N/A

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.01:

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.02:

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Biomedical Prevention Strategic Context

During development of its 5 Year Strategy the USG team in Zimbabwe decided that it should focus resources on high priority

areas, and that it did not have adequate financial or human resources to work in Blood Safety or Injection Safety. In May 2008, the

team undertook a Joint Portfolio Review that included a validation of that 5 Year Strategy. The team found that in spite of the

deterioration in the political and socioeconomic environment, to date Zimbabwe's blood supply remains safe. There is no

indication that USG resources are needed for Blood Safety at this time.

Given the sharp decline in availability of clinical equipment and supplies, particularly in the public sector, the USG team discussed

increasing concern about health providers' abilities to maintain universal precautions. The 2005-06 Zimbabwe Demographic

Health Survey (ZDHS) found that 96% of recent medical injections among women and 89% among men were given with a syringe

taken from a newly opened package. It is probable that these rates have decreased due to lack of syringe resupply at many sites,

particularly at the clinic level. The team agreed that Injection Safety - with a broader focus on universal precautions -- could

become an area of involvement for USG Zimbabwe should additional funding become available.

Given increased USG interest in injecting and non-injecting drug users (IDU/DU), the Zimbabwe team talked with partners about

needs and determined that the country's IDU/DU population is still quite limited. Though data are scant, UNAIDS estimates that

<1% of HIV transmission in Zimbabwe is IDU-related. Similarly, data on and experience with non-injecting drug users are scant.

USG will address any IDU/DU needs as they arise through on-going HVOP outreach and counseling activities.

As part of the strategy revalidation, the USG team reaffirmed its strong commitment to HIV prevention in Zimbabwe. Given

emerging international evidence on the benefits of male circumcision (MC) for prevention, and heightened interest in Zimbabwe

(described below), the USG team decided to allocate modest PEPFAR funds to leverage pilot efforts in FY09. These are

described below.

Male Circumcision Program Context

Low male circumcision prevalence together with high level of concurrent sexual partnerships are important factors that seem to

have contributed to the fast spread of HIV in Zimbabwe in the 1990s, reaching an adult (15-49 years) HIV prevalence peak in

1997 of 29.3 %. Despite the sharp decline in HIV prevalence that has been witnessed between 2001 and 2007, with a drop of

approximately 1.8 percentage points/year, Zimbabwe still ranks among the highest HIV burdened countries in the world, with an

adult HIV prevalence of 15.6%. 1.1 million adults and 133,000 children are currently living with HIV and AIDS in Zimbabwe.

Average life expectancy has dropped in the past two decades by over 20 years to 37 years in men and 34 years in women, largely

due to HIV and AIDS.

Except for minor ethnic groups like the Tonga, Chewa, Tshangan and small Moslem communities, traditional male circumcision is

generally not practiced in Zimbabwe. The 2005-06 Zimbabwe Demographic and Health Survey (ZDHS) found a total of 10.5% of

all men interviewed reporting that they had been circumcised, ranging from 5.3% in Mashonaland Central to 18.8% in

Matabeleland North. Drawing from the ZDHS data, it is estimated that out of 2.5 million sexually active men above the age of 20

years, approximately 90%, or 2.25 Million are not circumcised.

In view of the heightened international interest in MC and unequivocal evidence for its protective effect on HIV transmission, the

Zimbabwe National AIDS Council (NAC) and the Ministry of Health and Child Welfare (MOHCW) hosted a national MC

consultative meeting in June 2007. The purpose of the meeting was to update stakeholders on recent evidence on male

circumcision and HIV prevention, to obtain consensus on a national position regarding the integration of male circumcision into

comprehensive HIV and AIDS programming within the Zimbabwean context and to initiate the development of a roadmap on MC

and HIV prevention as guided by the national consensus. The meeting revealed a high level of interest and support by the

MOHCW and NAC, UN agencies, NGOs and community groups for MC and resulted in development of a roadmap to rapidly

scale up male circumcision.

Health services in Zimbabwe are provided through 5 central hospitals, ten provincial hospitals, 62 district and 88 mission hospitals

as well as over thousand rural hospitals and health clinics. Until recently, all district hospitals and mission hospitals had

functioning operating theatres and staffed with nurses and doctors. As the economic crisis has deepened an alarming number of

health staff have left their posts, but it is believed that most hospitals still have operating capacity.

