In Zambia, EGPAF aims to be a technical leader in high-quality pediatric programs – and to identify new funding sources for research that will improve care, PMTCT, and pediatric interventions. Currently, EGPAF is:
- Completing a qualitative study on use of infant nevirapine for PMTCT
- Collaborating with the MOH and London School of Hygiene and Tropical Medicine on follow on acceptability and quality studies regarding rapid syphilis testing
- Co-investigator on a NIH R01 study addressing HIV risk behavior in vulnerable youth
EGPAF is now implementing the five-year CDC-funded LiveFree project in Zambia. The project’s strategy is to help Zambia’s health system sustain, expand, and optimize the quality of HIV/AIDS prevention, care, and treatment programs by enhancing the capacity of the MOH to manage and lead the implementation of the national HIV/AIDS strategy.
The main focus of the LiveFree project is to work closely with the MOH to provide technical assistance and build capacity in strategic information and evaluation and SmartCare expansion, training, and management and data use. EGPAF also implements programs aimed at supporting vulnerable children and adolescents in Lusaka Province, counseling and hospice care as well as support for PMTCT and rapid syphilis testing initiatives. EGPAF also receives support through the Hilton Foundation for researching developmental delay in children.
EGPAF strives to increase the number of HIV-positive infants and children on treatment, enhance access to PMTCT for HIV-positive pregnant women, and strengthen awareness of and participation in care and treatment services by:
- Building upon its in-country strengths in technical support, grant management, and pediatric care, seeking to advocate for and scale up pediatric treatment and prevention using a family-centered approach;
- Focusing on pediatric HIV in Zambia and on increasing the number of infants and children receiving HIV/AIDS care, treatment, and support; and
- Supporting the SmartCare program in Zambia as it expands nationally to set higher standards for continuum of patient care, patient tracking, and data collection.
The LiveFree Project
Under the five-year CDC/PEPFAR-funded LiveFree project, EGPAF/Zambia’s goal is to support and complement the Government of Zambia’s efforts to provide comprehensive, quality HIV services in Lusaka, Southern, Western and Eastern Provinces, with a focus on the national electronic health records system (SmartCare) and a corresponding data use initiative. Under this project, EGPAF/Zambia provides strategic and programmatic input, financial management and information technology support and staff, and procurement of computer equipment, software, and hardware for SmartCare in order to set higher standards for continuum of patient care, patient tracking, and data collection. Key project components are detailed below:
Strengthening Early Childhood Development in Zambia
(The Conrad N. Hilton Foundation: 2012–2015)
- SmartCare: EGPAF is instrumental in the nationwide deployment of SmartCare, with over 500,000 clients already enrolled into the system. In 2012, the roll-out of an updated version of SmartCare with a prevention of mother-to-child transmission of HIV (PMTCT) platform reflecting the change in national guidelines was initiated.
- Data use: EGPAF supports the Ministry of Health (MOH) to sustain and expand SmartCare as a vehicle for improving SI&E in Zambia, including data use initiatives for strengthening health systems and improving quality of comprehensive HIV/AIDS prevention, care, and treatment services. Special emphasis is placed on identifying and addressing gaps in elimination of MTCT.
- Saving Mothers, Giving Life (SMGL): Working as part of a consortium, EGPAF has been intensively scaling up SmartCare in four districts with the goal of improving maternal child health outcomes.
- Integration of rapid syphilis testing: EGPAF is working with the MOH to ensure the integration of rapid syphilis screening into routine antenatal and HIV prevention services for pregnant women, beginning in the four SMGL districts. Pregnant women who are co-infected with HIV and syphilis are twice as likely to transmit HIV in utero compared to those infected with HIV alone.
- Pediatric care and treatment and palliative care: EGPAF provides technical and financial support to organizations specializing in pediatric HIV clinical care and pediatric palliative care. EGPAF leads efforts to introduce new pediatric and palliative care initiatives to better support children with life-limiting and life-threatening conditions.
- Counseling: EGPAF is providing skills-building training to counselors and peer mentors working with children and adolescents infected with or affected by HIV/AIDS.
- Policy and advocacy: EGPAF uses its expertise to provide TA and to support programmatic capacity building to the Zambian government on the national and provincial levels, as well as advocate for appropriate policies and programming to eliminate pediatric AIDS nationwide.
Under this project, EGPAF seeks to expand access to comprehensive early childhood development (ECD) services for vulnerable children infected with or affected by HIV/AIDS in Lusaka, Zambia so they may better realize their cognitive, social, emotional, and physical development. Through the development of two ECD Survive and Thrive assessment and promotion rooms at Lusaka clinics, and in collaboration with community-based organizations onsite in two high-prevalence areas in Lusaka, the project works with parents and caregivers to enhance their knowledge, supports community-based services, and expands clinical services to ensure that young children reach key developmental milestones.
Provision of Technical Assistance, Scientific and Applied Expertise Towards an Integrated Multi-Disciplinary Approach for HIV Care, Treatment and Prevention in the Choma District of Zambia
(CDC/Macha Research Trust: 2009–2014)
Since 2009, EGPAF has collaborated with the Macha Research Trust on a CDC/PEPFAR-funded project which has the following goal: “Provision of technical assistance, scientific and applied expertise towards an integrated multi-disciplinary approach for HIV care, treatment and prevention in the Choma District of Zambia.” Over the course of the Macha project, EGPAF has supported the Macha Research Trust with training and materials on prevention of mother-to-child transmission of HIV (PMTCT), care and treatment, early infant diagnosis, pediatric counseling and testing, HIV prevention, pediatric HIV care and support, and the integrated management of infant and young child feeding (IYCF). In project year four, EGPAF will conduct the following:
Local Collaboration to Strengthen National PMTCT programs for Elimination of Pediatric HIV in Zambia
- Palliative care training, using a mix of adult and pediatric cases
- PMTCT training for lay counselors
- A general follow-up assessment on IYCF practices
Through this project, EGPAF is supporting the Ministry of Health (MOH) and collaborating with UNICEF to strengthen national prevention of mother-to-child transmission of HIV (PMTCT) activities and support the roll-out of Option A in the Choma, Katete, and Chipata Districts. In the second year of the project, EGPAF intends to focus on the implementation and monitoring of Option B+ in these districts, with a strong focus on community involvement.
Monitoring and Evaluation Support
EGPAF currently provides targeted technical assistance to improve systems for monitoring and evaluation (M&E) of prevention of mother-to-child transmission of HIV (PMTCT) programs in Cameroon, Lesotho, and Zambia. In Zambia, EGPAF has worked with the Zambia Ministry of Health to adopt and implement Option A of the 2010 WHO recommendations for PMTCT, including development and revision of national data collection tools. In addition, EGPAF is supporting development of a PMTCT data use strategy; a national PMTCT monitoring, evaluation, and research framework; and a monitoring and evaluation quality assurance/quality improvement tool.
An exploratory study of Zambian pregnant women’s perceptions of the use of extended infant nevirapine to prevent HIV transmission during breastfeeding
The latest guidelines on prevention of mother-to-child transmission (PMTCT) and infant feeding from the World Health Organization (WHO) show promise towards eliminating confusion about infant feeding and move us closer to possible elimination of pediatric HIV infection. Zambia has adopted Option A, which outlines the use of extended infant nevirapine through the duration of breastfeeding. Through the use of extended infant nevirapine, these revised guidelines preserve breastfeeding as the safest method of infant feeding in resource-constrained settings.
The new WHO guidelines require women and caregivers to deliver infant nevirapine daily through the duration of breastfeeding (which, in sub-Saharan Africa where HIV is most prevalent, typically extends into the second year of life). While the extended use of nevirapine through the duration of breastfeeding is recommended, little is known about how mothers respond to this advice given issues of treatment fatigue, stigma, and disclosure issues. This study will improve understanding of how beneficiaries view the changes and their ability to carry out these revised guidelines over an extended period outside the support and guidance of a large clinical trial.
The study aims to improve our understanding of unforeseen challenges and possible solutions to implementing Option A of the WHO PMTCT guidelines. It will provide insight into possible solutions to overcome such challenges from the perspective of HIV-positive pregnant and lactating women. The exploratory, qualitative study will include focus groups and in-depth interviews with pregnant and lactating women in urban and rural sites, as well as interviews with health care workers in the selected sites.
Identifying and Understanding Effective Interventions for OVCs affected by HIV
EGPAF is working with Johns Hopkins University (JHU) on an NIH-funded Orphan and Vulnerable Children (OVC) study to evaluate the effectiveness of a cognitive-behavioral intervention compared to an existing intervention in improving a wide range of OVC outcomes including reduction in HIV risk behaviors, improved well-being, mental health, functioning, education, and caregiver health and support.
Helping Expand Antiretroviral Treatment for Families and Children (Project HEART)
Under Project HEART with support from PEPFAR, EGPAF/Zambia provided HIV care and treatment services since 2004 in Lusaka, Southern, Eastern, and Western provinces, and prevention of mother-to-child transmission (PMTCT) services since 2002 in Lusaka, Eastern, and Western provinces. EGPAF’s main implementing partner was the Centre for Infectious Disease Research in Zambia (CIDRZ), a research, training, and service provision organization originally affiliated with the University of Alabama at Birmingham (UAB). EGPAF/Zambia provided HIV care and treatment activities in 476 sites across Lusaka, Southern, Eastern, and Western provinces. Of all the patients supported across the five countries where Project HEART worked, Project HEART/Zambia accounted for the highest number of patients, with a total of 297,843 cumulatively enrolled in care and 196,122 patients cumulatively initiated on treatment, accounting for half the children enrolled in the country.
Project HEART also sought to invest in the training and mentoring of health staff in order to contribute to improvements in pediatric care and treatment. In Zambia, the project enhanced provider capacity through a pediatric mentorship program and targeted training of nurses in counseling and psychosocial support for children and caregivers, which increased the confidence and self-efficacy of health staff to treat children and their families. The program also trained more than 7,700 physicians, nurses, and other health care workers on proper antiretroviral therapy, in line with national guidelines.
EGPAF built in-country capacity through support of the national electronic patient records system (SmartCare) by providing financial management and information technology (IT) staff, and procuring computer equipment and hardware. As of March 2011, SmartCare was deployed in more than 570 facilities throughout Zambia, and has been adopted by the MOH as their patient records system.
Call to Action Project
Through funding from the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), EGPAF implemented the eight‐year global Call to Action (CTA) project in 12 countries around the world, including Zambia (from 2003 through 2007). This project sought to improve access and expand care and support for quality PMTCT services, while enhancing technical leadership and documenting successful program models. By project end, EGPAF had provided nearly four million women with access to PMTCT and antenatal care services. In Zambia, EGPAF helped expand PMTCT services to sites in rural provinces, and together with our partners supported nearly 300 PMTCT sites in Western, Eastern, and Lusaka Provinces.
Reaching More in Need: PMTCT Enhancement through Expanded Implementation and Operations Research
(The Bill and Melinda Gates Foundation: 2006–2011)
The Bill and Melinda Gates Foundation funded this project, which was designed to expand access to PMTCT services in 10 countries including Zambia, which allowed EGPAF to fill critical gaps, ensure continued service delivery in resource-limited countries, and leverage other donor resources to increase access to PMTCT services. Under this project, EGPAF:
- Provided support and technical assistance to host country governments to strengthen commitment to scale up PMTCT service
- Trained thousands of government personnel at the site, district, and provincial levels to build health care worker capacity to provide HIV services
- Strengthened integration with other essential services
- Improved linkages to care and treatment
In terms of operational research, several studies were conducted in Zambia, including a multi-country evaluation of PMTCT effectiveness. For the overall study, cord blood samples were analyzed from 27,893 mother-infant pairs treated at 43 separate clinics. HIV seropositive cord blood samples were then analyzed for the presence of nevirapine for 3,196 mother-infant pairs, with the major finding that 51 percent of HIV-exposed infants received the minimal regimen of nevirapine to protect them. The study also found that many HIV-positive women who were prescribed nevirapine before giving birth had no sign of the drug in samples of their umbilical cord blood. Reasons associated with these results include fewer antenatal visits and younger maternal age, although there was significant variation between sites and country programs. These results have mobilized EGPAF and other partners to develop strategies to improve and monitor adherence to ARV prophylaxis and the entire PMTCT cascade for mothers and infants.
Introduction of Rapid Syphilis Testing within Prevention of Mother-to-Child Transmission of HIV Programs in Uganda and Zambia: A Field Acceptability and Feasibility Study
Given that integration of syphilis testing into prevention of mother-to-child transmission of HIV (PMTCT) programs can prevent adverse pregnancy outcomes, this study assessed the feasibility and acceptability of introducing rapid syphilis testing (RST) into PMTCT programs in Zambia and Uganda. Using a pre-post intervention design, HIV and syphilis testing and treatment rates during the RST intervention were compared with baseline.
Maternal Events and Pregnancy Outcomes in a Cohort of HIV-Infected Women Receiving Antiretroviral Therapy in Sub-Saharan Africa (MEP)
This multi-country study was one of the first in sub-Saharan Africa to evaluate maternal and infant outcomes in women receiving antiretroviral treatment (ART) at time of conception and during pregnancy as part of routine HIV service delivery. The primary study objectives were to describe both the frequency of severe adverse events including major congenital defects, adverse pregnancy outcomes, and death among infants or fetuses born to mothers exposed to ART during conception and pregnancy and these events within a section of the general population, regardless of maternal or infantile HIV‐1 infectivity status. A secondary objective of the study was to describe the distribution of major congenital defects, adverse pregnancy outcomes, and infant death by various ART regimens being used in resource‐limited countries.
The study involved the observational surveillance of a cohort of HIV-positive pregnant women that were taking combination ART before becoming pregnant in South Africa and Zambia. In each country, 300 mothers were enrolled in the cohort. Infants born to these women were examined for major congenital defects at birth or as soon as possible thereafter, and until one year of age. Data on prevalence of major congenital defects and adverse pregnancy outcomes within the general population were abstracted from facility records during the same time period as data from the cohort was collected. Data collection is ongoing, and the study is anticipated to finish in early 2013 once all children in the cohort have been followed to one year of age.
With the expansion of the use of ART in pregnancy both for treatment and infant prophylaxis, it is critical that the safety of these drugs in women and their infants be evaluated in the African context. Outcomes of how ART protects infants from HIV infection in the actual ART program setting also will be determined. Data from this initial pilot will provide the building blocks for further work in this area, and will help in the scale‐up of pharmacovigilance activities in sub-Saharan Africa.