The Churches Health Association of Zambia (CHAZ) through its member health facilities and faith based organizations with support from cooperating partners manages programs such as HIV/AIDS Care and Prevention, ART/PMTCT, Malaria and TB.

CHAZ acts on behalf of the 16 Christian Churches (Catholic and Protestants) with a total of 146 church health facilities and faith based community. Registered members operate on a Not-for-Profit basis and within the policy framework of the Ministry of Health (MOH) whose vision is to provide equity of access to cost-effective, quality health care as close to the family as possible.

In FY2012, in line with PEPFAR Zambia Key priority areas, CHAZ AIDSRelief Transition (CART) project will continue to focus on Prevention, treatment, care and support and health systems strengthening for HIV/AIDS. PEPFAR Zambias agenda is aligned with the National AIDS Strategic Framework 2011-2015 and the National Health Strategic Plan 2011-2015 and falls under the Partnership Framework between the United States Government (USG) and the Government of the Republic of Zambia (GRZ).

Through the CART project, CHAZ will assume responsibility for implementing activities in 2 LPTFs in addition to the 5 LPTFs from FY2011. CHAZ will contribute to the national HIV/AIDS program outcome and impact results by ensuring the reduction of annual infection rate, reduction of MTCT, and ensuring an increase of the number of PLWHA who are alive at 36 months after initiation of ART

CHAZ will continue to work closely with, and support MOH to ensure country ownership, leadership, and strengthened capacity. Collaboration with other partners and integration will be strengthened to ensure efficiency and sustainability.

CHAZ will focus on the following Priority areas:

1. Comprehensive and family centered care services.

2. STI and OI management

3. Strengthen community and GRZ structures for service provision.

4. Integration and Linkages/ referral systems.

Adult care and support services are largely centered on the work of the Community Based Treatment Service (CBTS) team that focuses on incorporating the community to extend and optimize the quality of life for PLWHA.

In FY 2012 CHAZ will:

1. Train staff and Community health workers to utilize the patient as an entry into the family. All HIV-positive individuals, regardless of treatment status, benefit from general prevention and health promotion support, including PwP, family or partner testing, and nutrition advice. These activities further serve to keep pre-ART patients in the ART program where they are monitored for prophylaxis, treatment eligibility and opportunistic infections (OIs). LPTFs will also be assisted in creating a referral system for STI management, TB, maternal and child health, other health services including substance abuse or mental health services.

2. LPTF staff will be trained in OI and syndromic management of STIs to ensure provision of quality health services

3. The CBTS team will provide training to LPTF staff and community health workers on treatment preparation, support and reducing LTFU. Adherence will continue to be strengthened and will be incorporated into structured treatment preparation and ongoing treatment support. Strong community linkages will continue to be emphasized and created. The outcome of these adherence activities is an overall low lost-to-follow- up rate. CBTS will help to ensure that clients in care remain linked to the clinic and receive follow up CD4, and preventive health care including cotrimoxazole prophylaxis, insecticide-treated nets, nutritional assessment, education about clean water and treatment of diarrhea and other acute illnesses.

4. CHAZ will continue with technical support in strengthening integration and linkages with family planning, nutrition assessment, counseling and support, palliative and home based care and prevention with positives. The CBTS team will support linkages between the ART clinic and the community based support groups including palliative care services. Health workers will be trained in palliative care.

Priority areas for TB/HIV collaboration:

1. Linkages

2. Infection control, IPT and ICF (3Is)

3. Documentation

4. Health seeking behavior

5. Community treatment supporters

6. Training for health workers

7. Human resource

Planned strategies:

1. CHAZ will strengthen the linkage/referral system between the HIV/ART and TB programs thereby ensuring that HIV-positive clients are screened for TB and fast-tracked to appropriate treatment if co-infected, and also ensure TB patients are tested for HIV.

