URC is an implementing partner for PEPFAR Swaziland in three separate but complementary areas, HVTB, HLAB and HVCT. The HVTB component supports Partnership Framework efforts to improve the management of TB/HIV co-infection and facilitate the roll out of a comprehensive HIV-related care package. The HLAB component undertakes broad based efforts to build laboratory capacity in support of health systems strengthening and decentralization. The HVCT component focuses on expanding provider-initiated HTC and is described more fully below.

The overall goal of the URC/CDC-HTC project is to increase utilization of high quality provider initiated HIV testing and counseling services (PIHTC) in order to identify those in need of HIV care and treatment in Swaziland. The project has the following objectives in FY10: Strengthening PIHTC in the TB clinical settings thus increase number of TB patients and TB suspects with knowledge of HIV status Increase number of inpatients with knowledge of HIV status (TB suspects and non TB suspects) by expanding PIHTC in selected health facilities Improve quality of TB/HIV services by increasing integration of TB screening in HIV care setting and communities Increase number of household contacts for TB patients who know their HIV status by providing home-based HIV testing Provide specific prevention education and counseling based on knowledge of HIV status, including distribution of condoms

The URC/CDC-HTC project activities are aligned to the following Partnership Framework (PF) objectives: To increase the percentage of the adult and children population who know their HIV status. To strengthen national capacity to lead and manage roll-out of adequate HIV and TB care and treatment services.

From inception in 2006, the URC/CDC-HTC project targeted scaling up of PIHTC for TB patients and suspects in TB clinical settings, expanding from five facilities in the first year to 20 in FY09. In FY10 the project will continue to target TB patients, suspects and members of their households as well as medical inpatients as a priority and inpatients in non-medical wards (e.g. surgical wards) as a secondary priority. Facility-based coverage will include the 22 diagnostic units, Medical wards in 7 hospitals and 79 Peripheral clinics across all four regions of Swaziland.

HCI has a full time M&E officer to support the URC and MOH TB/HIV M&E activities. The M&E officer works closely with national systems to collect, collate, generate, analyze and disseminate data and information from facilities to national and international partners. The M&E officer and the TB/HIV officers provide direct technical assistance to facilities and national M&E staff to assure quality of data reported. Other URC staffs are also involved in assisting health facility staff to record, report and report facility based data during support supervision visits.

The URC/CDC-HTC activity has two cross-cutting budget code allocations for human resources for health and construction/renovation. The URC/CDC HTC project will contribute to strengthening human resources for health by providing resources for recruitment and deployment of eight lay counselors to high volume TB diagnostic health facilities in Swaziland. The project will also continue to support an HTC Technical Officer at SNAP to assist SNAP in HTC coordination and implementation. In terms of renovation/construction, the project will support placement of a prefabricated consultation space and furniture at one diagnostic facility

The URC/CDC-HTC activity addresses the following cross-cutting key issues;

Tuberculosis: With an estimated TB incidence rate of 1,160/100,000 population, Swaziland has the highest per capita burden of HIV related TB in the world. An estimated 80% of TB patients are co-infected with HIV. The URC/CDC-HTC project will focus on increasing HIV Testing and Counseling among TB suspects, patients and their families, in TB diagnostic units, inpatient facilities and communities.

Increasing gender equity in HIV/AIDS activities and services: In Swaziland, there is gender disparity in the TB and HIV disease burdens. To increase gender equity in TB/HIV/AIDS activities and services to ensure that men and women, girls and boys, have access to HIV and TB testing, counseling, prevention, care and treatment services HTC services will be provided to communities, TB diagnostic units and inpatient facilities.

Military Populations: The URC/CDC HTC project in collaboration with NTP and SNAP will continue to assist the military (USDF and Correctional Services) to implement HTC service delivery. These activities will be implemented in liaison with the US Department of Defense

Workplace Programs: The URC/CDC HTC project will work in partnership with URC-HCI in workplace TB screening and will provide TA in the TB/HIV workplace activities.

The URC/CDC-HTC project will support the following activities:

Policy support and technical assistance

URC in collaboration with other stakeholders will continue to provide technical assistance to MOH/SNAP to streamline policies on: integration of PIHTC in clinical services; finger prick testing (the shift to finger prick testing has been agreed upon in principle by the MOH, but policies have not changed); task shifting for HTC (the current policy discourages lay counselors & testers (non-health workers) in clinical settings); and issues of HIV testing in children. URC will also support policy dialogue workshops at national level to expedite the development of the policy to enable expansion of PIHTC.

Strengthen Multi Disciplinary Teams (MDTs) to integrate PIHTC expansion

These facility teams require a concerted effort from different cadres of health care workers, including clinical, laboratory, counseling and administrative staff as well as local PLWHA associations. The teams will be responsible for developing facility-level strategies for PIHTC expansion in medical wards through integration of HTC with various clinical services. URC will assist teams in the 5 hospitals & 6 health centers in basic skills related to planning and facilitating meetings, communicating effectively and making group decisions. Each facility team will review its HTC performance data (uptake of HTC) on a monthly basis by clinical service area (e.g., percent TB suspects) who were offered HTC; percent HIV+ by clinical service area referred for care and support services; etc).

Scale up PIHTC to TB patients and suspects

In order to increase the quality of care of TB patients, TB patients and suspects will be provided with routine HIV testing and counseling to provide an opportunity for patients to know their HIV status, to receive better diagnosis and to manage the illness. The project will place 8 lay counselors in TB clinics to scale up counseling of TB patients and suspects. URC intends to scale up HTC support from 5 medical wards in FY 09 to 11 wards in FY10 and to 22 TB diagnostic clinics.

Advocacy for space/ Creation Consultation space for TB clinics to promote confidential provider initiated offer of HIV counseling and testing

To address space shortages at some facilities, CDC in partnership with HCI project procured and placed mobile office/containers' at 5 health facilities in FY 08 and FY09. One additional container will be placed at Dvokolwako in Hhohho region for similar purposes.

Training

URC will continue to work with SNAP/MOH to provide training to clinic staff in PIHTC. The training will be provided to the TB diagnostic staff, medical inpatient an outpatient staff and NGO/CBOs involved in clinical work. The training will mainstream gender and will document and share experiences on a strategy to sustain PI-HTC.

On-the-job mentoring

On the job mentoring will constitute a central part of facilitative supervision and QI approach to HTC in facilities. The URC/CDC- HTC staff working in collaboration with the HCI project, alongside with NTP, SNAP coordinators and other key stakeholders will on a monthly basis visit facilities to ensure adherence to HTC guidelines; implement a systematic process to assure appropriate QI training for staff to reinforce the skills; disseminate information about QI activities to health care providers, clients and decision makers; auditing of client records; URC & NTP/SNAP staff will visit facilities to evaluate various processes including patient's perceptions and satisfaction, provider's observations and interviews will be conducted to measure provider skills, knowledge and perceptions regarding efficiency and effectiveness of support systems. Support supervision visits will be performed using a structured support supervision checklist.

Strengthen routine systematic monitoring and evaluation

URC will continue to work with the SNAP and NTCP M&E units to provide ongoing training and support for improving the paper based recording and reporting systems for PIHTC. Each facility will monitor data on total number of clients who have received PIHTC and HIV results. URC will work with the M & E unit to develop HTC M&E guide and simple summary tools for the facilities. Each focus region will organize data feedback meetings with all participating facilities quarterly to review PIHTC performance data and to identify problems and develop strategies to further expand access to and utilization of HTC services.

Referrals and Linkages

URC will continue to work with the Referrals and Linkages technical working group to finalize national referral tools and minimal health service packages for each level of care.

Increase community awareness about benefits of HIV testing

HTC will assist NTP, SNAP and the Health Education unit to improve its social and behavior change communication (SBCC) program and access to HTC. The project will support 5 communities in two regions to provide individual and small group interpersonal communication to community members on HTC and HIV/TB including HIV prevention and condom education, distribute HTC, HIV/TB IEC materials and condoms to sexually active populations. This activity will be provided through partnership with 2 local NGOs. The peer educators will also mobilize community members for HTC. The project will also support the AIDS day, national HTC month and TB day by conducting three grass root level awareness campaigns and reprinting IEC materials.

Home-based PIHTC

Home-based PIHTC is a relatively new concept in the country. The URC/CDC-HTC project will work in collaboration with the HCI project, MOH (NTP/SNAP), NGOs and CBOs to provide HTC/family-based HTC and TB contact tracing in the home environment. This will be initiated through provision of HTC services to an index TB patient, who when tests positive, will be a starting point for offering HTC to the family members through a community outreach/mobile system in conjunction with trained HTC providers/lay counselors. The project will continue to work with SNAP to finalize the home based PI HTC strategy and standard operating procedures.

Build capacity of the SNAP to lead and manage PIHTC activities

URC will continue to provide capacity building at the national and regional levels. In order to complement the in-country support provided by the URC-HTC, where relevant, support will be provided to the MOH officers for specific training programs in and out of the country. URC/ CDC-HTC staff and government counterparts will also be offered opportunities to participate in international conferences to present papers and to learn from successful programs.

Commodities support for rapid HIV testing kits and sharps disposal:

Recently, the country has had frequent stock outs of HIV rapid testing kits and this has affected HIV testing in TB clinical care settings. With expanding testing to include TB suspects and home based testing, the HTC project will work with the national laboratory services, SNAP and NTP to ensure uninterrupted supply of HIV test kits and training of health care workers on projection, quantification and rational management of HIV test kits. Should need arise, the project will procure limited quantities of test kits to bridge gaps in supply. HTC will also procure sharp boxes to ensure safe disposal of sharps related to HIV testing and administration of injections for anti-TB drugs in TB clinical care settings.

According to the "modeling of HIV report", in 2007, a total of 12.3 million condoms left the central stores and depots for distribution, leading to a theoretical condom number per adult of 29 in 2007. In 2008, URC collaborated with the Swaziland National AIDS Programme (SNAP) and the Swaziland National Tuberculosis Control Programme (NTP) to increase the HIV prevention in TB clinical settings in the country's health care facilities by promoting condom distribution and consistent and correct condom use. There was an effort also to promote risk perception changes in the "low risk" population reporting regular partnerships, that there is a potential for large numbers of new infections due to non-use of condoms in "low risk" encounters.. This drive was directed at synergizing prevention efforts towards TB patients and suspects to reduce missed opportunities for HIV prevention, treatment, care and support and further reduce spread of HIV in the country. URC CDC-HTC project expanded access to condoms through the involvement of CBOs/NGOs involved in TB/HIV services and improved capability and skills of health workers/ peers to promote consistent and correct condom use.

In FY10, the project will continue to scale up condom promotion activities that will target: TB patients and families; TB suspects and families and Communities. Within the communities prevention services will also target the youth, persons engaged in transactional sexual partnerships through the following activities:

Conduct HTC and HIV/TB education sessions to individuals and groups in their communities including HIV prevention and condom education.

Distribute male and female condoms to sexually active populations within their communities

Distribute HTC and HIV/TB IEC materials and provide interpersonal communication to community members

Mobilize community members for HIV testing and counseling

Conduct home visits and provide psychosocial support & Directly Observed Treatment to HIV and TB clients.

Conduct TB screening using symptom screening questionnaire for households contacts and refer appropriately

Make referrals as appropriate for testing and HIV/AID care

Geographic coverage:

Manzini in the communities of Nkamanzi and Ekudzeni, Ngculwini and Timbutini and in Lumbobo in the communities of Siphophoneni and two other communities

In order to promote quality for this activity, standard operating procedures will be implemented at health care facilities and community for quantification of condom needs to ensure uninterrupted supplies, storage and distribution. The following performance indicators will be monitored during supportive supervisions:

Number of condoms distributed by Community based peer educators

Number of individuals reached through community outreach to promote HIV/AIDS prevention through other behavior change beyond abstinence and/or being faithful i.e. male circumcision, PMTCT, Blood prevention etc.

Number of patients referred

Number of IEC materials distributed

The sources of data will include

Monthly reports from CBPEs

HTC monthly register

Monthly diaries for the number of condoms distributed

The URC HTC officers and supervisors from the community based organizations will provide regular supportive supervision for condom distribution activities