Southern Province has 11 districts with a population of 1,701,232 and a growth rate of 2.9% (CSO, 2010). The HIV prevalence rate is 14.5% (ZDHS 2007) translating to 246,679 persons with HIV, while 98,672 need ART. Currently, 54,796 are on ART although cumulatively 65,367 are on the registers. This is attributed to the assistance from USG over the past six years. In 2012, SPMO will support combination prevention strategies, treatment, care and support and health systems strengthening for HIV/AIDS/TB/STI care services. Using the base funds, the Southern Provincial Health Office (SPHO) shall promote family centered HIV prevention services integrated into all program areas; including prevention with positives, couple counseling and testing, PITC, PMTCT, MC and health education on consistent and correct use of condoms. The number of sites providing ART will increase to improve access. SPMO will scale up ART/ANC integration to all the 11 districts. TB patients with HIV will be commenced on HAART timely and all HIV positive patients without TB commenced on IPT. SPMO will ensure that all PLWHA undergo nutritional status evaluation and are linked to organizations providing support. SPMO will continue providing Adult and Pediatric care and support to complement existing services. The implementation of activities will be done through the established GRZ structures, use of MOH personnel and infrastructure in partnership with civil society organizations, local and international NGOs and the private sector partners.

Using the COP12 PMTCT PLUS UP funds ($170,000), SPHO will work towards accelerating of the national prevention of mother-to-child transmission (PMTCT) program towards the goal of MTCT elimination by 2015 in the Southern Province.

The level of care and support needed by PLWHA varies according to stage of illness, socioeconomic status, level of stigma and availability of health services. SPMO will continue to provide care and support at facility and community levels as family centered comprehensive services with appropriate referrals to complementary services. Currently the prevalence of HIV is at 14.5% translating into 246,679 people living with HIV. Presently 54,796 are active on ART with 65,367 cumulatively on ART translating to 18% lost to follow up. The lost to follow up is mainly due long distances to ART sites, economic status of the family and also includes the deaths, transferred out and defaulters. SPMO will ensure that mobile ART sites are increased from 48 to 60 by 2012 and increased to 72 in 2013. SPMO through the DMOs will implement a variety of interventions including voluntary CT, training in food and nutritional counseling, protection from stigma and discrimination through community sensitization, procure and distribute ITNs, procuring of HBC kits, treatment of STIs, and the prevention and treatment of OIs. To ensure sustainability of services, interventions will be integrated to include nutritional support and training of 110 HWs and 110 CHWs in nutritional requirements of patients, nutritional assessment and provision of micronutrients for HIV infected clients. We shall work with other partners to link support groups of PLWHA to micro-lending institutions for enhanced food security in homes, income for transport to access ARVs, care and support and sustain incentives for CBVs.

SPMO will provide leadership and technical guidance to implement TB/HIV integrated services across the province. This strategy resulted in increased uptake of Cotrimoxazole (CPT) among TB patients living with HIV from 41% in 2006 to 94.5% and increased HIV testing for TB patients from 39% in 2006 to 89.5% in 2010. SPMO will continue this effort and ensure effective collaboration with other partners to leverage resources. Seven districts (134 sites) will be supported while CIDRZ will support the remaining 4 districts. We shall intensify case finding and improve infection prevention, and ensure integration with ART to implement isoniazid preventive therapy (IPT) in Livingstone district as a pilot. Case finding will be enhanced at existing TB sites as well as opening ten new sites. We will use of drama groups for sensitization and strengthen EQA. 100 community volunteers from 7 districts will be trained using new MOH TB/HIV training manuals. 100 HWs will be trained in PITC and in infection control and ensuring availability of Cotrimoxazole and ART within TB clinics and reduce the transmission of TB in ART settings. We shall closely collaborate with ART to screen 90 % HIV positive clients for TB in 2012 and 100% in 2013. This will involve placing TB suspect registers and creating an indicator in HIV clinics. We shall also ensure close supervision and meetings between the HIV and the TB program where these services are not offered under one Stop. We shall work with MOH, CDC and CDL to develop protocols for MDR-TB surveillance and management. This will include training of 25 HWs in MDR TB Surveillance, procurement and training of laboratory staff on the use of Gene X-pert which will be used to test relapses, retreatments and treatment failures that may have MDR TB. We propose to conduct a program evaluation to gain new and deeper knowledge on MDR-TB in the province for effective program development. Community sensitization with traditional leaders, schools, support groups and mobile drama groups in each of the 7 districts will be conducted. Sputum will be collected during drama performances to improve on TB case detection. SPMO will ensure that all TB diagnostic sites enroll into the national QA for TB smear microscopy. SPMO will support TB/HIV coordinating bodies and strengthen DOTS to improve the cure rate which is at 85%. We will conduct quarterly technical support supervision and data review meetings at provincial, district and facility levels to analyze data using MOH guidelines. SPMO shall support quarterly district TB mortality audits in order to reduce the mortality ratio which is at 9.5%. This activity is linked to ART, SI, OHSS, CT and PMTCT