2. CHAZ will strengthen the LPTFs and the community in the implementation of the 3Is. The LPTFs will intensify TB case finding in the ART, OPD, MCH and inpatient departments and ensure that TB suspects are triaged and separated accordingly in order to reduce the transmission of TB to health workers and other patients especially those who are HIV positive. LPTFs will also ensure that PLWHA are being actively screened for TB as well as accessing IPT and CPT in accordance with the National guidelines

3. Quarterly onsite technical support and mentoring will be intensified to improve the quality of data in the source documents and reports

4. The poor health seeking behavior among community members is rampant, mainly due to ignorance, stigma, myths and misconceptions. Therefore, CHAZ will strengthen and facilitate implementation of the Advocacy, Communication and Social Mobilization (ACSM) strategy. The LPTFs and CBTS will embark on BCC via community gatherings/meetings, drama groups and radio programs

5. CHAZ will continue to build the capacity of CBTS through training in TB/HIV and quarterly meetings. The CBTS will also be provided with incentives in form of stationery, T-shirts and bicycles

6. Health workers will be trained in the Stop TB Strategy, TB/HIV integration, infection control, TB microscopy and Directly Observed Therapy (DOT) in line with the National TB Program. Stipulated guidelines will be disseminated and CHAZ will ensure that LPTFs use them

7. The human resource crisis is cross-cutting

CHAZ will carry on with the development and utilization of CHWs who assist with TB/HIV treatment adherence and specialized daily visits to the patients homes to directly-observe therapy and provide basic check-up. This is an innovative and cost-effective way to address severe health care shortages. Considering TB/HIV co-infection, CHAZ will maximize the utilization of CBTS for both HIV and TB so that there is only one volunteer attending to a patient at a time to avoid duplication of duties. This will lead to efficiency in the program.

Priority Areas:

1. Expansion of Early Infant Diagnosis (EID), and Care

2. Family/Male involvement

3. Training

4. TB/HIV Integration

Strategies to address the priority areas:

1. CHAZ will continue to focus on diagnosis and turnover of results for Early Infant Diagnosis to ensure timely initiation on treatment of all infants confirmed positive. CHAZ will also provide oversight and ongoing training of staff in correct DBS methodologies. All HIV exposed infants will be enrolled in care up to the age of 2 years to ensure ongoing Co-trimoxazole prophylaxis, prompt diagnosis, routine vaccinations, and support for maternal health. Three vehicles will be assigned to collect DBS samples from the Hubs to the Laboratory. Through collaboration with MOH and other partners, Innovative technologies such as SMS reminders will be used to increase timely feedback of PCR results from the Laboratories.

2. Family involvement is a key to supporting best outcomes for HIV positive infants and children, and emphasis on male involvement is incorporated into pediatric care messages. Providing strategies for ART clinics to see all family members on the same day helps promote this endpoint. This area will be strengthened.

3. CHAZ will continue to train LPTF staff in pediatric psychosocial counseling and IMCI to improve the care of the children

4. Integration of pediatric care with TB care will be strengthened. In addition all pediatric ART patients will continue to be routinely screened for symptoms of TB and other OIs

Cross-cutting activities in the areas of Food and Nutrition include the provision of pediatric scales and equipment necessary to provide nutritional assessments, and the provision of therapeutic and micronutrient supplementation.

Priority areas:

1. Data collection

2. Data entry & Backlog

3. Data utilization

Strategies

1. To ensure that quality data is collected; CHAZ will embark on training of both clinicians and hospital administrators on the importance of data for overall program management and tracking of patient data. This will include completing of patient paper forms and registers.

2. LPTF Data Entry Clerks (DECs) will be trained in the capturing and cleaning of data before entering into SmartCare. All clinical forms entered will be properly filed and kept in filing cabinets for confidentiality. This will lead to accurate reporting, program data availability and improved health outcomes.

SmartCare workload analysis tool:

3. Data Utilization

CHAZ CQI program will train and mentor LPTFs in the formation of on-site CQI committees. These teams would be supported with technical assistance in promoting; regular quality assessment of health outcomes, data utilization and onsite data ownership.

