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.

In FY 2008, CARE International will implement prevention of mother to child transmission of HIV (PMTCT)

services in three districts of the Eastern Province whilst Center for Infectious Disease Research Zambia

(CIDRZ) works in the other five districts. The model will be based on a rural expansion program that will use

other health cadres for counseling and testing (CT) and health workers for the implementation of the

service. Building on synergies created by the HIV/tuberculosis (TB) work in these districts, a comprehensive

package of HIV services will be used to mainstream these services. CARE International in Eastern Province

will build partnerships and work in collaboration with EGPAF/CIDRZ and the Ministry of Health to carry out

this task.

In order to have a significant impact on reducing the number of HIV-infected infants, PMTCT services need

to be provided with all maternal and child health (MCH) services. In 2007, a training needs assessment was

conducted in the project areas to assess the capacity of health workers (midwives, nurses, and doctors) to

provide basic PMTCT services according to the National Protocol Guidelines. Based on the results of the

assessment, training was provided to MCH staff in CT, TB screening, administration of PMTCT prophylaxis

as per national protocols and antiretroviral therapy (ART) for women that need it, midwifery, and obstetrical

practices to reduce the risk of transmission feeding practices and options for HIV positive mothers, pediatric

HIV care and long-term support to mothers, and monitoring procedures (e.g. how to use counseling and

blood test registers). The project coordinates activities with CIDRZ and the Provincial Health Office (PHO)

through the provincial MCH coordinator. Between 2006 and 2007, CARE International conducted PMTCT

trainings in Chama, Chadiza, and Lundazi Districts of the Eastern Province. A total of 171 health workers

and community volunteers were trained. Community health cadres were also trained in CT. A total of 15

PMTCT sites were instituted in these rural health centers in both FY2006 and FY 2007.

CARE International in FY 2008 will scale-up from the initial 15 health facilities and will scale-up and roll out

PMTCT and CT to 15 new health facilities in the three project districts. This means that in 2008 CARE

International will facilitate implementation of activities in a total of 30 sites. As a result of CARE

International's capacity building efforts, PMTCT activities will continue to be implemented in the old sites

with support and supervision from the district health offices (DHOs).

Routine CT will be provided to all pregnant women to know their HIV status in the 30 PMTCT health

facilities. HIV-positive mothers will be provided with a range of information on measures to reduce HIV

transmission to their babies, how to avoid potential health problems during pregnancy, HIV care and

treatment options, infant care, and family planning. This will involve further counseling on the different

options that are available to minimize the risk of transmitting the infection to the baby and this includes

prophylaxis for HIV treatment, importance of institutional delivery and education on infant feeding options.

These women and the infants will also be given a complete course of ARV prophylaxis. During postnatal

period, HIV positive mothers will be referred to the ART clinic for further assessment and management. HIV

-negative mothers will be supported with interventions that will help maintain their negative status. This

program will map existing support programs at the respective districts hospitals or neighboring districts for

service referrals and linkages and ART will be developed and strengthened. For example in cases, where

facilities for CD4 testing are not available or are non functioning, CARE will recommend to the PHO and

DHOs to identify health staff that can be trained in WHO clinical staging for HIV.

Pregnant women will also be linked to malaria prevention programs such as distribution of ITNs

implemented by projects such as RAPIDS and the Ministry of Health.

In FY 2008, CARE International will institute PMTCT services in three of the most underserved districts of

the Eastern Province where traditional birth attendants (TBAs) and other community health workers (e.g.

home-based care givers) play vital roles in the delivery of safe motherhood and reproductive health

services. An innovative approach of incorporating TBAs in the provision of PMTCT services has been

identified as an on-going activity from FY 2007 and will be rolled-out in FY 2008. As part of the activity,

TBAs are instrumental in delivering PMTCT services to pregnant women at the community level, referral of

these women to antenatal care services, and in providing follow-up advice and psychosocial support for

women at the community level. A package that encompasses all aspects of the PMTCT protocol is used for

training. The TBAs and CHWs will be trained in the provision of psychosocial support to HIV positive women

and their families. CARE International will also facilitate the formation and strengthening of support groups

for HIV positive women and encourage male involvement through working with key influential community

leaders. Communities will be sensitized on prevention of stigma and discrimination for HIV positive women

and the importance of providing support and care for these women.