The SPMO will support strengthening of the community component of care for children through mother baby follow up, monitoring and referrals, and linkage with community structures for adherence as well as provision of Cotrimoxazole prophylaxis as well as referral for HIV care to the local facilities. The SPMO will continue to support monitoring and provision of food and nutrition to children on Pre ART and ART who may need it. SPMO will support cooking demonstrations in 11 districts. We shall support 11 Clinical Care Teams (CCT) to conduct mentorship to 330 HWs on the new guidelines on PMTCT, ART, and feeding options. In addition, we will strengthen government and community structures and leverage for resources from other partners in order to make Paediatric care and support more efficient and sustainable. SPMO will support quarterly partners meetings at district level to include representatives from the community level. SPMO will also support comprehensive family centred services. We shall strengthen data collection and use through continuous TA and mentorship. SPMO will support the provision and distribution of relevant data collection and reporting tools as well as printing and distribution of relevant guidelines. SPMO will support districts for the strengthening EID through mentorship and support for DBS with concurrent strengthening of the courier system for the referral of samples and feedback for results. The program will continue to support and strengthen linkages between Paediatric care and support with TB clinics, community, nutritional rehabilitation units, paediatric wards, counselling and testing, PMTCT, and other child services such as IMCI and EPI. SPMO will support orientation of 110 HWs in new guidelines in Infant and Young Child Feeding for better care of children. SPMO will continue to coordinate all partner activities in the province through quarterly stakeholder meetings. SPMO will continue to provide other essential care services such as child counselling and provision of PITC.

The SPMO 26 laboratories that perform basic tests in Immunology, Hematology and Chemistry. These laboratory services are important in providing reliable, reproducible, and accurate results, for disease detection, diagnosis and monitoring. To ensure uninterrupted laboratory services, the SPMO will continue to support the procurement of laboratory equipment (2 CD4 machines for Choma, and Monze Urban; 2 Haematology analyzers for Dambwa and Shampande; 2 chemistry analyzers for Dambwa & Namwala hospital). Furthermore, the SPMO will procure laboratory equipment service maintenance contracts and train 20 super users in routine maintenance of lab equipment. In FY 2012, we will support 2 Laboratories for accreditation namely; Livingstone General and Monze Mission hospitals. In the subsequent year the SPMO intends to continue the process of accrediting 2 more laboratories namely Mazabuka and Choma General Hospital. In preparation for Laboratory accreditation, the SPMO will support training of laboratory staff in strengthening laboratory management for accreditation. We shall further allocate resources to improve laboratory network for sample transportation from lower level laboratories to Livingstone General Hospital where the PCR facility exists for EID in partnership with the Riders for Health Project that has health transportation experience. We shall support 2 laboratory personnel for PCR specialized training in South Africa. We shall build the local capacity to manage the PCR facility by orienting 4 Laboratory staff on operation and maintenance of PCR in collaboration with CIRDZ. The SPMO will support good lab practices, phlebotomy, basic computer skills, and laboratory information systems. We shall continue to implement strategies to prevent breakdown of automated and other equipment. This will include engaging energy experts to setup efficient, cost effective and sustainable power supply system as backup.