Although there has been significant out-migration of trained health personnel to the crisis, some level of health services at most

health care facilities are still maintained. Currently male circumcisions are performed by Government Medical Officers at district

and mission hospital level based on medical indications such as phimosis and paraphimosis in children and STIs including

condylomata acuminata in adults. There are very few requests for MC for cultural and/or religious reasons performed at

government hospitals. MC is routinely reported on the NHIMS as a minor surgical procedure. Generally, MC constitutes less than

5% of all minor surgical procedures done at district level. Currently only approximately 3-5 monthly procedures are performed in

the private and public sector.

In 2005, an acceptability study of MC in Harare beer halls found that 14% of men reported being circumcised and 45% of the

remainder was interested in becoming circumcised. (Halperin, McFarland, Woelk, 2005). A recent Tracking Results Continuously

study conducted by Population Services International/Zimbabwe found acceptability levels among men of 62%.

The USG and UNFPA are currently supporting the Partnership Project to undertake a rapid assessment of the feasibility (service

availability mapping) and acceptability of MC. With USG funding, a Partnership consultant team is also working on the

development of the national MC policy. The information gathered through the different assessments is intended to guide future

Zimbabwe MC program implementation.

USG Male Circumcision Program and Prospects

USG's primary partner for its PEPFAR Sexual Prevention program is the Partnership Project, which seeks to reduce the rate of

new HIV infections and the impact of HIV/AIDS on Zimbabweans. The Partnership Project undertakes comprehensive ABC

prevention strategies as well as more focused AB work with youth, and risk reduction work with most at risk populations.

Partnership is also a lead USG PEPFAR partner for HIV counseling and testing and PLHA care and support activities, and

provides significant capacity building to local organizations. With other USG funds, Partnership is fostering family planning

integration with Zimbabwe's national PMTCT program. The lead implementing agency for Partnership is Abt Associates, with

Population Services International (PSI), Family Health International, and Banyan Global.

In FY2009, the Partnership Project will move into Biomedical Prevention as well, through a new Male Circumcision initiative. The

initiative will initially be funded by $1.3 million in PSI corporate funding and $50,000 from UNFPA. Under the CIRC program

budget code, the USG will provide $100,000 through COP09 for a Program Coordinator. The Coordinator will play a lead role in

championing scale up of MC with the MOHCW and other key stakeholders, and provide MC leadership on the PEPFAR

Zimbabwe MC team. Under other program budget codes (HVAB, HVOP, HVCT, HBHC, OHSS) the USG will provide an additional

approximately $3.3 million to Partnership for its related prevention, care, treatment, and capacity building described elsewhere in

this COP.

The new MC program will undertake the following in FY09:

(1) Integration of male circumcision services as part of a comprehensive HIV prevention intervention package:

In collaboration with the MOHCW, with PSI funding, the Partnership Project will test models to roll out comprehensive male

circumcision services in Zimbabwe through the following steps: (a) Formation of a technical working group to develop national

MC policies, standards, guidelines and roll out strategies to ensure the implementation of safe MC services. (b) Adaptation and

development of standard guidelines for comprehensive MC services. (c) Selection of management information system (MIS)

indicators and monitoring and evaluation (M&E) tools to measure performance and implementation of activities. (d) Development

of information, education and communication messages and materials for MC clients. (e) Identification and upgrading of one MC

training centre and three learning sites to offer safe MC services. (6) Training of MC trainers in comprehensive MC service

delivery. The sites will be used to test the learning resource package and materials developed and to assess the feasibility of MC

services implementation.

(2) Communication to generate demand for safe male circumcision services:

The Partnership Project will build on its existing capacity to develop and implement a communication strategy. The strategy will

comprise messages and campaigns to create awareness about MC and its benefits and risks, including dispelling misconceptions

and addressing fears. The aim of the strategy is to stimulate demand for male circumcision within defined frameworks of

communication to address the primary and secondary target groups. Primary target groups consist of adolescent boys and young

men aged 13- 29 years. The secondary target groups consist of parents of adolescent boys, health providers, female partners,

community leaders as well as communities in general.

Formative research will be used to identify barriers to take up of MC services among the target group. These barriers will be

addressed by pre-tested and evidence-based communication materials and messages disseminated through mass media as well

as through interpersonal communication channels such as road shows, drama and peer education. The Partnership team will

build upon existing innovative communications activities to achieve rapid awareness and increase demand for MC such as (a) a

network of faith-based pastors to reach out to adolescent boys and their parents, (b) education-entertainment activities, such as

theater and sports programs, in rural areas, (c) outreach teams conducting interpersonal communications (IPC) sessions in the

workplace and in vocational training colleges, (d) a television and radio talk show with health experts to guide discussion and offer

advice and (e) the large network of counselors in HIV testing sites who will counsel HIV negative male clients about MC.

