In collaboration with the National Food and Nutrition Commission, the MoH will use the plus-up funds to strengthen the infant and young child (IYCF) component of the PMTCT program through training of health workers of IYCF counseling and support, revising the PMTCT curricula on infant and young child feeding, establishing feeding demonstrations/programs for faltering children, community follow up and support for HIV exposed infants. Through these funds, the MoH will also develop and coordinate a referral systems for HIV+ pregnant women to the ART program and linkages to child follow up and infant diagnosis. Lastly, since the success of a PMTCT program depends on how well the program is integrated into the MCH program, the plus up funds will be used to strengthen the MCH broad spectrum of safe motherhood components that directly have an impact on PMTCT and also strengthen the second prong of PMTCT which is family planning by providing policies and guidance on CT and an ART referral system for women accessing this service.

The United States Government (USG), through CDC aims to provide direct ongoing support to the Ministry of Health (MOH) for developing an effective prevention of mother to child transmission of HIV (PMTCT) monitoring system. The USG will also strengthen the supplies and logistics systems for the program. The proposed program monitoring system will capture data from facility level to national level using both paper-based tools and the electronic based system which, in turn will, feed into the continuity of care project. As services are expanded, it is critical to establish national systems for PMTCT program monitoring. Such systems will involve similar data collection, analysis and reporting requirements across countries. The PMTCT-MS is designed to: • Standardize data collection and monitoring procedures • Provide program monitoring information to identify progress and challenges and to improve PMTCT services • Facilitate standard reporting of national and international PMTCT indicators • Support a simple, national strategic information system for PMTCT • Be adaptable to meet country-specific needs In addition, CDC will second two new positions within MOH to provide logistical, monitoring and evaluation technical assistance to the national program. Other activities to be implemented include strengthening the reporting system at all levels of data capture, monitoring visits, training, strengthening the supply chain for the PMTCT supplies, and support for PMTCT buffer logistics

In FY 2007, all USG partners will be scaling up efforts to reach many women based on the population based coverage model, direct support to MOH via a memorandum of understanding will enable key technical staff to plan, coordinate and supervise the delivery of integrated services with implementing partners. In addition, MOH will ensure that the program is rolled-out as mentioned in the national PMTCT expansion plan. This plan embraces routine opt-out counseling and testing, universal access to PMTCT service, targets for program performance and will ensure that all HIV-positive women identified through the program are not only linked to antiretroviral therapy (ART) but access ART and care services.

Direct funding for PMTCT service delivery and technical assistance not only complements USG's other support to MOH such as in infant and young child nutrition, palliative care, ART services, reproductive health and strategic information but also ensures that the PMTCT program is sustainable through incorporating the PMTCT services in routine maternal and child health services.

In FY07, a plus up request ($150,000) and a reprogramming request ($75,000) are requested for this activity; the total amount requested for this activity is $325,000. In collaboration with the National Food and Nutrition Commission, the MoH will use the plus-up funds to strengthen the infant and young child (IYCF) component of the PMTCT program through training of health workers of IYCF counseling and support, revising the PMTCT curricula on infant and young child feeding, establishing feeding demonstrations/programs for faltering children, community follow up and support for HIV exposed infants. Through these funds, the MoH will also develop and coordinate a referral systems for HIV+ pregnant women to the ART program and linkages to child follow up and infant diagnosis.

Lastly, since the success of a PMTCT program depends on well the program is integrated

into the MCH program, the plus up funds will be used to strengthen the MCH broad spectrum of safe motherhood components that directly have an impact on PMTCT and also strengthen the second prong of PMTCT which is family planning by providing policies and guidance on CT and an ART referral system for women accessing this service.

This activity relates to activities in counseling and testing, laboratory infrastructure, palliative care: basic health support activity, and HVTB (#9032, #9017, #8819, #8992, #9037, #9006, #9046, and #9010).

In FY 2006, the USG supported the Ministry of Health to establish the National TB/HIV body. Further support was also given in training 20 provincial facilitators from 4 provinces in Diagnostic Counseling and testing. These trainings are being scaled up to district levels. Plus up funds are have been requested to provide technical support through supervision. The Ministry of Health will provide supervision from National TB/HIV Program at the headquarters and the Provincial Health Offices to the districts. This support will reach at least 50% of the districts in each province during every quarter. It is expected that by the end of the year all the 72 districts in the country could have been reached. Through supervision, the TB/HIV program officers will identify the strengths, weaknesses, opportunities and threats to the program and offer technical advise and map out strategies to strengthen the program. Through this activity, 800 health care providers will receive on the job training.

