N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 04 - HMBL Biomedical Prevention: Blood Safety

Total Planned Funding for Program Budget Code: $50,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

The biomedical prevention portfolio for PEPFAR Swaziland consists of blood safety (HMBL) and male circumcision (CIRC)

activities only. Both budget code narratives are listed here separately as their activities and partners are different.

HMBL - Blood Safety

The Swaziland National Blood Transfusion Service (SNBTS) is located in Manzini and is recognized for delivering an excellent

basic service. Over the past years, the SNBTS has gradually improved and extended its services, while successfully maintaining

HIV sero-positive donations below 1-2%. A very rigorous donor selection protocol is being used, and all blood donations are

tested for HIV. Despite these achievements, blood availability remains much below the minimum estimated requirement of the

country.

The SNBTS currently collects between 7,000 and 8,000 units of blood annually. It estimates that collections need to almost double

in order to provide adequate safe blood for the country. That would require an increase in blood collections to 18,000 units

annually (taking into account a discard rate of 10%). Blood is collected by two blood collection teams using mobile blood collection

drives which are mainly targeted at secondary schools. Each team consists of one registered nurse, one nursing assistant, two

phlebotomists and a driver. The nurse also functions as a pre-donation counselor. The teams cover the entire country.

The SNBTS is not receiving any external assistance, other than limited support from PEPFAR through Safe Blood for Africa

(SBFA). SBFA has supported the SNBTS with the development of a Strategic Plan, including the establishment of a dedicated

SNBTS organizational structure. Donor recruitment was identified as the priority area of need, so specific funding for the

recruitment, training and salary of a Blood Donor Recruitment Officer was provided. In addition, all SNBTS personnel were trained

on donor recruitment and several new donor recruitment strategies were developed for gradual implementation. Besides the

focus on blood donor recruitment, SBFA has supported the development of SOPs for SNBTS activities, addressed a number of

issues related to blood safety and quality assurance, assisted with the development of an information system to routinely measure

success and identify challenges, and provided overall management and administration training and support.

In FY09, PEPFAR, through SBFA, will continue to provide operational and technical assistance in line with the Strategic Plan that

was developed for SNBTS in August 2008. PEPFAR blood safety support will also be in line with the new National Strategic

Framework for HIV/AIDS (NSF) for 2009-2013 that is currently under development.

1) SBFA will assist with a review of the existing Swaziland National Policy for Blood Transfusion Services. The reviewed policy will

promote the establishment of an independent service, a dedicated building solely for the SNBTS, and the re-establishment of an

adequate SNBTS organizational structure, with adequate staffing, aligned with regional best practice and WHO recommendations.

2) SBFA will continue to provide technical assistance to further develop, implement and maintain effective strategies for blood

donor recruitment, in order to increase the pool of voluntary non-remunerated blood donors. The purpose of these strategies will

be to educate the youth and the public in general about the importance of blood transfusion in the health sector and the

community, to increase blood donations, to promote repeat donations and, ultimately, to fully meet the need for safe blood for the

country.

3) SBFA will continue to train SNBTS personnel on WHO recommended guidelines and best practices. SBFA will also provide

follow-up training on safe blood collection. SBFA will also continue to provide technical assistance and support training and

mentoring for the implementation of an effective Quality Management System to support the in-country trainings, SBFA will

provide continued mentorship by facilitators and trainers via telephone communication or email.

Products/outputs: National Policy for Blood Transfusion Services, National Strategic Plan for Blood Transfusion Services, SNBTS

donor recruitment strategy, SNBTS Total Quality Management System.

This is a minimal investment that would continue with pre-Compact budget levels.

CIRC-Male Circumcision

It is estimated that of the total 953,000 Swazi population, approximately 200,000 are sexually active men. The vast majority of

males are not circumcised (estimates: 97-85%). Swaziland has established a National Male Circumcision (MC) Task Force (TF)

that aims to scale up MC service delivery due to recent scientific studies showing this is an effective part of a comprehensive

prevention strategy.

As part of the Ministry of Health and Social Welfare's (MOHSW) plan to scale up service delivery they have welcomed donor

assistance. The PEPFAR Swaziland Prevention Technical Lead sits on the Task Force and is an active member to promote the

way forward for this activity. The MOHSW has repeatedly stated the government's commitment and desire to move MC forward.

Even in the absence of robust national level efforts to promote the service (due to the severe supply constraints at the moment),

demand in Swaziland for MC services is high. Quantitative and qualitative studies indicate high level of acceptability of MC and a

high level of demand for the service in the context of HIV prevention.

The MC TF is chaired by the MOHSW Deputy Director of Health Services and contains representatives from the National

Emergency Response Committee on HIV/AIDS (NERCHA), MOHSW, PEPFAR, the UN agencies, Population Services

International (PSI), the Family Life Association of Swaziland (FLAS), and service providers. The TF has two subcommittees:

Clinical (Chaired by a Urologist) and Communications (with PSI as Secretariat). The Clinical Subcommittee addresses issues

such as standardized training, competency assessment, draft national clinical protocols and standard operating procedures

(including pre-screening to determine HIV status, STI diagnosis and risk reduction counseling as part of comprehensive service

delivery, and neonatal services), and equipment, supplies, and public sector facility availability. The Communications Sub-

commitee has already begun work to develop a comprehensive communications strategy for MC promotion and service scale-up

for multiple target audiences, including accurate messaging about MC for HIV prevention for boys and men, risks and benefits for

women, parents of newborns, and teenage sons. An official national MC policy has been finalized, and its approval and

dissemination are imminent. A national strategic plan has been drafted and should be finalized by the end of the year.

Private sector facilities have seen a large rise in the number of circumcisions they have performed. In the NGO sector, FLAS has

continued to provide a subsidized service for those members of the population who can afford to pay for the service, but who lack

the private health insurance and/or resources to obtain the service in the private sector. For the vast majority of the population, the

service remains unattainable at the moment. The service is offered in the public sector for free; the waiting list to obtain the

service at MGH is 8-12 months. Currently, approximately 250 MC's are performed per month; 75 in MGH or other public facilities,

150 in the private sector including FLAS. The MOHSW's unwritten but stated policy for the foreseeable future is to require that

the service be provided only by doctors. An increase in the number of trained doctors performing the service in the public sector is

needed to reach desired and needed coverage rates.

In order to achieve national scale up of MC in Swaziland, several options for service delivery will need to be explored due to the

extreme challenges in human resources. Task shifting to nurses, importation of short-term foreign doctors, etc will all be options

to be explored under the purview of the national TF on MC.

MC is promoted as part of the overall national HIV prevention strategy in Swaziland. All efforts conform to WHO guidelines.

While it is noted that MC is an HIV prevention strategy, and counseling and testing will be promoted (but not mandated) at all

PEPFAR supported sites, HIV positive men will not be denied services.

The Gates Foundation is in the process of approving funding to a consortium of NGOs, including PSI, which will complement

PEPFAR's involvement in MC activities in Swaziland. Collaboration between PEPFAR and Gates throughout this process will

remain important.

Swaziland has been designated as a FY 08 Compact Country. MC is one of the five key areas in the Compact under

development with the government. Technical and financial support will be provided to assist Swaziland in reaching its national

scale up goals. In FY09, the USG will greatly expand its support for the national effort to scale up Male Circumcision programs

and services as a major area of emphasis in HIV prevention.

In FY09 PEPFAR Swaziland will fund five MC partners to support a comprehensive program:

(1) The FLAS program will continue with a new activity aimed at expanding the provision of MC to the Manzini Clinic to enable

easier access by rural men. FLAS will increase its reach substantially which will require strengthened financial, monitoring and

evaluation, management systems, and operational research to accommodate the growth and maximize sustainability. In FY09,

Pact will continue to provide the capacity building support necessary to develop and strengthen these vital systems.

(2) As PEPFAR's lead partner in MC, PSI will incorporate a robust counseling strategy as a standard part of the MC service

delivery package. The strategy will stress the benefits and shortcomings of MC, encourage safer sexual behavior and discuss the

need for post procedure abstinence. Messages will communicate clearly that MC is not a magic bullet and thus HIV can be

acquired and transmitted even though men are circumcised. MC benefits and risks for the females will be part of the

communication package to enhance partner support for MC. Other partners, including FLAS which supports private sector MC

services and ICAP, EGPAF and Pact that provide community-based MC education, will include messaging to reduce the potential

for unintended consequences, including for women.

PSI's MC activities will include; a) public sector strengthening for MC service delivery and a multi-sectoral approach to service

delivery; b) develop and implement a behavior change communications strategy to educate target groups about MC and increase

informed demand for MC; c) conduct monitoring and evaluation to improve the quality and cost effectiveness of large scale MC

service delivery and disseminate the findings and d) collaborate with government and donors to enable a transition from small

scale MC to a sustainable effort to increase and eventually maintain high MC prevalence. The primary emphasis areas for this

activity are training, human resources, infrastructure, supply chain, equipment and communications. Note that there is an addition

of core funds for rapid scale up refurbishment. PSI will also support the national clinical coordinator for MC.

(3) The Futures Group's MC Program Coordinator will focus on the national coordination; policy development and on-going policy

dialogue; identification of operational barriers to policy implementation; as well as leveraging the resources of the private sector in

the scale-up of male circumcision. The Program Coordinator will be key to promoting MC efforts and providing technical

assistance among the implementation partners.

(4) FY09 funding of $15,000 for DOD will support limited training and limited provision of supplies should MC be ready to be

scaled up in Swaziland. USDF can provide HIV counseling and testing and prevention counseling for those undergoing MC. Once

trained, the USDF nurses can provide post-surgical wound care.

(5) A TBD partner will continue to support the work of a private doctor at FLAS for service provision. The physician will perform

circumcisions, train 50-70 new doctors in WHO-endorsed techniques, serve on the national MC Task Force and assist with the

overall push to bring MC to national scale up in Swaziland.

Products/Outcomes: Final, approved National MC Policy, Final, approved National Strategic Plan for MC, Refurbishment of 5

public facilities to carry out MC services, Finalization of national BCC campaign for MC.

The planned national scale up of MC services in Swaziland is recognized globally and is heavily dependent on Compact funding.

With pre-compact funding levels (and cut-off of central support), plans for scale up would be severely compromised. In particular,

refurbishment of facilities, MC integration into sexual prevention services and the recruitment and training of clinical staff in both

the public and private sectors would be significantly scaled back. Without full PEPFAR funding in this area, rapid MC scale-up is

not achievable.

Table 3.3.04: