INTEGRATED ACTIVITY FLAG:

This Africa Centre PMTCT activity is related to other Africa Centre activities in Basic Health Care and Support (#7274), TB/HIV (#7913) CT (#7911) and ART Services (# 7275).

SUMMARY:

The Africa Centre for Health and Population Studies, in partnership with the Hlabisa Department of Health (DOH), based in Hlabisa Health District in rural KwaZulu-Natal, operates the Hlabisa antiretroviral treatment (ART) program and aims to deliver safe, effective, efficient, equitable and sustainable ART to all who need it in Hlabisa district. The program emphasizes integration of the government Prevention of Mother-to-Child Transmission (PMTCT) Program and Antiretroviral Treatment (ART) Program. The target population for the integrated PMTCT and ART Program are pregnant women, people living with HIV and AIDS, HIV-infected pregnant women and HIV-infected infants (0 to 5 years). The major emphasis area of this program is development of network/linkages/referral systems, and minor emphasis areas include information, education and communication, local organization development and training.

BACKGROUND:

The Africa Centre, a population research department of the University of KwaZulu-Natal, implements a PMTCT program in partnership between the KwaZulu-Natal Department of Health (DOH). The program is based in Hlabisa sub-District, a rural health district in northern KwaZulu-Natal that provides healthcare to 220,000 people through one government district hospital and 13 peripheral clinics. The ART Program is embedded in the DOH ART rollout whereby the Africa Centre and KwaZulu-Natal DOH work to complement each others abilities and resources in providing ART. The Africa Centre has expertise in infectious diseases and management that are not available at the district DOH. In addition to clinical staff, and infrastructure, the district DOH provides the necessary drugs and laboratory testing for effective ART rollout.

With FY 2007 funds, the Africa Centre will continue to partner with the district DOH to improve and expand PMTCT services by providing additional human resources and training. In addition, Africa Centre will integrate PMTCT services with its tuberculosis (TB)/HIV, palliative care, counseling and testing, and treatment programs. Increased attention will be given to addressing gender inequality (including increasing male involvement in PMTCT) and promoting HIV service delivery amongst men and children.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Partnership with South African Government (SAG)

All government clinics within Hlabisa District offer PMTCT services. However, many of these clinics are under-resourced and require additional human capacity to ensure that HIV-infected women are enrolled in the PMTCT program. Africa Centre provides training, supervision, mentoring, and systems strengthening in support of PMTCT services in Hlabisa district. The PMTCT program is the main referral base for assisting HIV-infected women with ART. Africa Centre aims to address the lack of human resources and partners with the district DOH to recruit and place nurses and treatment counselors at government facilities to assist with pre and post-test counseling. During pregnancy, if criteria are met, or during post delivery when women become eligible, nurses will provide HIV rapid testing, CD4 counts and referrals to trained ART counselors. In turn, counselors will offer pre and post-test counseling and further facilitate enrollment into the ART program. In addition, counselors will offer pregnant women continued follow-up and support.

Africa Centre (AC) conducts workshops and meetings with DOH to promote linkages between the PMTCT and ART programs and educates clinic staff about available services. Africa Centre will develop and distribute informational materials for wider distribution in the hospital and clinics and will target pregnant women.

ACTIVITY 2: PMTCT and Treatment

Africa Centre will provide clinics with clinical service (via the provision of doctor/s and other health workers) to initiate HIV pregnant women enrolled in the PMTCT program on ART. Africa Centre's assistance provides the full package of PMTCT services in line with the National Department of Health's PMTCT standards. Doctors will be present in clinics at appointed times, on a weekly basis, and will provide treatment management including work-up, consultation, screening, symptom and pain management, and patient counseling (including maternal nutrition and family planning). PMTCT clients will be referred to Africa Centre supported ART services. These services will also provide patients who experience adverse side effects or treatment failure with additional monitoring and support. All patients transferred into the ART program from the PMTCT program will be tested for TB and receive TB treatment if necessary.

