Boston University Center for Global Health and Development, through its Zambian NGO partner, Zambia Center for Applied Health Research and Development (ZCAHRD), will continue to expand theMOH PMTCT program in 8 districts in Southern Province (SP). The primary objective will be support of MOH efforts in scaling-up and sustaining quality PMTCT and early infant diagnosis (EID) services within maternal and child health programs. ZCAHRD will : Increase access to quality PMTCT services; Improve quality of PMTCT services integrated into routine safe motherhood activities; Increase coverage of counseling and testing services, particularly couples counseling and testing; Increase uptake of dual andHAART, providing HAART to HIV positive individuals within a discordant couple; Improve referral and linkages to ART; Increase access to an expanded EID program; Improve palliative care to HIV-affected children; Improve the use of MOH health records systems; reach less accessible rural populations through the use of CHW, tTBA, and PMTCT lay counselors; Continue the promotion of exclusive breastfeeding; Continue to work closely with traditional leaders to increase male involvementIncrease health worker retention in rural facilities; Increase utilization of maternity services including labor and delivery, including through mobile ART delivery; continue to expand integration models for ANC and ART for increased coverage of more efficacious ARV regimens for PMTCT including HAART; Continue to expand sustainable intra-district laboratory sample courier systems; support MOH in building systems and capacity for monitoring maternal and infant syphilis out-comes; standardize protocols for implementation of community PMTCT services, and; standardize approaches for increasing male involvement.

COP 12 activities will result in the continued scale-up and maintenance of the of the infant HIV diagnosis program in SP through ongoing collaboration with the SPMO, University Teaching Hospital, CHAI, CIDRZ, UNICEF and other partners. Activities will focus on building and operationalizing a stronger referral system to ART care and treatment centers. Earlier HIV diagnosis will lead to earlier referral and initiation of antiretroviral therapy at much younger ages.

In partnership with SPMO and the DMOs, ZCAHRD will conduct routine technical support visits to all supported facilities to reinforce the package of care for exposed infants, including antiretroviral prophylaxis during breastfeeding, uptake of co-trimoxazole, ongoing nutrition assessment, and repeat testing during and after breastfeeding cessation. Emphasis will also be on provider initiated testing of older children in the maternal and child health clinic, prompt referral to care and treatment for identified positive children, and appropriate infant and young child feeding practice.

COP 12 activities will also include working with MOH to find more efficient systems to deliver EID results to the very rural areas of SP. Some of the inherent logistical difficulties surrounding EID in SP stem from delays in promptly returning DBS results to the rural health facilities. In partnership with the MOH, ZCAHRD will continue to expand a DBS online laboratory database system which will allow results to be accessed both via internet as well as through direct cell phone SMS communication to the facilities where they were collected. Confidentiality will be ensured by using only patient identification numbers. SP DHMT and PHO can then access the database securely via the internet to get immediate results. Concurrently, rural and urban healthcare facilities will be sent batched DBS results for their specific facility via SMS messages. Additionally, a module will be added to the SMS system to enable PMTCT lay counselors to receive client reminder messages regarding results awaiting collection at the facility, appointments for retesting/medication and general lost to follow up. Using the COP12 Plus-up funds Boston University will work in collaboration with Pediatric ART implementing partners (e.g. CIDRZ) as well as MOH to address the lack of adequate referral documentation and processes for getting children into care, including linking mothers and babies to nutritional support services. Where appropriate SMS technology will be used to strengthen the feedback loop from referral facility to ART facility as well as to nutritional support services in the community. Boston University will also use part of these additional funds to standardize protocols for community PMTCT programming including models for increased male involvement in peri-urban and urban areas

In order to expand access to laboratory testing for determination of ART eligibility (CD4 screening) and capacity to monitor patients on ART with lab screening, Boston University will work in in select districts, to support the DMO to address intra-district transport issues; these issues dramatically affect access to timely and comprehensive care. such efforts will build on the planned scale-up of a national laboratories transport system. Where appropriate and based on Ministry of Health authorization, Boston University will strengthen access to lab services through procurement and deployment of point of care equipment rather than supporting transportation of laboratory samples.

Against the background of evidence that HIV and syphilis co-infection rates in ANC are still high in Zambia and that co-infection augments HIV MTCT, Boston University will work in select areas, to conduct program evaluation activities to assess how the rollout of rapid syphilis testing and strengthened health provider training is affecting syphilis outcomes for mothers and infants This work is expected to contribute towards the development of national standardized M&E strengthening

As a follow-on activity, and leveraging efforts from the initial activity from COP10 funds, Boston University will apply the allocation from the COP 12 PMTCT acceleration funds to implement a cost-outcomes study of the implementation of PMTCT Option A, at purposively selected sites to represent urban v rural, small v large facilities. Plans will be made to factor in a second component to compare the results of the first study with a second study on the costs and outcomes of Option B. In order to contribute towards local capacity building, workshops will be conducting for the MOH and other stakeholders in which economic evaluation results will be used to explain the objectives and methods of this kind of research to help participants understand the implications and limitations of the findings, as well as the usage of the results to inform program re-focusing and planning.

For the initial evaluation, the key question to be answered by the exercise would be; What is the average cost per mother/baby pair provided with Option A PMTCT services and per infant alive and in care after a specific duration of follow up under different approaches to service delivery and in different settings? Methods will be based on conducting a cost-outcomes study using retrospective medical record review at multiple service delivery sites.

For the second component, the key question to be answered by the exercise would be; How does the cost of delivering PMTCT services based on WHO option A compare with services based on WHO option B. Methods will be based on conducting a cost-comparison study using retrospective medical record reviews.

To further contribute towards improved quality of clinical services and so increase coverage of comprehensive PMTCT services towards MTCT elimination through increasing presence of trained health workers in facilities where it has been difficult to attract or retain health workers Boston University will work with the SPMO to identify refurbishment activities for rural health facility staff housing. This activity will contribute to the MOH rural human resources retention scheme that is supported through other funding streams.

The Boston University (BU) will train 104 health workers in the national PMTCT training package and will continue to focus efforts on training health workers in data management, ensuring all facilities are correctly completing MOH registers, using SmartCare according to MOH procedures and reporting complete monthly data to DMOs. In addition to the national training package, BU staff will conduct routine technical support visits to emphasize technical areas such as provider initiated counseling and testing (including couples testing), retesting of HIV negative pregnant women, early ANC initiation, supply-chain management, family planning (FP), syphilis testing and treatment.

Boston University will continue to support MOH efforts to develop networks and referral systems for pregnant women to better access health services such as FP and ART services including reflex CD4 screening, and will also support the provision of counseling on appropriate feeding options for infants born to HIV positive women and those of unknown status. Seventy five health care workers will be trained in long term FP methods.

To address the health center staffing shortfalls which affect PMTCT (e.g. counseling and testing, mother-infant follow-up, community engagement of male involvement), BU will continue supporting a cadre of PMTCT lay counselors whose work focuses on: male involvement, loss to follow up, early ANC initiation, and FP. An additional 52 PMTCT lay counselors will be trained in the MOH PMTCT Lay Counselor training package.

The BU will continue to pursue innovative approaches to improving early initiation of ART for pregnant women through the use of point of care testing and the integration of ART services within ANC. Using the COP12 PMTCT PLUS UP funds, Boston University will support improved quality of clinical services, infrastructural renovations and equipping Mothers shelters so as to increase facility deliveries. and procuring basic equipment like beds, bed nets, and storage and cooking facilities in order to make these facilities more attractive for expectant mothers to desire to utilize.

Additionally, these funds will be used to expand the ART/ANC integration work initially evaluated using the FY 11 PMTCT Plus-up funds in order to bring HAART access to scale in the smaller and more poorly equipped and staffed rural facilities. Boston University will further work towards developing and implementing mobile ART systems whilst supporting prioritized and appropriately qualifying sites to be strengthened enough for them to become satellite ART/ANC integrated sites. Boston University will continue to implement the ART/ANC integration project in 6 pilot MNCH facilities in Southern Province. These funds will contribute towards on the job training, mentorship, lay counselor training and retention, and innovations for LTFU using SMS technology.

Realigned program to meet treatment gap.

In COP 11, ZCAHRD was granted this first round of funds to work towards strengthening the linkage system for mother-baby pairs through prophylactic treatment during breastfeeding and/or into pediatric treatment. The drop in the cascade from PMTCT into care and treatment for the child has been identified and continues to be an intractable problem throughout Zambia. A tracking system is being implemented using community held registers and trained PMTCT lay counselors, and during COP 12 this system will continue to be expanded throughout the ZCAHRD supported PMTCT sites. Also in COP 12 new innovations using SMS technology will be explored so that ART sites are alerted to expect identified HIV positive individuals and trigger a lay counselor follow-up if individuals fail to attend the clinic in a reasonable period of time. Also, efforts will continue to focus on addressing barriers to care such as insufficient numbers of CD4 machines, insufficient numbers of medical personnel who can initiate patients on ART, and transport challenges between clients home clinic and the ART site.