This activity links with the Project Concern International (PCI) and JHPIEGO's assistance to the Zambia Defense Force (ZDF) comprehensive HIV/AIDS care and treatment programs including Palliative Care TB/HIV and ART programs. The administration of this will be conducted by the DOD PEPFAR office in Lusaka. ZDF has not benefited from the successes the Ministry of Health (MOH) has scored in the fight against HIV/AIDS and DOD remains their single most important partner. The program will contribute to improved service delivery in HIV care and treatment through Systems Strengthening and Policy Development.

In 2009, a letter of agreement was signed by Ministry of Defense (MOD) and MOH to facilitate ZDF access to ARVs and HIV test kits from the Medical Stores. By linking the ZDF to the national drug supply system, the supply chain has improved and stock outs are things of the past. In FY 2010, DOD will support the three services in the Zambia Defense Force to come up with service specific HIV/AIDS Action Plans. These plans will be drawn from the ZDF HIV/AIDS Policy and ZDF Strategic Plan. It is expected that this process will help in fostering buy-in and enhancing ownership and sustainability of the program. The Defense Institute of Medical Operations conference will continue to be used as a training ground for leadership in HIV/AIDS programs; participation will be extended to the Defense School of Health Sciences and targeting the senior faculty members. Monitoring and Evaluation and Operational Research training will also be provided to key members of the Defense Force Medical Services (DFMS) and Directors of Medical Services for Zambia Army, Zambia Airforce and Zambia National Service. This is in response to the needs identified by the ZDF who want to take an active step in the area of operational research and M&E. The capacity, when developed, will enhance appropriate generation and utilization of medical data which will be used for programming by the ZDF, thereby enhancing ownership and sustainability of the program. In FY 2010, more strategic ZDF personnel will participate in the PEPFAR Implementers meeting in order to share and cross pollinate ideas and form lasting linkages. This capacity is developed in the ZDF personnel themselves thereby ensure sustainability well beyond PEPFAR.

Limited resources in the ZDF, coupled with an increasing population have left the military and uniformed services with substantial laboratory infrastructure deficits, which are compounded by the remote location of many of the camps, as well as inadequate support from donors and the Ministry of Health. While it is government policy to enhance comprehensive HIV/AIDS care and treatment programs which include PMTCT, Adult Care and Support, TB/HIV and Adult Treatment activities and training, deficiencies in infrastructure to include proper laboratory facilities have negatively affected the process.

This activity contributes to the national laboratory strategic plan by incorporating government personnel and policies and links with Centers for Disease Control and Prevention (CDC-TA #9022) activities in the Laboratory section, Project Concern International (PCI) and JHPIEGO's assistance to the Military and other Uniformed Services living in camps with comprehensive HIV/AIDS care and treatment programs which include PMTCT, Adult Care and Support, TB/HIV and Adult Treatment activities and training. The program will improve infrastructure to include laboratory facilities which will contribute to improved service delivery in HIV care and treatment by providing environments that are conducive to facilitating comprehensive HIV/AIDS Voluntary Counseling and Testing (VCT), Adult Care and Support and ARV delivery.

Infectious Diseases Institute (IDI): Training for nurses and clinical officers, doctors and laboratory staff at this institution is ongoing. The South to South training has proven to be highly cost-effective in. In FY 2010, more nurses and clinical officers, doctors and laboratory staff will be trained and train others. New cadres to be trained will include personnel in the medical records section and monitoring and research division. Some of these courses will be provided by the University of Zambia and Mildmay in Uganda.

Military International HIV Training Program (MIHTP): Training of physicians on antiretroviral therapy, opportunistic infections, statistics, computers, and management of HIV associated diseases is ongoing. In FY 2010, DOD/SD civilian health care providers will expand their trainings to MSMH FSU.

Family Support Unit: This multidisciplinary clinic will provide comprehensive "one stop" HIV/AIDS services to families. Any family member seen at this unit will be an entry point for other family members. Disclosure especially in discordant couples will help reduce HIV infection. The extra rooms at FSU will increase office space at Maina Soko Military Hospital. Comprehensive family care will enhance couples and family counseling while the child care section will foster specialized care in a child friendly environment. Training at Naval Medical Centre, San Diego will continue in FY 2010. Food and Nutrition Support for malnourished pre-ART and ART patients will follow Zambian draft Food by Prescription guidelines. Linkages between ART and nutrition program will improve treatment outcomes.

Prevention with Positives workshops: In FY 2010, a minimum package for PLWH will be enhanced by JHPIEGO (clinical activities) and PCI (community).

Northern Command Hospital: This referral hospital will cater to the North Western, Luapula, Northern, Copperbelt province and Central Provinces. The Northern Command Hospital will help decongest MSMH and improve service delivery. Once plans have been finalized, DOD will work closely with ZDF leadership to strengthen the HIV/AIDS unit of this hospital, the laboratory and the family support unit.

PMTCT one time plus-up funds are being added to support: This will involve Improvement of infrastructure for PMTCT clinical services. Many antenatal and maternity facilities are improvised and not appropriate for delivery services and lack private space for HIV testing and PMTCT counseling. Further some facilities have provision only for antenatal care, without any delivery rooms. In many rural facilities, staff housing for PMTCT staff is limited or substandard to attract qualified staff. Facility deliveries are low due to long distances and lack of transport. Many sites lack electricity and proper water supply affecting quality of delivery services. These would require solar power and boreholes to improve service delivery. As these funds will be provided on a one-time basis. All recurring costs from these enhancements will be transferred and factored into the routine program interventions, of which a greater proportion of future costs should be assumed by the GRZ and the ZDF

Specific to the military health facilities, infrastructure improvement under this one-time funding will be considered for the following:

1.1 Construct, upgrade, remodel or refurbish antenatal clinics, maternity units, MCH and laboratory facilities to improve efficiency in PMTCT services. The ZDF will assist in site selection based on criteria that places emphasis on prioritizing facilities with poor infrastructure and potential impact;

1.2 Where there is a need for mother's shelters (pre-delivery), staff housing or solar power, provide these or other improvements; and

DOD PEPFAR has been improving infrastructure in partnership with the ZDF and the Ministry of Works and Supply; another important partner will be the Ministry of Health to review existing and approved maternity wings that can help to meet the needs of both clinicians and the mothers. This activity will go towards expansion of existing structures to provide adequate space for testing and counseling and onward referral to PMTCT services, additional space will be for delivery, recuperating and possibly admission for review and observation, laboratory services should also be housed in these spaces to ensure there is no loss to follow up due to referral for external lab services as has been in the past. Military health facilities are not part of the MOH service delivery system and as such the activity has to be planned for and budgeted for separately, the ZDF has not received the same level of investments as the MOH and this will help to jump start and scale up the PMTCT activities. The military health facilities cater for military members, their facilities and the community surrounding the military bases, this has brought about an overwhelming burden but is an opportunity to reach women and children receiving services from them. An estimated 253, 000 people are being reached through the military bases around the country. Community approaches to improve uptake of highly efficacious PMTCT, this is due to the

unique nature of the military setting and their possible exclusion from other initiatives in the civilian community

Partners testing. Developing and building programs that improve and expand confidential testing and counseling and PMTCT is critical for achieving overall primary prevention of HIV in Zambia. According to the 2007 ZDHS, only 45% of infected women and 28% of infected men had ever been tested for HIV. Overall, 11.2% of cohabiting couples are discordant for HIV, including 6.6% of couples where the man is positive and woman negative, and 4.6% of couples where the woman is infected. With low national uptake of counseling and testing, the vast majority of Zambians do not know their HIV status and that of their partners/spouses. While over 80% of pregnant women were tested in 2008, only about 10% of their male partners were tested. Low levels of male partner involvement in PMTCT services in Zambia have been of great concern. PMTCT services need to be strengthened using a number of effective approaches to enhance partner counseling and testing. Increased male partner involvement in PMTCT will ensure that couples access testing where they will know each other's HIV status and receive important preventive services and education on condom use to prevent the spread of infection in discordant couples, information on reduction of multiple concurrent sexual partners and repeat testing for both mothers, infants and male spouses. Implementing prevention strategies that target couples in PMTCT is most effective when they receive HIV results and counseling together. Thus the program will provide male partners with the opportunity for additional counseling, risk reduction messages, direct links to male circumcision services and screening and treatment for STIs. By counseling men and women together on the importance of PMTCT, this will reinforce and encourage adherence to these HIV prevention methods. Both partners will understand the essence of preventing transmission to the child and will be able to openly talk about how they can prevent transmission in discordant and re-infection in concordant couples.

Community Mobilization around PMTCT. Increased male partner involvement in PMTCT is a key ingredient to reducing HIV transmission among discordant couples. Male/partner testing and counseling needs to be promoted through mobilization of communities and their leaders need to take active involvement in PMTCT matters. To increase PMTCT uptake among both men and women, focus should be placed upon male involvement through direct participation and sensitization using various innovative strategies and approaches. If traditional leaders' influence and involvement in PMTCT services is aggressively solicited to promote community involvement, the uptake of male partner counseling and testing is more likely to increase resulting in reduced infection among women and their infants and also among negative male partners in discordant relationships. Traditional and other community leaders can also play a critical role in assisting to ameliorate negative social norms associated with gender imbalances. Social norms that promote infidelity are hard to stamp out and therefore need concerted efforts capable of altering community values that continue to promote negative practices and behaviors. Well informed traditional leaders, committed and motivated community lay counselors, support groups and others community members, can, collectively, make a big impact on male involvement in PMTCT resulting into potentially increased partner counseling and testing and HIV status disclosures. Active involvement of all the key stakeholders at community level resulting into increased partner counseling and testing will also reduce stigma. While health facilities are the nucleus of PMTCT services in any given locality, outreach activities that promote and encourage increased community participation in breaking down barriers to partner counseling and testing are necessary and crucial. Such activities need to draw from expertise of health staff as well as on the local knowledge and positive traditions where the potential for enhanced male involvement can be nurtured and fostered.

