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The Zambia Prevention, Care and Treatment Partnership (ZPCT),
funded by the US Presidents Emergency Plan for AIDS Relief
through the US Agency for International Development, has achieved
high levels of performance in technical and program management
areas, and its staff are sought after to provide national, regional, and
even global technical assistance to grantees, partners, and peers.
With this publication, Family Health International (FHI) presents
ZPCT as an example of a high-quality country program in HIV/
AIDS whose lessons need to be shared across the organization.
FAMILY HEALTH
INTERNATIONAL
2008
The Zambia
Prevention, Care and
Treatment Partnership:
A Model Program
ZAMBIANS AND AMERICANS
IN PARTNERSHIP TO FIGHT HIV/AIDS
The Zambia
Prevention, Care and
Treatment Partnership:
A Model Program
2008
aoo8 Family Health International (FHI). Tis publication was funded by the US Presidents Emergency Plan for AIDS Relief
through the US Agency for International Development.
:nsIv ov to:v:s
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Background: ZPTC and HIV}AIDS in Zambia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ZPCT Organizational Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ;
ZPCT Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ZPCT as a Technical Model: Key Areas and Innovations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,
Counseling and Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,
Prevention of Mother-to-Child Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,
Clinical Care and Antiretroviral Terapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Laboratory and Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Referral Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Monitoring and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ZPCT as a Program Management Model: Key Areas and Innovations . . . . . . . . . . . . . . . . . . . . . . . . . . . ,
Decentralization of Decisionmaking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,
Infrastructure Refurbishing and Procurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,
Lessons Learned and Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a
Appendix: Services in 97 Facilities Receiving ZPCT Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . aa
2 The Zambia Prevention, Care and Treatment Partnership: A Model Program
ntovIvoomv:s
Te Zambia Prevention, Care and Treatment Partnership (ZPCT), funded by the US Presidents Emergency
Plan for AIDS Relief through the US Agency for International Development, has achieved high levels of
performance in technical and program management areas, and its sta are sought after to provide national,
regional, and even global technical assistance to grantees, partners, and peers. With this publication, Family
Health International (FHI) presents ZPCT as an example of a high-quality country program in HIViAIDS
whose lessons need to be shared across the organization.
ZPCT provincial and technical teams and Zambia Ministry of Health sta at all levels provided invaluable
input for this document, which was drafted by consultant Mannasseh Phiri, MD, with the assistance of the
following FHIiZambia sta:
Kwasi Torpey, MD, ZPCT Director of Technical Support
Catherine Tompson, Country Director and ZPCT Chief of Party
Asha Basnyat, ZPCT Director of Programs and Deputy Chief of Party
Prisca Kasonde, MD, ZPCT Associate Director of Technical Support
Parsa Sanjana, ZPCT Senior Program Coordinator
Mushota Kabaso, Monitoring and Evaluation Advisor
Jonathan Mukundu, Monitoring and Evaluation Ocer
The Zambia Prevention, Care and Treatment Partnership: A Model Program 3
ntuovms
ADCH Arthur Davison Childrens Hospital
AIDS Acquired immune deciency syndrome
ARV Antiretroviral drug
ART Antiretroviral therapy
ARTIS ART Information System
ASW Adherence support worker
CHAZ Churches Health Association of Zambia
CT Counseling and testing
DATF District AIDS Task Force
DHMT District Health Management Team
ECR Expanded Church Response
EMS Expedited mail service
FHI Family Health International
GRZ Government of the Republic of Zambia
HAART Highly active antiretroviral therapy
HIV Human immunodeciency virus
JHUiHCP Johns Hopkins UniversityiHealth Communication Partnership
M&E Monitoring and evaluation
MSH Management Services for Health
MSL Medical Stores Limited
MoH Ministry of Health
NAC National AIDS Council of Zambia
OI Opportunistic infection
PCR Polymerase chain reaction
PEPFAR US Presidents Emergency Plan for AIDS Relief
PHO Provincial Health Oce
PLHA People living with HIViAIDS
PMTCT Prevention of mother-to-child transmission
QAiQI Quality assuranceiquality improvement
STI Sexually transmitted infection
TB Tuberculosis
USAID US Agency for International Development
ZPCT Zambia Prevention, Care and Treatment Partnership
4 The Zambia Prevention, Care and Treatment Partnership: A Model Program
vxvtu:Ivv summnuv
Te Zambia Prevention, Care and Treatment
Partnership (ZPCT) is a cooperative agreement
between Family Health International (FHI) and the
US Agency for International Development (USAID)
through the Presidents Emergency Plan for AIDS
Relief (PEPFAR). ZPCT runs from aoo to aoo,
and works to strengthen and expand HIV and
AIDS services in ve of Zambias nine provinces, in
partnership with the countrys Ministry of Health
(MoH) and the National AIDS Council (NAC).
ZPCT assists the MoH to implement its policies
in program planning, implementation, and moni-
toring by providing support to provincial health
oces and district health management teams and
at the health facilities.
Te key to ZPCTs success is its partnership with
the Government of the Republic of Zambia (GRZ)
and with NGOs, local communities, and workers at
healthcare facilities. ZPCTs activities and support
avoid the creation of parallel structures and sys-
tems, making use of and supporting MoH policies
and guidelines that benet patients, and integrating
programs that are initiated or improved into exist-
ing systems and at district and facility levels.
Since implementation began in May aoo, ZPCT
has assisted the government to initiate, improve,
strengthen, and scale up counseling and testing
(CT), prevention of mother-to-child transmission
(PMTCT) services, and clinical care, especially
antiretroviral therapy (ART).
ZPCT initially supported the scale-up of services
in health facilities in , districts, expanding to ,;
MoH facilities in a6 districts by September aoo;.
Further expansion is planned to reach districts
and a6 facilities. ZPCT-supported facilities have
provided CT services to 6a, persons and ART
for o,,,, individuals, including a,8o; pediatric
clients. Te facilities have also delivered PMTCT
services for ;,6a pregnant women. In addition,
male attendance and involvement in antenatal
clinics and HIV testing have increased signi-
cantly, especially in Luapula Province. To achieve
these results, ZPCT supported and implemented
simple but eective technical, program, and man-
agement strategies.
In all facilities, the hiring of data entry clerks and the
introduction of regular audits improved the quality,
handling, management, and appreciation of data as
a management tool. To enhance knowledge levels
and accurate data collection, data collected in each
province are audited by ZPCT sta from a dierent
province and the head oce in Lusaka.
Day-to-day program functions have been decentral-
ized to ZPCT provincial oces, where a provincial
program manager is assisted by technical ocers
for clinical care, PMTCT services, laboratory and
pharmacy services, and monitoring and evaluation
(M&E). Tese ocers receive technical assistance in
their specialty from Lusaka, while they themselves
provide training and technical assistance for local
healthcare workers in ZPCT-supported facilities.
To initiate and expand HIV and AIDS services,
ZPCT obtained the agreement of local health
authorities on needed infrastructure renovations,
essential medical and laboratory equipment, and
capacity building. ZPCT then signed recipient
agreements with district health management teams
(DHMTs) and hospital boards that spelled out the
support to be provided. ZPCT then followed the
GRZ tender process, working with the MoH and
Ministry of Works to provide renovations, and
cosigned contracts with the DHMTs. ZPCT thus
facilitated renovations of outpatient departments
In remote areas, ZPCT provides motorcycles equipped with
coolers, which are used to transport blood samples to labs and
take results back to clinics and health centers.
