The aim of this, nutrition project ,Zambian Nutrition Assessment Counseling and Support (ZAMNACS) is to improve the nutritional status of PLHIV, adults and children and OVC by promoting good nutrition, preventing and treating malnutrition. The project will provide a technical assistance in order to scale-up and integrate Nutrition Assessment, Counseling and Support (NACS) package of services within HIV/AIDS programs at facility and community levels. It also supports the training and development of Nutrition/HIV specialists at clinical level and through use of counselors and training of service providers. Activities will include identifying promising practices for integrating NACS into existing programs, thereby enhancing the effectiveness of the intervention.

The project will act as a catalyst to promote broader and better food and nutrition support by USG agencies and selected partners working with targeted populations, including elements of clinical and community activities, education and training, and nutrition intervention product availability. Support will also be provided for the development of a locally sourced and produced High Energy Protein supplement (HEPS) and purchase of Ready to Use Therapeutic Food (RUTF) which can be provided through pharmacies but which may also have a non-clinical use. Key sustainability issues within this project will be addressed by: First, host country ownership will rest on the ability of the project to train local staff to provide quality nutrition services. Second, the private sector will be involved to develop the food product. Third, gender will be a focus given the dynamics at the household level which guide food availability and use.

Activities in this area will support the integration of NACS activities as one of the standard of chronic HIV care for PRE-ART to adult HIV positive clients. In particular, the project will develop and expand new and existing opportunities to integrate NACS package of interventions to HIV care and support services with the expectation that this will result in enhanced chronic patient outcomes. Food and Nutrition Support for malnourished pre-ART clients will follow Zambian nutrition guidelines for care and support of PLHIV (revised February 2011) developed by the MOH and National Food and Nutrition Commission (NFNC), as well as adhering to OGAC Food and Nutrition guidance on NACS.

Illustrative activities include identifying a producer to manufacture a product (HEPS/RUTF) locally which can then be used in a prescriptive fashion for patients on pre-ART. Other actions include identifying counseling and dispensing mechanisms for use with the prescriptive approach. Emphasis here is on how to integrate NACS into the clinical setting without adding undue burden on existing health care providers. In some cases, additional cadres of staff may be required including Community Health Volunteers, lay counselors or adherence support workers.

The partner will use more than one implementation modality perhaps urban/rural models or high capacity and lower capacity models for integrating NACS into the clinical setting. Regardless, the activities will focus on proving the concept of how services could be provided. Large scale implementation will be the role of existing USG HIV treatment partners.

Food and nutrition support may also facilitate clinic-to-community linkages between VCT/PMTCT, HBC, and ART that will further reduce loss-to-follow up from HIV diagnosis throughout pre-ART stage and ARV treatment period. The project will also develop a strategy to improve the quality of NACS integration to clinical services at national, program, and clinic level. The project will also support the national nutrition surveillance and monitoring and evaluation of nutrition interventions at service delivery level, program level and national level.

Specific targets for ART clients will be finalized upon award of the contract. Furthermore, the partner(TBD) will provide one time food supplementation for HIV positive and TB/HIV inmates to improve their nutritional status particularly for HIV positive pregnant and lactating women.

The new Nutrition TBD mechanism will primarily act as a provider of technical assistance, training, and guidance (including instructional and behavior change materials and messaging) and design for other service delivery projects. Accordingly, the Nutrition TBD will offer TA and training support as resources permit and as appropriate, first, to other USG partners, then to the GRZ, and other donor-supported efforts.

The Nutrition TBD will assist providers to ensure that any OVC Food and Nutrition Support will follow Zambian national nutrition guidelines, and will adhere to OGAC Food and Nutrition guidance. OVC nutrition support will prioritize at-risk infants starting as young as six months, up to five years. All HIV positive and HIV exposed infants will be considered OVC as they are all vulnerable.

The Nutrition TBD will assist OVC service providers to: link to PMTCT providers to ensure continuity from clinic to community, and ensure initiation of infant nutrition support from six months; and adopt the first goal, long-term post-natal HIV-free survival for infants, and the second goal, to avoid irreparable physical/mental harm to children less than five years due to malnutrition.

