Our goal is to ensure the sustainability of quality HIV care for all Zambians in the target provinces through two primary strategies. The first is to transition direct HIV program support from the Centre for Infectious Disease Research in Zambia (CIDRZ) to the Provincial Health Offices (PHOs) by building clinical and management capacity to deliver reliable essential services. The second is to promote the long-term viability of HIV care by developing effective models that integrate Prevention of Mother to Child Transmission (PMTCT) and Antiretroviral Therapy (ART) in existing primary health care services and leverage this investment to provide better and more comprehensive basic care. We have five overarching objectives across PMTCT and adult and pediatric HIV care and ART service support areas:

1. Support continuous, quality health services during the transition period

2. Build capacity and promote ownership through performance evaluation and quality improvement

3. Transition direct site support to the PHOs

4. Develop integrated and comprehensive care model sites in each province

5. Support MOH-led training and mentoring

Our Eastern, Southern, and Western provincial teams will continue to support PHO plans and activities as requested, working in close collaboration with the PHOs, CDC, and other partners to promote complementary support and services. CIDRZ central and provincial specialists include experienced HIV medical officers specializing in advanced clinical training, quality improvement nurses and clinical officers, laboratory technicians and managers, pharmacists, and data managers and analysts.

Improve retention in care and treatment for pre-ART and ART patients

1. Increase ART treatment preparation according to new guidelines by having minimum of three adherence visits before initiation of ART

2. Improve referral and feedback between higher and lower level ART sites through training and the creation and use of feedback forms

3. Strengthen linkages and referral networks between community groups and ART sites

4. Strengthen community program to improve pre-ART retention and early detection of patients needing ART through community trainings

Integrate HIV care and treatment services with other services and improve linkages

1. Improve the care and treatment of TB/HIV co-infected patients by intensified case finding for TB in 50 HIV clinics

2. Enhance linkage between ART and TB clinics by referral and reflex CD4 testing for all patients with HIV and active TB

3. Enhance provision of HAART in PMTCT services through training of 40 midwives, mentoring of midwives to support ART in stable patients in MCH clinics, and referral of complicated cases to ART clinics

4. Integrate provision of ART services in general outpatient (OPD) services (in clinics with adequate infrastructure)

5. Strengthen provider-initiated testing and counseling (PITC) in OPD and inpatient wards and links to HIV care and treatment

6. Increase referrals and linkages to MC services

7. Integrate Nutrition Assessment, Counseling and Support (NACS) within clinical management and community support for clients

8. Start cervical cancer (Ca Cx) screening at 4 new sites

9. Continue to support Ca Cx screening at 10 existing sites

Laboratory testing

1. Support MoH to provide pre ART laboratory testing to 70% of patients accessing care at CIDRZ supported sites

2. Support MoH to scale up laboratory testing for pre ART services

Improve the total health of HIV infected children and exposed infants/children through early identification of HIV infection, linkage to care and treatment, provision of psychosocial services, and linkage to available support services.

Improve retention of paediatric patients in care

1. Assist paediatric counselors to start 20 paediatric support groups per year

2. Support the formation of 20 adolescent support groups:

3. Support 16 pediatric puppetry performances per month

4. Train 80 community agents in mother-baby tracking

5. Support the development of 20 care-giver support groups in the CIDRZ supported sites in Lusaka

6. Promote health-seeking behavior through improved counseling

Support the development of integrated clinic systems

1. Develop protocols and improve clinic flows

2. Strengthen the referral of patients to other services such as nutrition

3. Support the integration of infant feeding trainings for MCH and paediatric ART support staff 4 per year, one in each province

4. Support integrated trainings for MCH and pediatric ART health care workers (HCW) in EID 4 per year, one in each province

Support transition by building clinical and mentoring capacity through joint activities

1. On-site mentoring of 40 pediatric peer educators/counselors

2. Train 3 PHO/DHO point persons to supervise pediatric counselors/peer educators

3. Train 60 pediatric counselors in adolescent counseling

4. Train 40 peer educators in bereavement counseling

5. Train 40 lay health care workers (LHCW) in full clinic support package

Promote the delivery of quality pediatric support services

1. Conduct quarterly supportive supervisory visits

2. Identify training needs of support workers and recommend for training

Promote equity of access to ART by disadvantaged children

1. Support the linkage of orphaned/disadvantaged children from ART services to social support systems

2. Support the linkage of orphaned/disadvantage children from community support systems to ART services

3. Support the linkages of children between different service centers within the health system and outside the health system

Laboratory testing

1. Support MoH to provide laboratory testing to 70% of pre ART paediatric patients accessing ART at CIDRZ supported sites

