based prevention interventions. Previous operations research studies have been focused on economic strengthening and care & support. During this period ZPI will identify research opportunities in other areas of intervention. ZPI has developed technical briefs in core prevention lenses and will continue during this period to disseminate briefs and develop additional briefs. The ZPI Prevention evidence based literature review will remain an active document and will remain at the Afya Mzuri knowledge management center. The literature review has already defined what constitutes a best practice or a promising practice using criteria from AIDSTAR-One, CDC and UNAIDS. ZPI will continue to build the literature review and develop an on-line best practice in prevention resource.

ZPI will work with the Alliance of Mayors and Municipal leaders initiative for community action on AIDS (AMICAALL) as well the local government association of Zambia. We will rely on these local structures to integrate HIV and AIDS programs. In some cases, we will build on their existing work and in others we will propose new activities.

Through this partnership with local government ZPI will aim to assist local authorities in identifying focal point persons. Once identification has taken place, ZPI will work with the associations to review their existing HIV and AIDS work plans with a view to identifying entry points for HIV and AIDS prevention activities. The proposed training interventions will be based on ZPIs lensed approached based on risk and vulnerability to HIV and AIDS. This approach will help deepen understanding of both individual and social vulnerability to HIV infection and enhance programming. Areas such as Alcohol and Drugs as well Gender and Gender Based violence will be used as the entry points to engage the local authorities. Furthermore, ZPI will also strengthen the currently existing teacher support groups in each province to increase the sustainability of the teacher support groups to increase disclosure of those tested positive

People with disabilities (PWD) are often excluded from HIV and AIDS prevention messages and campaigns, partly due to the widespread perception that PWD are not sexually active. In reality, they are just as sexually active as their non-disabled peers and should therefore not be denied access to information about HIV and tailored prevention messages. Information, education and communication (IEC) materials and other interventions have excluded men, women and children with different abilities. Key among the findings of the study was the belief that PWD, especially the hearing impaired, mute, and visually impaired, are endowed with high sexual performance.

ZPI will work with the Zambia National Library and Zambia Agency for People with Disabilities. Together with these institutions we will identify equipment and materials that are needed for production. Examples of information that will be transcribed into Braille will include: Introduction to Antiretroviral Therapy, Alcohol use and Abuse, GBV, Men and HIV in Zambia, HIV and AIDS basic handbook for entrepreneurs.

ZPI will implement AB activities through community mobilization approaches that exemplify the core principles of meaningful involvement and active participation of the target group and sustainability of the interventions. The AB activities will be carried out in both rural and urban communities which under ZPI, are broadly defined to include geographical areas (such as villages or districts); communities based on shared values (such as religious groups); communities based on shared experiences (such as PLWHA); those based on gender and age; and those based on particular experiences (such as alcohol and drug misuse or experiences of gender-based violence) or professional groups. In addition, ZPI will identify champions who will serve as advocates representing the different target groups.

Some of the identified methodologies which will be used to implement AB activities will include a range of approaches including assertiveness training, Participatory Learning and Action (PLA), Theatre for Development (TfD) and peer group process work. AB activities will be implemented through peer groups, formed of 10-20 members of the same sex and similar age, work together through a sequenced program of sessions that enable participants to explore a range of issues that affect their sexual health. These include gender roles, money, alcohol use, traditional practices, attitudes to sex and sexuality, attitudes to death and inter-generational relations. These approaches will empower people to collectively respond to, and where necessary, challenge negative social norms, stigma or structural issues which affect quality, evidence-based HIV prevention.

Furthermore, the utilization of multiple platforms for working with different sectors of Zambian society and through community structures will be encouraged. This process will include identifying where ZPI is positioned in respect to health care providers for CT, PMTCT and ART, as well as examining the types of networks which would be advantageous for AB activities to thrive. Monitoring, learning and innovation is recognized as a key project component which would lead operational research, documentation of best practices and encourage the implementation of innovative ideas through the sub-granting mechanism. ZPI will link the sexual prevention activities with facility-based treatment and care and support partners by creating referral mechanisms and client tracking system using volunteers for clinic-based care and support programs including but not limited with condom programming, counseling and testing, partner disclosure and etc.

ZPI will work towards increasing the uptake of TC, including supporting provision of services. The strategy for the uptake of TC will be anchored in the community mobilization activities which will use participatory methodologies for HIV information dissemination and activities around social behavior change. The dialogue which will occur with the clients through mobile, home based and community activities, will aim to deepen peoples understanding of personal and collective risk.

ZPI will use community-based peer groups created through Reflect Circles, Stepping Stones, radio listening groups, PLWHA and other support groups to recruit clients for TC. In concert with the recruitment for uptake of TC, ZPI will review the list of available health care providers offering mobile and static services; this will be conducted in all ZPI operational areas. Where a gap in TC provision exists, the project will endeavor to partner with either the District Health Offices (DHOs) or other service providers to ensure that the affected communities receive TC services. ZPI will ensure that all TC points in its jurisdiction offer referral information on care and support, treatment and family planning support.

The project will also utilize a range of outreach workers who are involved in community mobilization of other HIV related programs such as PMTCT, MC, post-exposure prophylaxis (PEP), TB, and STI to increase the uptake of TC. An inventory of these community based individuals will be conducted to establish their skill base since ZPI aims to build on what has already been established in the communities. In this respect the project will support the lay counselors in the aspect of couples counseling, notification, disclosure and child counseling. ZPI will also be working with the lay counselors to build their capacity to deal with the underlying root causes that put people at risk such as GBV, alcohol and drug use/misuse, mental health and economic vulnerability.