Strategic Information (SI) is a core program of the SPMO Strategic Frame work for HIV/AIDS 2012/2013. In FY2012, SPMO will prioritize the strengthening of the HMIS infrastructure and enhance the integration of HMIS with SPMO strategic framework and the NAC Strategic Plan 20112015 and NHSP. We will support HC to capture routine data in order to complete standard national reporting forms for the MOH. We shall procure eleven motor bikes for DHIOs and DAs to improve consistence, timeliness and quality in reporting of data submitted from HC to DMO. SPMO will procure one 4x4 Toyota Twin Cab for strengthening M&E activities in the districts and collaborate with partners to ensure that SI and M&E plans are effectively implemented. We shall provide funds to the districts directly for quarterly self-evaluations for PEPFAR performance using Next Generation Indicators and HMIS priority completion of Semi-Annual and Annual progress reports. For effective data utilization and reporting, we shall train 120 health workers in Epidemiology and Data Utilization (EDU) techniques using the MOH curriculum. We shall increase SmartCare facilities from 144 to 190 sites and provide quarterly TSS and onsite mentorship in SmartCare and HMIS. SPMO will support the nineteen hospitals in the roll out of Hospital HMIS using the recently developed MOH curriculum. For performance improvement and quality assurance, we will dedicate resources to quarterly provincial and district review and data audit meetings. We shall also procure IT equipment namely: 1 projector, twenty-two laptops, 3 Digital Cameras, twenty-two External Hard drives, twenty-five Flash Disks in ensuring that DHIOs and DAs conduct monthly merges in SmartCare sites. SPMO will support monthly submission of data including transfer of data bases from HCs to DMOs, PMOs and eventually MOH. SPMO will continue to support internet services at the DMOs and selected hospitals for enhanced communication and reporting.

The SPMO faces challenges in strengthening health systems owing to inadequate financial resources from the GRZ especially in the past three years. Most of the infrastructure not only physical buildings but also equipment for HIV and TB diagnosis and monitoring , human resources for health program, and systems for program and financial management are either weak or not conducive. These will need strengthening. This will be important for building pillars for establishing mechanisms for sustainability and ownership of current programs once outside resources are no longer available. We continue to support community based income enhancing activities to build long term sustainability mechanisms. These will be monitored closely to ensure accountability through the medical offices. To enhance this strategy, we shall build the capacity of environmental health technicians who work with communities for effective community programs management. As a stop gap measure, we shall work with the district medical offices to develop retention strategies and use of retired health professional in the hard to reach populations and underserved communities. This will include improving maternity facilities for enhanced PMTCT services. We shall also endeavor to train district health and hospital managers in the new health management system for the MOH. To enhance learning and provide scientific support for professional development, the SPMO shall subscribe to international scientific journals and search engines such as PubMed, Medline, Hinari, and Cochrane. This will also include establishing learning resources centres in five major hospitals of Choma, Monze, Maamba, Mazabuka, and Kalomo hospitals. We shall also continue to provide support to partner coordination, performance assessment, annual planning and budgeting. This activity is linked to laboratory infrastructure, SI, OP, PMTCT, CT and ART services. The SPMO continue will supporting training of Provincial and District staff in data quality assessments, data analysis, M&E and report writing through advanced Epidemiology for Data User trainings each year. The Provincial staff would be trained as trainers who would then conduct two trainings for district staff. These trainings enable staff to create epidemiological profiles, conduct data quality assessments and conduct various analyses of HMIS, NACMIS and SmartCare systems to inform decision-making.