The Zambia Prevention, Care and Treatment Partnership: A Model Program 5
and disused hospital outbuildings to create ART
centers that provide comprehensive HIV and AIDS
care or space for storing antiretroviral drugs (ARVs)
and diagnostic items. Te renovations needed to
expand services helped to improve the environ-
ments of health workers and their morale.
Sophisticated ZPCT-supported laboratories can
now be found in low-level facilities such as health
centers. HIV test results are available the same day,
improving acceptance of testing and the collection
of results. In more remote locations, lab samples
and results are transferred by motorcycle to refer-
ral labs, obviating the need for clients to travel long
distances to a clinic and return to obtain their test
results. In addition, parents and guardians of pedi-
atric clients at the ART center at the Arthur Davison
Childrens Hospital (ADCH) can now access adult
HIV services instead of going to dierentand per-
haps distantinstitutions on dierent days.
ZPCT also supported a new polymerase chain
reaction (PCR) laboratory for the ADCH that pro-
vides accurate HIV testing for children less than 8
months old to centers in the ve provinces through
an innovative sample referral system. From a wide
catchment area, dried blood-spot samples drawn
from children under 8 months are transported to
the hospital by expedited mail. Results are relayed
to the originating facilities by the same means,
increasing service uptake and reducing inconve-
nience for clients.
Te need to increase uptake and expand ser-
vices in the face of the countrys serious
shortage of trained healthcare workers spurred
innovative coping mechanisms to ll gaps. One such
mechanism entails the training of community
volunteers as lay counselors, adherence support
workers (ASWs), and PMTCT motivators. Te
ASW volunteers are living with HIViAIDS and
are consumers of HIV services. Tey have helped
to make these services sustainable and averted the
suspension of programs.
In addition, ZPCT is supporting training for health-
care workers on ART, pediatric ART, PMTCT, CT,
and other technical areas. Where possible, this
training is oered in the health facilities where they
work during afternoons and evenings. Tis timing
means that sta are not removed from their stations
while they are most needed and clinics are open.
Improving access and addressing equity issues
requires the design of HIV intervention strategies
that are creative as well as practical. In addition, the
program must work collaboratively with the GRZ
to ensure sustainability without compromising the
speed of implementation.
Working in close collaboration with the MoH,
ZPCT has brought HIV-related care and treatment
services as close to the community as possible. Tis
has been achieved in spite of the human resource
shortages and weak infrastructure capacity, mak-
ing these intervention strategies a model for other
programs. Bold innovations that address criti-
cal shortages, overcome other obstacles, increase
uptake, support adherence, and expand services
are the programs hallmark, but they owe their suc-
cess to the strength of ZPCTs partnerships and its
adherence to existing systems.
Under the ZPCT initiative, male attendance and involvement in
antenatal clinics and HIV testing have increased signicantly,
especially in Luapula Province.
6 The Zambia Prevention, Care and Treatment Partnership: A Model Program
Background: ZPCT and HIV/AIDS in Zambia
ZPCTs objectives are to
increase access to and use of CT
increase access to and use of PMTCT
interventions
increase access to and strengthen delivery of
clinical care for HIViAIDS, including diagnosis,
prevention, and management of opportunistic
infections (OIs), and prevention and management
of other HIV-related conditions and symptoms
increase access to and strengthen delivery
of ART
ZPCT provides technical, program, and manage-
ment support for national, provincial, and district
structures and systems through a memorandum of
understanding with the MoH and provincial health
oces (PHOs). ZPCT provides national-level sup-
port by participating in technical working groups to
develop policies and national treatment guidelines
with the MoH and the National AIDS Council. At
district and facility levelsand in a6 districts and ,;
health facilities in the ve provincesZPCT sup-
ports the implementation of HIV clinical services,
including CT, PMTCT, ART, and related laboratory
and pharmacy support services.
Working within the FHI global network, ZPCT
developed unique innovations and an exceptional
program. At the end of September aoo;, ZPCT had
supported the MoH in providing CT services to
6a, persons, ART to o,,,, individuals, includ-
ing a,8o; pediatric clients, and PMTCT services to
;,6a pregnant women.
Te estimated HIV prevalence rate in Zambia for
adults ages , is 6. percent, with more women
infected (8 percent) than men ( percent). Te
number of Zambians living with HIV and AIDS is
estimated to be .a million, and the number needing
ART is estimated to be ;o,ooo. As of September
aoo;, over o,ooo were receiving free ART in pub-
lic sector health programs.
As in other resource-limited settings, Zambia is
challenged to provide access to available, aordable,
and acceptable CT, PMTCT, and ART interven-
tions. Approximately o,ooo children in Zambia
are infected with HIV, and o,ooo acquire the infec-
tion vertically each year. Mitigating the impact of
HIViAIDS and preventing new infections require
adequate human and material resources, as well
as innovations that address this need. However,
for all cadres of healthcare workers, the countrys
current human resource capacity is far below rec-
ommended levels.
ZPCT, a six-year cooperative agreement between
FHI and USAID that is funded through PEPFAR, is
strengthening GRZ programs in order to provide
HIV clinical services in ve of the nine provinces
Central, Copperbelt, Luapula, Northern, and North
Westernand increase access to ART in public-
sector health facilities. Management Sciences for
Health (MSH) is a partner for laboratory and phar-
macy technical areas, other partners are Churches
Health Association of Zambia (CHAZ), Expanded
Church Response (ECR), and Kara Counselling and
Training Trust.
The Zambia Prevention, Care and Treatment Partnership: A Model Program 7
ZPCT Organizational Structure
AIDS services through district-wide referral net-
works and coordinated mobile CT activities.
Managers of provincial oces represent their
respective program teams and report to the direc-
tor of programs in the Lusaka oce. Te managers
supervise provincial oce sta (program, nance,
and technical), oversee ZPCT activities at the pro-
vincial level, build relationships and work closely
with district and provincial partners, and ensure
that activities in targeted health facilities and com-
munities are implemented in accordance with
ZPCT technical strategies.
Te director of technical support oversees technical
sta and the technical direction of all areas of HIVi
AIDS clinical care, including ART, CT, PMTCT,
quality assuranceiquality improvement (QAiQI),
training, laboratory and pharmacy services, and
M&E. Te technical support team directs and sup-
ports the work of provincial-level technical ocers.
Tough they report to provincial managers, these
technical ocers receive guidance and direction
from technical advisors in the Lusaka oce.
Te director of nance and administration over-
sees all ZPCTs nancial operations and ensures
compliance with the contractual requirements of
USAID and other donors. From the Lusaka oce,
nance and administrative sta work with their
provincial- counterparts on nancial and account-
ing functions, as well as on procurement and the
distribution of equipment and supplies. Tey also
work together to ensure that accounts are consis-
tent with FHI policies and procedures and donor
regulations, and they develop and submit nancial
reports that follow ZPCT procedures and conform
to the regulations of USAID and other donors.
Much of ZPCTs success can be attributed to its
organizational structure. It has six oces: the
main oce is in the capital city, Lusaka, and it has
an oce in each of the ve provincial capitals. Of
the sta of 6, only four are expatriates. ZPCT is
headed by a chief of party, who is assisted by a dep-
uty chief of partyidirector of programs, a director
of technical support, and a director of nance and
administration.
Te chief of party is responsible for all program,
nancial, and technical activities, and is answerable
to USAID on the progress of the program. Te per-
son in this position supervises directors, maintains
relationships with the MoH, USAID, other part-
ners, and programs, and sets the strategic direction
of program activities.
