The funding level for this activity in FY 2008 has increased since FY 2007. Narrative changes include

updates on progress made and expansion of activities.

This activity is linked to SoPHO PMTCT.

Tulane University, through its sub-partner Boston University and local non-governmental agency Boston

University Center for International Health and Development, Zambia (BUCIHDZ) (formerly the Zambia

Exclusive Breastfeeding Study, ZEBS), and in collaboration with the Southern Provincial Health Office

(SPHO) began providing prevention of mother to child transmission of HIV (PMTCT) in FY 2006 in three

districts. By the end of 2007, they directly supported government clinics in eight districts while indirectly

supporting the government initiative in the remaining three districts of the Southern Province.

In FY 2007, BU received additional funds to strengthen the entire PMTCT program with special emphasis

on increasing coverage of rural populations with improved maternal and child health (MCH) services;

providing effective PMTCT antiretroviral (ART) prophylaxis; improving the postnatal care for mother-child

pairs; establishing infant and young child feeding support and lastly, to train traditional birth attendants

(TBAs) in the delivery of PMTCT services. With the plus-up funds, BUCIHDZ also further enhanced the

linkage between PMTCT and ART through improved referrals of all pregnant women for baseline CD4

screening. These funds will also permit the expansion of the successful performance-based bursary aimed

at improving community outreach in the most rural regions. This bursary is a resource for facilities to

strengthen PMTCT specific community outreach programs as well as incorporate PMTCT messages into all

other outreach activities. The pilot has proven successful as the numbers of women tested in the field

during outreach has increased significantly. Lastly, these funds will be used to continue strengthening

MCH programs and efficiently integrating PMTCT services into these services.

Through additional funding, BUCIHDZ also established a comprehensive exclusive breastfeeding (EBF)

demonstration project in one urban site (George Clinic, Lusaka) and in three rural sites (in Mazabuka

District, Southern Province. Provided the project is successful, this funding will be used to add additional

demonstration sites in consultation with national PMTCT partners. There are three specific objectives: 1) to

promote and achieve high levels (> 75%) of EBF through six months of age among pregnant HIV-infected

women booking in the antenatal clinics; 2) to promote and achieve high compliance with first line ART

among HIV-infected pregnant women who qualify according to the national guidelines; 3) to discourage and

minimize cessation of breastfeeding or non-EBF among women who learn their infant's negative HIV

infection status through early infant diagnosis polymerase chain reaction (PCR).

FY 2008 activities will result in: (1) increased access to quality PMTCT services; (2) improved quality of

PMTCT services integrated into routine MCH services; (3) increased coverage of voluntary counseling and

testing (VCT) services; (4) higher use of a complete course of ARV prophylaxis by HIV-positive women; (5)

improved referral to ARV treatment programs as they are developed within the districts; and (6) expansion

of the successfully piloted innovative community-based VCT, and PMTCT program to rural populations not

ordinarily reached through facility-based PMTCT services.

In FY 2008, BUCIHDZ will continue expanding PMTCT services in the Southern Province. In collaboration

with the SPHO and district health management teams, BUCIHDZ will directly support PMTCT services in 8

districts of Southern Province and in partnership with the PHO support PMTCT services in the remaining

three districts. BU will aim to have at least 80% of health centers in these districts establish PMTCT

services. As of March 2007, the United States Government (USG) through its partners, Academy for

Educational Development and BUCIHDZ were supporting 90 health facilities out of a total of 217 MCH sites

in the Southern Province. By the end of FY 2008, BUCIHDZ will provide direct support to 190 sites in all 11

districts (pending direct SPHO support to three districts) and will, in collaboration with the province, provide

technical assistance to sites that will be established by district health teams. BUCIHDZ, in partnership with

SPHO and district teams will train health workers in these facilities on all components of PMTCT services

and integrate these services into routine MCH services, and provide back up commodities for the province.

By working in collaboration with the district health teams, capacity will be increased to ensure that

sustainable programs are developed and maintained. Additionally, BUCIHDZ will continue to focus efforts

on training health workers on data management, ensuring all facilities are correctly filling in government

registers, and reporting accurate and timely data to the DHOs for integration into the HMIS. Sustainability

of the PMTCT program will be achieved through the integration of PMTCT services into routine MCH

activities using existing government health workers and systems. Health workers will continue to be trained

in the implementation of the four-pronged approach to PMTCT in counseling, the minimum package of care

of PMTCT, logistics, data management, and quality assurance, as well as in the early infant diagnosis

package of didactic theory, specimen collection, packaging, transport and follow-up (see Palliative Care

Narrative).