2. Support MoH to scale up laboratory testing for pre ART paediatric services

Provide clinicians with essential diagnostics for decision-making through laboratory services and systems strengthening

1. Continue to offer rapid and high quality comprehensive laboratory testing services for HIV-related programs in Lusaka province at the CIDRZ-Kalingalinga Central Lab

2. Provide DBS PCR testing (Eastern, Lusaka, Western) in support of national EID program

3. Provide TA support to laboratories in Eastern, Lusaka, Southern, and Western Provinces

Improve reliability and quality of PHO laboratory services through technical assistance, reagent support , laboratory equipment and training

1. Support PHO planning of 3 Lusaka Province laboratories

2. Equip 2 provincial hub labs to provide CD4, haematology and biochemistry services

3. Provide back up reagents to EP, WP and SP

4. Provide generators to ensure uninterrupted services at 2 provincial laboratories.

5. Train PHO lab staff in laboratory planning and management

6. Work with PHO and MoH to evaluate and recommend appropriate back up energy sources

Ongoing support:

1. Meet the diagnostic requirements of new guidelines and improved TB and STI screening through expanded laboratory systems

2. Assist MOH laboratory teams in reviewing system performance for ongoing operational and QA/QC planning

3. Support planning and activities to improve national specimen referral (Note: CIDRZ Lab will continue to participate in activities currently led by CHAI in support of strengthening national specimen referral system)

4. Provide TA in national LIS planning and implementation

5. Provide support to MOH EQA accreditation initiatives

6. Support MOH with design, installation and maintenance of appropriate energy source systems to ensure continuous supply of electricity for the laboratories

We will work with the Ministry of Health and local partners to support the collection, analysis and assessment of routinely collected programmatic data.

We will gradually hand over the site level data entry to the MoH

1. We will directly support data entry at 80% of the present sites

2. We will support 18 monitoring and evaluation mentors to support data entry in newly transitioned sites

3. We will provide technical support and supervision to information officers at the District and Provincial offices

4. We will provide assistance with SmartCare training

To build capacity at the provincial and district levels to monitor and evaluate the ART and PMTCT services to ensure a smooth transition of management of services from CIDRZ to MoH and further integrate and strengthen integrated services in TB, PMTCT, Family Planning (FP) and Maternal Child Health services (MCH).

Activities

1. Hold technical consultative meetings with the provincial and District teams

2. Implement ART services in TB, PMTCT, MCH areas focused on strengthening of the Drug Information Systems in 25 ART sites (ie integration of HIV services within TB corner, MCH and OPD)

3. To work with Provincial lead mentors for continuous onsite training and mentorship to ensure buy-in of the staff at the service delivery point ( quarterly)

4. Support activities which will strengthen Drug accountability and logistics through on QA/QC at the district warehouse level and sampled ART sites in Lusaka.

Support enhanced PMTCT commodities stock availability security in all supported districts to ensure an efficacious program and eliminate use of sdNVP

Build capacity in good ART pharmacy practice to be able to support advanced ART services

We will work with CDC partner AIHA to coordinate activities to avoid duplication of effort. In some areas where AIHA is not yet active and the MOH requests it, we will be able to support the following:

1. Support technical assistance for development of training materials, participate in conducting Advanced Pharmacy ART ToT ( six Pharmacists)

2. Technical Assistance to MoH Provincial Pharmacists mentors

3. Technical Assistance to Provincial Pharmacists to develop a training schedule for Pharmacy staffs in ART sites

4. Technical assistance to Provincial Pharmacists to build indicator for Pharmaceutical Monitoring and Evaluation of the ART services.

5. Introduce bar coding technology at the service delivery point and the warehouse level to enhance accountability and reduce wastage through expiration and over stocking- Lusaka pilot this in four sites and centrally in Lusaka). This will be under taken as part of Operational Research

6. Train 40 new graduate pharmacist in good commodity management and M&E

Increase equity of access to provision of family planning services and ensure all ART pharmacies stock family planning products by September 2012.

1. To hold three one day meetings at provincial level to sensitize Provincial Pharmacists on gender issues and equality to access of comprehensive services including family planning

2. Offer Technical Assistance to the Provincial Pharmacists Conduct training workshop for pharmacy staffs in provision of family planning services and Family Planning products, MoH Staffs to take a lead role. Train four pharmacy staffs (principle pharmacists) in a one day training

To work with Provincial and district pharmacists to support enhanced commodities security for FP supplies to meet the increased uptake/ need of HIV positive girls and women under ART services (30 ART pharmacies to stock family planning products)

CIDRZ will support the GRZ National Male Circumcision strategy by expanding the coverage of adult and neonatal male circumcision.