Te director of programs is responsible for overall
management of program rollout and implemen-
tation, with the assistance of the Lusaka-based
program sta and ve provincial management
teams. Te program team in Lusaka liaises with
sta in the technical and nance departments on
overall program design, implementation, monitor-
ing, and deliverables. Tis team also takes the lead
on developing annual work plans, quarterly reports,
and other USAID deliverables.
Each provincial oce takes the lead in developing
its respective programs, recipient agreements, work
plans, and monthly reports, with the support and
assistance of the Lusaka program team. On the sta
of each provincial oce are one or more technical
ocers in the following categories: clinical care,
CTiPMTCT, laboratory and pharmacy, community
and referral, and M&E. Provincial sta also develop
activities that mobilize communities to access HIVi
8 The Zambia Prevention, Care and Treatment Partnership: A Model Program
ZPCT Partnerships
pharmaceutical services. MSH technical sta report
to ZPCTs director of technical support, and they
provide information to ensure the sustained supply
of laboratory reagents, equipment, HIV testing kits,
and pharmaceuticals (including ARVs) throughout
all programs.
At the national level, as with all technical sta, the
MSHiZPCT pharmacy and technical sta par-
ticipate in the development of MoH policy and
guidelines. Tey also provide training and mentor-
ing for laboratory and pharmacy sta in supported
facilities and at provincial and district levels.
Te Churches Health Association of Zambia
(CHAZ) supports mission health facilities in North
Western, Northern, and Luapula provinces through
a subagreement with ZPCT. ZPCT provides fund-
ing to CHAZ to identify and complete renovations
and procure essential medical and laboratory equip-
ment to expand HIViAIDS services. Tese activities
have been completed at four health facilities. ZPCT
and CHAZ jointly identied three additional health
facilities for support, which began in July aoo;.
ZPCT and CHAZ sta jointly monitor implementa-
tion progress at the selected mission health facilities,
with ZPCT taking the lead on technical assistance.
Kara Counseling and Training Trust, the best
known and longest-serving HIV and AIDS coun-
seling training service in Zambia, is responsible for
training counselor supervisors at ZPCT-supported
health facilities and at the district level. As of
September aoo;, Kara had trained and certied ;
counselor supervisors.
Te Expanded Church Response (ECR) is respon-
sible for working through church communities to
increase knowledge and demand for HIViAIDS ser-
vices at ZPCT-supported facilities. To accomplish
this, ECR set up coordinating committees that focus
on selected health centers in two provincesCen-
tral and Copperbelt. Church members requiring
HIV services are mobilized and referred appropri-
ately, whether for services in the community or in
the district. In addition, the ECR has implemented a
few mobile CT activities at their churches.
Partnership is the cornerstone of ZPCT operations
and of their success. Partnerships are at the central-
government level, with the MoH and the National
AIDS Council, and have been developed with in-
ternational organizations, local and national faith-
based organizations, and community-based NGOs.
At the inception of ZPCT, FHI signed memoranda
of understanding with the MoH and each of the
ve PHOs.

Each of these oces was consulted

to determine which districts to assist, then each
district was consulted to identify which facilities
to support. ZPCT then collaborated with district
health oces and selected hospitals to assess their
needs, in terms of training, infrastructure, labora-
tory, and equipment.
ZPCTs level of support for a given health facility
depends on the level of health services the facil-
ity provides, the state of its infrastructure, and the
extent to which it needs services that ZPCT pro-
vides or supports. For each supported facility, an
implementation plan is used to develop a recipient
agreement. Such agreements are signed by DHMTs
or hospital boards and the FHI country director,
who is also the ZPCT chief of party. Te agreements
outline all the proposed support from ZPCT for a
given facility, including ongoing expenses, items
to be procured, infrastructure improvements, and
training activities planned.
By signing recipient agreements, the parties consent
to their roles and responsibilities in implementing
activities under the partnership. Te agreements
provide detailed technical information on what is
required to improve HIViAIDS services in each
health facility, taking into account stang, infra-
structure, client load, catchment area, and other
services available in the district. ZPCT manages the
funds on behalf of the recipients and in accordance
with the recipient agreements, since USAID rules
and regulations make it dicult to provide funds
directly to a government entity.
MSH, a subpartner in the cooperative agreement, is
responsible for technical support for laboratory and
1.
The memoranda of understanding were signed with the MoH and the Central
Board of Health. The latter has since been consolidated into the MoH.
The Zambia Prevention, Care and Treatment Partnership: A Model Program 9
COUNSELING AND TESTING
By the end of September aoo;, ZPCT had facilitated
rapid expansion of CT services, extending them to
,; facilities in the ve provinces and 6a, people.
Further expansion to a total of a6 facilities started
in October aoo;.
CT has been expanded by
establishing dedicated CT rooms within health
facilities
providing testing corners in clinical areas, such as
in hospital wards, STI and TB clinics, and general
outpatient departments
providing testing through the Ndola Catholic
Diocese home care program
integrating CT into antenatal services
using multidisciplinary mobile outreach counsel-
ing teams
ensuring constant and uninterrupted supplies of
test kits and other supplies
To increase pediatric access to CT, ZPCT estab-
lished it as a routine service in 10 pediatric inpatient
Fig. 1. Current and New Pediatric Clients on ART at ZPCT Sites, May 2005September 2007
No. of children currently receiving ART No. of new pediatric clients initiating ART
Current and New Pediatric Clients on ART, ZPCT Sites,
May 2005September 2007
443
654
876
1,096
1,344
1,597
1,949
2,203
2,484
2,807
248
294
229 240
174
81
399
352
403
331
0
500
1,000
1,500
2,000
2,500
3,000
May 05Jun 05 Jul 05Sep 05 Oct 05Dec 05 Jan 06Mar 06 Apr 06Jun 06 Jul 06Sep 06 Oct 06Dec 06 Jan 07Mar 07 Apr 07Jun 07 Jul 07Sep 07
P
e
r
s
o
n
s

s
e
r
v
e
d
No. of persons currently receiving ART (children) No. of NEW clients initiating ART (including pregnant women)
wards and selected under-5 clinics. Tis service has
helped increase the number of HIV-positive chil-
dren who are diagnosed and linked to care and ART
(g. 1).
Task shifting and involvement of non-healthcare
workers in provision of CT helped to expand ser-
vices and address the limited number of trained
workers in health facilities. To provide these ser-
vices, ZPCT trained and placed lay counselors to
work alongside healthcare workers.
PREVENTION OF MOTHER-TO-CHILD
TRANSMISSION
Between the inception of ZPCT and September
aoo;, ;,6a pregnant women accessed PMTCT
services from ,6 facilities in the ve provinces.
Tese women received CT services and their test
results, and o,68o also received full ART prophy-
laxis. In addition, , providers (doctors, midwives,
nurses, clinical ocers, and laboratory and phar-
macy sta) were trained to provide PMTCT services.
Further expansion to a total of ,6 facilities started
in October aoo;.
ZPCT as a Technical Model: Key Areas and Innovations
10 The Zambia Prevention, Care and Treatment Partnership: A Model Program
Innovations contributing to increased uptake
Te opt-out approach to CT at antenatal clinics in
health facilities was MoH policy when ZPCT began
implementation. Since then, ZPCT has operation-
alized routine CT, with same-day results for all
pregnant women attending antenatal care. Tis has
led to sustained high uptakeover , percentof
PMTCT services in antenatal clinics, which includes
CT and clients receiving their results (g. a).
Te creation of testing corners within maternal and
child health clinics and the training of healthcare
workers also contributed to increased uptake. So
did hands-on mentoring and task shifting: nurses
are conducting the HIV tests, and trained lay coun-
selors provide some components of service delivery,
such as motivational talks and HIV testing.