(3) Service Delivery:

In FY09, with PSI corporate funding the project will establish the following MC service delivery sites and build capacity of health

personnel in MC: (a) One MC training site will be established at central level to train MC trainers and program implementers. (b)

Three MC learning sites will be established within existing health care facilities to offer safe MC services. (c) 26 health care

workers (surgeons and nurses) will benefit from initial training in comprehensive MC service delivery. (d) 230 New Start

counselors will benefit from training on MC counseling and MC referral. [New Start is the brand for the Partnership project-

operated HIV testing and counseling (T&C) program in Zimbabwe. Partnership currently supports 20 New Start T&C centers and

21 outreach teams. In FY08 they tested over 200,000 individuals, and expect to reach or exceed that number in FY09.]

(4) Monitoring & Evaluation:

The Partnership team will monitor activities by tracking the number and type of providers trained, equipment and consumables

used, number of clients seeking MC, number of testing and counseling clients referred for MC, number of clients receiving MC,

number of follow up visits, number and nature of complications and side effects, number of quality assurance visits, number of

people reached by communications and marketing materials/advertisements, and any other indicators being tracked through the

national MIS systems. Demographic information on MC clients will be recorded including age, marital status, educational level,

HIV testing history and outcome, medical history, and how the client heard about the MC provider.

Since male circumcision is a new prevention intervention in Zimbabwe, national MIS indicators for MC currently do not exist. The

MC program will support the integration of MC indicators in the current national MIS. Data collected during the pilot phase will be

analyzed to inform the wider roll out of MC, which will follow the learning phase.

Expected Results

In FY09, through these sites and trained personnel, 2000 adolescent boys and men will be circumcised and will receive follow up

services and intensive counseling on safer sexual behavior and 40 000 HIV negative adolescent boys and men 16 years and

above will receive information and counseling on MC. In FY09, the project expects to reach 2,000,000 men aged 13 -29 years, as

well as parents, community leaders, and health care workers, through mass media communications, and 5,000 young men in

schools and church communities through interpersonal communication.

Wraparounds/Leveraging

As stated above, the USG investment of $100,000 for an MC Coordinator (plus direct and indirect costs of the Partnership Project

from other COP budget codes) will leverage $1.3 million from PSI and $50,000 from UNFPA. When the political and economic

conditions in Zimbabwe improve, there is a good probability for significant funding from private foundations and other donor

sources.

Program Budget Code: 05 - HMIN Biomedical Prevention: Injection Safety

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 06 - IDUP Biomedical Prevention: Injecting and non-Injecting Drug Use

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 07 - CIRC Biomedical Prevention: Male Circumcision

Total Planned Funding for Program Budget Code: $100,000

Total Planned Funding for Program Budget Code: $0

Table 3.3.07:

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.08:

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Table 3.3.09:

n/a

New/Continuing Activity: Continuing Activity

Continuing Activity: 18642

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

18642 18642.08 U.S. Agency for US Agency for 8057 4087.08 USAID $0

International International

Development Development

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $2,377,871

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

In spite of evidence of a sharp decline in HIV prevalence between 2001 and 2007, Zimbabwe still ranks among the highest HIV

burdened countries in the world, with an adult HIV prevalence of 15.6%. About 1.1 million adults and 133,000 children are

currently living with HIV and AIDS in Zimbabwe. Average life expectancy has dropped in the past two decades by over 20 years,

to 37 years in men and 34 years in women, largely due to HIV and AIDS.

With USG and other donor assistance, Zimbabwe is working toward a national goal of universal testing for HIV by 2010. The

Zimbabwe Demographic and Health Survey (ZDHS) 2005-06 found that 21.7% of adult women and 16.4% of adult men had been

tested and had received their results. In 2007, the USG-funded Partnership Project undertook a population-based survey and

found that uptake had increased significantly, to 32% of adults. While impressive, these data indicate that the country has a long

way to go before reaching its goal.

Counseling and testing (CT) services in Zimbabwe are offered through standalone voluntary counseling and testing sites, CT sites

co-located within public health clinics and hospitals, and community -based outreach and mobile clinics. MOHCW also provides

diagnostic testing at opportunistic infection clinics, PMTCT sites and other health facilities. Demand for CT services is high and

growing as provider-initiated testing and counseling (PITC), launched in 2006, is rolled out.