CHAZ will also ensure that LPTFs have adequate resources to support and manage SmartCare, the national Electronic Medical Record (EMR) system. The LPTFs will collaborate with CHAZ, CDC and the MOH to ensure SmartCare certification for data managers. The LPTFs will ensure that generated reports are accurate, valid and timely. They will synthesize PEPFAR quarterly reports using Demand for Data Information Use (DDIU) approaches.

Health Systems Strengthening (HSS) is key in delivery of the right volume and distribution of health services.

Priority areas in HSS:

1. Integration

2. Referral /linkages

3. Human resource

4. Transport

5. M & E

6. Laboratory capacity

7. Financial compliance.

CHAZ will address these areas through:

Provision of Integrated services through the holistic, family centered care model which shares the same core values as the AR-T project which promotes integration of adult and pediatric clinical and community service. CHAZ and the LPTFs will work closely with the national, provincial as well as the District AIDS Task forces and strengthen partnerships with other civil society.

CHAZ will facilitate strengthening of community involvement in health service delivery through formation and or strengthen community structures and involvement in planning to promote the spirit of health service ownership. This will be done in to strengthen referral and linkage. Furthermore CHAZ and LPTFs will continue to participate in the District, provincial and central level planning and review processes.

CHAZ capacity will be strengthened through the implementation of the AIDS Relief-CHAZ transitional Plan in advanced ART management, strategic information, financial management and USG grant administration. CHAZ will support LPFT and ensure communities retain their staff through non financial support.

In the first year CHAZ secretariat will outsource transport as provided in the budget and in year 2 will procure vehicles.

CHAZ will continue to train CQI teams, will procure and distribute computers to strengthen the physical capacity of LPTFs use of Smart Care, employ data managers for LPTFs and provide guidelines and algorithms, mentor clinicians in drug toxicities and long term side effects of ARVs.

CHAZ will continue to build capacities of lab staff and clinical staff in LPTFs. CHAZ will continue to participate in the national EQA program and Quantification meetings for Laboratory test kits, reagents, OI drugs and ARVs.

CHAZ will continue to use Sun Systems accounting package to capture accounting transactions and ensure that LPTFs Financial Reports are adequately reviewed monthly in accordance with USG and accounting Standards. Specific Finance staff will be allocated to the program. These will among other things review financial reports and provide mentoring to the LPTFs. The internal Audit on the other hand will provide independent assurance of financial Reports.

Cross cutting issues that have been added to strengthen the HSS are Human Resource for health, construction and renovations of LPTFs infrastructure.

The CHAZ will also utilize the additional funding from the Partnership Framework Implementation Plan (PFIP) allocated under COP12 ($187,262) to strengthen sub-national logistics supply systems covering drugs and laboratory commodities by procuring 3 utility vehicles. The vehicles will be dedicated to assuring steady availability of drugs for HIV/AIDS services and laboratory commodities in the FBO health facilities under CHAZ, and that whenever necessary, commodities are re-distributed between districts/facilities to prevent stock-outs at service delivery sites.

Priority Areas:

1. Trainings and task shifting

2. Scale-up male circumcision services

3. Community sensitization

4. Linkages

5. Unsafe practices of Male circumcision

6. Technical support

To address the priority areas CHAZ will:

1. Train health workers, and will support MOH in task shifting by training other health workers such as Clinical officers and nurses in carrying out Male Circumcision (MC). This will help the program to reach more people. CHAZ will train peer educators in school and Youth Friendly corners to deliver MC messages.

2. Scale-up male circumcision (MC) at all the LPTFs - This will be achieved through provision of static and mobile MC services to the rural health centers and the communities by the LPTFs.

3. Community sensitization will be strengthened in all communities. In some parts of Zambia MC is not practiced traditionally. In these areas CHAZ will further strengthen community sensitization and mobilization.

4. CHAZ will establish and strengthen linkages between the community, MC centers, ANC, ART and other health services. The MC services will be integrated with the CT to check on the HIV status of the males coming for the service.