ZPCT is also working with PMTCT motivators
lay female volunteers who are trained to encourage
pregnant women to access these services. Originally
trained through the Academy for Educational
Developments Linkages Project, the cadre was
incorporated into ZPCT after that program ended.
CD4 estimations and a systematic
follow-up system
CD4 evaluations are conducted for all HIV-positive
pregnant women to ensure provision of more e-
cacious ARVs, including HAART, for women
whose levels warrant full ART. Tis is done through
a sample referral system that allows blood samples
from HIV-positive pregnant women to be sent to
a lab with CD4 capability, with results returned to
the originating facility.
Within existing maternal and child health struc-
tures, ZPCT established a systematic mother-baby
follow-up system and early infant HIV diagnosis.
Te systematic follow up of HIV-positive women
after they give birth ensures early infant diagnosis
and continuity of care. ZPCT also facilitated initia-
tion of cotrimoxazole prophylaxis and HIV testing
for infants through the PCR technology. Te newly
established system is used to collect dried blood
spots from infants for analysis and to oer linkages
to appropriate HIV services.
Male involvement in PMTCT
In Luapula and North Western provinces, male
involvement is higher than in other parts of
Zambia. Tis is due to work of US government
partners, such as Johns Hopkins Universityi Health
Communication Partnership (JHUiHCP), and
innovative approaches with traditional leaders. In
Luapula Province, for example, women who attend
antenatal clinics with their husbands are given pri-
ority and seen rst. Tis encourages other women
Percentage of Pregnant Women Accepting Testing, ZPCT Sites,
May 2005September 2007
29%
49%
59%
75%
84%
93%
93%
95%
96%
98%
0%
20%
40%
60%
80%
100%
120%
May 05Jun 05 Jul 05Sep 05 Oct 05Dec 05 Jan 06Mar 06 Apr 06Jun 06 Jul 06Sep 06 Oct 06Dec 06 Jan 07Mar 07 Apr 07Jun 07 Jul 07Sep 07
P
e
r
s
o
n
s

s
e
r
v
e
d
Fig. 2. Percentage of Pregnant Women Accepting Testing at ZPCT Sites, May 2005September 2007
The Zambia Prevention, Care and Treatment Partnership: A Model Program 11
who wish to avoid long queues to come to the clinic
with their husbands.
Te community sensitization conducted by JHUi
HCP in the Chembe area (bordering the Democratic
Republic of Congo) led to the creation of Safe
Motherhood Action groups that promote male
involvement in antenatal care, including PMTCT.
Now, when women come for antenatal services,
Chembe Clinic also caters to the health needs of
their partners.
Tese activities have led to a signicant increase
in male participation in PMTCT. Before sensitiza-
tion, male attendance at antenatal clinic was zero.
Within ve months of starting sensitization activi-
ties, ;oo percent of antenatal clients arrived
with their male partners, and acceptance of HIV
testing by women also increased.
CLINICAL CARE AND ANTIRETROVIRAL THERAPY
As of September aoo;, o,,,, people were receiv-
ing ART through ZPCT-supported government
facilities (g. ).
ART clinics
To scale up ART services, ZPCT initiated the pro-
vision of ART in the outpatient departments of all
central, general, and district hospitals in the ve
provinces and several urban and rural health cen-
ters. Te ART services are provided as static or
outreach services.
Setting up ART clinics required healthcare worker
training and the development of job aids and
standard operating procedures. In some cases, ren-
ovations of sections of outpatient departments or
hospital outbuildings were also required. Te ART
clinics set up include waiting areas that are also
used for group counseling and education, counsel-
ing rooms used by psychosocial counselors, ASWs,
and lay counselors, and dedicated ART pharmacies
for dispensing ARVs and other ART-related medi-
cations. Laboratory services are either at the sites
or nearby.
Te new ART clinics facilitated the ow of clients
and made access to services much more conve-
nient. Previously, clients attended clinics that were
held one day a week, in single rooms in outpatient
departments. Tey had to go from there to hospital
laboratories for blood tests, return to the clinics to
have their results interpreted, and then go to the
general hospital pharmacy to collect medications.
Now all services are in one location.
Current and New Clients on ART, ZPCT Sites, May 2005September 2007
6,729
8,994
12,893
16,914
21,111
25,003
28,743
32,950
36,464
40,999
4,896
981
2,217
3,555
4,062
4,628 4,276
5,150 5,068
4,786
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
May 05Jun 05 Jul 05Sep 05 Oct 05Dec 05 Jan 06Mar 06 Apr 06Jun 06 Jul 06Sep 06 Oct 06Dec 06 Jan 07Mar 07 Apr 07Jun 07 Jul 07Sep 07
P
e
r
s
o
n
s

s
e
r
v
e
d
No. of persons currently receiving ART (including pregnant women)
No. of NEW clients initiating ART (including pregnant women)
Fig. 3. Current and New Clients on ART at ZPCT Sites, May 2005September 2007
No. of persons currently receiving ART (including pregnant women) No. of new clients initiating ART (including pregnant women)
12 The Zambia Prevention, Care and Treatment Partnership: A Model Program
Family-centered care
Te family-centered ART clinic created at the
ADCH provides ART services for children and
their parents in a renovated building and serves as
a referral center for the ve provinces. Parents of
HIV-positive children receiving ART can access CT
and ART for themselves at the same center, saving
them from the inconvenience of going to dierent
health facilities on dierent appointment dates.
Instead, under the same roof, the same caregiver
provides continuous HIV clinical care, treatment,
and monitoring for parents and their children.
Pediatric HIV services
Te commissioning of the PCR testing laboratory at
the ADCH in August aoo; means that infant HIV
diagnosis is now available to all districts.
a
A dried
blood-spot sample referral system is used to meet
infant diagnostic requirements and make available
PCR testingand thus early, accurate diagnosis of
HIV infection in infantsin all government health
facilities in the ve provinces.
Dried blood-spot samples, collected on lter paper
in hospitals, clinics, and health centers in all districts,
are delivered to the laboratory within a8 hours
2.
This is the third such facility in Zambia; the other two are in Lusaka.
through the expedited mail service (EMS) system
of Zambias National Postal Services Corporation.
After the samples are processed, tested, and read,
results are delivered by the EMS to originating
districts and conveyed to the appropriate facility
within two weeks. Te distribution network and
the rapid expansion and accessibility of this service
are unprecedented, both in Zambia and within the
FHI global network.
Te introduction of routine HIV testing of all chil-
dren admitted into childrens wards, regardless of
their admission diagnosis, has also enhanced pedi-
atric HIV diagnosis and treatment. Appropriate
pediatric formulations of ARVs are available
throughout the ve provinces to initiate HIV-
infected children on treatment and facilitate smooth
scale-up of pediatric ART.
One of ZPCTs goals is that children constitute
o percent of all ART clients. As of September
aoo;, a,8o; pediatric patients were receiving
ART; percent of all clients.