Although the national program planned to shift from the current parallel rapid testing protocol to a serial testing protocol in mid-

2008, this was not possible. The Laboratory Professionals Council is resisting the move to serial testing due to lack of human

resources for necessary supervision. USG and its partners continue to pursue this issue with MOHCW and the Lab Council, and

have offered technical support to public sector laboratories in terms of supervision and mentoring. At this time, the shift to serial

testing is not projected to begin in 2010.

Summary USG CT Program

USG's HIV CT program follows the PEPFAR Zimbabwe 5 Year Strategy to implement PITC while also maintaining a core set of

VCT centers in urban areas, with increased mobile outreach to rural populations. The USG's lead implementing partners for

Counseling and Testing are the Partnership Project, a bilateral contract, and the central Supply Chain Management Systems

(SCMS) mechanism. In FY08, SCMS procured approximately 60% of Zimbabwe's HIV rapid test kits and provided technical

assistance to maintain a less-than-5% stock out rate at CT sites around the country.

Over the period FY06-FY08 the Partnership Project counseled, tested, and provided results to 705,000 individuals through a total

of 20 outlets that provide counseling and testing according to national and international standards. The Partnership Project is also

the USG's lead implementing partner for sexual prevention and PLWH care and support activities - both of which have important

linkages to CT - and provides significant capacity building to local organizations. With other USG funds, the Partnership Project is

fostering family planning integration with Zimbabwe's national PMTCT program. The lead implementing agency for the

Partnership Project is Abt Associates, with Population Services International (PSI), Family Health International, and Banyan

Global.

By the end of FY08, a cumulative total of approximately 2,545,000 adults had been tested for HIV, with 1,231,184 (48 %) having

accessed CT services through the USG-funded New Start network. A total of 254, 868 individuals were tested through New Start

in FY08. This figure represents approximately 4% of the total Zimbabwean adult population].

FY08 Social, Economic and Political Context

Implementation of the USG PEPFAR program in Zimbabwe during FY08 was subject to a number of severe stresses. From

January to March, during the run-up to the March 29, 2008 general elections, the highly charged political atmosphere led to a

number of disruptions and hampered implementation. The situation was even worse from April - June. Widespread Government

sponsored violence effectively closed most rural areas in the country and many urban areas. Hundreds were killed and tens of

thousands were displaced. A number of USG-supported community outreach activities - including those related to CT -- were

either suspended to protect staff and potential participants, or shifted to urban areas that required less travel and exposure. On

June 4, the Government of Zimbabwe suspended most NGO activity for almost 3 months, until August 29, setting back many

programs. Neither SCMS nor the Partnership Project is an NGO, and both were able to continue providing vital HIV rapid test kits

and New Start counseling and testing throughout the country. In June, however, during the final week of deliveries prior to the

election, SCMS truck drivers were stopped on several occasions and ordered to unload everything to prove they were not

distributing food aid. In each instance, the delivery vehicles were allowed to proceed with their delivery routes after the forced

inspections.

Throughout the year the continuing collapse of the Zimbabwean economy and inflation that reached billions of percent put severe

strains on programming and local partners. In general, the unprecedented hyperinflation and eventual collapse of Zimbabwean

currency, lack of public utilities (water and electricity), widespread violence, and extreme political uncertainty created barriers to all

programs.

USG HVCT Program and Prospects

In FY08, SCMS procured approximately $1 million worth of HIV rapid tests and assisted the MOHCW to quantify test kit

requirements for future years. SCMS also assisted the MOHCW to implement a supply chain management system for rapid tests

that will ensure their availability to the public. The USG-financed tests represented approximately 60% of Zimbabwe's national

requirements.

Also in FY08, USG, MOHCW and SCMS agreed to add HIV rapid tests and PMTCT Nevirapine to the Zimbabwe National Family

Planning Council's Delivery Team Topping Up (DTTU) system that achieved 95% coverage and reporting, with stock out rates

below 10%. After a successful pilot phase, resulting in increased information essential for preventing stock-outs and expiries,

SCMS facilitated roll-out of the system nationwide. By the May-June period the system achieved stock out rates of less than 5%

or rapid test-kits and PMTCT Nevirapine.