Our specific objectives and activities are to:

1. Introduce adult MC in 10 new sites and provide MC to 12,500 HIV-negative males in the first year; specifically:

a. Recruit one MC implementation coordinator and one data coordinator.

b. Recruit and train 15 full time MC providers to be based at MC sites and perform MC.

c. Provide surgical supplies and consumables to 10 MC supported sites.

d. Provide ongoing support to all sites to ensure provision of high quality MC services through supportive supervision.

e. Conduct skills transfer and mentoring of 40 MOH staff in surgical MC skills at these sites.

f. Train 60 MOH staff in MC benefits, risks, post-operative care and management of complications.

g. Support MC demand generation through community mobilization

h. Hire and train 10 peer educators for the new sites to support demand creation and follow up of clients missing their review dates.

i. Promote couple counseling in the MC program and facilitate linkages to HIV care, family planning, STI treatment, and PwP programs.

j. Conduct safe outreach MC services in consultation with the PMOs, DMOs.

k. Support high quality data collections, reporting and use through support to part time data clerks.

2. Continue support to the 5 NMC service delivery sites and expand support to 3 additional sites and provide 6,000 neonatal male circumcisions

a. Recruit 3 additional dedicated NMC providers to perform NMC and provide supportive supervision in order ensure maintenance of high quality services.

b. Conduct skills transfer and mentoring of 10 MOH staff in surgical NMC skills at these sites.

c. Train 15 MOH staff in MC benefits, risks, post-operative care and management of complications

d. Hire and train 6 peer educators for the new sites to support demand creation and follow up of clients missing their review dates.

e. Provide support for non-consumable supplies for MC.

3. Promote integration of MC with other services

a. Train peer 40 educators and 40 health care staff across a variety of services to provide integrated referrals

b. Support clinic integration meetings and ongoing mentoring aimed at integrating MC with other prevention, such as PMTCT, family planning, and counseling and testing.

4. Support the national MOH MC program

a. Support MOH-led initiatives and implementation of national guidelines and training programs.

b. In collaboration with other stakeholders, support the MOH in finalization and launch of NMC training manuals.

c. Support implementation of the National MC Communications strategy.

d. Participate in national MC technical working groups.

e. Assist in monitoring and evaluating scale-up activities and provide technical guidance to GRZ on future scale-up.

5. Improve demand through community education

a. Participate in annual MOH campaigns such as national male circumcision and child health week campaigns to promote MC and NMC.

b. Print and distribute Information, education, and communication (IEC) materials tailored to address community concerns.

c. Hold meetings with neighborhood health committees, community-based organizations, and community leaders to gain program acceptance from the community, dispel myths about MC and NMC, improve community awareness, and build NMC demand.

d. Improve linkages between male partner testing and male circumcision

Provide family-centered, quality, comprehensive and integrated safe motherhood services

1. Support HIV counseling and testing (CT) and STI screening services for women and their partners

2. Identify discordant and concordant couples and refer for care and treatment (including male circumcision (MC))

3. Integrate CT in family planning

4. Integrate TB screening, gender-based violence (GBV) counseling, cervical cancer screening and youth friendly services in maternal-child health (MCH) services

5. Mentor health staff using on-site QA/QI to support integrated services

6. Orient and mentor community structures to promote early ANC, couples counseling, facility delivery, and postnatal attendance throughout breastfeeding

Provide more efficacious PMTCT regimens to ALL HIV positive women

1. Support CD4 sample referral systems

2. Introduce cell phone text messaging for active client referral

3. Mentor health staff in integrated PMTCT/ART services, including HB and WHO clinical screening and drug logistics systems

4. Train and mentor lay community health workers and community structures

5. Incorporate MOH standardized package for family planning counseling and messaging into ART, PMTCT, and PwP training

Provide comprehensive HIV prevention, treatment and care services to HIV exposed babies

