ZAMBIA DEX QUARTERLY REPORTS

ZAMBIA DEX QUARTERLY REPORTS Reporting Period: January June 2015: Global Fund Single Stream of Funding (SSF) HIV/AIDS Project Country Office: Annual Umbrella Authority: Project Specific Authority Substantive Reporting Zambia No Yes 1. Introduction This project, a Single Stream of Funding (SSF) for HIV and AIDS with a grant portfolio of US$ 156 million is intended to contribute to reduced HIV transmission and AIDS mortality through scaling up prevention, treatment, care and support services to people infected and or affected by AIDS. The Scope of Funding under this grant is mainly Procurement of ARV drugs (first and second line adult and pediatric drugs); Support implementation of PMTCT, including roll-out of option B+ by train of service providers to deliver PMTCT; Voluntary Medical Male Circumcision (VMMC); HCT ( train service providers to deliver HCT services); Blood safety and universal precaution; Strengthen procurement and supply management and M&E and health management information system; Strengthen the health system capacity for Public Financial Management; capacity development for the MoH to manage Global Fund grants, as well as the MCDMCH and MSL and support program management and administration related costs 2. Programmatic: The performance of HIV s single stream of funding grant has continue to perform well, and has continued to contribute remarkably to the GRZ s national response to scaling up universal access to HIV prevention, care and treatment. The UNDP has continued to support the capacity transfer of the MoH to manage the Global Fund as new PR for the NFM, and as SR under this grant - HIV/AIDS Single-Stream of Funding (SSF). In April 2015, the Global Fund approved the Phase 2 Capacity Development Plan for Medical Stores Limited (MSL), Ministry of Health (MoH), and Ministry of Community Development and Mother and Child Health (MCDMCH), and implementation since started. Accomplishments HIV counselling and testing: Reports from health facilities show significant increase in number of people opting for a test to know their HIV status, by the mid of 2015, reported at 1,383,930. However, during this period, a number of GRZ partners

projects that implementation of HCT program, including national wide outreach program, door to door HCT, and supporting CHWs on demand creation for HIV counseling and testing has come to an end, and their funding had not been renewed by end of June 2015. This lack of funding affected the achievement of target set for this period, as targets were set based on the initial financial commitment from the GRZ and partners. However, during the reporting period, the country had no stock-out of HIV test kits at central MSL level. By end of June 2015, stock-levels at central MSL was 5.6 month of stock for UNIGOLD HIV 1/2 rapid test, and at 4.9 month of stock for DETERMINE HIV 1/2 rapid test. The country is on cause to ensuring uninterrupted supply of HIV test kits. By end of June 2015, on the pipeline there are orders from UNDP (of 7,500 Unigold that has just arrived at Medical Stores) and other two orders of 3,900 kits for Unigold and 5,600 kits for Determine planned to arrive in December 2015. These orders, coupled with additional order by JSI- SCMS of 18,000 kits for Unigold expected to arrive in September 2015 will increase the months of stock for HIV test kits to 10.3. The HIV test kits supplies are planned to arrive in the country in staggered deliveries throughout the year to manage the shelf life since the HIV test kits are generally of a limited shelf life. The MoH and MCDMCH in collaboration with partners have continued to strengthen universal HCT approached through mass campaigns, and integration of HCT services with VMMC, PMTCT, TB, Cancer and MCH (family planning) services, including training of health care workers in HC&T. Outreach mobile VCT services were also expanded targeting hard to reach areas and school youth. Prevention of Mother to Child Transmission of HIV (PMTCT): The country has recorded progress in scaling up of PMTCT services. During this period, the MCDMCH and MoH continued with the rollout of Option B+ across the country. The GRZ in collaboration with partners, including the Global Fund have supported training of health care workers and community health workers in Option B+ to support rollout at facility levels. In order to improve EID, the MCDMCH has continued with the rollout of PCR/CD4 count services to provincial. By end of June 2015, PCR/ CD4 machines were available in nine out of 10 provinces by end of June 2015. With support of Global Fund a total of 144 HCWs from Eastern (47), Muchinga (48), and Northern (49) province were trained in Option B+ in line with consolidated guidelines. Training in Option B+ targeted HCWs directly involved with provision of PMTCT services. A total of 225 CHWs on SMAGs were trained in focused antenatal care (FANC) to continue strengthening the linkage between health facilities and communities to support the PMTCT program Voluntarily Medical Male Circumcision Program (VMMC): Generally the targets are considered to be overambitious, and resources were not mobilized as initially projected in the VMMC Strategic Plan 2011-2015. The program will revise these targets before end of 2015. The MCDMCH in collaboration with partners conducted VMMC data audit in May 2015 indicated that the VMMC program still faces the challenges of reporting on the number of people receiving MC services through the HMIS. The outreach MC services supported by partners are not always reported through the HMIS. This has affected the performance of MC programmes. Currently, in most settings the VMMC is implemented as a stand-alone partner supported program, which is not sustainable.

The MCDMCH is planning to address these challenges through integrating VMMC into the basic health services and reported through the HMIS. Provision of Antiretroviral treatment (ART) to people in need: The number of adults receiving ART has increased from 625, 546 by end of 2014 to 673,764 in June 2015, which literally shows 48,218 new enrolments into treatment over the last six month. Likewise, the number of children currently receiving ART (46,675) has exceeded the target (44,525). The new ART treatment guidelines whose roll-out continued during the reporting period has seen HIV positive children being enrolled to start ART irrespective of their CD4 counts or clinical stage. The number of ART sites increased from 592 in December 2014 to 633 sites by end of June 201 This high performance in enrolment and retention of people on ART has been possible due to regular supply of ARVs and OIs drugs in the country through the support of the GRZ, the Global Fund, USG and other partners. During the reporting period, the MoH and MCDMCH in collaboration with partners started the implementation of new ART guidelines which has expanded antiretroviral treatment eligibility criteria, including starting on treatment HIV positive people with 500 CD4 count threshold from 350; implementation of Option B+ for PMTCT and systematic enrolment into treatment - regardless of their CD4 counts- of HIV positive children, discordant couples and HIV/TB co-infected patients. Following the endorsement of ART tasks shifting in Zambia, the nurse certified as prescribers to provide ART initiate the pediatric ART in MCH settings. This strategy has helped to link prevention and treatment services to both mothers and their children. Enrolment and retention of this number of people on children on ART has been possible due to regular supply of HIV test kits and ARVs, available through the support of the GRZ, the Global Fund, USG and other partners. HIV/TB Integrated services, including HIV-positive TB patients treated with ART: There have been remarkable improvements from trends reported previous year in abiding to ART treatment guidelines to ensuring systematic enrolment of all HIV/TB co-infected patients on ART, reported at 73% in 2014 from the results of 66% achieved in 2013. The program has also reported increased percentage of TB patients who are testing for HIV from 91% in 2013 to 92% in June 2015. During this reporting period, the new integrated ART Treatment Guidelines was roll-out throughout the country, and more improvements are expected in implementation of HIV/TB collaboration interventions. By end of June 2015, the country has 56 Xpert MTB RIF- an increase from 14 machines reported by end of 2014. These included 15 Xpert MTB RIF procured and installed with support of Global Fund. The performance of this indicator is affected by the low coverage of accredited ART health facilities (592) compared to the number of all health facilities (1956) which provide TB treatment services. Some HIV/TB co-infected clients have to cover long distances from their TB treatment sites to access ART at another facility leading to some not started ART, dropping out or not being consistent on the treatment. Health Systems strengthening through training of HCWs and CHWs: During this period, the Global Fund grant has supported training of 868 health care workers in PMTCT-Option B+, HC&T, ART and Health Information Systems (HMIS); and a total of 225 Community Health Workers trained on Safe Matherhood and Early FANC Booking and Mother Baby Follow ups. The quality and completeness of health data : During the reporting period, the functioning of the national Health Information Systems HIMIS/DHIS.2 has improved remarkably. The HMIS s report completion rate is now at 95%. The quality

of data reported has also improved. Prior to production of this report, on-site data quality and completeness review was conducted between 9th to 16th August 2015, with team comprising of MoH, MCDMCH and UNDP in all the provinces, and targeted low performing Districts earlier assessed as lagging behind in terms of completeness of data. From 24-26 August, 2015, a team of Program Officers and M&E Officers from MoH, MCDMCH, UNDP held a workshop to review and validate the quality and completeness of data submitted in this report. With support of Global Fund, the MoH has printed the revised HMIS Tools and distribution will start the first week of September 2015. With support of Global Fund, the MoH has elaborated the Hospital HMIS to complement the existing HMIS which only captured services provided under primary health care services. With GF funding, the MoH now has a web-based DHIS.2 data base and elaborated the paper-based HMIS Tools. 3. Procurement and Supply Chain Management ARVs Stock status and pipelines at Central MSL level:the largest portfolio of this grant is allocated intensively on procurement of ARVs. The ARV drugs stock situation in Zambia is fairly secure at both central level and service delivery points except for four drugs as follows; Abacavir 300mg tablets are currently at 1 month of stock cover (22,542 packs at central level with average monthly issues at 21,620 packs). To curb the stock out, there are two (2) USAID/PEPFAR funded shipments through JSI SCMS, the first one being 100,000 bottles expected to arrive at the end of August 2015 to improve the pipeline to 4.62 months, an additional shipment of 60,030 bottles also by JSI- SCMS expected to arrive in October 2015, this will secure the supply chain with 2.77 months of stock. For Lopinavir/Ritonavir suspension 80/20mg/ml, the country has 5,9 months of stock on hand at central level (54,025 bottles with average monthly issues of 9,089 bottles). There is a planned shipment from GRZ of 42,820 bottles and this will push the country for another 4.7 months. There is currently less than 1 month of Lamivudine/Zidovudine 30/60mg (692 bottles at central level with average monthly issues of 5,798 bottles). To alleviate the stock out, there is an order of 11,720 bottles from GRZ expected to arrive in October 2015 that will last the country for another 2 months. There is another additional planned order from GRZ of 5,322 bottles expected in November 2015 to beef up the supply chain with an additional 1 month of stock. There is a near stock out of Efavirenz 600mg at central level at the moment, however there are planned shipments as follows to bridge the gap; 52,224 bottles from SCMS, expected to arrive next week which will improve the stocks supplies by another 2 months, 150,000 bottles ordered through JSI- SCMS expected to arrive in October 2015, this will last the country another 4,7 months. In additional, UNDP has ordered the shipment of 120,500 packs expected to arrive in November 2015. The GRZ ordered shipment of 180,720 bottles will arrive in November 2015. This will be sufficient for the country for 12,4 months given the current average monthly issues of 30,692 packs. The demand for Efavirenz 600mg product is expected to decline since the prescribers are now using the 3FDC, Tenofovir/Lamivudine/Efavirenz (300/300/600mg) as the main product of choice. At central level, the country has an average of 10 months of stock for the flagship products such as TLE which is consumed by over 70% of the ART patients. UNDP has ordered TLE worth USD 45 million for 2015 which has started to trickle in the country and is being delivered in a staggered fashion to curb any logistical challenges that may arise due to manufacturing pressures from the suppliers and storage constraints at the central warehouse. The shipments are on sea freight in order to keep the freight costs in check.

4. Quality Assurance of Pharmaceutical Products Quality Assurance of pharmaceutical products. Grant Closure Capacity Development Exit Strategy Selected pharmaceutical products procured under this grant were randomly sampled and collected for quality control purposes from the Central, Districts and service delivery points as part of UNDP and MoH joint monitoring of the supply chain management systems. The WHO pre-qualified laboratories in the Southern African Region were selected to conduct quality assurance tests. Pharmaceutical products will continue to be sampled for quality testing at different intervals in the supply chain. Not applicable 5. Status of Capacity Development and Transition Plan Through working partnership between the UNDP and MoH, the Ministry of Health was able to resume the principal recipient-ship of the Global Fund grants, starting from January 2015. This was as a result of successful implementation of the capacity development and transition plan which focused on programme management and institutional strengthening, financial management, procurement and supply management and strengthening of a functional health management information systems (HMIS) and M&E systems. UNDP has started the implementation of the Phase 2 of Capacity development plan and budget for the activities relating to the capacity development of the Medical Stores Limited (MSL), Ministry of Health s capacity for sub-receipient management (which was not covered during Phase 1 of CDP), and Ministry of Community Development and Mother and Child Health (MCDMCH). 6. UNDP PR ship Exit Strategy The implementation of Capacity Development and Transition Plan, approved on 13 th June 2012 forms the core exit strategy for the DEX implementation modality. In order to ensure full implementation of the CD Plan, the UNDP and MoH have put in place joint high profile officials -Global Fund Steering committee - which will provide oversight and follow-up of implementation. As the Ministry strengthens its capacities, the UNDP has since January 2014 started advancing cash to the to the MoH, starting with less risky activities, in the transition period. Through working partnership between the UNDP and MoH, the Ministry of Health was able to resume the principal recipient-ship of the Global Fund grants, starting from January 2015. UNDP will continue to provide technical assistance to the MoH Note: For the substantive reporting please provide a brief description on the achievements, efforts being made even with DEX to improve the national capacities and exit strategies to shift to NEX modality. Budget Summaries:

List of Projects Award ID in Atlas # Programme Name* 00076058 Reduced HIV transmission and AIDS mortality through scaling up prevention, treatment, care and support services to people infected and or affected by AIDS. Project/Budget Number 00087640 Total Budget USD 156,509,071 Expenditures up to June 2015 USD 69,529,060.93 (cumulative from Nov 2013 June 2015) as per the CDRs Donor The Global Fund Project Duration Status (active/complete d) 1Nov 2013 31 Aug 2016 Active Approval Date and Authorization Period November 2015 up to November 2016