ACTIVITY 3: Counseling and support - safe infant feeding practices, family planning and referrals to support services

To reduce vertical transmission of HIV from mother-to-child, treatment counselors will provide counseling on appropriate infant feeding and support into routine PMTCT. The selection of counseling content and material will be informed by the results from a large local vertical transmission study conducted by the Africa Centre. In addition, counseling on family planning will be offered. The program will address gender, by attempting to increase gender equity (key legislative area) by promoting the involvement of male partners in the PMTCT and family planning sessions. The PMTCT counselors will ask pregnant women and mothers to come with their male partners during follow-up visits. Finally, counselors will refer eligible patients to the government services that are available (for instance, for food aid or to a social worker if domestic violence is suspected).

ACTIVITY 4: Human capacity development

The South African DOH and Africa Centre counselors and nurses will be trained in all aspects of the full PMTCT package according to government guidelines and standards. Refresher and on-the-job training will be provided as needed, keeping healthcare providers up to date in the delivery of PMTCT services. All healthcare providers who work in the PMTCT program will receive training on HIV and ART. A baseline course is based on the DOH curriculum and comprises four sessions of three hours each. The four sessions cover basics of HIV and ART, follow-up of patients, assimilation of follow-up and practical work with a patient (including blood taking for CD4 counts and viral loads). This training will be enhanced with clinic visits from training officers, during which the officers will monitor counseling and provide individual mentoring. In addition, nurses and treatment counselors will be offered to participate in short courses covering the management of ART side effects, opportunistic infections, and pediatric ART.

Africa Centre's integrated PMTCT and ART program contributes to PEPFAR's 2-7-10 goals for South Africa by improving capacity, access and demand for PMTCT and ART for pregnant women and mothers. These activities ensure that new infant infections are averted and the HIV-infected treatment-eligible women are referred and initiated on treatment in a timely matter.

INTEGRATED ACTIVITY FLAG:

This activity relates to The Africa Centre's Hlabisa activities in ART services (#7275), TB/HIV (#7913), PMTCT (#7914), and CT (#7911). This partner may benefit from the Partnership for Supply Chain Management ARV Drugs activity (#7935), which will explore current pain and symptom management practices, drug availability and cost, and provide recommendations.

SUMMARY:

The Hlabisa ART program aims to deliver safe, comprehensive, effective, efficient, equitable and sustainable ART to all who need it in Hlabisa District, in rural KwaZulu-Natal province. Hlabisa District is characterized by a high HIV prevalence (about 22 percent), high HIV incidence, unemployment and poverty. Basic care and support services are part of the overarching HIV Care and Treatment program that is jointly run by the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, and the Habisa District Department of Health (D0H). In FY 2007, the program will for the first time provide mobile palliative care teams that bring HIV care to people's homes and support the families of HIV-infected people. The major emphasis area is the development of Network/Linkages/Referral Systems. The minor emphasis areas are human resources, local organization capacity development and IEC. This will be done through support to South African Government (SAG), clinical and physical care, home-based care and human capacity development. The target population is People living with HIV and AIDS (PLHIV) and their families.

BACKGROUND:

The Africa Centre is a department within the University of KwaZulu-Natal, fully funded by grants from mostly overseas institutions. The Program is based in Hlabisa sub-District, a rural health district in northern KwaZulu-Natal which provides healthcare to 220,000 people at one district hospital and 13 peripheral clinics. In September 2004 the program started delivery of ART in Hlabisa and has since expanded ART services to Kwamsane clinic and Somkhele clinic. The Africa Centre and KwaZulu-Natal DOH work to complement each others abilities and resources in providing care and treatment. The Africa Centre has expertise in infectious diseases and management that are not available at the district DOH. The district DOH has clinical staff and infrastructure on which to build a care and treatment program. The Africa Centre contributes nurses, treatment counselors and physicians to the DOH staff, organizes trainings, supports the management of the supply chain and conducts monitoring and evaluation in cooperation with the DOH. The Africa Centre follows all National Department of Health guidelines, standards, and policies through its basic care interventions which are largely focused on wellness, the period from when a patient tests positive until such time as s/he requires ART. The basic preventive care package is part of the program as is symptom and pain management.