In FY09, the SCMS project will again procure approximately $1 million worth of HIV rapid tests (540,000 Determine rapid tests,

540,000 SD Bioline rapid tests, and 10,000 INsti tie breaker rapid tests) and will assist the MOHCW in accurately quantifying HIV

rapid test kit requirements. SCMS will continue to work with the MOHCW as it moves toward a serial HIV testing protocol. The

project will also continue to assist the MOHCW in implementing a supply chain management system for rapid tests that will ensure

their availability to the public. Based on the successful pilot and roll-out of integrating HIV rapid tests with the DTTU system during

FY08, the system will continue throughout 2009. The performance indicator for the system will be less than 5% stock out of the

two first-level HIV rapid tests at time of delivery by end 2009.

In FY09, the Partnership Project will continue its efforts to increase utilization of the USG/SCMS-procured test kits through CT

outreach, counseling, testing and follow-up through the following activities:

(1) Further expansion of client initiated CT (CITC) services with focus on mobile outreach services to reach vulnerable population

groups with CT services.

The Partnership Project will further expand its 20 New Start testing and counseling centers' (static sites) and its 21 mobile

outreach teams' provision of CITC services using models to reach especially underserved vulnerable population groups in rural

areas, at workplaces (through the workplace CT activity) and vulnerable, mobile populations in Zimbabwe. These efforts will

include work with returned migrants in collaboration with the International Organisation of Migration. The partners will continue to

provide CITC at two returned-migrant reception centers in Beitbridge and Plumtree established in FY08.

Each CT site and outreach team will continue to use geographic positioning systems (GPS) to map CT services coverage and

identify coverage gaps to guide project implementation. Approximately 45%-50% of clients are expected to access CITC through

mobile outreach services in peri-urban and rural areas.

(2) Maintain high quality of CITC service delivery.

The project will continue to implement mystery client surveys to assess service delivery standards and provide feedback for

quality assurance and training. Project supervisors and site managers will undertake periodic assessments of counselors and

sites using standardized supervisory tools. The project will conduct annual refresher courses of all counselors, receptionists, office

assistants and drivers using practical exercises throughout the year. Training guidelines will be updated based on new

developments in the HIV field. With funding from the Dutch Government in FY09, the project will provide intensive training in

family planning to all counselors, with specific emphasis on the concept of dual protection.

(3) Enhance referral and referral tracking system.

Referral linkages strengthening will be the core of CT services. The project will ensure that all HIV positive clients are referred for

post-test support services to access treatment, care and support. This will include referrals to New Life post-test support services

(supported under the HBHC budget code) for ongoing psycho-social support and positive prevention counseling. The project will

increase the percentage of referrals tracked from the current 45% to 50% through intensified direct linkages to post-test service

providers. As described in the Biomedical Prevention program narrative, the project plans to integrate male circumcision (MC) into

CT service provision and to establish a dual referral system to increase access to MC for HIV negative men (referral from CT

services to MC sites) and vice versa.

(4) Support to the MOHCW in scaling up PITC.

Buidling on experience to date, the Partnership Project will continue to provide training and technical assistance to facilitate the

scale up of PITC services to other health care facilities. As a member of the HIV testing and counseling and PMTCT partnership

forum, the project will continue to share best practice to create an enabling environment for TC scale up.

(5) Increased demand creation for CT, including CITC for uniformed services.

The Partnership Project team will strengthen demand creation activities to focus on both CITC and PITC. PITC communications

will improve understanding of the concept and inform individuals about the availability of PITC services at health care facilities.

Specific tasks will include: (a) Developing and implementing new mass media campaigns to increase couple testing for HIV

positive and discordant couples; (b) Developing and implementing new mass media campaigns to support targeted promotions for

high risk groups such as couples and women; (c) Implementing IPC campaigns to increase couple client flow in rural areas; (d)

Developing IEC materials (brochures, flipcharts) to promote knowledge of status.

Based on consultation with the USG country team in Zimbabwe, the Partnership project will further expand its workplace CT

activity to include Zimbabwe's police and military personnel. Access to police and military camps has been limited because of

concern about confidentiality. During FY06-08, the project reached prison officers and prisoners throughout the country, with high

uptake of CT services. The project will continue to provide CT services to the prisons on a regular basis, where possible

expanding in the number of prisons involved. The project will also expand CT activities to reach employees and their families in

police and army camps wherever the political environment permits and will collaborate with the USG Defense Attache Office. The

project will continue CT activities at border posts, such as Beitbridge, Plumtree, Mutare, Nyamapanda and Chirundu, and will also

target border officials, an important group at high risk of acquiring HIV infection.

(6) Increase Demand for other services beyond CT.

In FY09, the Partnership Project will finalize development of and implement communications to increase knowledge and use of

ART literacy and care. The project will also continue to implement the mass media campaign to increase cross-referrals and

uptake of PMTCT and family planning services, and to finalize the development of mass media and IPC campaigns to increase

risk perception and knowledge of the link between TB and HIV.