5. To ensure quality in MC, CHAZ will sensitize the ethnic groups who practice traditional male circumcision so that theres collaboration between such traditional groups and the medical male circumcision teams from the LPTFs. This collaboration will ensure that circumcision (surgical procedure) at such traditional ceremonies is conducted by medical personnel as a mobile intervention. Traditional rulers will be sensitized on the need for this collaboration and its advantages.

6. CHAZ will conduct technical support to all the implementing sites to assess the quality of MC services being done and conduct mentorship on site.

Priority Areas:

1. Scale-up Counseling and Testing

2. Trainings

3. Motivation of the Community Based Volunteers

4. Linkages with other programs

Strategies to address the priority areas include:

1. CHAZ will scale up the Counseling and Testing (CT) so that more people access this service through the use of rapid HIV tests which can be performed at almost any site, including the home and community through mobile CT, home based services and community mobilization. Provider initiated testing and counseling (PITC) will be scaled up in all the health facilities for all the clients and patients in high risk groups such as pregnant women, STIs, TB, patients with Opportunistic infections, and all the children admitted in the wards. The PITC will compliment the Client-initiated for HIV testing and counseling. Mobile outreach CT programs will be scaled up in all the health facilities so that more people have access to this service.

The CBTS will work with the LPTFs, CHWs and community leaders to sensitize the community in CT. CBTS will assess community involvement in CT, access to testing services, map other CT providers and develop an implementation plan. Target populations will include couples, MARPS (truck drivers at Chirundu), pregnant women, and the general population. The CBTS team will develop messages for co- habiting and discordant couples and these will be disseminated in the community.

2. Community health workers (Volunteers) will be trained in the HIV/AIDS community counseling and testing. Health workers will be trained in couple counseling and basic CT. The training on finger prick testing for HIV will be scaled up to all the health workers especially in the rural areas to scale-up CT.

3. To motivate the Community health workers, non monetary methods will be used like provision of stationary, T-shirts and bicycles.

4. CT services will be integrated into other health services at all the LPTFs, and referral systems will be strengthened to other services such as PMTCT/ART, TB and MC.

Priority Areas:

1. Most-at-risk populations (MARPs)

2. STI management

3. Community Participation

4. Youth

5. HIV Workplace Initiatives

Strategies to address the priority areas include:

1. Most-at-risk population (MARPs)

Target Population Approx Dollar

Amount Coverage

Number to be reached by each intervention component Activity

Truck Drivers NIL 50 in FY2012

100 in FY2013 Mtendere LPTF CBTS team will offer individual BCC and CT to

Truck drivers at Chirundu

Boarder post

CHAZ will work with Mtendere LPTF near Chirundu Boarder Post in the Southern Province of Zambia to target truck drivers. The CBTS team from LPTF with support from CHAZ will offer individual Behavior Change Communication (BCC) and counseling and testing (CT) to the truck drivers. The intervention will include provision and promotion of condom use. The LPTF will strengthen the referral systems from the community to the health facility for care, support and treatment. Screening for Sexually Transmitted Infections (STIs) will be intensified at the health facility, and early treatment of STIs will be instituted as a prevention measure of HIV infection. All the clients found to be HIV positive will be linked to ART services.

2. CHAZ will train health workers in syndromic management of STIs to improve case management. Through onsite mentoring, screening for Sexually Transmitted Infections (STIs) will be strengthened, and early treatment of STIs will be instituted as a prevention measure of HIV infection. All the clients found to be HIV positive will be linked to ART services.

3. CHAZ through the CBTS team will engage community leaders to drive prevention activities, and promote radio programs and BCC material distribution. LPTF staff will be trained in Prevention with Positives (PwP), and will empower the community in PwP. Community mobilization and sensitization will include HIV prevention messages and strategies. CHAZ in collaboration with The Faithful House will conduct couples' workshops to scale-up HIV prevention among couples.