The SPMO will implement strategies to accelerate voluntary male circumcision (VMC) services as part of HIV prevention. The SPMO has demonstrated full program ownership by providing leadership, and allowing USG and non USG implementing partners to provide VMC services through Government health facilities and NGO MC clinics. Southern Province will continue collaboration with other USG partners such as JHPIEGO and SFH to provide a comprehensive and integrated package of MC services which includes CT for HIV, treatment of sexually transmitted diseases, referral of HIV positive clients for HIV management, and post-operative follow-up of clients. In FY2011, 89% provincial target set by MOH was achieved. In 2012, SPMO proposes to reach the target 15,207 men with MC services. SPHO will strengthen the national MC program by recruiting an MC coordinator dedicated to overseeing MC program activities at provincial level and provide ongoing support to all sites to ensure provision of high quality MC services.

This will be achieved by building the capacity of six static MC sites for daily MC services and supporting monthly mobile MC for one week in 11 districts throughout the year targeting but not restricted to the adult men who are at immediate risk of HIV infection.. We shall work with the 7 community radio station to educate and inform members of the community on the benefits of biomedical MC services. This will be reinforced by working with the Ministry of Information and the National Agriculture Information services that have greater reach in the communities to mobilize for MC. We shall capitalize on school holidays to capture more youths in partnership with the Ministry of Education. This will also involve holding of MC camps in selected zonal health centres across the province. We shall also take advantage of the availability of mobile hospitals in the province to expand MC coverage. To increase the capacity of MC services we shall train 82 Health providers and procure MC equipment and medical supplies for static and mobile services. This activity is linked CT and OP.

The SPMO is cognizant that counseling and testing (CT) is an essential entry point for HIV prevention, treatment, care and support. However, access to CT is a challenge especially in hard to reach rural areas and has not been universally accepted by the people of southern province where only 12% have been tested under general VCT. We therefore propose to work with other USG partners to increase the coverage of CT to 30% in 2013 through a range of strategies. To achieve this, we shall strengthen community-based counseling and testing through door-to-door counseling and testing, provide support to two mobile drama groups in each district for community mobilization, and support bi-weekly mobile CT services in each of the 11 district to reach the underserved communities. To enhance this we shall ensure availability of trained counselor at health facilities and community level. For facility based CT, we shall train 100 health workers in Provider-Initiated Testing and Counseling (PITC) and 100 in rapid HIV diagnostic testing. An additional 110 health workers will be trained in child counseling to reinforce PITC services. We shall ensure that couples counseling and testing is rigorously explored and implemented in all testing sites. This will include supporting weekend testing and during traditional ceremonies and national days. We shall also use family support units as entry point to this strategy and train 100 health workers in couples CT.

For enhanced community involvement and mobilization, we shall work with DMOs to mobilize community and religious leaders for CT. To reinforce this strategy, SPMO will collaborate with Modeling And Reinforcement to Combat HIV/AIDS in Zambia (MARCHZ) program to develop and disseminate CT messages through their community reinforcement activities and the serial radio drama. We will also partner with 7 community radio stations with the goal of reaching 80% of the population in the Province with CT messages. The materials will also be translated into local language and disseminated through community structures and integrated in prevention, care and treatment programs. We shall provide funds to the 11 DMOs for infrastructure assessments and renovations of two CT sites per district. We shall support quarterly external quality assurance for HIV testing and disease monitoring for all the 254 CT sites. This will include quality assurance for CD4 in partnership with MOH testing where this service exists. We shall strengthen existing referral system to ensure that clients who receive CT services are linked to and are enrolled in other HIV prevention, care and treatment services. HIV negative clients will be supported to maintain their status and IGAs will be implemented to raise funds for paying community based volunteers and sustain community activities.

This activity is linked to PMTCT, MC, OP and Laboratory support.