The project has established a strong referral system for TB suspects, who are referred from the CT network to TB diagnostic

centers for TB investigations and treatment. All HIV positive clients are screened for TB symptoms at the 20 project New Start

centers. Currently 14% of all HIV positive CT clients are TB suspects. All TB suspects are referred to the diagnostic centers, of

which 50% -60% report for further investigations and TB treatment. The project will further strengthen the TB screening and

referral system and expand TB screening to all clients (both those testing HIV positive and HIV negative clients) tested at the New

Start centers in FY09.

In addition to funding for SCMS and Partnership, FY09 funding is also provided for direct USG technical expertise and staffing.

Wraparounds/Leveraging

In FY09 USG will provide approximately $1 million in test kits, the Clinton Foundation $148,000 and UNFPA $120,000. Anticipated

funding from DFID is expected to increase the number of NGO CT partners and anticipated funding from Global Fund Round 5

would be available to cover additional test kits if needed. The Dutch Government will provide $550,000 to permit family planning

counseling of positive and discordant couples at New Start sites.

Table 3.3.14:

N/A

New/Continuing Activity: Continuing Activity

Continuing Activity: 18645

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

18645 18645.08 U.S. Agency for US Agency for 8057 4087.08 USAID $300,000

International International

Development Development

Table 3.3.14:

N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 16 - HLAB Laboratory Infrastructure

Total Planned Funding for Program Budget Code: $1,686,414

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

In spite of evidence of a sharp decline in HIV prevalence between 2001 and 2007, with a drop of approximately 1.8 percentage

points/year, Zimbabwe still ranks among the highest HIV burdened countries in the world, with an adult HIV prevalence of 15.6%.

About 1.1 million adults and 133,000 children are currently living with HIV and AIDS in Zimbabwe. Average life expectancy has

dropped in the past two decades by over 20 years, to 37 years in men and 34 years in women, largely due to HIV and AIDS.

Laboratory services are an essential part of the Zimbabwe healthcare delivery system and play a pivotal role in its HIV/AIDS

healthcare plan to support prevention, care and treatment programs. The Ministry of Health and Child Welfare (MOHCW) is the

largest provider of diagnostic medical laboratory services, from district to central levels of healthcare. These laboratories operate

as a network of 61 district, 7 provincial, 5 central and 2 national reference laboratories, the National Microbiology Reference

laboratory (NMRL) and National Tuberculosis Reference Laboratory (NTBRL). There are also 1,200 health centers that provide

primary heath care services and very limited laboratory testing. The Zimbabwe Association of Church Hospitals, a faith-based

organization (FBO), also provides lab services at the rural hospital level, of which 14 are recognized district hospitals.

Zimbabwe has achieved ongoing success in laboratory system support to the national HIV and AIDS response, as demonstrated

by: the successful national roll-out of HIV counseling and testing services to 930 sites (600 public sector sites); revision of the

standard HIV testing package; expansion of CD4 capacity, evaluation and adoption of more cost effective CD4 testing

technologies; and international accreditation of the Zimbabwe National Quality Assurance Program (ZINQAP). Currently, 28 sites

in the public health system and 10 in the private sector offer CD4 testing services and participation in an external proficiency

testing (PT) program through ZINQAP.

There are still challenges. In general, laboratory infrastructure for diagnosis of different diseases is underdeveloped in Zimbabwe.

Reference and public hospital laboratories have limited facilities to meet existing demands for diagnosis, monitoring and

surveillance of HIV, TB, malaria and various opportunistic infections. Given the economic crisis, reagents and other critical

supplies are often in short supply. Human resources are also lacking, with out-migration of qualified health workers due to the

economic crisis. In FY08, vacancy rates were 49% for lab scientists, and this has adversely affected service delivery. In response

to the human resource crisis, in 2007 the MOHCW introduced new cadres to the system and embarked on redefining core

competencies and task shifting. With USG and other donor assistance, the MOHCW, has initiated training of Microscopists and

State-Certified Medical Laboratory Technicians, and is providing a new course of specialized lab training for Bachelors of Science

generalists. These efforts are expected to retain critical staff and reduce out-migration to neighboring countries. In addition, these

efforts will enable the MOHCW to fill the gaps and produce a critical mass for supporting the services.