4. CHAZ in collaboration with Youth Alive and Expanded Church Response will train youths in peer education to promote HIV/AIDS prevention

5. CHAZ will promote appropriate Post Exposure Prophylaxis (PEP) management in accordance with national guidelines at all LPTFs. CHAZ will train 60 managers in selected districts to implement MOH HIV work place programs

In FY 2012 CHAZ will focus on the following priority areas:

1. Orientation in the new 2010 MOH guidelines to scale-up the program and coverage

2. Retention of mother/baby pairs

3. Couple counseling

4. Male involvement

5. family planning

6. Integration and Linkages

CHAZ will address these challenges by:

1. Training healthcare workers and providing technical assistance in rolling out PMTCT and increasing LPTFs capacity to comply with new guidelines. This will scale-up the number of health workers both at LPTF and community level providing PMTCT services, and the number of sites offering the service

2. Retention of mother/baby pairs will be ensured through extension of the LPTFs network of pre-delivery maternity mothers shelters and augmentation of the clinical intervention with robust community mobilization which will lead to increased uptake of the service. This will be coupled with evidence-based family strengthening curriculum that builds upon and complements other aspects of the comprehensive approach, including supported disclosure, and testing of family members.

3. Couple counseling to identify discordant couples and strengthen family support will be intensified through training of health workers and ensuring implementation by those who are trained. CHAZ will increase couple strengthening and communication skills building through The Faithful House for PMTCT workshops for couples.

4. Engagement of men through family-focused service expansion, sensitization and de-stigmatization training of community leaders will further strengthen the uptake of the service.

5. CHAZ will train healthcare workers and Community Based Distributors (CBDs) to sensitize the communities on the use of family planning methods to increase the uptake of family planning from the current low levels of 27%.

6. PMTCT services will be integrated into maternal child health and reproductive health services, ART, and other broader prevention programs. At smaller facilities CHAZ will ensure proper referral systems with other sites such as DHMTs. Linkages with sites offering VCT, ART, immunizations will be strengthened. Outreach and mobile services will be provided for those in hard to reach areas as a way of decentralizing the services. Integration and well-defined linkages will decrease the unit cost and increase coverage, and thereby improve program efficiency.

CHAZ pharmaceutical services establishment was an outcome of members call for an improved pharmaceutical service to church health institutions. The aim was to contribute to access and affordability of essential medicine and medical.

CHAZ will provide assistance to the LPTFs in the area of supply chain management, improvement and implementation of logistics systems, specifically in ARVs and OIs.

In this view, CHAZ will focus on the following priority areas at both central and LPTFs level:

1. Central Level

Disbursement of funds

Technical support to LPTFs.

Selection of ARV Drugs (In line with new guidelines)

Forecasting and quantification

2. LPTFs Level

Timely reporting

Poor Communication.

Medicine stock outs.

Storage space

Documentation

Shortage of Pharmacy personnel in most facilities due to high attrition rate. (Cross cutting issue).

Refresher courses.

STRATAGIES:

CHAZ will work hand in hand with the government in addressing these challenges:

Selection: The antiretroviral drugs to be used will be selected based on the national standard treatment guidelines (ART and PMTCT). This program will work according to the national program. New treatment guidelines will be considered on the selection of the ARVs.

Forecasting and Quantification: CHAZ participates in the national ARVs forecasting and Quantification activities conducted by MOH and supported by JSI deliver project. Forecasting and Quantification of ARVs will be based on the national targets and Regimen data provided by the supported facilities. The ARVs will be quantified together with the national requirements.

Storage: Improve storage capacity through refurbishment.

Reporting: The facilities are expected to send every month a report and requisition form for ordering of medicines. The reports will be processed at the logistics management unit based at Medical Stores Limited. In addressing the issue of poor and late reporting CHAZ will conduct on site mentorship and will work hand in hand with LPTFs to ensure timely reporting.

Distribution: The ARVs will be distributed to the supported facilities by Medical Stores Limited. Facilities will be issued with medicines on monthly basis and will be allowed to stock medicines up to the maximum of three months in order to avoid stock outs.

Technical Support: CHAZ will be responsible for this activity. The supply chain specialist and other pharmaceutical staff will be conducting technical support visits in order to strengthen inventory management and rational medicine use.