Outreach ART activities
To broaden the scope and availability of ART ser-
vices, DHMTs and other trained health workers
travel from static sites to more remote facilities to
Fig. 4. Percent of Current and New ART Clients Receiving Services at ZPCT Outreach Sites, May 2005September 2007
No. of persons currently receiving ART (including pregnant women) No. of new clients initiating ART (including pregnant women)
Percentage Current and New ART Clients Receiving Services, ZPCT Outreach Sites,
May 2005September 2007
25%
24%
22%
20%
17%
16%
13%
10%
7%
5%
13%
13%
17%
21%
25%
27%
28%
30%
33%
30%
0%
5%
10%
15%
20%
25%
30%
35%
May 05Jun 05 Jul 05Sep 05 Oct 05Dec 05 Jan 06Mar 06 Apr 06Jun 06 Jul 06Sep 06 Oct 06Dec 06 Jan 07Mar 07 Apr 07Jun 07 Jul 07Sep 07
P
e
r
s
o
n
s

s
e
r
v
e
d
Percent outreach current clients Percent outreach new clients
The Zambia Prevention, Care and Treatment Partnership: A Model Program 13
initiate and monitor clients on ART. For this out-
reach, the DHMT typically comprises a medical
doctor trained on ART, a laboratory technician,
andior pharmacy sta. Because clients no longer
have to make long and costly trips to access ART,
uptake has improved tremendously, as has compli-
ance and adherence (g. ).
In Copperbelt Province, the outreach team works
closely with the Catholic Dioceses home-based
care program, providing ART services through
three home-based care centers in communities in
Ndola, Chingola, and Kitwe districts. Home-based
care teams, trained in HIViAIDS management,
assess and register clients and perform a prelimi-
nary screening for ART by using the World Health
Organization clinical staging system.
Clients reached by ZPCT-supported ART services
are among the poorest members of a community.
Patients in stages three and four are seen dur-
ing weekly visits of the outreach ART team, who
clinically assess and examine clients and perform
pre-ART investigations, including taking blood
samples for testing. Te team initiates patients on
ART, providing adherence counseling and dispens-
ing ART drugs. Team members also review and
manage clients already on ART, monitoring prog-
ress and restocking their drug supplies.
Te Catholic Diocese provides transportation to
facilitate the outreach teams travel from DHMT
clinics to communities. Te DHMT provides the
sta of the outreach teams, as well as the drugs,
equipment, and reagents, and ZPCT provides
the allowances required for outreach activities.
Eventually, all these clients will be referred to MoH
facilities for ongoing services.
Laboratory-sample referral system
Laboratories in central and district hospitals and,
in some cases, in centrally located clinics and health
centers have been upgraded and equipped with
the capacity to perform ART-related tests: CD4
counts, full blood counts, and blood chemistry. Sta
have been trained and, where necessary, retrained
to carry out these tests.
To make lab facilities available to all health centers
and clinics in the districts, ZPCT provided motor-
cycles to DHMTs and to hospitals and clinics with
laboratory facilities. Tis innovation has given
clients, even those in remote areas, access to sophis-
ticated laboratory tests. Te motorcycles are used
to transport blood samples to labs and take results
back to clinics and health centers. Tey also carry
infants dried blood spots to the PCR laboratory.
In addition, the use of motorcycles has greatly
reduced client inconvenience. Many clients had
to travel long distances to have their blood tested
at laboratories, then needed to return within a
few days for their results. Now they make short
journeys to the nearest health center or clinic,
where they have their blood drawn and later receive
their results.
Technical assistance and mentorship
Clinical care ocers within the technical sta in
ZPCT provincial oces are trained ART experts
who provide supervision, training, technical assis-
tance, and mentoring for all healthcare workers
involved in ART in their respective provinces.
Clinical care advisors in the technical support oce
in Lusaka train these ocers on new trends and
innovations and keep them up to date on revisions
and changes to national guidelines. In turn, the o-
cers do the same for technical sta in government
facilities in the provinces.
LABORATORY AND PHARMACY
Laboratory services
High-quality laboratory services are important for
the diagnosis, treatment, and monitoring of HIV
infections. As such, they are a crucial component
of the eective scale-up of all HIViAIDS services,
especially for ART and PMTCT. To this end, ZPCT
has refurbished laboratories to create adequate
working and equipment space, and has provided
standard state-of-the-art equipment and ongoing
training of personnel on handling the new equip-
ment. Modern laboratories have thus been created
in facilities that were previously run-down town-
ship clinics or health centers.
Each ZPCT-supported district now has at least one
centralized laboratory that is capable of perform-
ing ART-related blood tests. Several laboratories
in each district have the capacity to perform full
14 The Zambia Prevention, Care and Treatment Partnership: A Model Program
blood counts and blood tests relating to liver and
renal functions. In larger provincial centers (such
as Ndola in Copperbelt Province and Kabwe in
Central Province), the DHMT and ZPCT divided
health facilities in the district into zones and linked
them to a centralized laboratory that has a CD4
machine. Blood samples from health facilities in a
particular zone are taken to a specied laboratory.
Tis zoning system has been set up in all the prov-
inces to ensure that a CD4 test is available within
oo kilometers.
In Ndola, two trained laboratory sta who are based
at a clinic in a township health center spend one
day a week in a centralized laboratory, performing
CD4 count tests on samples from their own center
and others. In this manner, skills are centralized on
a periodic and regular basis.
A major logistic challenge is ensuring that a network
of sophisticated laboratories is functional and well
stocked with reagents, possesses serviced equip-
ment, and maintains high standards and quality
control. To this end, ZPCT procured HIV test kits
until the MoH system was in place and continues to
provide some reagents for laboratories.
To avoid stockouts, ensure uninterrupted supplies,
and promote sustainability, all supplies are ordered
by the district through Medical Stores Limited
(MSL),

the central stores for all medical supplies,

which has a standard MoH supply system in place.
Other US Government partners are working with
MSL to improve this MoH supply logistic system
and ensure that needed amounts of supplies are
properly quantied.
ZPCT provides supervisory and technical assis-
tance to laboratories to monitor quality and ensure
timely performance of tests and release of results.
An automated laboratory information system is
being introduced in selected facilities to enhance
accurate inventory management and patient test
proles. An internal quality control system for lab-
oratory tests associated with HIV and ART is being
3.
MSL, a private company based in Lusaka, is the MoHs central supplier of drugs,
reagents, and equipment, and distributes to all provinces, districts, and centers.
ZPCT, in collaboration with a project of John Snow Inc., often communicates directly
with MSL on stock levels and timely placement and delivery of orders.
piloted to monitor the quality of services provided,
in collaboration with the MoH and other partners.
Pharmacy services
Pharmacy support activities are integral to the
ZPCT-supported comprehensive HIV prevention,
care, and treatment program. Pharmacy services
are cross-cutting and closely coordinated with CT,
PMTCT, ART, and clinical care services.
ZPCTs technical approach to pharmacy services
includes
training facility sta to eectively forecast, quan-
tify, order, procure, and store ARVs, OI drugs,
and other supplies and avoid stock outs and
shortages
improving storage space at all health facilities
providing appropriate equipment to support the
management of pharmaceuticals
strengthening inventory management systems,
logistics, and security, and improving the delivery
of ARVs and other drugs to facilities
assisting the GRZ in its formulation and imple-
mentation of standard operating procedures for
inventory management systems, recordkeeping,
and good dispensing practices
It is also important to note that ZPCT obtains
ARVs and test kits through the national drug sup-
ply system, and that sta training provided helps to
strengthen the system.
The ART pharmacy in Ndola, Copperbelt Province, was
refurbished by ZPCT. It is an important element of the
comprehensive prevention, care, and treatment program.
The Zambia Prevention, Care and Treatment Partnership: A Model Program 15
Numbering among ZPCT innovations is the
adoption, support, and scale up of the automated
Zambia Pharmacy ART Program (also known
as the ARTServ Dispensing Tool). Developed
by MSH through the USAID-funded Rational
Pharmaceutical Management Plus Program, the
tool is now in use in all pharmacies with computer
technology. ARTServ has simplied the monitor-
ing of drug consumption by clients and improved
patient care. Pharmacy sta have been trained to
use it, and provincial laboratory technical ocers
provide supportive supervision and mentoring.