Community leadership coupled with health worker commitment is critical to improve uptake of new regimes, of partner testing, and to improve coverage of four antenatal visits, testing uptake, facility delivery, repeat maternal testing, early infant diagnosis, and prompt treatment of infected children. Lessons learned from successful communities will be disseminated.

One-time funding will be considered for the following to strengthen communities' promotion of PMTCT and also sharing information on successes and challenges among facilities and groups.

The activities under this mechansim will remain unchanged from FY 2009. In FY 2005 FY2009, the Zambia Defense Force (ZDF) identified eight regional sites located in the following provinces: Copper belt, Southern, Lusaka, Eastern, Central, Western and, Northwestern to focus on strengthening their HIV/AIDS treatment and care services. The sites received basic laboratory equipment and training. During the same period, the labs were linked to SCMS to ensure sustainable operations. Five additional pre-fabricated laboratories known as Togatainers were ordered and earmarked for health care facilities in the Zambia Army and Zambia Airforce. The process of establishing an Early Infant Diagnosis (EID) laboratory at Maina Soko Military Hospital was commenced and includes renovations to existing infrastructure, procurement of equipment and supplies, equipment maintenance agreements and certification of biological safety cabinets and other equipment. Technical assistance for the expansion of the EID services will be supported by CDC through the Lusaka provincial health office and CDC Lab technical staff. The activities will compliment and support the MOH National Lab QA program, to continue to build local capacity and sustainability.

In FY 2010, DOD activities will also include improvement and expansion of ART and laboratory infrastructure on 5 existing sites at Lumezi ZNS (Lundazi, Eastern Province), Chisamba ZNS (Chibombo, Central Province), Katandano ZNS, (Solwezi, Northwestern Province), Mtetezi ZNS (Katete, Eastern Province) and Luanshimba ZNS (Mkushi, Central Province) which will aid in scaling-up interventions to meet the HIV/AIDS prevention, care and treatment. Procurement of laboratory equipment will also be made for the Togatainers and other laboratories. Sustainability of services will be ensured through construction of permanent and improved infrastructure, training of personnel and linkage to the national laboratory strategic plan by incorporating government personnel and policies. All 5 laboratory facilities will be accredited and certified by the national QA system.

PMTCT one time plus-up funds are being added to support: This will involve Improvement of infrastructure for PMTCT laboratory services. Many antenatal and maternity facilities are improvised and not appropriate for delivery services and lack private space for HIV testing and PMTCT counseling and lab services. Further some facilities have provision only for antenatal care, without any delivery rooms or labs. Facility deliveries are low due to long distances and lack of transport. Many sites lack electricity and proper water supply affecting quality of delivery services, this has also impacted laboratory services on the ground which are generally non-existent and have created a critical gap in the provision of quality services. These would require solar power and boreholes to improve service delivery. As these funds will be provided on a one-time basis. All recurring costs from these enhancements will be transferred and factored into the routine program interventions, of which a greater proportion of future costs should be assumed by the GRZ and the ZDF.

Specific to the military health facilities, infrastructure improvement under this one-time funding will be considered for the following:

1.1 Conduct district level laboratory assessments with ZDF and other partners and procure equipment as appropriate for maximum cost-effectiveness and coverage:

1.1.1 CD4 machines for district or facility laboratories

1.1.2 Hematology to measure anemia

1.1.3 Blood chemistry

1.2 Assess and strengthen, as necessary and in consultation/collaboration with MOH, courier systems for facilities without full laboratory services;

DOD PEPFAR has been improving infrastructure in partnership with the ZDF and the Ministry of Works and Supply; another important partner will be the Ministry of Health to review existing and approved laboratories that can help to meet the needs of both clinicians and the clients. This activity will go towards expansion of existing structures to provide adequate laboratory services that should be housed within the maternity to ensure there is no loss to follow up due to referral for external lab services as has been in the past. Military health facilities are not part of the MOH service delivery system and as such the activity has to be planned for and budgeted for separately, the ZDF has not received the same level of investments as the MOH and this will help to jump start and scale up the PMTCT activities. The military health facilities cater for military members, their families and the community surrounding the military bases, this has brought about an overwhelming burden but is an opportunity to reach women and children. An estimated 253, 000 people are being reached through the military bases around the country.