The Government of Zimbabwe is emphasizing a comprehensive approach to HIV prevention, care and treatment with strong political support and ambitious goals and is working to recover from deterioration of the public sector health system. Recently, the dollarization of the economy has stabilized the plummet in purchasing power. Yet health and education goods and services remain unavailable or financially out of reach for the majority of Zimbabweans. The private sector (non-governmental, faith-based and commercial entities) is responding to demand by assuming an increasing role in health and education services, especially for HIV-related services. The dynamic economic and political environment in Zimbabwe necessitates responsive, innovative approaches to delivering essential social services. PSI has been a key implementing partner for the USAID-funded Zimbabwe HIV and AIDS Partnership Project from October 2005 to July 2010. Through this and other projects, PSI Manages a franchise for HIV counseling and testing (CT) that tested 322 000 clients in FY10; Oversees a franchise for post-test support that provided care to more than 127, 000 HIV positive clients in FY10 Assists the Ministry of Health and Child Welfare (MOHCW) in piloting the country's national strategy for scale up of male circumcision; Over 10, 000 males have been circumcised in FY10. Distributes family planning products and provides FP counseling to clients accessing HTC and care services. Provides TB screening and referral for all HIV positive clients accessing HTC and care services. Develops and implements evidence based behavior change communications for reduction of concurrent sexual partnerships that reached 233,847 individuals in FY10 Distributes male and female condoms through a network of 12,885 condom service outlets Assists the Ministry of Health and Child Welfare in developing and implementing service communications for Provider Initiated Testing & Counseling (PITC), TB and HIV infection, Treatment literacy and PMTCT using mass media and interpersonal communications Implements marketing and interpersonal communication activities for HIV related products and services for testing and counseling and condom use that reached 581,984 individuals in FY10

For FY11 under the Zimbabwe Strengthening Private Sector Services Project (SPSS) PSI proposes a comprehensive HIV prevention and care strategy to support national efforts to reduce HIV incidence and HIV and AIDS related morbidity and mortality in Zimbabwe by scaling up interventions which have proven to be successful in previous years of implementation as well as rolling out recently piloted innovative approaches such as MC and integration of TB laboratory services with HTC and HIV care services.

2. Goals and strategies for FY 2011

The goal of this proposed program is to improve the health of the people of Zimbabwe through reduced HIV prevalence among young adults and reduced mortality and morbidity among PLHIV. The strategic objective is to increase the availability of social sector services and related products through the private sector. To contribute to the goal and strategic objective, the SPSS program will work primarily through the private sector to achieve the following project objectives: 1. Expand and improve private sector based health services; 2. Improve the availability and range of affordable health products or supplies; and to 3. Promote healthy behaviors

3. Sustainability and country ownership

The program supports the GOZ HIV/AIDS National Strategy and Plan for all program areas. In addition, the program is using national agreed performance indicators to measure performance. Thus, funds will be used to achieve national targets for all program activities. Implementation of both HIV services and communications will include linkages with public and private sectors. For instance, the program will complement national TB/HIV collaborative activities and the HIC care program will continue to support the national ART and OI program with ART adherence counseling. Also, all communication activities will be implemented in line with the national behavior change communication strategy and the distribution of male and female condoms will be implemented through a network of private sector retail outlets nationwide.

4. Health systems strengthening and Human Resources for Health The MC program will provide the necessary commodities in form of disposable, male circumcision kits and equip the three MC sites and three mobile teams with the necessary material and infrastructure to provide safe MC services. This will also contribute to further strengthen the Zimbabwean health delivery system, as the improved infrastructure can also serve for surgical interventions such as caesarean section and other procedures. Training and capacity building of health care staff in MC service delivery will also contribute to further strengthen the current health system. PSI will continue to support the MOHCW in scaling up provider initiated testing and counselling.