With FY 2007 funds the Africa Centre will continue to support the functions mentioned above and expand its support for the DOH. Specifically, Africa Centre involvement will strengthen the TB/HIV Program, PMTCT, palliative care, and the provision of ART and counseling and testing. Increased attention will be given to address gender issues and to promote the care and treatment services amongst men (key legislative area) and children.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Support to SAG in Hlabisa District through home-based care

FY 2007 funding will finance three nurses, one social worker and one secretary who will constitute the core of a mobile team to provide home-based palliative care. In addition, funds will be used to finance a car, pharmaceuticals and other necessary supplies. The nurses in the mobile team will provide basic HIV-related care including prevention messages and symptom and pain screening and management; the social worker will refer families for psychosocial services provided by the government (government food aid, government grants and the services of social workers). A partially financed physician will selectively visit patients who need more specialized care. The program secretary will be available to receive telephone requests for palliative care and will schedule the

home-based visits. A toll-free number will be financed to facilitate this process.

The target population for home-based care via the mobile team is non-ambulatory patients who cannot access treatment in clinics and ambulatory patients who request a home visit, in order to involve their partners and other family members in their care. In order to succeed with the home-based care initiative, it will be crucial to identify non-ambulatory HIV-infected patients. For this purpose, a toll-free number will be available to request home visits. Information about the home-based care initiative will be disseminated during community events, the Africa Centre road shows, and in pamphlets that will be available in all DOH clinics.

ACTIVITY 2: Clinical and physical care

HIV-infected people who are not yet eligible for ART will receive palliative care consisting of screening and treatment of TB, screening for pain and symptoms and elements of the preventive care package such as prophylactic treatment with cotrimoxazole, INH and fluconazole. Patients will be advised to return to the clinic 6 monthly for a CD4 test and clinical assessment. DOH funds are used for laboratory services (CD4 counts, viral loads, routine blood and urine tests) and drugs (ARV medication, drugs to treat and prevent opportunistic infections (OIs), and drugs to treat non-HIV-related diseases in HIV-infected patients). Patients on ART and those who are monitored for ART eligibility will be referred to a physician for further care should their condition require that. A pharmacy assistant will be trained to assist the DOH pharmacist to facilitate faster treatment of OIs and pain.

ACTIVITY 3: Nutrition

All participants will be referred for nutritional assessment and monitoring for food aid (Philani porridge, sugar beans) from the DOH. In order to ensure nutrition and food security, PEPFAR funding will be used for nutritional education to teach families the basics of good nutrition. Volunteers will be recruited to train the community in nutrition and food preparation. Africa Centre will seek to establish partnerships with other organizations for sustainability of these activities (e.g. Kellogg foundation, Garden Africa, Seeds for Africa that may develop into a public/private partnership PPP).

ACTIVITY 4: Referrals and linkages

In order to ensure delivery of holistic palliative care, counselors will be trained on available government support structures to link PLHIV and their families to other government programs, like screening for TB/HIV, PMTCT clinics, food aid, legal assistance and social workers, who can assist the families with applying for government grants.

These activities will advance the PEPFAR 2-7-10 goals by providing clinical and psychosocial care to those needing care as part of a comprehensive community and clinic based program and will directly contribute to the 10 million who will receive care through PEPFAR assistance.

INTEGRATED ACTIVITY FLAG:

The Africa Centre's Hlabisa TB/HIV activities also relate to ART Services (#7275), Basic Health Care and Support (#7274), PMTCT (#7914), and CT (#7911).