USG Summary Program

Laboratory organizational and physical infrastructure, procurement systems, supply availability, equipment, and trained staff are

fundamental elements of PEPFAR Zimbabwe's program implementation. USG's laboratory strengthening program conforms to

the PEPFAR Zimbabwe Five Year Strategy and focuses on national laboratory system strengthening and capacity building so that

the system can be sustained over time. The USG provides the national laboratory system with direct technical assistance,

training, commodity procurement and logistics, and other support. The USG also provides funding to ZINQAP, the MOHCW, and

lab technical training providers.

In FY08, USG support focused on: (1) Strengthening the national laboratory Directorate as a policy coordinator and planning

body; (2) Development of NMRL and the NTBRL for national quality assurance; (3) Improvement of the national PT system and

quality system through technical and financial support to ZINQAP; (4) Support to the national laboratory training schools; (5)

Improvement of laboratory networking, referral linkages and national laboratory management capacity through training; (6)

National roll-out of rapid HIV testing training; and (7) Improvement of clinical lab services through revision of the standard

operating procedures (SOP) manuals and procurement of equipment and supplies.

Forty public hospital laboratories supported by USG have now the capacity for laboratory monitoring of ARV treatment, i.e.,

CD4/CD8, hematology and chemistry tests. In FY08, with USG support, more than 50,000 HIV disease monitoring tests were

performed in those laboratories and a total of 22 laboratory professionals were trained in HIV disease monitoring.

FY08 Social, Economic and Political Context

Implementation of the USG PEPFAR program in Zimbabwe during FY08 was subject to a number of severe stresses. From

January to March, during the run-up to the March 29, 2008 general elections, the highly charged political atmosphere led to a

number of disruptions and hampered implementation. The situation was even worse from April - June. Widespread Government

sponsored violence effectively closed most rural areas in the country and many urban areas. Hundreds were killed and tens of

thousands were displaced. A number of USG-supported technical assistance and training activities - including those related to

laboratory strengthening -- were either suspended or delayed because of high attrition rates of trained laboratory staff, and very

limited logistic and management support by the government. On June 4, the Government of Zimbabwe suspended most NGO

activity for almost 3 months, until August 29, setting back many programs. Throughout the year the continuing collapse of the

Zimbabwean economy and inflation that reached billions of percent put severe strains on programming and local partners. In

general, the unprecedented hyperinflation and eventual collapse of Zimbabwean currency, lack of public utilities (water and

electricity), widespread violence, and extreme political uncertainty created barriers to all programs.

USG HLAB Program and Prospects

Given the fundamental role that laboratories play in the national response, in FY09, USG will triple its funding to Zimbabwe's

laboratory system to 6% of the total. The additional funding will permit a greater USG focus and is expected to build capacity of

the national lab system to respond to the expanding CT, PMTCT, and ART programs. In the HLAB budget code, USG will support

the following:

(1) Strengthening Quality Assurance Program.

USG will continue its support to improve the quality of lab services through strengthening and expanding the External Quality

Assessment (EQA) schemes to major tests (HIV rapid test, CD4 testing, TB, hematology and chemistry tests, DNA- based early

infant diagnosis). In partnership with ZINQAP, NMRL and NTBRL support will be focused in implementation of quality system

essentials at major facility levels that support laboratory diagnostic and monitoring services.

(2) Training.

USG will support in-service training in HIV diagnosis and disease monitoring (hematology, chemistry, CD4, HIV serology, early

infant diagnosis, TB and malaria smear microcopy). USG technical advisors, in conjunction with ZINQAP and the African Institute

of Biomedical Science and Technology (AIBST), will collaborate to develop and standardize lab training modules, training of

trainees, and roll-out of trainings to health districts. More than 600 laboratory staff will be trained. USG and its collaborators will

also conduct follow-up of training to assess the performance of trainees and improve the laboratory services rendered.

As part of the longer term strategy for human capacity development, USG will provide technical and financially support to the

MOHCW in pre-service training for mid- and high-level laboratory science professionals. With FY08 USG support, the MOHCW in

collaboration with the University of Zimbabwe has initiated a 6 month course for HIV/TB Microscopists; an 18 month course for

State Certified Laboratory Technician; and a 2 year supplementary upgrading course to enable non-lab Bachelor's of Science

graduates to become laboratory scientists.

(3) Strengthening policy, leadership and management capacity.

USG will continue to support the Director of Laboratory Services, MOHCW, to play a leadership and coordination role in

implementation of national policies and guidelines, and strategic plans. Support will also be provided to implement the "Maputo

Declaration" for standardization of the national laboratory system. As part of local capacity development and sustainability, the

USG PEPFAR team will closely work with the MOHCW, reference laboratories and local partners.