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.

Continuing from work began in fiscal year FY 2007; CARE International will expand the coverage of

tuberculosis (TB) and HIV activities in the districts of Chipata, Petauke, Katete and Lundazi. These activities

include the need to strengthen both the capacity (technical and physical) of health service providers and

community volunteers as well as expand and institutionalize multi-level linkages between the response to

TB and HIV/AIDS.

CARE International will implement a program to increase the coverage of integrated TB/HIV activities to

more remote areas in the targeted districts. The focus is on testing for both TB and HIV in order to address

the increasing incidence of co-infection. By the end of the budget period of FY 2008, CARE International,

working with District Health Management teams in the four districts, will have implemented TB/HIV activities

in all the 117 (100%) sites in the four districts. This will be achieved through training of health workers in TB,

counseling skills and training of community health workers in TB/HIV linkages. Of a total of 3,411 TB

patients to date, 1,595 (47%) were counseled and tested for HIV.

Linking the testing and referral services to the provision of community based care for those found to be

positive for either infection will greatly increase the uptake of testing, improve treatment adherence and

consequently, reduce the incidence of onward transmission. In a way similar to the prevention of mother to

child transmission (PMTCT) component, linkages to organizations, both US Government-supported (e.g.

Center for Infectious Disease research in Zambia) and non-USG supported (e.g. Mwami Mission Hospital)

will be maintained to ensure a linked and comprehensive response within the province. Specifically, CARE

International proposed interventions aimed to assist the government by increasing the expertise of field-

based staff and lay volunteers while building stronger referral networks so that the planned national

response can reach beyond its current extent.

Strengthening community-focused responses and networks will be the platform for information, education

and communication (IEC) work centered upon reducing the stigma and discrimination surrounding both TB

and HIV/AIDS. Materials previously developed by CARE International in collaboration with HIV/AIDS

Alliance will be used to support the IEC work.

The program will continue scaling up combined TB/HIV service in all the 117 sites in the four districts in FY

2008 by upgrading health worker skills in diagnostic counseling and testing using the nation training model.

The training program will be based on a "training-of-trainers' model and will include training and supervision

in train skill of the trainers through collaboration with JHPIEGO and with technical support from CIDRZ. A

total of 200 health workers will be trained in collaborative TB/HIV actives such as ART patient referrals for

TB in the four districts. 200 health workers from the ART for TB and refer for TB treatment were necessary.

An additional 255 community health workers will receive training in TB/HIV. Current work has revealed

significant weakness in regard to data collection, management and analysis. Some training will be

specifically focused on this issue and health workers will be trained in documentation and record keeping.

Additional community members (in particular home based care volunteers and community health advisors)

will be trained in the basics of TB and HIV/AIDS, caring for those infected and working with community level

support groups and referral systems. Community volunteers will be provided with information on the

availability service outlets and encouraged to refer those needing care to these facilities. These will add

significant capacity to the various civil society actors who, along with faith-based organizations are providing

the majority of care and support services in the province. CARE International will work with the district

health management teams to ensure their requisitions for laboratory reagents, testing kits, drugs for

opportunistic infections and other supplies are processed through the government system early to avoid

stock outs. A total of 15 sites in selected clinics, based on needs, will be rehabilitated in order to scale up

VCT and TB diagnosis and reduce the risk of transmission of TB.

With an additional $75,000 plus-up funds CARE proposes to renovate/rehabilitate five sites spread across

three of the districts targeted for TB/HIV support: Lundazi, Petauke, Katete. During the coming 12 months

CARE will work with the DHMTs and the Provincial Health Office to establish which five sites will be covered

and collect bids etc, as appropriate so as to be able to commence the part of the program once the follow-

on award is confirmed. Criteria for site selection will centre on what improvements (inc. equipment

purchase if necessary) can be easily maintained and continued by those charged with managing the health

facilities with realistic budget allocations. Where practical the DHMT will be encouraged to select facilities

which are more remote as these are less likely to have received support of this nature in the recent past.

Of the targeted 3,500 TB patients, 2,450 (70%) will receive HIV counseling and testing over the period

October 2007 to September 2009 and those testing positive will be referred for HIV care and treatment.

These will result in approximately 1,500 HIV infected individuals being referred for HIV care and treatment.

Supportive supervision for TB/HIV activities in the districts will be carried out in conjunction with the

provincial TB officer and the provincial TB/HIV officer. Regular review meetings will be linked to TB Directly

Observed Treatments (DOTS) review meetings. CARE International is a member of the national TB/HIV

coordinating body and this will help to ensure that all the programs implemented are in line with the national

strategy for TB/HIV activities and the overall national health strategic plan.

The provincial Health office is also being funded by the USG and supports the other four districts in the

province in TB/HIV collaborative activities and also supervises the implementation of the overall health care

services in the province.

The funding level for this activity in FY 2008 will remain the same as in FY 2007. Only minor narrative

updates have been made to highlight progress and achievements.

Zambia faces unique challenges in tackling the increasing convergence of Tuberculosis and HIV infection.

There are difficulties in achieving equitable coverage of health care activities in areas of low population

density with limited transport and physical infra structure to provide services. Poor treatment seeking

behavior is compounded by high level of stigma and discrimination. Severe human resource constraints

exist among health care staff especially across all facilities within rural districts.

In the fiscal year FY 2008, the United States government funding through this mechanism will focus on

increasing the coverage of and access to counseling and testing services in Chipata, Katete, Petauke and

Lundazi of Eastern Province. The work will focus on infra structure rehabilitation in some of the 31 sites and

increase community mobilization to encourage uptake of voluntary counseling and testing (VCT) in the

catchment area. The work will target the general population as every one needs to know their HIV status.

There will be 31 facility-based service outlets providing counseling and testing and one mobile outlet. It is

estimated that 10,000 clients will receive counseling and testing for HIV and receive their results through

this funding mechanism. This activity will link closely with the EPHO HVCT to ensure wider coverage of

districts and avoid duplication. Links with treatment and care services, EPHO HTXS and EPHO HLAB will

be established as well.

CARE's proposed intervention aims to assist the government of the Republic of Zambia (GRZ) through

increasing the expertise of field based staff and lay volunteers in VCT while building stronger referral

networks so that the planned national response can reach beyond its current capacity. Once people have

been tested and are receiving antiretroviral drugs (ARVs) adherence becomes a crucial issue. Promoting

adherence to ARVs is crucial to successful treatment. CARE will therefore training of 300 health staff and

600 community volunteers (including treatment supporters) in adherence counseling for clients on TB

treatment and antiretroviral therapy. The training will include helping clients understand what adherence is

and how to recognize side effects of the drugs and how to cope those side effects among other things.

Mechanisms for follow up of clients to ensure adherence will also be developed during the training to ensure

that they are culturally appropriate and feasible.

In FY 2008, to properly support the increased need in human capacity, CARE will encourage the district

health management teams to under take simple infrastructure rehabilitation to 10 out of 31 Zonal VCT and

PMTCT sites. The project will also provide basic equipment, furniture for 31 zonal VCT sites in more remote

areas across 4 districts (Chipata, Petauke, Katete and Lundazi). CARE will work hand in hand with DHMT

to carry out the survey of proposed facilities.

Mindful of the challenges for distant populations with limited transport options of accessing health care

facilities, CARE will establish and run a mobile VCT service to increase access for people in need of VCT in

Lundazi. Chipata, Petauke and Katete are relatively better served by existing mobile VCT than Lundazi.

Cost per client reached in such mobile VCT situations increased dramatically as transport cost of the mobile

service are high.

Care International will conduct technical supportive supervision to the health staff and community lay

counselors quarterly to ensure that quality service is provided to the recipients.

This piece of work is envisaged as part of a longer-term supportive partnership with GRZ in the selected

districts aimed at establishing a functioning comprehensive CT network to which every one in the general

population has access and linked to equally effective referral system.

The Provincial Health office will receive funding from the USG for CT to implement activities in the other four

districts (Nyimba, Mambwe, Chandiza and Chama). Coordination, linkages and referral systems will be

enhanced between CARE International and the Provincial Health office.

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