SUMMARY:

The Hlabisa antiretroviral treatment (ART) program aims to deliver safe, effective, efficient, equitable and sustainable ART to all who need it in Hlabisa district, rural KwaZulu-Natal. The program emphasizes the integration of the government PMTCT and Care and Treatment Programs. An important part of the Care and Treatment Program is the diagnosis and management of TB. Co-infection rates are high and the Medical Research Council estimates that 58% of people with TB also have HIV. The target population is people affected by HIV and AIDS. The major emphasis area is Development of Network/Linkages/Referral Systems.

BACKGROUND:

The Africa Centre for Health and Population Studies (Hlabisa ART Programme) is a partnership between the KwaZulu-Natal (KZN) Department of Health (DOH) and the Africa Centre, a population research department of the University of KwaZulu-Natal . The DOH program is based in Hlabisa sub-District, a rural health district in northern KZN and provides healthcare to 220,000 people at one government district hospital and 13 fixed peripheral clinics. The comprehensive ART Program, that includes TB services, is embedded in the DOH antiretroviral therapy roll-out. TB/HIV services are considered part of the comprehensive ART roll-out. The Africa Centre and KZN DOH work to complement each others' abilities and resources in providing TB/HIV and related services. The Africa Centre has expertise in infectious diseases and management that is not available at the district DOH. In addition to clinical staff and infrastructure, the district DOH provides the necessary TB/HIV drugs and laboratory testing for effective roll-out.

With FY 2007 funds, the Africa Centre will continue to partner with the district DOH to improve and expand TB/HIV services by providing additional human resources and training. In addition, Africa Centre will continue to provide comprehensive and integrated services for TB/HIV, palliative care, PMTCT, CT and ART.

With FY 2007 funding the Africa Centre will improve TB and HIV screening and diagnosis for patients and their families. Specifically, Africa Centre involvement will strengthen the TB/HIV Program, palliative care, provision of ART and VCT. Increased attention will be given to address gender issues and to promote the TB and ART services among men and children.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Partnership with South African Government

Africa Centre will expand TB/HIV screening and diagnosis services in collaboration with the DOH DOTS program and will explore other options for TB screening (including CT and PMTCT). The Africa Centre will work closely with the DOH to ensure that all patients who enter the ART program are screened for TB and treated, if necessary. In addition, Africa Centre will provide training and mentorship to medical staff in order to strengthen the referral of people who receive DOTS for HIV testing.

ACTIVITY 2: Screening and Diagnosis

As part of general patient work-up for the ART program, Africa Centre-placed staff in close collaboration with DOH physicians and nurses will ensure that all patients in the ART program receive TB screening and diagnosis. For those individuals who are unable to produce sputum for TB diagnosis, Africa Centre and DOH staff in line with current SAG standard practice refer patients for chest X-rays. Currently, patients will either incur large transportation costs or pay for the chest X-ray out of their own pocket at private providers. In FY 2006 the ART program will contract private physicians in Mtubatuba sub-District to provide chest X-rays for free for patients in the ART program. This will

substantially reduce the expenses and time costs of a large proportion of ART patients in having chest X-rays. Contracting the services of more accessible service providers ensures increased access to the service for patients who need it.

ACTIVITY 3: Treatment

All individuals in the ART program who are diagnosed with TB are treated with DOTS in close collaboration with the existing DOH DOTS program. Africa Centre, in addition to initiating TB screening in all individuals who are enrolled in the ART program, monitors the completion of DOTS both in individuals in the monitoring cohort and before ART initiation.

In accordance with the South African national HIV and AIDS treatment guidelines, all HIV-infected patients who are also TB positive will receive a full course of TB medication independent of their HIV stage. In addition, before TB positive patients can receive ART, they will have been treated for TB (for two months if CD4 count >50, at least for two weeks if CD4 count <50). All patients who receive DOTS for TB will also receive cotrimoxazole prophylaxis. A family centered approach will be adopted. Given the contagious nature of TB, patients with TB will be encouraged to bring their families in to be screened. Africa Centre will use this approach to increase male participation.