Other prevention activities will target the most at-risk populations HIV in Zambia which include: 1) partners of persons who practice casual heterosexual acts; 2) persons who practice casual heterosexual acts; 3) persons in stable sexual relationships, including marriages; and 4) babies born to HIV+ mothers. Other groups at comparatively high risk include highly mobile populations such as migrant workers, sex workers, long-distance truck drivers, minibus drivers, refugees, prisoners, uniformed personnel (such as the military and police) and men who have sex with men (MSM).

Each of these groups are seen as struggling with stigma and discrimination specific to their risky behaviors thus sexual prevention interventions for the target group will be implemented through the use of a series of screening tools. These tools will either be adapted or developed in order to determine the level of vulnerability to HIV in relation to their specific situation. These screening tools will be used in a clinical setting as well as community and households in order to identify vulnerable individuals, families and group to assist the program in designing relevant interventions. A general HIV risk assessment tool will be designed to capture different vulnerabilities to HIV and will focus on biomedical and socioeconomic issues. In addition, targeted risk assessment tools such will be used to assess and determine key risks for specific target groups, such as young women, and to key risks such as GBV, child sexual abuse, alcohol and drug abuse. ZPI link clients to other services as appropriate, including PMTCT, MC, HBC, OVC and HIV prevention services in general.

The use of tools will help in disaggregating information about the target which will in turn enable ZPI to implement OP activities which will not only prevent new HIV infections, but also protect those who might already be positive. The activities will also protect those who are negative but vulnerable to HIV infection due to their gender, age, economic status or their physical or mental disability. ZPI will also increase access to HIV/AIDS information in education sector through mobilizing teachers and training workshops in each provinces and providing HIV/AIDS support to the 14 teacher training colleges in Zambia. To increase the sustainability of the teachers support groups and increase disclosure of those testing positives ZPI will strengthen the existing support group models in each province.

Although Zambia has made significant progress in scaling up PMTCT services, reaching HIV-positive pregnant women and their infants with timely, comprehensive PMTCT services is still a challenge. The vision of Ministry of Health (MOH) is to eliminate pediatric HIV by 2015 through implementation of national PMTCT guideline (revised in December 2010). In FY 2012 and F2013, ZPI will contribute to this vision by providing gender sensitive interventions that promote: early registration for ANC of pregnant women (at least by 14 weeks of gestation); deliveries at a health facility; male partner involvement; and adherence to comprehensive PMTCT package. The project will also identify areas that lack PMTCT services and support outreach services. PMTCT activities under ZPI are primarily mobilization and engagement of communities for the uptake of PMTCT. However, these strategies will involve provision of district-wide behavior change messages for reducing risks of HIV transmission. In addition, these community activities will be integrated with promotion of medical MC.

Therefore, although minimal direct numbers on selected PMTCT indicators will be collected, the targeted populations (girls, boys, men, women, including pregnant women and their spouses) will also be reached with individual and/or small group level HIV preventive interventions that are based on evidence and/or meet the minimum standards required. Specific activities will include: training of community leaders, community health workers, champions and other para-health workers in mobilizing and engaging the targeted populations to demand for PMTCT services in all prongs; support to health facilities and DHOs to implement outreach PMTCT services; training of health workers and para health workers to provide TC services to pregnant women and their partners and if testing positive, referral to HIV care and support services. The trained providers of TC services will also assist the health facilities in minimizing loss to follow up of mother infant pairs through regular home visits as family supporters, provision of positive health dignity and prevention or PwP services and prompt referral to health facilities for medical management if indicated

Under the care and treatment technical area, ZPI will work with PLHA to promote community-based care and support. ZPI aims to create a safe space for friendly services which promote free participation. Specific tools will be used to assess sexual activity, partner status, STIs, FP, and need for nutritional education and food support. Providing appropriate counseling and support to women living with HIV and couples, will enable them make an informed decision about their future reproductive life, with special attention to preventing unintended pregnancies will also be part of the community based interventions. The community mobilization activities in care and support will ensure that referrals for a range of clinic based services which include partner testing, STI treatment, family planning and pregnancy counseling. These activities will also be referred to other sites such as those established by the Corridors of Hope Project, or static services supported by the ZPCT Projects. The target group will be encouraged to enroll into a support group.

Care and support activities in the community will also be closely linked to economic empowerment activities to ensure that people on treatment are able to meet their dietary needs. The FANTA-II project in collaboration with the Zambia National Food and Nutrition Commission recently updated the nutrition guide for PLHA. This resource will be disseminated to the target group.

Finally, ZPI will work closely with identified PLHA and PLHA groups to promote positive livings and behavior change. Using the ZPI lenses the project will focus on issues such as reduction in alcohol or abuse of other substance that may interfere with ARV drug adherence. ZPI will wrap-around economic empowerment interventions using the GROW model to introduce financial savings programs with PLHA groups. ZPI is operates at community levels and no specific facility-based sites. Provincial and district staffs will provide routine supervision for mobile counseling and testing services and community volunteers to improve the quality of service and data. ZPI will support the facility-community linkage and referral mechanism to improve retention of patients initiated on ART. ZPI will outsource activities to more than twenty (20) local organizations which enhance community-based prevention interventions, promote transition to local ownership and sustainability for HIV prevention activities and ART service delivery.