5. Monitoring and Evaluation The program's performance monitoring strategy is designed to provide accurate and timely evidence for program decision making. Research, Monitoring and Evaluation activities in FY11 will include conducting: 1. Tracking Results Continuously (TRaC) surveys population-based survey that collects quantitative data on target populations' behaviors (concurrent sexual partners, correct and consistent use of condoms and HIV testing and counseling) and their behavioral determinants. 2. Framework on Qualitative study on male circumcision. The program will seek to better understand factors influencing uptake of male circumcision. PSI/Z will use findings from these qualitative studies to improve TRaC questionnaires and to develop archetypes of target populations for better demand creation communications for MC. 3. Brand Equity Study. This study will seek to understand factors surrounding the decline in condoms sales volumes as well as assess Protector Plus's brand relevance and appeal to target audiences. Moving forward, this type of study will be repeated depending on market place changes. 4. MIS. To respond to an increased portfolio of HIV services and expanded reach proposed under this program, PSI/Z will update its services MIS. In the new MIS, program outputs and client record information will be computerized and linked as necessary.

6. Wraparounds and leveraging for increased impact/sustainability The program will continue to leverage funds from other donor sources. The Gates Foundation is expected to contribute 11 Million USD between 2010 and 2013 to contribute to MC scale up by targeting specifically personnel with the Uniformed Services, but also including civilians living in the areas surrounding military and police camps. 148 000 men are expected to be reached with the additional funds over the three year period, providing funds to circumcise 25 000 males in FY11. PSI has also been successful in leveraging funds for HIV services communications, including MC and TB/HIV with GF Round 8. A total of $ 2 Million received from GF will be used to scale up mass media and interpersonal communication activities to raise awareness and increase demand for HIV services. PSI will continue to leverage funds through DFID to support all HIV services activities funded by USG under this program. The amount of funding expected from DFID for FY11 is still unknown but is assumed for planning purposes to start from May 2011 and to be an estimated $4 million annually..

With increasing numbers of people knowing their HIV status, the demand for post-test support services for PLHIV has increased significantly in the past years. Under the HIV and AIDS Partnership Project, PSI and partners established a franchise of 15 New Life post-test support centers. All centers work with a network of community-based counselors, peer counselors and support groups for PLHIV to provide post-test support services directly in clients' communities and for patients enrolled in the national PMTCT and ART programs.

PSI will maintains its network of 14 New Life centers in FY11. Counselors and peer counselors from New Life centers will continue to provide psycho-social counseling and ART adherence counseling to patients and their families accessing public sector health care facilities. The 14 centers will expand reach to workforces with post-test support services. New Life teams will provide direct psycho-social counseling and information on positive living to HIV positive employees. These teams will also build the capacity of peer educators at workplaces to provide ongoing support, to establish support groups for PLHIV and to sensitize employers and employees on the importance of post-test support services for their HIV positive colleagues (see section 12, key issues below). The New Life care program is expected to reach 105 000 PLHIV with care and positive prevention services in FY11.

Quarterly supervisory visits to all 14 sites are the cornerstone of PSI's approach to assuring the quality of services offered through New Life. PSI staff assesses sites and counselors against a checklist of quality standards. These visits are complemented by annual external mystery client surveys to all sites and all mobile teams (conducted by an external research agency), annual refresher trainings for all providers and counselors, and ongoing sharing of best practices

In collaboration with the ZACF, EGPAF and with technical support provided by the University of Zimbabwe, PSI will expand comprehensive HIV care and treatment services, including ART, OI prophylaxis and treatment and comprehensive PMTCT services through the private sector. PSI will integrate franchised ART services into one existing New Life center in Harare in FY11. Only a limited number (50) of PLHIV will be reached with the care and treatment services in FY11, assuming funding leveraged from DFID. Specific emphasis will be placed on reaching marginalized mobile population groups such as sex workers, who have difficulties in accessing ART in the public sector. The current program has already started to reach such population groups with mobile T&C services. The program will offer a holistic approach to HIV treatment and care led by a multidisciplinary team (nurses, doctors, counselors, and clinical psychologists) using a family-centered, gender-sensitive approach that is nurse driven, an innovation in task shifting that PSI will test through this program. PSI will work with pharmacies in proximity to the clinic to stock and dispense ARVs and OI drugs to clients of the New Life ART franchise. New Life ART patients initiated on treatment and stable for 6 -12 months will be moved, where feasible, to outreach sites using the city health clinics. The clinical management hand-over process will be facilitated through the team of private doctors and nurses who will work closely with nurses at city health clinics. It is expected that this process will also improve the capacity of public sector nurses to manage patients on ART. This process will allow PSI to increase the number of new patients initiating ART through the franchise by 'graduating' stable patients to long-term ART follow up services nearer to the communities where they live. As treatment is a new area for PSI, other partners will closely work together with the PSI services teams. ZACF and EGPAF will be responsible for training all cadres of participating providers in comprehensive HIV related care and treatment of both adults and children and provide supervision of treatment and care providers. The Zimbabwe National Quality Assurance Program (ZINQAP) will provide external quality control of laboratory services (e.g., CD4, hematology, chemistry tests). The performance of all sites will be measured against target values and all participating laboratories. As part of this package of quality assurance for treatment, PSI/Z will establish an advanced MIS system that will integrate data from the other service delivery elements of this program. The system will allow for patient clinical record management and patient follow-up to track adherence and compliance.

Approximately 2 Million Zimbabweans have been tested for HIV through the VCT services provided through New Start program since its inception in 1999 representing an estimated 60% of the total number of Zimbabweans tested for HIV in Zimbabwe. An average of 30,000 people are currently accessing C&T services through the New Start program each month, and demand for the C&T services is on the increase.

Based on the recommendations by the MOHCW CT services constitute an important approach to identify people living with HIV in Zimbabwe and also represent an important behavior change HIV prevention intervention especially for (discordant) couples. PSI therefore proposes to maintain the New Start CT network with its static sites and outreach teams in FY11.

PSI will maintain 4 directly managed C&T centers including 8 outreach teams located in the major urban areas of Harare, Chitungwiza, Bulawayo and Masvingo as well as 14 local partner managed C&T sites. The program has been successful in increasing the proportion of men and women accessing C&T as couples. The requested additional funds will be used to further increase couples C&T services. Mobile outreach C&T services currently contribute 55% of the total number of monthly C&T clients and about 10% of the mobile C&T services are targeted at population groups in high risk areas such as workplaces, prisons, resettlement areas and to vulnerable, mobile population groups (MVP). FY11 funds will be used to further expand mobile outreach services in order to reach these vulnerable and hard to reach population groups.

With support of the Clinton Health Access Initiative PSI was able to establish CD4 cell count laboratory services at 4 New start centers. With USG funding PSI will expand CD4 cell count services to an additional 4 mobile teams. CD4 cell count laboratory services integration with HTC has shown to improve access to early treatment and care by HIV positive clients.

The program will continue to provide FP counseling routinely offered to all clients accessing New Life and New Start services. An estimated 250 000 people will benefit from FP counseling in FY11. .

The program is expecting to provide C&T services for a total of 280 000 adults above 16 years of age and 2000 children under 16 years of age. PSI will continue to monitor CT performance using the current M&E tools. Quality of services will be monitored by Mystery Client surveys and quarterly supervisory visits of all CT centers.

PSI supported the MOHCW in initiating male circumcision services in Zimbabwe. Four MC pilot sites and one national MC training centre have been established. M&E tools, MC operating guidelines and a procurement and supplies system for MC commodities has been put in place. A national training program has been established. Also, advocacy and communication strategies and campaigns and a national MC policy and national MC strategy and implementation plan have been developed. Five thousand boys and men have been circumcised thus far. Funds requested in FY11 will be used to contribute to the implementation of the national strategy for scale up with the ultimate goal to reach 1.2 Million males aged 15-29 between 2010 and 2015. The proposed strategy will support key operational aspects of the MC scale up including MC service delivery and MC demand generation communications. Service delivery will leverage human resources from the private sector through public/private partnerships. Funds requested are expected to also improve the health infrastructure at public sector hospitals and to build the capacity of health care providers for safe MC services. The program provides the necessary commodities and equips the MC sites with the necessary tools and instruments to provide the services.