This activity provides for the following activities in support of the national implementation of TB/HIV activities; 1.) Collaborative TB/HIV activity meetings 2.) Providing technical support to the provinces and districts through supervision 3.)Dissemination of TB/HIV guidelines/TB manual to the Provincial teams. 4) Evaluation of TB/HIV recording and reporting tools in selected districts. 5) National TB/HIV review meeting. 6) One full time TB/HIV officer to be based within the Ministry of Health

In FY 2006, the US Government (USG) provided direct support to the Ministry of Health (MOH) through CDC Technical Assistance (#9021) in the national integration of Tuberculosis (TB) and HIV services by providing support to a variety of areas at the national and local level, including support to develop TB/HIV guidelines and materials, and preparation of TB clinical decision support systems.

A National level TB/HIV coordinating body within the MOH with the following membership; staff from the TB, HIV, counseling and testing (CT) units in MOH; multilateral organizations; research groups; faith-based organizations; non-governmental organizations; and community representatives. This body was tasked with developing and implementing a single, coherent TB/HIV strategy and communication message based on the best existing evidence. As a result national guidelines for the implementation of TB/HIV activities were developed based on the World Health Organization (WHO) Interim Guidelines for TB/HIV collaboration. Additional support was provided for the revision of TB data collection forms and registers, based on WHO forms that incorporate the collection of HIV data. The USG supported the MoH to print the revised patient treatment form, identification card, and registers that have been distributed to all provinces and districts. Technical support was provided for the orientation of health staff in the new forms. In addition the USG co-funded, with the MOH, WHO, and JHPIEGO, technical assistance will be provided to ensure that the national TB manual is revised to include updated information on TB/HIV, produced, and disseminated. Technical support will be provided to the National TB program for the National TB Review meeting for the evaluation of the implementation of the Stop TB strategy.

Following the distribution and orientation of district staff in the new recording and reporting forms, the USG, in collaboration with the TB/HIV coordinating body, will provide technical assistance to the MOH in FY 2007 to evaluate the implementation of these new registers and forms in selected districts and health centers. The evaluation will assess the functionality of the revised forms and registers in collecting TB/HIV data and assess the training needs for improving the surveillance of TB/HIV. Particular attention will be paid to assessing the referral links between the TB and HIV programs and to determine whether the systems in place are adequate to ensure collection of quality data.

The increased work load in the National TB program coupled with shortage of human resource has impacted negatively in the implementation of some TB/HIV collaborative activities. To strengthen the human resource capacity in the National TB program, in FY 2007, the USG will support the Ministry of Health by placing a full time TB/HIV officer. This officer will concentrate in the implementation of TB/HIV activities working directly under the jurisdiction of the National TB Program Manager.

Targets

Target Target Value Not Applicable Number of service outlets providing treatment for tuberculosis (TB)  to HIV-infected individuals (diagnosed or presumed) in a palliative care setting Number of HIV-infected clients given TB preventive therapy  Number of HIV-infected clients attending HIV care/treatment  services that are receiving treatment for TB disease Number of individuals trained to provide treatment for TB to 1,000
HIV-infected individuals (diagnosed or presumed)

Table 3.3.07:

Activities related to this include monitoring visits, training, policy and guideline dissemination, participation national quality improvement efforts, and integration and scale-up of the national ART information system, the Continuity of Care: Patient Tracking System (CC:PTS), EGPAF support to Ministry of Health drug resistance monitoring.

In 2006, the Zambia Ministry of Health (MOH) implemented a policy which stipulates that antiretroviral therapy (ART) and related services are to be provided free of charge to all eligible Zambians. An evaluation of the national ART program was conducted and determined that additional support for quality improvement, policy and guideline dissemination and training was desperately needed.

In ongoing efforts to support national efforts, the United States Government (USG), through HHS/CDC aims to provide direct support to the MOH for supervision and coordination by national teams on ART service delivery and to enable improved linkages with the provincial and district ART programs in fiscal year (FY) 2007. These funds will provide a new position within MOH, a Quality Assurance Advisor for HIV/AIDS services.

Direct support to MOH in FY 2007 will enable key technical staff to plan and integrate services with partners and carry out the 2006-2008 HIV/AIDS Treatment, Care and Support Plan. This plan embraces the ideal of universal access and sets targets for program performance and ensures sustainability of the ART services.

Direct funding for ART service delivery and technical assistance will complement other support to MOH such as in tuberculosis (TB)/HIV, and strategic information.

A second critical activity in FY 2007 for the MOH is to launch a formal system of ARV drug resistance monitoring, in collaboration with CDC and other USG-supported partners. The FY 2007 funding will enable the MOH to establish a system to monitor HIV drug resistance (HIVDR) emerging during treatment. Such a system will include the initiation and coordination of an MOH HIVDR working group to develop a national strategy for HIVDR resistance monitoring, design and implementation of an appropriate prospective cohort in which to monitor HIVDR emerging during treatment and to collect information on behavioral and other risk factors associated with increased risk of HIVDR development, technical assistance with building laboratory capacity to perform genotypic HIV drug resistance testing, support of management and analysis of data on the magnitude of HIVDR in the selected study population, and coordination of report dissemination to the Government of the Republic of Zambia, health professionals, the public, and the scientific literature.