ZPCT has also improved pharmacy infrastructure
and storage space, and has supported the installa-
tion of air conditioners to maintain drugs at opti-
mum temperatures.
REFERRAL NETWORK
Te needs of people living with HIViAIDS (PLHA)
are diverse: apart from ART, they need medical
care and psychosocial, nutritional, and nancial
support. Among many community-level service
providers that address these needs are the DHMT,
the district AIDS task forces (DATFs), faith-based
organizations, and local and international NGOs,
including ZPCT.
ZPCT initiated a coordination process at the dis-
trict level by working with DHMTs, DATFs, the
Network of Zambian PLHA, health center com-
mittees, community leaders, faith-based and
home-based care organizations, and other commu-
nity-level organizations. Tis led to the formation
of a referral network in each district that includes a
referral coordinating unit, selected through a par-
ticipatory process by network members. Te unit
is responsible for convening meetings, coordinat-
ing activities, mobilizing resources, and providing
technical assistance to new members.
At the district level, the referral network is managed
by the DHMT or DATF. At regularly held network
meetings, issues of common interest relating to
the welfare of PLHA are discussed. ZPCT and the
network members in each district contribute to
logistics for regular monthly meetings, such as sta-
tionery, printing, and meeting venues. Indicators,
targets, and mechanisms for gathering data are
agreed upon before implementation. ZPCTs con-
tribution focuses on referral activities at the health
facilities it supports, where a referral focal-point
person is responsible for documenting referrals.
ZPCT developed and disseminated standard tools
to refer and monitor the movement of clients
between ZPCT-supported health facilities and
other HIV-related support services and commu-
nity assistance. Health workers have been trained
in the use of these referral tools. Tey comprise
a referral form to be returned to the referring
organization, with a detachable section that is
retained by the receiving organization
a referral register, used by referral focal-point
persons to document all referrals
a directory of services with contact details of all
organizations providing HIV-related services for
PLHA and their families within a district
a referral operations manual, developed by all
network members to dene principles and pro-
cesses that guide its functioning
MONITORING AND EVALUATION
ZPCT is working with the MoH to implement an
M&E system that guides the rapid scale-up of ser-
vices, while responding to the information needs of
the GRZ, PEPFAR, USAIDiZambia, and the NAC.
To meet all these information needs, ZPCT works
with its partners to harmonize information and data
systems, avoid duplication, and adhere to the three
ones principle for the M&E component. ZPCT is
collaborating with the MoH and US Government
partners in the design and implementation of the
SmartCare ART patient-tracking system, which
will be used in all MoH ART sites.
SmartCare, a computerized system with a paper
backup, can capture patient characteristics and
simplify follow-up. Reports generated are in line
with MoH and PEPFAR indicators. Te prototype
patient-tracking system was rst introduced by
the DHMT in Lusaka, with the support of Center
for Infectious Disease Research in Zambia and the
US Centers for Disease Control and Prevention.
SmartCare is being rolled out by ZPCT in sites
16 The Zambia Prevention, Care and Treatment Partnership: A Model Program
the program supports to replace the manual- and
paper-based ART information system (ARTIS).
In the ve provinces, the M&E system focuses on
activities and results at facility, district, and provin-
cial levels. Tese provide the basis for
monitoring performance in achieving rapid scale-
up of quality HIV-related services
ensuring best practices for ART, clinical care, CT,
and PMTCT are documented and shared
ensuring that best practices for ART are devel-
oped through evidence-based approaches and
are implemented by monitoring adherence and
immunologic and clinical responses and applying
results
measuring the contribution of program eorts
toward achievement of the objectives of the MoH,
PEPFAR, USAIDiZambia, and the NAC
strengthening M&E capacity at national, provin-
cial, and district levels
Te M&E system depends on the recruitment, train-
ing, and placement of data entry clerks, the training
of healthcare and health information sta in ARTIS
and the CT and PMTCT information system, and
onsite technical assistance and mentoring for sta
at all levels.
Data entry clerks
ZPCT recognized that the collection, maintenance,
and management of good-quality data are vital to
the success of the scale-up eort, and that budget
constraints have led to a dearth of health facility
sta who can perform these functions. Tus, as of
September aoo;, ZPCT had recruited and trained
data entry clerks for the ART sites and facilities
it supports.
Tese clerks, directly and fully funded by ZPCT,
are placed in ZPTC-supported health facilities
through the DHMTs. Initially hired through con-
sultancy agreements, the clerks were transitioned
by ZPCT to full-time contracts at rates equivalent
to other GRZ employees at the same level. Funds
for their salaries and benets are included in recipi-
ent agreements.
Since their introduction, the timeliness and qual-
ity of data have greatly improvedso much so
that the government is considering including data
entry clerks in their district establishments. To
further improve data quality, data entry clerks are
attached to additional non-ART sites and health
facilities in their districts, where they spend one
day in a month to compile and collect data for MoH
and PEPFAR reports.
Equipment
ZPCT has supplied essential computer equipment
for data storage and ART reporting to all health facil-
ities it supports. SmartCare, a standardized patient
tracking system developed by US Government
partners and the MoH, is being installed in all ART
clinics and centers, in collaboration with the MoH
and other partners.
Data audits
ZPCT instituted data audits at all sites to ensure
that data collected are standardized and of high
quality. So far, ve audits have been conducted
covering the period October aoo to March aoo;.
Tese data audits are carried out by ZPCT M&E
sta from Lusaka and provincial oces, with sta
from one province assisting with data audits in
other provinces.
Te quality of data collection in MoH facilities at
the onset of ZPCT was limited. Te recruitment
and placement of data entry clerks, the provision of
equipment and data collection tools, and the data
audit process have greatly improved management,
collection, and quality of data from all provinces.
HUMAN RESOURCES
Maintaining trained and experienced sta in ZPCT-
supported sites is a formidable challenge. ZPCT
developed innovative approaches to counter severe
sta shortages and high attrition rates due to trans-
fers, resignations, and deaths. Tese have resulted
in the retention and training of human resources
essential for the successful scale-up of HIV services.
However, the human resource shortage continues
to be an issue in Zambia.
Training
Because the shortage of healthcare workers has
reached crisis proportions, sta at facilities are
The Zambia Prevention, Care and Treatment Partnership: A Model Program 17
stretched to the limit when their colleagues are away
from their stations for training. ZPCT devised alter-
native training approaches to address this problem.
Sta numbers are maintained at the highest possible
levels when the workload is heaviest, but essential
training is provided onsite, where possible, and in
the late afternoon, after the days work is nished.
Te onsite training at Ndola Central Hospital pro-
duced no signicant dierence in scores, compared
with the conventional two-week residential training.
Signicant reductions in training cost also allow more
health workers to be trained with this approach.
ZPCT is assisting the GRZ and other partners to
train healthcare workers in CT, PMTCT, care of
OIs, ART, and laboratory and pharmacy services.
Where available, national training packages and
national trainers are used, and ZPCT is working
with the MoH to develop trainers and adapt pack-
ages in areas where they are not.