ACTIVITY 4: Human capacity development

The mobile team initiative started in FY 2006 with the goal to provide ART in all 15 DOH clinics, instead of only in 3 DOH clinics as in FY 2005. In FY 2007, this concept will be extended to provide home-based palliative care, with a team consisting of nurses, counselors, social worker and the assistance of a physician when required. Home-based palliative care will include educating patients about the need to screen for TB and to treat TB, if necessary.

The target population for home-based care is non-ambulatory patients who cannot access treatment in clinics and ambulatory patients who request a home visit, for instance to involve their partners and other family members in their care. The team will be able to provide ART and symptom relief, including symptomatic management of pain. The social worker will provide social counseling and information to the household on how to access available government psycho-social services (food aid, social workers, and government grants).

The nurses and the social workers who form the palliative care mobile team will receive intensive training. A baseline course is based on the DOH curriculum and comprises of four sessions of three hours each, covering the basics of HIV and ART, follow up of patients, and practical issues (including blood taking for CD4 counts and viral loads). In addition, the mobile care team will be specifically trained in administering and managing palliative care in the family setting.

This training will be further supported with clinic visits from training officers, during which the officers will monitor counseling and provide individual mentoring. In addition, nurses and treatment counselors will be offered to participate in short courses covering, inter alia, the management of ART side effects, TB and HIV, and pediatric ART. Counselors and nurses will be trained to provide TB care with a focus on the family.

ACTIVITY 5: Referrals and linkages

Counselors will be trained on available government support structures to link PLHIV and their families to other government programs, like ART services, PMTCT clinics, food aid and social workers, who can assist the families with applying for government grants. All patients who have TB will be tested for HIV and referred to the ART clinic if tested positive.

Individuals presenting to the DOH DOTS program independently from the ART program, will be routinely referred to HIV VCT. In order to start this activity, DOTS staff will be systematically and repeatedly informed where to access VCT and how talk to patients about HIV.

These activities will contribute to the PEPFAR goals of 2-7-10 by contributing to the goal of 10 million people receiving care through PEPFAR assistance.

INTEGRATED ACTIVITY FLAG:

The Africa Centre's Hlabisa CT activities also relate to ARV Services (#7275), Basic Health Care and Support (#7274), TB/HIV (#7913) and PMTCT (#7914)

SUMMARY:

The Hlabisa antiretroviral treatment (ART) program aims to deliver comprehensive, integrated, safe, effective, efficient, equitable and sustainable ART and related services to all who need it in Hlabisa district. Voluntary counseling and testing (VCT) is part of this program in Hlabisa District Department of Health (DOH), rural KwaZulu-Natal, South Africa. The target population for the program is adults and people affected by HIV and their families. The major emphasis area of this program is community mobilization/participation. Minor emphasis areas include information, education and communication (IEC), local organization capacity development, and quality assurance and supportive supervision.

BACKGROUND:

The Africa Centre for Health and Population Studies (Hlabisa ART Program) is a partnership between the KwaZulu-Natal Department of Health (KZNDOH) and the Africa Centre, a population research department of the University of KwaZulu-Natal. The Hlabisa ART Program is comprehensive and based on integration. VCT related activities fall within this program. The rogram is based in Hlabisa District, a rural health district in northern KwaZulu-Natal, and provides healthcare to 220,000 people at one government district hospital and 13 fixed peripheral clinics. The ART Program is embedded in the DOH antiretroviral therapy roll-out where the Africa Centre and KZNDOH work to complement each others abilities and resources in providing ART. The Africa Centre has expertise in infectious diseases and management that are not available at the district DOH. In addition to clinical staff and infrastructure, the district DOH provides the necessary drugs, laboratory tests and rapid test kits for effective roll-out.

With FY 2007 funds, the Africa Centre will continue to improve and expand VCT services by providing additional human resources and training. Africa Centre will link VCT services to PMTCT services, TB/HIV, palliative care, and treatment programs. Increased attention will be given to addressing gender inequality (including increasing male involvement in VCT and care) followed by the promotion of ART services amongst men and children.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Human Capacity Development

PEPFAR funding will be used to fund three VCT centers with two VCT counselors per center. As part of capacity building, counselors are recruited from the local area, and trained to do the counseling. Counselors will receive mentoring and supervision on a regular basis by Africa Centre VCT supervisors. In addition, counselors will meet to discuss their work with their peers. Counselors will participate in short courses to refresh their counseling skills. These courses will incorporate education on new initiatives that had not been a part of their initial training.

ACTIVITY 2: Counseling

Counseling centers have been established in partnership with the Africa Center's main funder, the Wellcome Trust-UK. These centers will be expanded with PEPFAR funding and promoted in the community. Moving away from clinics and offering the VCT in a broader range of settings (e.g. close to a supermarket, in town), the Africa Centre hopes to attract hard-to-reach people to VCT. Further, it is hoped that VCT centers in non-clinical settings will help to minimize the stigma attached to taking up HIV testing and counseling. The counseling centers will offer rapid testing with pre and post-test counseling. VCT services will follow SA Government protocols. VCT counselors will refer testers to appropriate further services, including the ART program, the TB program and government support services (disability grant, food help). VCT counselors will encourage testers to disclose their status to partners. Prevention counseling will be especially aimed at people who are

at increased risk for HIV and will be tailored to the specific needs of the patient. Those receiving VCT will be counseled on personal risk reduction including messages about partner reduction and behavioral changes to achieve healthy life styles. Counseling and testing takes place in separate closed rooms in order to ensure confidentiality. All testers will receive their test results during the post-test counseling session.

ACTIVITY 3: Community Mobilization

The Africa Center road shows (mobile IEC services) and other community events will be used to promote VCT. Specifically, the community will be informed that rapid testing will be offered at the three VCT sites. The road shows will also be the forum to reduce the stigma around visiting a VCT center. All possible efforts will be made to encourage couples and youth to receive counseling and testing.

ACTIVITY 4: Referral and Linkages

Africa Center will strengthen the referral system from the DOH TB program to VCT by providing training to direct observation treatment supporters (DOTS) on the need for HIV testing for patients who receive TB treatment. HIV-infected people will be referred for CD4 testing and treatment when applicable. The counselors will inform the testers on where to enroll in the ART program and on how to access government support programs, such as disability grants and food aid.

These activities will contribute to the PEPFAR goals of 2-7-10 by contributing to the 10 million people who will receive care through PEPFAR assistance by providing counseling and testing to many individuals in Hlabisa district.

INTEGRATED ACTIVITY FLAG:

The Africa Centre Hlabisa ART program also relates to Basic Health Care and Support (#7274), TB/HIV (#7913), PMTCT (#7914), and Counseling and Testing (#7911).

SUMMARY:

The Africa Centre Hlabisa antiretroviral treatment (ACHART) program aims to deliver safe, efficient, equitable and sustainable ART to all who need it in the Hlabisa district through the district health department, rural KwaZulu-Natal. The target population for the treatment program is people living with HIV (PLHIV), HIV-infected pregnant women and HIV-infected infants and children. The major emphasis area of this program is human resources, and minor emphasis areas include commodity procurement, local organization capacity building and supportive supervision.

BACKGROUND:

The ACHART Program is a partnership between the KwaZulu-Natal (KZN) Department of Health (DOH) and the Africa Centre, a population research department of the University of KwaZulu-Natal. The DOH program is based in Hlabisa sub-district, and provides health care to 220,000 people at a government hospital and 13 fixed peripheral clinics. The ACHART Program is embedded in the DOH antiretroviral therapy rollout where the Africa Centre and KZNDOH work to complement each other's abilities and resources in providing ART. The Africa Centre has expertise in infectious diseases and management that are not available at the district DOH. In addition to clinical staff and infrastructure, the district DOH provides the necessary drugs and laboratory testing for effective rollout.