MC Training: PSI supported the MOHCW in developing the national MC training program. PSI will work with the MOCHW to expand the national training program at the central level MC training site in Harare to train 160 doctors and nurses ( 80 of which will be funded by the Gates Foundation). Outside of training and quality assurance duties, the national training site and team will double as MC service delivery site. PSI will apply the WHO quality assurance toolkits to assess quality and to support teams in improving the quality of services delivery. Quality improvement teams will visit each of the six MC teams every quarter to conduct a supervisory visit.

MC Service delivery: To attain high coverage of MC services, PSI will use a combination of fixed sites and mobile services. Fixed sites will consist of one stand-alone MC center already established in Bulawayo and three larger fixed sites co-located at public sector hospitals, and smaller fixed sites also co-located at public clinics, which will be visited by three mobile teams. An additional three mobile MC teams will be dedicated to quickly reach large numbers of men. Mobile services will follow community mobilization teams and will work out of lower level primary health care facilities, using tents to create additional space for MC procedures. To ensure efficiency and maximize outputs, PSI continues to use several components of the WHO's MOVE models.

PSI is currently implementing the first phase of a communications campaign to raise awareness of the risks associated with concurrent sexual partnerships. By July 2010, the campaign had reached 233,847 individuals with small group discussions on partner reduction.

With leveraging from The Global Fund Round 8, funds requested in FY11 will be used to develop and implement the second phase of a multi media communications campaign through mass media and interpersonal communication (IPC) channels.

The second phase of the concurrency campaign will focus on the perceived costs of engaging in concurrent partnership for young urban women (15-29 years) and older men (15-39 years) and on the perceived benefits of concurrent partnering for young women. Small group level interventions using participatory techniques will be implemented among young urban women focusing on confidence building and sexual decision making skills in support of reduction of concurrent sexual partnerships. Road shows using music, dance and games will be utilized to mobilize men to attend small group discussions on partner reduction at workplaces, beer halls, shopping centers and other community gathering places.

PSI will train community based organizations and drama groups to implement interactive IPC activities and motivate the target audience to internalize risks and make the commitment to reduce concurrent sexual partnering. The IPC intervention is expected to reach 266,400 individuals with messages to promote reduction of concurrent partnering in FY11.

Supervision and monitoring are key components of PSI's IPC interventions. To ensure consistency in the implementation of the IPC strategy across partners, PSI has a monitoring plan that includes periodic supervision and assessment of the intervention delivery. A checklist helps supervisors assess IPC sessions in a systematic and focused manner and provide feedback for improvement. Periodic IPC assessments are randomly conducted by the Research department.

The objectives of this program area are to improve the availability of affordable health products through the distribution of Protector Plus male and care female condoms, to increase use of HIV related services and products through the development and implementation of evidence based communications.

The previous hyper inflationary environment in FY08 led to significant wholesale outlet closures. Funds requested for FY11 will be used to maintain overall availability of socially marketed male and female condoms through direct distribution mechanisms to retail outlets. Distribution efforts will focus on geographic areas that have a higher HIV prevalence than the national average including rural growth points, mining and farming areas, border towns and organizations with a large mobile workforce.

Using results of the research survey on traders conducted in FY10, the program will explore opportunities for indirect distribution systems through Coca- Cola stockists to increase availability of male condoms in high risk outlets such as liquor outlets, service stations and tuck shops. Under this program, PSI will deliver product to all Coca- Cola depots and independent wholesalers to allow customers to purchase condoms in addition to beverages.

The dollarization of the Zimbabwean economy in FY09 brought about some relative stability to the retail sector for fast moving consumer goods. Consequently, stiff competition for shelf space at outlet level has emerged as manufacturers resume operations. To enhance product visibility and sustained uptake of products, PSI will establish private sector partnerships for merchandising activities in major high volume outlets contributing more than 35% of monthly sales.

To successfully promote the use of the female condom, interpersonal communication is vital. Funds requested for FY11 will be used to train hair dressers and male barbers in high risk areas to promote correct and consistent use of the female condom. The program will also train IPC agents to reach young women in tertiary colleges, women subjected to gender based violence, pregnant and lactating women under the PMTCT program and sex workers with customized benefits promoting female condom use. More emphasis will be placed on reaching men with IPC messages to increase acceptance and use of the product.

The project will use internal MIS based systems for product monitoring and control purposes. MIS will also be used for strengthening stock management at retail level and to monitor sales staff route cycle compliance and coverage. The previous hyper inflationary period may have affected the brand equity for Protector Plus. In view of this, the program will conduct a brand equity survey to determine if Protector Plus needs to be refreshed as a brand in FY11. This will be dependent on DFID leveraging.

The program will utilize IPC activities to target sexually active men and women 20-40 years with integrated messages to increase consistent use of male and female condom in high risk and regular relationships including concurrency. Through edutainment and small group discussions, IPC interventions will impart skills to negotiate and use condoms. With leveraging from the Global Fund Round 8, the program will develop new communications campaign for male circumcision using mass media and interpersonal communications channels to increase understanding of the HIV preventive benefits of MC, to dispel misconceptions and to ensure behaviour maintenance post-procedure. Efforts will be made to work with youth and religious organizations to mobilize young men to access the service. A network of male champions will also be trained to disseminate messages on MC and to recruit their peers for male circumcision.

PSI/Z, in collaboration with the MOHCW, integrated TB symptomatic screening for all HIV positive clients accessing CT services at New Start and New Life centers in 2005. Counselors use a standard questionnaire to assess each client for clinical symptoms of TB and other chest infections. All TB suspects are referred to TB diagnostic centers. Currently, 14% of all HIV positive clients tested through New Start are TB suspects, and a total of 1000 TB suspects are referred every month for laboratory investigations. Due to constraints in the current health system, referred HIV positive TB suspects are often not able to access clinical diagnosis or services. To help fill this gap, PSI will integrate TB smear microscopy into two New Start sites (Harare & Bulawayo) to facilitate early diagnosis and treatment of HIV infected TB patients.

Funds will be used to equip the two sites with the necessary instruments consisting of light microscopes and accessories, with the necessary quantities of reagents to conduct the TB investigations. Existing staff will be trained on sputum smear microscopy. All clients accessing New Start CT services will continue to undergo clinical symptom screening using a brief questionnaire administered by trained counselors as previously mentioned.

All clients with productive cough, identified as TB suspects at New Start sites in and around Harare and Bulawayo, will collect sputum on three consecutive days for smear microscopy. All clients with positive TB sputum results will be referred for anti-TB treatment to be commenced immediately at TB treatment centers. All other TB suspects with negative smear results will be referred for further TB investigations at public sector health care facilities. It is expected that a total of 500 TB suspects will benefit from the additional laboratory services, the intensified referral system and the improved access to immediate TB treatment offered at the five CT sites every month.

The program will build on the work started so far by developing a multi - media communication campaign to increase awareness of the availability of TB diagnostic services to those who test HIV positive at the New Start centers. The campaign will seek to encourage sexually active people to know their status early at the New Start centers in order to receive early diagnosis of TB and receive appropriate medication if they are HIV positive.

PSI will monitor TB laboratory performance using internal and national external quality control mechanisms which are already in place. The program will use existing national M&E tools to report on implementation progress.