Te following table shows courses oered and num-
bers trained by ZPCT, as of September aoo;:
Training Number trained
Counseling and testing 395
Counseling and testing refresher 82
Counseling supervision 171
Couple counseling 24
Lay counselors 206
HIV testing for lay counselors 141
PMTCT 460
PMTCT refresher 39
ART/OIs 663
ART/OIs refresher 72
ART/pediatric 364
ASW training 273
Adherence counseling (healthcare workers) 348
Laboratory and pharmacy 243
M&E for data entry clerks 36
M&E for health information ofcers 16
M&E for healthcare workers 1,220
Sta retention
Retaining healthcare workers and other sta mem-
bers who have been trained continues to be a
challenge because conditions of service in the pub-
lic sector are beyond the scope of ZPCT. Within
these limitations, ZPCT continues to put in place
innovations that reduce workloads for healthcare
workers and motivate and retain sta in ZPCT-
supported facilities.
Transport reimbursements
ZPCT works with facilities to determine how many
extra shifts are needed to provide services and
provides transport reimbursement funds to the
DHMT for those approved shifts. Te amount of
the reimbursement is determined by the districts,
in accordance with their policies.
Tis initiative has been implemented in most health
facilities where ZPCT-supported activities have
been introduced. It has helped to alleviate sta
shortages, served to maintain high sta morale,
and ensured continuity and sustainability of new
and old services.
Lay counselors
To relieve pressure on HIV psychosocial counsel-
ors who are also health workers, ZPCT is training
volunteer lay counselors to provide CT services
at health facilities. Selected by the facility and the
DHMT, these volunteers are primarily community
members who have been engaged in some com-
munity-based service, perhaps as a member of a
neighborhood health committee.
Prospective lay counselors are interviewed to
assess if they have previous HIViAIDS training,
can read and write in English, and are motivated
to become counselors. Volunteers selected undergo
training that is based on the national CT curricu-
lum. Recently, after a change in national guidelines
allowing non-medical persons to perform HIV
tests, ZPCT began training lay counselors in the
use of rapid tests for HIV testing.
As volunteers, lay counselors receive a monthly
stipend of oo,ooo kwacha (about USsa), the
standard volunteer stipend of partners of the Global
Fund to Fight AIDS, Tuberculosis, and Malaria. Tese
payments are included in recipient agreements.
18 The Zambia Prevention, Care and Treatment Partnership: A Model Program
Adherence support workers
Another ZPCT innovation is the new volunteer
cadre of ASWs. Tey are PLHA who are on ART,
drawn from the community and trained in adher-
ence counseling. ZPCT developed the curriculum
for training ASWs, which has been published and
made available, both within Zambia and globally.
ASWs work three days a week: two days in a health
facility and the third in a nearby community, where
they visit patients to support their adherence to
treatment and track down defaulters and try to
reengage them. To facilitate this work, ZPCT pur-
chased one or two bicycles per facility that the
ASWs share.
ASW counseling rooms are available in each facil-
ity, adjacent to or near health workers consulting
rooms. Tere, ASWs provide adherence counsel-
ing for clients before they receive their ARVs. Such
counseling is provided at the rst prescription visit
and when clients return for further supplies.
Interviews to select ASWs are conducted jointly
by ZPCT and the DHMT, with the participation of
facility sta and members of nearby communities.
Te major requirement is that ASWs be on ART
themselves and exhibit a penchant for volunteerism
and a willingness to model their own experiences
as PLHAs. Tey also need to be able to read and
write in English.
Retention of ASWs is good. Tey receive the same
incentives as the lay counselors (oo,ooo kwacha
per month), and these payments are included in
recipient agreements. Currently, only aa of the a;
trained ASWs have stopped oering the service.
Te involvement on the HIV services team of peo-
ple openly living with HIV and on ARVs is unique,
and it has been well accepted by health workers,
clients, and PLHA alike.
Another ZPCT innovation is the new volunteer cadre of ASWs.
They are PLHA who are on ART, drawn from the community and
trained in adherence counseling.
The Zambia Prevention, Care and Treatment Partnership: A Model Program 19
ZPCT as a Program Management Model: Key Areas and Innovations
DECENTRALIZATION OF DECISIONMAKING
Lusaka-based program sta provide assistance and
support for program design, implementation, mon-
itoring, and deliverables. Tey also take the lead on
developing annual work plans, quarterly reports,
and other deliverables for submission to USAID,
but the overall management of program rollout and
implementation has devolved to the ve provincial
management teams.
In each province, the ZPCT oce takes the lead in
developing programs, recipient agreements, work
plans, and monthly reports, with assistance from
the Lusaka program team. Within provincial oces
are sta who are tasked with M&E and pharmacy
and laboratory services. Technical sta in these
oces also develop activities to mobilize commu-
nities to access HIViAIDS service in the facilities
through district-wide referral networks and coor-
dination of mobile CT activities.
Each provincial program team is headed by a pro-
vincial manager, who supervises all provincial oce
sta (program, nancial, and technical), and over-
sees all ZPCT activities at the provincial level. Te
provincial manager builds relationships and works
closely with district and provincial partners, ensur-
ing that activities in targeted health facilities and
communities are implemented according to ZPCT
technical strategies. Provincial managers report to
the director of programs in Lusaka.
New counseling rooms at the Kasanda Clinic, Kabwe, Central
Province, were converted from a disused garage.
INFRASTRUCTURE REFURBISHING
AND PROCUREMENT
Infrastructure renovations to accommodate the
delivery of HIViAIDS services have been made
in nearly all ZPCT-supported health facilities
that provide CT, ART, and PMTCT services.
Renovations have varied by site, depending on the
condition of existing infrastructure and services to
be provided. USAID-mandated environmental site
assessments, commissioned by ZPCT, precede all
renovation work.
USAID regulations governing ZPCT activities
do not allow for the construction of new build-
ings, they permit only the renovation or refurbish-
ment of existing structures. Despite this challenge,
some innovative and functional renovations have
been accomplished, including the conversion of
a dilapidated and abandoned garage into two
counseling rooms at the Kasanda Clinic in Kabwe,
Central Province.
An old, disused outbuilding at Kabwe General Hos-
pital was renovated to create a center that provides
ART services and has convenient patient ow, wait-
ing space, and adequate furniture. Two water tanks
installed at Pollen Clinic in Kabwe have ensured
continuous availability of clean running water for
The post-delivery room in the Pollen Maternity Clinic in Kabwe is
now supplied with clean running water.
20 The Zambia Prevention, Care and Treatment Partnership: A Model Program
all services and have improved PMTCT services in
the middle of a high-density township.
At Pollen Clinic, the introduction of PMTCT ser-
vices was accompanied by provider-initiated HIV
testing for all children at the under- clinic. Tis
model is being piloted in ve ZPCT-supported
clinics in Kabwe, Ndola, Kitwe, and Mansa. With
ZPCT support, Pollen Clinic has started an ART
clinic that provides services solely for pregnant
women requiring ARTthe rst of its kind.
At the ADCH, the pharmacy department was relo-
cated from the third oor to a more spacious and
accessible location on the rst oor. Te ultramod-
ern laboratory now houses DNA PCR equipment
for early diagnosis of HIV infection in infants.
Renovations undertaken by ZPCT and hospital
authorities at Liteta District Hospital in Central
Province to accommodate new ART services cre-
ated ample space for storage of pharmaceuticals
and dispensing of drugs.
All renovations are agreed upon and executed jointly
by ZPCT provincial oce sta, district health
authorities, and health facility sta. Certications
of quality, issued when renovations are complete,
are undertaken by ZPCT-hired architects and GRZ
public works and supply departments, since the
buildings are GRZ property.
Hand-in-hand with renovations that improve ser-
vices is the training or retraining of sta to provide
these services. For example, pharmacists and phar-
macy technicians must be trained in counseling and
the dispensing of new ARV and OI drugs that the
expanded pharmacy can now provide, and labora-
tory sta must be trained to handle new laboratory
equipment before it is commissioned.