BUCIHDZ will continue to support district efforts to develop networks and referral systems for pregnant

women to access other services offered at health centers and in the communities, including family planning.

These networks are critical for linking HIV-positive pregnant women to antiretroviral therapy (ART) services

and developing an approach where all HIV+ women are referred for baseline CD4 counts and women

needing ART are referred to the nearest ART center. BUCIHDZ will also provide counseling on appropriate

feeding options for infants born to HIV-positive women and those of unknown status. By the end of FY

2008, data on HIV-positive women and infants referred to ART and care services will be available as this

information is currently being incorporated as indicators in the PMTCT monitoring system.

Scarce and unequal allocation of human resources for service delivery is the biggest constraint limiting

coverage of HIV/AIDS services in Zambia. An innovative approach is crucial to extending human capacity

development, especially in the rural areas of Zambia, where access to care is extremely limited. In these

areas TBAs play a key role in implementing effective interventions in remote and rural settings. To address

the shortfall in counseling services, BUCIHDZ developed an innovative program of community-based

training of lay counselors in the provision of pre- and post-test HIV and lactation counseling. A cadre of

community members and traditional birth attendants was identified and trained to perform VCT at the health

posts and/or within the community. As part of their scope of responsibilities, the TBAs also performed real-

time community-based HIV testing using whole blood or oral fluid rapid tests, or linked these counseling

services with same-day HIV testing at the corresponding rural health center. Based on the success of this

approach, the model will be scaled-up to three other districts in the province by the end of FY 2008.

Activity Narrative:

BUCIHDZ will expand and continue providing leadership to the USG partners on the work piloted in FY

2007, involving TBAs in the provision of PMTCT services. This strategy has the potential to extend

essential PMTCT services to an otherwise difficult-to-reach but majority-segment of pregnant women in

rural health districts in Zambia. If successful, this approach can be implemented throughout the entire

Southern Province and other rural areas in Zambia.

Masters level students, from the Department of International Health at the BU School of Public Health in the

US, will continue to be recruited to work with the project in Southern Province on three to six month field-

based applied study projects and provision of cross-training support to health workers and managers.

Targets set for this activity cover a period ending September 30, 2009.

The funding level for this activity in FY 2008 has increased since FY 2007. Narrative changes include

updates on progress made and expansion of activities.

Anti-retroviral (ARV) treatment services and Prevention of Mother to Child Transmission (PMTCT) activities

are rapidly being scaled-up in the Southern Province of Zambia including pediatric treatment which was

introduced at the Southern Provincial Hospital in 2007.

In 2007, Boston University (BU) developed palliative care services to support children who are HIV-infected,

HIV-exposed or have been the subject of HIV-exposure through child sexual abuse. In FY 2008, BU will

continue to provide palliative care to children who are HIV-infected, HIV-exposed or have been the subject

of HIV-exposure through child sexual abuse. Specifically funds will 1) insure that co-trimoxazole is available

and being prescribed to all children born to HIV-infected women within the overall Southern Province

PMTCT Integration Program; 2) actively promote breastfeeding among HIV-infected children; 3) provide

psychosocial therapy to HIV-exposed and infected children in the Child Sexual Abuse Clinic in Lusaka; 4)

facilitate referral to the Pediatric Center of Excellence; and 5) where possible actively promote the capture

into ART care all children who are identified as HIV-infected. BU has special expertise in and is assisting

with the implementation of psychosocial assessment and treatment for HIV-infected children identified at the

University Teaching Hospital (UTH) Child Sexual Abuse Clinic in Lusaka. Child sexual abuse services and

post-exposure prophylaxis of HIV services are intended to soon be provided in Livingstone (Southern

Province). BU's participation in the development and implementation of this pilot program will be key to its

success in Livingstone.

In 2008 BU will provide technical data management, monitoring and evaluation assistance to the Child

Sexual Abuse Clinic (CSAC) at University Teaching Hospital (UTH) in Lusaka. BU will coordinate with UTH

and the director of CSAC to build an efficient data management system using the Teleforms system, and

provide technical assistance for data analysis. This monitoring and evaluation system will improve follow up

and care of HIV-exposed children, indirectly improving palliative care services. Additionally, BU will provide

technical expertise in the area of psychosocial support and trauma-based therapy. With extensive

experience in this area in other developing countries, BU technical staff will develop, validate and implement

culturally appropriate, psychosocial measurement tools which are currently unavailable in the country. BU

plants to integrate these child-friendly and psychosocial aspects to all components of the CSAC clinic. It will

support two full time CSAC staff members as well as a part-time data manager. BU's expert in mental

health and child trauma will build local capacity by training all staff at the CSCA clinic in psychosocial

measurement tools and child-friendly methodology. Child sexual abuse services and post-exposure

prophylaxis of HIV services will soon be offered in Livingstone Provincial Hospital (Southern Province), and

will ideally benefit from the locally trained staff and the psychosocial measurement tools.

Another component of this activity is a continuing to pilot a program on early infant HIV diagnosis that that

was stated in 2007. Funding for this activity will be used to continue strengthening palliative care services

and linkages to support adults and children infected with and affected by HIV/AIDS.

The funding will be used to establish and strengthen palliative care support for mothers and children. Parts

of the Southern Province are very rural and services are scarce and far apart from one another, and extra

effort is needed to establish sustainable palliative care linkages to support treatment and PMTCT services.

Palliative care support will include: infant care and follow-up support for HIV infected children and mothers

including the provision of infant and adult cotrimoxazole; nutritional supplements where necessary; bed

nets; and building linkages with home based care programs in the province. Funding will also be used to

support training for home based care within a rural setting.

In FY 2008 BU will 1) identify large numbers of exposed (at risk) children and ensure that infant and adult

cotrimoxazole is available and being prescribed as per MOH guidelines; 2) actively promote breastfeeding

among HIV-infected children and strengthen infant feeding counseling; 3) facilitate referral to the

Livingstone Pediatric Center of Excellence; 4) work with partners including CIDRZ and the Clinton

Foundation to increase the availability of early infant diagnosis and refer all children who are identified as

HIV-infected to ART treatment centers; and 5) strengthen linkages between PMTCT sites and identified

home based care programs in the province, including, but not limited to, RAPIDS, SUCCESS and Mothers 2

Mothers.

Additionally, BU will use this funding to integrate the Early Infant HIV Diagnosis training into the existing

PMTCT training package, as well as include this program in its in-service facility based monitoring program.

Therefore, all participants trained in PMTCT will also be competent in the didactic DNA PCR theory as well

as specimen collection, packaging, transport and follow-up. BU will coordinate with the Clinton Foundation

and/or CIDRZ to ensure specimen transport is available throughout Southern Province

Another component of this activity will continue working with the Southern Provincial Health Office and

District Health Offices to implement wrap-around palliative care activities benefiting people living with

HIV/AIDS (PLWHAs) and their caretakers. Target areas will include communal areas, schools, and clinics,

strategically located to serve both the host facility and the local community.

Home-based care training will be provided to approximately 200 community members, and will be

coordinated with other partners currently working in home based care such as RAPIDS and CIDRZ. In

addition to working with communities to improve nutrition, community workers will be trained to actively

identify and refer people to local HIV/AIDS services, such as counseling and testing or treatment evaluation.

Health promotional strategy techniques, such as the ART adherence "Buddy System" and the formation of

support groups will also be taught to the community workers.

Targets set for this activity cover a period ending September 30, 2009.

The following activity is newly proposed ¬for FY 2008 with Plus-up funds.

Early infant diagnosis service has lagged in ART services provision due to lack of capacity leading to high

early mortality of children born with HIV infection. Using Plus-Up funds ($1M total for scaling-up infant HIV

diagnosis nationwide in Zambia), Boston University (BU) will collaborate with Southern PHO and the

National Infant Diagnosis Reference Lab at University Teaching Hospital to make infant HIV diagnosis using

dried blood spots available throughout rural and urban areas of Southern Province. The activity will link in

closely with prevention to mother to child transmission of HIV services and infant follow-up at all health

centers supported by BU in the province. Earlier HIV diagnosis will lead to earlier referral and start of

antiretroviral therapy at a much younger age, leading to improved long-term outcomes. This activity will also

contribute to scaling of pediatric ART services in Southern Province where the number of children

accessing ART services has been low.