The SPMO will coordinate with other USG partners such as ZISSP and the Zambia Prevention Initiative to implement HIV prevention services in line with the Zambia National Prevention Strategy 2009. We will target the most at risk populations (MARPS), youth, couples, PLWHA for prevention with positives and strengthen community response to HIV/AIDS. Youth activities will be scaled-up including life-skills training, distribution of male and female condoms and promotion of Adolescent Sexual Reproductive Health services in all districts. DMOs will be supported quarterly to engage community leaders in driving prevention activities and run meetings in zonal centers focusing on HIV prevention. In FY 2012/13, 220 CBVs/counselors will be trained in Behavior Change Communication (BCC) for HIV prevention. SPMO will collaborate with 7 community radio programs in 6 districts and lead development and dissemination of BCC materials in local languages. DMOs will collaborate with MOE to implement HIV prevention programs for teachers as well as support distribution of BCC materials for HIV prevention. To enhance BCC among pupils, 5 teachers per district will be trained as trainers in BCC and skills building. These will train teachers and pupils to scale up evidence based prevention for the youth. Skills based on HIV/AIDS education will target in and out of school youth with an aim of delaying sexual debut and promoting sexual abstinence.

HC staff will be trained to manage youth friendly corners targeting out of school youths and will include training of 30 peer educators per district. Funds will be provided for infrastructure improvement at 3 youth friendly-corners per district. In 2012, about 596,015 will be reached through radio programs, FGDs and drama performances on abstinence. In 2012, 4 managers per district will be trained to implement the HIV work-place policy incorporating CT. Roll-out of peer education at the HF level to address HIV prevention will be supported. SPMO will train 100 HWs in Syndromic Management of STIs to improve case management and prevent transmission of HIV. DMOs will develop flexible CT schedules to cater for working couples. Monitoring will be through TSS, quarterly review meetings and HMIS and SmartCare reports. SPMO will support the accelerated programming for aggressive male circumcision strategies and maintain blood safety to reduce transfusion transmissible infections. This activity will be linked to the MC, PMTCT, CT and ART services.

SPHO has 234 PMTCT sites out of which 36 are supported directly through SPMO. In 2010, the first ANC attendance was 84% with 90% receiving CT. Using base funds SPHO will focus on quality enhancement of PMTCT services by increasing access to HIV testing with emphasis on couples counseling and testing, CD4 monitoring, and re-testing of HIV negative pregnant women in order to contribute to the MOH goal of the virtual elimination of Paediatric HIV by 2015. SPMO will provide more efficacious ARV regimens in line with the new PMTCT guidelines and ensure the integration of PMTCT and ART at all levels. SPMO will engage retired midwives in 18 facilities in the 3 districts; this is critical in the provision of EMONC, ANC, post natal services. SPHO will aim to increase deliveries by skilled staff from 60% to 80% and in turn increase institutional deliveries from 36% to 50% in 2012. Additionally, SPHO will ensure the treatment of HIV positive partners in discordant relationships with HAART regardless of their CD4 counts and prioritize syphilis screening and treatment in the PMTCT services and procure laboratory equipment for HIV disease monitoring. SPMO will train 141 mid-wives in integrated ART, 30 HWs in LTFP, in EID and infant tracking. We will support community outreach services aimed at promoting early ANC attendance and mother-baby pair retention. SPMO will procure back-up supplies to ensure availability of HIV testing kits, RPR/RST kits, heama-cues, CPT. SPMO shall work with BU and ZISSP to conduct quarterly mentorship and TSS/TA and data review meetings. We shall support the intra districts courier system for DBS. To increase male involvement in PMTCT, an incentive package will be introduced in form of 2 bags of fertilizer and a 10kg of maize seed which will be provided to men that escort their spouses to the health facility for ANC at 14 weeks of pregnancy, labor and delivery, and six weeks postnatal care. An additional incentive will be the provision of baby layette during the above scheduled visits. SPMO will address loss to follow-up throughout the PMTCT cascade from initial ANC visit (84%) to the 4th visit (60%) and delivery in a HF (36%). Extended NVP for breastfeeding HIV exposed children will be enhanced by providing IEC to the community and use of SMAGS with cooperating partners.

Using the COP12 PMTCT PLUS UP funds ($170,000) will implement one-off activities intended to strengthen the base of the PMTCT program in the province. These activities will be designed to: Increase health worker retention in rural facilities; Increase utilization of maternity; continue to expand integration models for ANC and ART; Support development of integration models for PMTCT, pediatric HIV care, and routine MNCH services such as EPI, growth monitoring, nutritional support and post natal services; Continue to expand sustainable intra-district laboratory sample courier systems.

SPMO will provide leadership, supervise and coordinate the provision of comprehensive HIV treatment and care services in line with the new guideline for MOH 2011. This will be done mainly through TA to District Medical Offices, health facilities and quarterly coordination meetings with cooperating partners in the province. SPMO will assess the 35 ART sites that are not yet accredited and ensure that at least 10 of them are accredited in 2012 in conformity with health professional council of Zambia standards. SPMO will also visit the 13 ART sites that are currently accredited to ensure that standards are maintained. SPMO will ensure that of the 15 mobile ART sites, 5 will be turned into static sites while an extra 10 mobile sites will be added. The provision of continuing medical education to staff trained in ART will be provided at existing ART sites. SPMO will ensure the implementation of the new Anti Retroviral Treatment guidelines in all ART sites by orienting 330 health workers in the new guidelines. These trainings will include training care providers from the private sector. SPMO will ensure that ART is readily available for pregnant women living with HIV by supporting ART services in MCH in at least 2 sites per district and continue to support DHOs in the provision of mobile ART services in 20 selected sites of remote and hard to reach areas. SPMO will continue to support strengthening clinical care teams and mentorship program aimed at improving quality of care for PLWHA. SPMO will continue with bi-annual clinical symposia to improve HIV/AIDS management and allow exchange of experience. SPMO will procure laboratory equipment for viral loads and drug resistance surveillance and monitoring, two CD4 machines for Choma, & Monze Urban; two Haematology analyzers for Dambwa & Shampande; one Chemistry Analyzer for Dambwa.

SPMO will train HWs in adherence counseling for adult ART to enhance retention into care and treatment for all patients. SPMO and Livingstone DMO will ensure that all HIV positive patients who do not have active TB will be put on IPT. SPMO will train and support 11 ART treatment support groups to reduce the proportion of lost to follow up from 18% to 10% by 2013. SPMO will perform a program evaluation to analyze the issues surrounding the high proportion of loss to follow up. SPMO will also train 25HWs in pharmacovigillance to monitor adverse drug reactions and 25 health workers in rational drug use. This activity is linked to PMTC, TB/HIV, SI , CT and OHSS

The MOH recently developed guideline for effective management of paediatric ART services in Zambia. In line with this, we shall train 110 HWs in Comprehensive Pediatric HIV Care (CPHC) using the new training curriculum at all points of entry will be done for greater impact on identification and assessment of paediatric patients for enrolment on ART. For performance improvement, we shall implement TSS and mentorship activities through the Clinical Care Teams (CCT) in the districts to include private providers. SPMO will also support some ART providers to attend the Annual National ART updates meetings overseeing by the MOH. Linkages will be strengthened between Paed ART and all ART entry points which include TB clinics, community, nutritional rehabilitation units, paediatric wards, counselling and testing, PMTCT, and other child services such as IMCI and EPI. SPMO will support training for 25 relevant HWs in Data collection and use as well as printing and distribution of guidelines. SPMO will support strengthening of the community programmes to improve pre ART retention and early detection, follow up, and referral of Paediatric patients for ART through training of 66 Community Health Workers (CHWs) in community based Provider -Initiated Testing and Counseling (PITC) as well as strengthening of linkages with community structures particularly those attending to mothers in labor and with postnatal mothers. SPMO will continue to lobby for partners to support nutritional care and treatment services. SPMO will continue to support EID particularly community referrals for DBS services. SPMO will support service integration for Paed ART such as in TB and MCH services. A further 55 HWs will be trained in Integrated Management of Childhood Illnesses (IMCI) and 55 HWs in DBS collection. We shall maintain the number of Pediatric Centers of Excellence (PCOE) and include all PCOEs in the planned symposia. Infrastructural improvements will be supported in 5 sites. We will train and strengthen all 16 hospitals in Performance Improvement Approaches (PIA). The SPMO will also support the production of job aids such as algorithms and dosing charts. SPHO will support ongoing assessment, retention and adherence of pediatric patients including adolescents on the ART program.