Training sta to run renovated facilities and addi-
tional services is an ongoing activity, as buildings are
renovated and ZPCT-supported activities expand
and are rolled out. All training is planned and con-
ducted jointly by ZPCT and health authorities at
provincial, district, and facility levels. Candidates for
training are selected in consultation with the MoH.
Procurement Procedures
When ZPCT started, FHI procedures and regu-
lations governed the procurement of goods and
services. Te program thus had parallel procedures
in government-run health facilities, and this was
found to be unworkable. As a result, ZPCT adopted
GRZ tender procedures and incorporated them
into its own procurement guidelines. Tese pro-
cedures, now used for all goods and services, have
made procurement much easier.
These tanks are the source of the Pollen Maternity Clinics new
water supply.
General and ARV stocks at the newly refurbished Liteta District
Hospital Pharmacy, Central Province.
The Zambia Prevention, Care and Treatment Partnership: A Model Program 21
Lessons Learned and Conclusion
Engaging the Ministry of Health. From the inception
of ZPCT, the MOH has been engaged at all levels,
and involved in the planning, implementation, and
monitoring of all programs. PHOs, DHMTs, and
facility-level management run these programs, and
ZPCT provides support. Tis has ensured that own-
ership remains within the GRZ and government
facilities.
Integrating activities into existing systems. All pro-
grams initiated, improved, or enhanced by ZPCT
are integrated into existing MoH systems. For
example, procurement for ZPCT programs became
much easier when MoH procedures were integrated
into the FHI procurement system.
Implementing policies and guidelines. In several
instances, national policies and guidelines were
not being implemented at the district or facility
level. For example, routine CT at antenatal clinics
was policy, but was not implemented until ZPCT
provided technical assistance. ZPCT activities sup-
ported the implementation of such policies and
guidelines, to the benet of the health of patients.
New policies are not always needed, instead, what is
often required is assistance in implementing exist-
ing plans, policies, or guidelines.
Combining multiple strategies. Te family-centered
approach at the ART center at the ADCH in Ndola
is an example of how multiple strategies increase
uptake and use of services. Te ART center is in a
childrens hospital, but it also provides full ART ser-
vices to the childrens parents and caregivers, saving
them from the inconvenience of attending a dier-
ent facility.
Using community volunteers. Sustainable HIV ser-
vices would not have been possible without the
ZPCT volunteer program. Te training of com-
munity volunteers as lay counselors, ASWs, and
PMTCT motivators served to avert suspension of
programs caused by the critical shortage of trained
healthcare workers.
Introducing data audits. Regular data audits have
improved the management, quality, and apprecia-
tion of data. Te use of sta from dierent provinces
to audit data from other provinces enhances knowl-
edge levels and appreciation of the need for accurate
data collection.
Instituting same-day results. Te availability of HIV
test results the day the test is done has improved
the acceptance of testing and the collection of test
results. Previously, many clients who were counseled
and tested did not return to the clinic on another
day to get results. Tis was a serious problem for
pregnant women attending antenatal clinics.
Using a sample referral system. Te sample referral
system increased the uptake of services. It reduced
the burden for patients who previously needed to
travel long distances to laboratories to be tested and
then return to obtain their results.
Improving the work environment. ZPCT programs
demonstrate that ensuring the availability of reagents,
drugs, and diagnostic equipment is as essential in
motivating healthcare workers as improving the
physical environment in which they work. Such
environments improve sta performance.
Co-signing contracts. All contracts for infrastruc-
ture renovations or for the supply of services are
co-signed by the DHMT, ZPCT, and the contractor,
thus giving joint ownership of contracts to health
facility managers or the DHMT and to ZPCTiFHI.
Conclusion
In the ve provinces where ZPCT operates, the part-
nership has had a remarkable impact on HIViAIDS
clinical services. ZPCT support, combined with the
GRZ policy of free ART services, has resulted in
greatly expanded delivery of ART. Within a relatively
short time, HIViAIDS services have been scaled up
and free ART made available to thousands, in rural
as well as urban areas. Te partnerships innovative
strategies have reduced the burden of traveling long
distances for many and brought HIViAIDS clinical
services closer to remote communities.
By operating at all levels, integrating new activities
into GRZ systems, and supporting the implementa-
tion of its existing policies and guidelines, ZPCT is
making a real dierence in the lives of Zambians.
22 The Zambia Prevention, Care and Treatment Partnership: A Model Program
Services in 97 Facilities Receiving ZPCT Support
Indicator
Achievements (May 1, 2005September 30, 2007)
Workplan
(1 Apr 06
30 Sep 07)
Quarterly Achievements
(1 Apr 0730 Sept 07)
Achievements
(1 Apr 06
30 Sept 07)
Percent
Achievement
Cumulative LOP
Achievements
(1 May 05
30 Sept 07 )
TARGET FEMALE MALE TOTAL
CT
Service outlets providing CT 97
Persons trained in CT 402 125 594 148% 974
Persons receiving CT services 52,512 13,945 13,301 27,246 129,050 246% 162,433
PMTCT
Service outlets providing PMTCT 96
Persons trained in PMTCT 200 21 212 106% 460
Pregnant women provided with PMTCT
services, including CT
35,851 16,799 16,799 90,758 253% 117,562
Pregnant women provided with a complete
course of ART prophylaxis
8,963 2,015 2,015 8,817 98% 10,680
BASI C HEALTHCARE AND SUPPORT
Service outlets providing clinical palliative
care services
97
Service outlets providing general HIV-related
palliative care
97
Persons provided with OI management and/
or prophylaxis
34,547 22,895 57,442 62,474
Persons provided with general HIV-related
palliative care
34,547 22,895 57,442 62,474
Persons trained to provide general HIV-
related care
100 32 280 280% 663
TREATMENT
Service outlets providing ART services 60
Health workers trained in ART 100 32 280 280% 663
New clients receiving ART 16,300 2,769 2,017 4,786 28,804 177% 39,619
Total clients receiving ART 28,410 24,366 16,633 40,999 40,999 144% 40,999
PEDI ATRI C TREATMENT
Health workers trained in pediatric care 150 17 364 243% 364
New pediatric clients receiving ART 660 156 175 331 2,027 307% 2,751
Total pediatric clients receiving ART 1,151 1,408 1,399 2,807 2,807 244% 2,807
TB AND CARE
TB-infected clients receiving CT services 5,000 440 499 939 6,210 124% 6,210
HIV-infected clients attending HIV care/
treatment services who are receiving
treatment for TB disease (new cases)
2,188 537 569 1,106 3,515 161% 3,515
Appendix
Family Health International
4401 Wilson Blvd., Suite 700
Arlington, VA 22203 USA
tel +1.703.516.9779
fax +1.703.516.9781
www.fhi.org
aids.pubs@fhi.org
The Zambia Prevention, Care and Treatment Partnership (ZPCT),
funded by the US Presidents Emergency Plan for AIDS Relief
through the US Agency for International Development, has achieved
high levels of performance in technical and program management
areas, and its staff are sought after to provide national, regional, and
even global technical assistance to grantees, partners, and peers.
With this publication, Family Health International (FHI) presents
ZPCT as an example of a high-quality country program in HIV/
AIDS whose lessons need to be shared across the organization.
FAMILY HEALTH
INTERNATIONAL
2008
The Zambia
Prevention, Care and
Treatment Partnership:
A Model Program
ZAMBIANS AND AMERICANS
IN PARTNERSHIP TO FIGHT HIV/AIDS