1. Provide HIV testing, nevirapine (NVP) prophylaxis, cotrimoxazole (CTX) prophylaxis and infant feeding counseling

2. Provide HIV testing to siblings of HIV exposed infants

3. Introduce cell phone text messaging for active referral of HIV positive babies

4. Mentor health staff to strengthen HIV exposed baby care

5. Review and introduce a community register for exposed baby tracking

6. Integrate neonatal male circumcision services

7. Support outreach activities during child health weeks to test HIV exposed babies

Strengthen Monitoring and Evaluation to enhance data quality and use

1. Support revision of HMIS registers

2. Support CDC epidemiology for data user (EDU) training

3. Conduct integrated data quality audits

4. Mentor health staff in optimal use of electronic record systems and data use for performance evaluation

5. Orient community structures in data appreciation and use

6. Assist with strengthening of Smart Care in supported PMTCT sites

Improve quality of advanced HIV care

1. Train 100 health care workers on identification of patients failing treatment using the viral load testing algorithm

2. Provide ongoing quality clinical care for complicated patients

3. Train 40 health workers in facilities on quality assurance/quality control and performance quality improvement and transition these activities

4. Train 10 select health workers in HIV drug resistance monitoring

5. Roll out early warning Indicators for quality control in conjunction with the PHOs

6. Enhance referrals for complicated HIV care to Advanced Treatment Centres and provide ongoing technical support for advanced treatment care

7. Improve phone and email consultations to HIV clinicians from ART/PMTCT/TB sites

8. Continue support to health facilities to reach accreditation standards for quality health care

9. Establish a two-way referral support between facility and community services for NACS

Transition training and mentoring to PHOs and DHOs

1. Coordinate with PHOs to orient ART trained health care workers in new treatment guidelines

2. Support PHO-led clinical trainings in advanced HIV and OI management and basic ART

3. Coordinate with PHOs to train peer educators and point persons at 40 sites in nutrition assessment and counseling

4. Provide joint on-site clinical mentoring

5. Continue to build capacity in PHOs through ongoing training of trainers (TOT) and clinical mentors training

Provide equity of access to comprehensive services

1. Partner with organizations working in 12 rural sites to increase access to ART care

2. Continue HIV testing, TB screening, and treatment for prisoners (1 site)

3. Treat HIV-positive partners in discordant couples and refer HIV-negative males for MC

Provide technical support to the Ministry of Health

1. Participate in Adult Treatment, HIV Drug Resistance, and National Quality Improvement Technical Working Groups

2. Participate in consultative meetings with the Health Professions Council of Zambia on accreditation of ART and MC sites

3. Support the annual National Technical Update

Laboratory testing

1. Support MoH to provide laboratory testing to 70% of patients accessing ART at CIDRZ supported sites

2. Support MoH to scale up laboratory testing for ART services

Quality Assurance

1. Train and mentor key point persons at PHO, DHO and sites to provide ongoing QA/QC assessments and quality committee meetings

1. Provide support for accurate, comprehensive data collection and data entry for ongoing QA/QC and program management

The overall goal of the pediatric treatment program is to increase the survival and improve health of all the HIV infected children through the provision of quality and uninterrupted antiretroviral treatment according to the prevailing national guidelines.

Promote paediatric ART initiation and retention of pediatric ART patients in care by:

1. Training 60 peer educators to provide adherence counseling

2. Training 60 peer educators in child counseling including disclosure

3. Supporting community awareness programs on pediatric ART; support 12 sensitization activities per year

4. Using QI reports (quarterly) to identify children in need of treatment who are not yet on treatment

Support the integration of pediatric clinical care through

1. Supporting training of staff at 10 integrated sites

2. Supporting the integration of PITC at all pediatric points of contact

Support capacity building of HCWs through:

1. Provide technical support for pediatric clinical mentoring with PHO/DHO mentors quarterly visits per site

2. Provide technical support to PHO for training of clinical mentors

3. Provide technical support to PHO for 4 trainings per year in pediatric ART management

4. Supporting 4 HCW trainings per year in adolescent HIV management

5. Providing technical support to UNZA for one training per year in pediatric ART management (pre-service)

Support internal capacity building of CIDRZ staff through

1. Supporting international travel to 2 conferences per year

2. Supporting local CME activities for all staff

Ensure provision of quality pediatric clinical care through

2. Orienting all CIDRZ supported ART sites on new pediatric ART guidelines

3. Ongoing clinical mentoring at CIDRZ supported sites

4. Ensuring availability of pediatric job aids and guidelines in all CIDRZ supported sites

5. Providing quarterly supportive supervisory visits by the CIDRZ clinical team:

6. Providing technical support to MOH by actively participating in the pediatric technical working group

7. Support for accurate, comprehensive data collection and data entry for ongoing QA/QC and program management

Promote equity of access to comprehensive pediatric care through:

1. Supporting the mentoring of 4 nurse practitioners working in remote sites

Laboratory testing

1. Support MoH to provide laboratory testing to 70% of paediatric patients accessing ART at CIDRZ supported sites

1. 2. Support MoH to scale up laboratory testing for paediatric ART services