Training: CHAZ will conduct training workshops of pharmacy personnel in pharmaceutical management.

CHAZ will focus on the following priority areas:

1. Implementation of new (2010) guidelines

2. Implementation of guidelines on Discordant couples

3. Implementation VL monitoring guidelines, Point of care CD4 testing, HIV/AIDS Drug resistance and surveillance , Rolling out of Early Warning Indicators (EWIs)

4. TB/HIV co-infection

5. Community program strengthening for Pre-ART

6. Integration and Linkages/referral systems

Strategies to address the priorities will include:

1. CHAZ will focus on strengthening the quality and delivery of the ART services through in-service training of LPTF staff on the guidelines and follow-up on-site mentoring. During these visits CHAZ will continue to collect indicators such as LTFU, mortality, number of clients eligible for ART but not yet on ART, number of HIV positive clients in discordant couples who are not yet on ART, to assist in determining site needs and to identify gaps.

2. CHAZ will ensure LPTF staff are trained and implementing the guidelines for ART for discordant couples.

3. Capacity will be built to ensure use of immunological and clinical monitoring as tools to prompt VL monitoring to confirm treatment failure. CHAZ will support MOH in implementing Point of Care CD4 testing, HIV/AIDS Drug resistance and surveillance and rolling out of Early Warning Indicators (EWIs).

4. CHAZ will strengthen the capacity of LPTF staff to screen for TB among PLWHA through onsite mentoring, and ensure treatment of those who are co-infected appropriately with TB drugs and ARVs in line with the current guidelines. To ensure that LPTFs continue to provide quality TB/HIV services, CHAZ will continue to train LPTF staff and community health workers in TB/HIV.

5. Enrolment in the ART program of Pre-ART patients and their follow-up will be strengthened through technical support to LPTF staff and the community health workers.

6. CHAZ will continue with technical support in strengthening integration and linkages with family planning, nutrition assessment, counseling and support, palliative and home based care and prevention with positives.

Cross-cutting activities primarily support the areas of Human Resources for Health. CHAZ will continue to support MOH in training nurses and Lab personnel in various institutions throughout the country. MOH also provides retention schemes for health workers in rural areas.

CHAZ will focus on the following priority areas:

1. Roll out of updated (2010) treatment guidelines

2. Scale-up of treatment for children

3. Training

4. Integration

5. Expansion of EID

Strategies will include:

1. CHAZ will ensure orientation of LPTF staff on the new 2010 Pediatric ART guidelines through trainings and onsite mentoring.

2. CHAZ will contribute to scaling up pediatric treatment for HIV infected children aged 0-15years of age. CHAZ is committed to ensuring the long term health of all HIV-infected children through the provision of comprehensive quality care and treatment. This will be done through on-site mentoring of LPTF staff in assessing eligibility for ART, initiation, and follow-up of both Pre-ART and ART patients. Providers will receive ongoing training and mentoring in recognizing and treating ARV-related toxicities; treatment failure; OI treatment and prevention; and nutrition recommendations for infected children on treatment.

3. CHAZ in partnership with AIDSRelief will provide both central and local training and mentoring in the MOH Pediatric HIV Care Training Course for staff and providers that have not yet received it. In an effort to both decentralize care and strengthen district-level capacity, providers from rural health centers affiliated with our local partners, as well as those from the associated district-level facilities, will be included in these trainings.

4. Pediatric HIV treatment services will be integrated into MCH services with linkages to nutrition support programs. To increase retention in the program, linkages with the community programs will be strengthened through training and mentoring of community volunteers by the CBTS, and formation of support groups.

5. PITC will be provided to all infants, children and adolescents coming in contact with a health worker to ensure early diagnosis and treatment for those who test positive. Three vehicles will be assigned to collect DBS samples from the Hubs to the Laboratory. Through collaboration with MOH and other partners, Innovative technologies such as SMS reminders will be used to increase timely feedback of PCR results from the Laboratories to the LPTFs and finally to the clients.