This activity relates to EGPAF SI (#9001), JHPIEGO SI (#9034), AIDSRelief - Catholic Relief Services (CRS) (#8828), Technical Assistance/Centers for Disease Control and Prevention (CDC) (#9023), Zambia National Blood Transfusion Service (ZNBTS) (#9698), and CCPTS COMFORCE (#9691).

This cooperative agreement (CoAg) with the Ministry of Health (MOH) supports SI objectives of strengthening local health management information systems (HMIS) and improving human resource capacity for monitoring and evaluation (M&E).

Building on last years successes, in fiscal year (FY) 2007, this activity will continue to support improved use of routine health information through national patient level information systems, aggregate systems, survey efforts, and monitoring and evaluation activities. This activity also includes the procurement of equipment required for further deployment of the nationally adopted Continuity of Care and Patient Tracking System (CCPTS) which may include touch screens for data entry, electronic medical record (EMR) Care Cards (smart cards) for data transport, card readers, printers, computers, and computer and printer consumables.

Highly competent and skilled information technology (IT) and information systems (IS) personnel are essential to support and ‘locally own' a national EMR system. Support will be provided for capacity building activities within the MOH at Central, Provincial, District, and Facility levels by assisting the Ministry to hire appropriate technical leadership staff holding internationally recognized standard certifications, and other objective measures of skill and experience. In light of the new MOH structure, and the change opportunities associated, this is a key time to support transition to higher level skills and authority in information systems and management.

Funding for the facilitation of roll-out and scale-up planning meetings as the system capacity expands will be provided as well as technical assistance to provincial and district levels in handling system upgrades. While the United States Government (USG) is very supportive of this project, for sustainability it is imperative to have the MOH authorize and lead all aspects of the deployment of the new national EMR system.

This funding will provide support for continued improvement of linkages between national clinical information systems such as CCPTS, and the national HMIS. Training for the national CCPTS at the central levels will continue to expand in FY 2007 in the following areas: (1) software development training to build MOH's capacity to maintain and develop enhancements to the system; (2) user training for staff facilitators having expertise with the system; and (3) system maintenance training.

As a result of these trainings, 10 people will be trained in software development, 120 people will be trained as users of the system, and 70 people will be trained in the maintenance of the system. JHPIEGO is providing on-the-job training to 250 clinical staff at facility-level through a mobile team of IT professionals who train, install, and assist with troubleshooting and data entry.

Support will also be provided for MOH to include an M&E Data Use Specialist in the central M&E Directorate to maximize information systems and train provincial and district counterparts on localized use and feedback processes. This specialist will work with USG staff to assist in the CCPTS roll out, create data use curricula and tools, and support national HMIS restructuring and file exchange.

The FY 2007 funding will also enable the Zambia MOH to support and expand its surveillance of HIV and other causes of HIV-related morbidity and mortality through the following activities: 1) begin the analysis, reporting, and dissemination of data from the Zambia 2006 Antenatal Clinic Sentinel Surveillance Survey and the Zambia 2006 Demographic and Health Survey on estimates of HIV and syphilis prevalence (and recent infections) in relation to important socio-demographic factors; 2) strengthen the Zambia National Cancer Registry for surveillance and reporting of AIDS-related malignancies to enable the Government of the Republic of Zambia in its monitoring of the impact of antiretroviral therapy scale-up on the risk of these important AIDS-related complications (note: Cancer Registry data suggest that the leading cancers for both men and women in Zambia are viral related. Monitoring cancer rates is a way to triangulate on the course of

the epidemic and the impact of the PEPFAR interventions in the capital, where the earliest and largest of the ART services exist and from which the Cancer Registry draws most of its cases. This type of approach is helpful in the absence of good mortality data.); 3) support MOH staff training in bioethics and human subject research protection to increase awareness and proficiency in patient privacy and confidentiality, issues that are critical and fundamental to all HIV/AIDS M&E and surveillance data collection and data use, including CCPTS; 4) assist the MOH to archive historic and current national level surveillance and M&E data to better support trend and impact analyses, and encourage the use and reporting of health information collected to inform MOH planning and to evaluate the impact of MOH programs; and 5) build capacity in health research methodology including study design, data management, statistical analysis, scientific writing, preparation of manuscripts for publication in the scientific literature, methods and resources for accessing international electronic health information and literature, and communication of health information and research results to health professionals, policy makers, and the general public. These activities aim to increase the proficiency of MOH staff in the systematic collection and use of HIV/AIDS M&E and surveillance data, effective communication of results for MOH planning of HIV/AIDS services and program evaluation, and capacity building within MOH so that M&E and surveillance activities can be sustained by Zambian health professionals beyond FY 2007.