As Nutrition TBD resources permit, food support (preferably specially formulated) and multi-vitamin, micronutrient supplements, may be provided to infants from six months up to five years. Nutrition assessment and counseling will precede provision of food supplements.

OVC funds can provide nutrition support to HIV-exposed children six months-five years. Family food security needs of OVC clients, and other types of feeding such as for school-age children, will generally be referred to other providers such as WFP.

Food and Nutrition Support for PMTCT clients (HIV positive women and their HIV exposed infants) will follow Zambian national guidelines: PMTCT (revised in December, 2010), Infant and Young Child Feeding (IYCF) and also adhere to OGAC Food and Nutrition guidance. The project will promote long-term HIV-free survival of infants and maternal nutrition support to ensure maternal health and a healthy birth. All HIV positive and HIV exposed infants are high priority for nutrition support.

In COP2012/13, the project will promote breast feeding during facility and community interactions and will also support ARV treatment during the breastfeeding period. Also the project will support the Government of the Republic of Zambia (GRZ) to roll-out the PMTCT guidelines by promoting breastfeeding and complementary feeding practices, infant feeding during illness (including HIV) and maternal nutrition, using Community Health Volunteers(CHV), safe motherhood action groups and peer educators. Services will include counseling on infant feeding practices as well as practical support for informed choices with regard to infant feeding practices. Support may include the use of food in a prescriptive fashion based on nutritional status. The nutrition project will develop and test activities. Full implementation will be through existing partners with funding and services in these areas.

Activities in this area will focus on scaling-up community and clinic-based approaches to reach women and children who are infected and affected by HIV/AIDS through PMTCT services. Ideally, services will be expanded beyond the delivery period to ensure that children born to HIV positive mothers are not lost from the system.

Training options may range from the one-week IYCF course, to decentralized short courses using the national training materials already developed by the previous IYCN project. The project will also link PMTCT clients/infants and their families to food security and other family income or livelihood programs such as Feed the Future (FTF) initiatives and WFP. Specific targets breakdown to each beneficiary will be finalized upon award of the contract.

Activities in this area will support the integration of NACS package of interventions to adult HIV-positive clients on treatment. In particular, the project will develop and expand new and existing opportunities to integrate NACS package of interventions to HIV treatment with the expectation that this will result in enhanced patient outcomes. Food and Nutrition Support for malnourished pre-ART and ART patients will follow Zambian nutrition guidelines for care and support of PLHIV (revised February 2011) developed by the MOH and National Food and Nutrition Commission (NFNC), as well as adhering to OGAC Food and Nutrition guidance on NACS. National guidelines on Integrated Management of Acute Malnutrition (IMAM) may soon require diagnosis and treatment of malnutrition in all clinical settings, including ART.

Illustrative activities include identifying a producer to manufacture a product (HEPS/RUTF) locally which can then be used in a prescriptive fashion for patients on ART. Other actions include identifying counseling and dispensing mechanisms for use with the prescriptive approach. Emphasis here is on how to integrate NACS into the clinical setting without adding undue burden on existing health care providers. In some cases, additional cadres of staff may be required including Community Health Volunteers, lay counselors or adherence support workers.

Ideally more than one implementation modality will arise perhaps urban/rural models or high capacity and lower capacity models for integrating NACS into the clinical setting. Regardless, the activities will focus on proving the concept of how services could be provided. Large scale implementation will be the role of existing HIV treatment partners.

Food and nutrition support may also facilitate clinic-to-community linkages between VCT/PMTCT, HBC, and ART that will further reduce loss-to-follow up from HIV diagnosis throughout pre-ART stage and ARV treatment period. The project will also develop a strategy to improve the quality of NACS integration to clinical services at national, program, and clinic level. The project will also support the national nutrition surveillance and monitoring and evaluation of nutrition interventions at service delivery level, program level and national level. Specific targets for ART clients will be finalized upon award of the contract.