(4) Procurement of laboratory supplies, equipment and maintenance services.

USG will continue support for the procurement of rapid HIV test kits and laboratory equipment (CD4, hematology, chemistry

analyzers) for additional public sector ART sites to expand coverage. In addition, to fill identified gaps, USG will provide limited

quantities of reagents and supplies including CD4, hematology and chemistry, reagents, and other essential supplies to support

the ART program, surveillance, and TB diagnosis at national reference laboratories.

(5) Strengthening Laboratory Information System (LIS).

In Zimbabwe, almost all laboratories use a manual information system, but the scale-up of ART and monitoring programs is

forcing these laboratories to develop and implement a computer-based LIS to handle the ever-increasing volume of data that they

receive and report. The nascent LIS will support workflow and information flow in all steps of the laboratory testing process,

including patient registration, test ordering, sample collection, testing, and reporting. The LIS will enable laboratories to manage

their data, to maintain quality, and to improve efficiency. In FY08, USG supported the procurement of LIS software and related IT

equipment, need assessment and piloting at NMRL. In FY09, USG will continue supporting the implementation of the LIS at

national reference laboratories, with expansion to central and provincial laboratories when appropriate. The support includes

procurement of LIS software and computer accessories (barcode printers, barcode readers, and barcode printer paper), training

for laboratory technicians and receptionists, networking, cabling and internet connection, and supportive supervision. Technical

assistance will also be provided MOHCW to strengthen the laboratory monitoring and evaluation system in all laboratories. These

include the standardization of lab forms, record/register books and reporting and supportive supervision.

(6) Surveillance.

USG will continue its support to the NMRL for performance of national ANC based HIV surveillance sample analysis, including

incidence testing. Technical support will also be provided to both national reference laboratories to establish HIV and TB drug

resistance surveys.

(7) Strengthening Early Infant Diagnosis (EID):

USG will support the NMRL to expand capacity for EID referral testing and will improve quality through participation in the EQA

program. Technical assistance will also be provided in for validation and evaluation of critical new technologies for infant

diagnostics and more cost effective CD4 testing technologies.

In FY09, with USG support, 600 public health facilities will have the capacity to perform HIV tests and more than 40 public

hospitals will provide laboratory monitoring services (CD4/CD8, hematology and chemistry tests). This support will enable these

labs to undertake 800,000 HIV tests, 400,000 TB diagnostic tests, and 360,000 HIV disease monitoring tests, reflecting indirect

targets to be reached with USG funding.

In addition to funding to partners, USG will retain $750,000 in FY09 funds for direct procurement of items above. FY09 funding is

also provided for direct USG technical expertise and staffing, and to the management firm Ernst and Young for select technical

assistance and audit requirements.

Wraparounds/Leveraging

USG funding is strengthening the national laboratory system and filling gaps not covered by other donor funding. For labs, this

includes: Global Fund for AIDS, Tuberculosis and Malaria (GF) Round 1 (GF1 - 12 districts), GF5 (22 districts, including the first

12), the British Department for International Development-led, multi-donor Expanded Support Program (ESP - 16 districts), World

Bank (training schools), and European Union (training schools). As discussed elsewhere in this COP, USG funding covers service

delivery (outreach, counseling, provision of tests) in several other program areas (MTCT, HVCT, HTXS, PDTX) and broad system

strengthening (OHSS). Limited and site specific laboratory support also is provided by NGOs including Medecins Sans Frontieres

and Italian Cooperation.

Given USG's close relationship with MOHCW and familiarity with the national laboratory systems, USG provides extensive

technical support to MOHCW in planning and coordinating lab services and GFATM and other donors. These include planning for

lab procurement and training and incorporation of laboratory planning into national roll-out strategies. USG personnel are active

members of Zimbabwe GF's Country Coordinating Mechanism's technical writing teams. Total support to national laboratory

services over the past three years is estimated at $20 million of which GF contributed about 75%.

Table 3.3.16:

N/A

New/Continuing Activity: Continuing Activity

Continuing Activity: 18331

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

18331 6532.08 U.S. Agency for US Agency for 8057 4087.08 USAID $41,000

International International

Development Development

11641 6532.07 U.S. Agency for US Agency for 5838 4087.07 $150,000

International International

Development Development

6532 6532.06 U.S. Agency for US Agency for 3937 3937.06 $300,000

International International

Development Development

Table 3.3.17: