Partner will support the ZDF to improve overall clinical prevention, care, and treatment services around the country throughout the three branches of the military service Zambia Army, Zambia Air Force and Zambia National Service. The partner will work closely with other partners implementing the MCH program, SMGL, as a component of the PMTCT program. The goal of the project is to develop sustainable training, supervision, and M&E systems to rapidly expand HIV/AIDS services to additional clients served by the ZDF. This includes strengthening management and planning systems to support PMTCT and HIV/AIDS care and treatment services, with the appropriate integration, linkages, and referrals to minimize transmission of HIV.

Our program objectives are:

Objective 1: Increase clinical capability by supporting ART, TB/HIV, and PMTCT

Objective 2. Integrate HIV counseling and testing into Palliative Care and STI services through PITC

Objective 3: Strengthen STI diagnosis and management services within the ZDF

Objective 4: Strengthen Male Circumcision services within the ZDF

Objective 5: Work with ZDF and other partners to strengthen systems

The Defense Force Medical Services (DFMS) supports health facilities at 54 of the 68 ZDF sites, with the remaining sites relying on military medical assistants and outreach support. These health services are dispersed across hard-to-reach areas around the country and serve both ZDF and local civilian populations. In addition, given the mobile nature of the ZDF, it is often the first responder to medical emergencies and disasters throughout Zambia. The partner will support services in a total of 14 sites focused in three provinces: Eastern, Southern and Western.

Provision of palliative care is cardinal in the continuum of care of HIV positive individuals. Health care providers must have a high index of suspicion for clients presenting with opportunistic infections and other AIDS defining diseases at the health facilities. Appropriate care must be provided to all clients as and when they need it. Jhpiego will ensure that ZDF health care providers are equipped with knowledge and skills necessary to provide appropriate care to HIV positive individuals. In collaboration with DFMS, capacity building for health care providers will be conducted through two training workshops in PITC for health care providers. A total of 40 health care providers will be trained in PITC using the group-based approach. Follow up supportive supervision will be done by ZDF trainers. The revised National Provider Initiated Testing and Counseling (PITC) Training Package will be utilized for all provider trainings. This package, adapted from CDCs counseling protocols and training materials by Jhpiego, MOH and partners, takes a no lost opportunities approach to prevention, effectively integrating PICT with TB care and treatment and linking it to identification and treatment of other common co-infections, such as STIs and other opportunistic infections. CECAP activities will be integrated into palliative care for women presenting at the health facilities for other services such as family planning. Prevention with positives (PwPs) will be integrated in this comprehensive care through screening of sexual activities, condom distribution, gravindex testing and STI management.

Jhpiego will further support a mentorship program at 14 sites in Eastern, Western and Southern provinces, working through case studies with service providers. Mentorship will be integrated with supportive supervision. Effective monitoring of service provision will be done through client registers and appropriate PEPFAR indicators. M&E systems shall be strengthened through trainings, supervisions and program review meetings. Site strengthening at the 14 sites will be done through procurement and distribution of basic medical equipment, commodities and supplies.

PITC is a key component of the diagnostic work-up for patients who present with TB and/or other symptoms and signs that could be attributed to HIV. Through training, providers are not only equipped with the knowledge and skills needed to provide HIV/CT services, but gain an appreciation for the importance of provider-initiated CT that is essential to effective implementation of this service. It further reinforces the delivery of a comprehensive and continuous package of services that does not end with a positive HIV test or initiation of ART.

HVTB

In FY13, Jhpiego will initiate Paediatric care and support program. In this regard Jhpiego will provide or strengthen knowledge and skill among ZDF health provider to routinely assess and monitor growth and development among pediatric HIV patients recognizing that children living with HIV tend to have these milestone affected and faltered. Special attention will be emphasized on assessing and monitoring growth and nutritional status of children both in care and on treatment and, in line with the Zambian guidelines, appropriate nutrition counseling will be provided to all children through their parents or guardians, as the case may be. Jhpiego will make available all the necessary tools for appropriate nutritional assessment; and children found to be clinically malnourished will be linked to programs providing nutritional support and these children will be followed up accordingly. Jhpiego will also ensure that ZDF health providers have the necessary knowledge and skill to promptly and accurately diagnose opportunistic infections (OIs) among children living with HIV so that those with illness are immediately put on appropriate treatment and that complicated cases are immediately referred to the next level of care. To achieve this Jhpiego will train 40 ZDF health providers in Comprehensive Management of Childhood Illnesses in the context of HIV, through two 5-day group-based trainings. Jhpiego will support minor refurbishments to establish child friendly corners at 5 ZDF sites.

The scope of training undertaken by the Defence School of Health sciences has improved over the years. The DSHS currently conducts training for Military Medical assistants, Pharmacy assistants and Laboratory assistants. With improved infrastructure, in FY 13, the DSHS is aspiring to go even further by training Registered Nurses. Jhpiego will provide technical assistance to enable the school to get accreditation with the regulatory bodies such as the General Nursing council, Health Professions Practitioners Council and Pharmacy Regulatory authority.

Jhpiego will continue to support the DSHS to train MMA, pharmacy and laboratory assistants. Jhpiego will facilitate follow up supportive supervision to ensure complete transfer of knowledge.

Jhpiego will build on the support provided to the school by ensuring that the DSHS clearly defines the cadres of health care providers that will be trained by the school, assist the school prepare a staff establishment required to provide the necessary trainings. Jhpiego will work with the school to develop sustainable systems for students, lecturers, and suitable clinical training settings where students will practice.

Jhpiego will continue to provide training skills updates to all staff teaching at the school. All staff providing training at the school will be targeted for the skills training.

Jhpiego will assist the school to develop/update training curricula for all the training programs that are provided by the school ensuring that such curricula are in line with good governance principles and the regulatory bodies (Health Professions Council, General Nursing Council and Pharmacy Regulatory Authorities of Zambia). The partner will work with DFMS to ensure that plans are developed that will sustain operations at the school and ownership

Jhpiego will build on its earlier work with the ZDF in providing VMMC services to military personnel, their families and the surrounding communities. Jhpiego will support DFMS to provide VMMC services at six (6) Fixed sites (ZNS Chiwoko, ZNS Kafue, ZNS Choma, Arakan, Luena and ZAF Mumbwa). To be able to reach out to more clients in the ZDF catchment areas, Jhpiego will support Mobile VMMC services to the remaining sites in Eastern, Southern and Western provinces. Mobile MC services will be led by the ZDF mobile MC team.

To ensure continuous flow of clients, Jhpiego will support sustained demand creation activities at all the sites in the three provinces. In collaboration with PCI, peer educators will be supported to generate VMMC demand in the communities. Over the past years, ZDF unit commanders have come out in full support of VMMC programs in the camps. Jhpiego will further provide a VMMC orientation workshop for unit commanders to enable them appreciate the program.

The biggest challenge with VMMC in the military is the continued inadequate availability of VMMC skilled personnel. Despite the training of staff, transfers and deployments always create an artificial shortage of trained manpower as staff are moved from VMMC providing sites. To mitigate the effect of mobility, Jhpiego will train an additional 30 health care providers in VMMC skills at all the sites. An additional 20 counselors will be trained in VMMC counseling. This will include staff from all the 14 Jhpiego supported sites. At sites where there is no fixed service, the VMMC trained staff and counselors will mobilize clients for MCs and when an optimum number (to be agreed with DFMS) has been reached, the mobile team will be called to perform circumcisions. When the mobile team has left, the trained providers and counselors will continue to provide follow up care.

Jhpiego will ensure continued availability of VMMC consumables, infection prevention commodities, surgical instruments and other accessories such as autoclaves at all the VMMC sites.

Collaboration with MOH will be strengthened through participation in National VMMC Campaigns. With lessons learnt from its public sector VMMC program funded by CDC, Jhpiego will employ similar campaign strategies for demand creation, program leadership at the facility level with a VMMC focal point person, utilization of district health office staff to support the campaigns and rewarding/recognizing sites that reach their set targets in the ZDF. Outside the campaign periods, ZDF sites will provide VMMC services routinely through scheduling of procedures.

Supportive supervision will be intensified during the campaigns to ensure provision of quality services. The quality of MC services provided will objectively be monitored using quality improvement tools. This will ensure that adverse events are kept below the recommended 2%. All (100%) clients will be provided with the VMMC minimum package of care. A total of 3500 clients are expected to be circumcised during the implementation period.

Sexual prevention activities will be closely collaborated with other prevention activities such as cervical cancer screening, VMMC, Family Planning and Provider Initiated Testing and Counseling (PITC). The mobile nature of the military puts them at high risk of HIV and STIs. Early detection and treatment of STIs using the Syndromic approach prevents transmission and acquisition of HIV. Offering STI treatment and partner management at the HIV positive clients first visit mitigates re-infections as well as prevention of drug resistance.

Twenty (20) health care providers will thus be trained in Syndromic management of STIs in the delivery of ART, TB, PMTCT and other outpatient services. Training will emphasize, partner treatment, risk assessment and reduction, and for male clients VMMC counseling and circumcision. Standard MOH training materials will be used for these trainings. Targeted interventions contribute to the overall goal of reducing STI prevalence and slowing HIV transmission.

Jhpiego will engage ZDF STI/HIV trainers to provide follow-up and mentorship at all 14 sites in Eastern, Western and Southern provinces. Improved monitoring will be facilitated by updated indicators and registers. ZDF staff will be encouraged to take the lead in providing all technical support and monitoring, including assessing service delivery and addressing gaps. Using this approach sustainability of the program is ensured.

Jhpiego will build on its activities in the ZDF that are aimed at the virtual elimination of pediatric HIV, targeting 1,500 pregnant women. Based on routine data collected in past years, it is expected that 12% to 15% of the targeted pregnant women will test HIV positive. Jhpiego will ensure that all pregnant women testing HIV positive and those with HIV known status be enrolled in HIV care, in all 14 sites that will be implementing eMTCT activities. In support of national policies, Jhpiego will spearhead the implementation of Option B+ (a strategy that ensures that all HIV positive mothers are commenced on triple ARVs for life irrespective of CD4 count) in ZDF facilities in Eastern, Southern and Western Provinces. Jhpiego will ensure that the new guidelines and job-aids are available at the ZDF sites. Jhpiego will also work closely with other partners including PMTCT lay workers to follow cohorts of HIV positive mothers and their babies to ensure that the program records the expected outcomes for both mother and baby. However, patient retention and drug adherence is likely to be a more complicated issue with the transition to Option B+, as women with high CD4 counts generally feel healthy and might be reluctant to take treatment for the rest of their lives. Jhpiego will ensure that specific attention is given to patient retention and drug adherence issues; at each follow up visit, adherence counseling including patient education and pill counts. Working with the trained facility health center staff, Option B+ oriented Neighborhood Health Committees (NHCs) will be engaged in monitoring the performance of CHWs in the follow up of HIV positive women and HIV exposed infants. NHCs will enhance community mobilization and implement a robust adherence support mechanism both at the facility and within the community. Jhpiego will therefore retrain 20 health care providers and 16 PMTCT lay workers in the new approach to PMTCT. Early infant diagnosis will continue to be strengthened through linkages with the district health offices. In support of the mothers, Jhpiego will also ensure that activities under the Saving Mothers Giving Life (SMGL) initiative are integrated into the PMTCT program. During implementation, Jhpiego will focus SMGL activities at four (4) additional sites. 16 health care providers will be trained and supported in SMGL activities. With technical assistance from the cervical cancer experts at headquarters, Jhpiego will adopt its cervical cancer prevention (CECAP) program to the Zambian situation, targeting 500 women. A cervical cancer screening and treatment learning resource package (LRP) will be developed for ZDF. To ensure quality of service provision, cervical cancer screening performance standards will be developed and incorporated into the mentorship tool. Baseline assessments will be conducted at four (4) additional sites. A total of 16 health care providers will be trained in cervical cancer screening and treatment at the four (4) sites. Jhpiego will work in collaboration with PCI to strengthen CECAP activities at 4 sites where mobile services are in existence. Linkages will be established between CECAP, VMMC and Family Planning programs within the ZDF. Further collaboration between programs will be strengthened by introducing TB and Syphilis screening in PMTCT settings.

In FY13, Jhpiego will build on previous work to support comprehensive HIV/AIDS prevention, care and treatment services in ZDF health facilities. The partner will work with the 14 supported sites to expand quality ART services in the three provinces of Eastern, Western and Southern. During the site visits, orientation of health workers in HIV/AIDS will be done at each of the camps to ensure that senior managers at the camp understand HIV/AIDS programs at the health facility.

Group based trainings in ART will be provided to all sites to increase their capability to provide comprehensive HIV/AIDS treatment services with a total of 20 health care providers trained, using the updated national ART training package. Jhpiego will provide a re-fresher ART training course to another 20 ZDF health providers who received this training two or more years ago so that they are updated or equipped with the new developments, changes and recommendations in the Zambia HIV treatment/ART guidelines. And to further ensure desired HIV treatment outcomes, Jhpiego will support training of 20 health providers in adherence counseling.

To support performance improvement of systems and quality adult treatment service delivery, the partner will conduct supportive supervision and mentorship visits to all the facilities in the Eastern, Southern and Western provinces. In order to ensure sustainability, Jhpiego will work within the existing ZDF structures and plans. All the sites will be visited twice per year to document performance standards.

The partner will emphasize prevention activities in clinical settings and re-enforcing prevention messages at every clinical encounter with HIV positive clients. A minimum package of care for HIV prevention among clients receiving HIV care will be implemented at all the sites. To achieve this Jhpiego will train 40 ZDF health providers in Prevention with Positives, using a nationally approved training package. Jhpiego will provide all the necessary tools, including regular mentorship and supervision, to support successful implementation of this strategy.

Collaboration with other partners shall be improved through joint planning, joint supportive supervision and sharing of reports. Community linkages will be strengthened through community ART adherence supporters.

Jhpiego will also strengthen effective TB infection control, prevention and management measures in the health setting through, among other activities, implementation of Intensified TB Case Finding (ICF) in all ART sites. Providers will be trained or oriented, provided with the necessary tools and support to successfully implement this strategy.

The Jhpiego ART team will work closely with the PMTCT team to implement and roll-out the option B+, a strategy that the Zambian government, through the Ministry of Health has adopted and endorsed as policy with immediate effect in 2013, as currently the most effective way of eliminating mother to child transmission of HIV infection (eMTCT).

Jhpiego will support ZDF with reaching accreditation standards in some sites to the level required by the Health Professionals Practitioners Council of Zambia.

Jhpiego will also print and distribute Adult ART treatment job aids and national guidelines.

In FY13, Jhpiego will strengthen Paediatric HIV Treatment in ZDF-supported units by ensuring early identification of infants and children who are exposed to HIV as well as through provider initiated counseling and testing and timely and effective linkages to appropriate diagnostic facilities. Jhpiego will work to ensure children identified to have HIV infection receive timely initiation of ART and also put on cotrimoxazole prophylaxis. This will be made possible through capacity building of health care providers working in these units. Therefore, 40 ZDF health care providers will receive group-based ART training courses.

Treatment will also be enhanced through provision of regular hands-on mentorship and supervision to ZDF ART-supported sites by technical persons with knowledge, expertise and experience in management of Paediatric HIV, to ensure sustained provision of quality HIV care to children living with HIV and AIDS.

Key to the success of HIV management is adherence to treatment on the part of the client and care giver (s) and indeed on knowledge and skill in providing adherence education and support to the client and care giver on the part of providers; and so in this regard, Jhpiego will support a training of 20 providers in adherence counseling, in children.

Jhpiego will also print and distribute Paediatric ART treatment job aids and national guidelines.