With FY 2007 funds the Africa Centre will continue to support the provision of ART treatment and expand its support for the KZNDOH. Increased attention will be given to address gender issues (especially reaching men) and to promote the ART services among men and children.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: Support to South African Government (SAG)

The ART program is jointly run by the KZNDOH and Africa Centre. The Africa Centre contributes human resources and co-finances facility needs and supplies. The Africa Centre supports the KZNDOH with strategic planning and the implementation of the SAG HIV and AIDS Comprehensive Plan for Care and Treatment. This includes the establishment of an up and down referral system that ensures that HIV-infected people are treated at the optimal level of care at each stage of the disease. The Africa Centre support further extends to operating the supply chain of drugs from the central pharmacy to the peripheral clinics and the transport of blood samples from the peripheral clinics to the central laboratories. In addition to this, Africa Centre also supports the monitoring and evaluation of the ART program and the development of management and treatment algorithms.

With FY 2007 funding, additional support will include park-homes (inexpensive portable prefab long lasting structures) which will be set up in peripheral clinics whose patient load exceeds facility capacity. Operational assistance will be in the form of funding to support training of staff, transport, logistics, IT support and administrative assistance to smaller peripheral clinics.

The program will also procure lactometers for the early detection of lactic acidosis caused by d4T, one of three drugs included in first-line ART in South Africa. Early detection is critical in order to prevent more severe consequences of lactic acidosis. Nine government clinics will be equipped with lactometers in FY 2007 and in each clinic, two nurses will be trained in the operation of the equipment.

Activity 2: ARV Treatment

The Africa Centre will continue to support the expansion of the ART program at Hlabisa

hospital and the 13 KZNDOH clinics. Through CT, TB and the mobile ART and palliative care programs, the Africa Centre will work to increase uptake of ART among targeted communities. Mobile teams of nurses and counselors will provide ART in the clinics, and community mobilization activities will be used to enhance community awareness and uptake of services.

In FY 2007 additional mobile teams will visit clinics bi-weekly to provide onsite training, assess complicated patients, and do quality assurance checks. This process will institute a continuous process of quality improvement. Data capturers, supervised by the M&E officer, will move with these teams to capture data from the clinics. A doctor will join the mobile team to initiate patients on ART at smaller clinics and assist with treatment of side-effects and adverse events. All patients will be trained in prevention of HIV transmission and the importance of treatment adherence. Prophylaxis against common opportunistic infections includes cotrimoxazole prophylaxis in all patients with CD4 count under 200, and fluconazole prophylaxis in patients with CD4 count under 50. Data from these activities will be monitored to ensure that clients receive comprehensive services and that all eligible individuals are put on prophylaxis at the earliest opportunity.

Activity 3: Human capacity development

KZNDOH and Africa Centre counselors and nurses who work on the program will receive training on HIV and ART. The baseline course is based on the KZNDOH curriculum and comprises four sessions of three hours each, covering basics of HIV and ART; follow-up of patients, assimilation of a follow-up, and practical work with a patient (including blood taking for CD4 counts and viral loads). Counselors, nurses and physicians will receive additional training, emphasizing side-effects and second-line treatment to treat patients with therapeutic failure of first-line therapy. The program will finance a diploma course for a pharmacy assistant to assist with a satellite dispensing service at the clinics to support the KZNDOH pharmacist at Hlabisa Hospital. This trainee will be recruited locally. Doctors and nurses working on the ART program will attend the AIDS Certification Course, run by another PEPFAR partner, the Foundation for Professional Development.

Activity 4: Human resources

Africa Centre staff provides clinical care alongside KZNDOH staff in the clinics in order to support the ongoing ART program and to facilitate skills transfer to build sustainability. The sustainability of the program largely depends on availability of skilled staff, which is difficult to attract to this rural area. The Africa Centre is continuously working on recruiting physicians and pharmacists. In FY 2007, Africa Centre staff in the ART program will be increased to 8 nurses, 4 HIV counselor trainers, 40 HIV counselors, 2 doctors, 2 social workers, 2 M&E officers and 2 data capturers. All staff are mentored and supervised by Africa Centre staff.

Activity 5: Surveillance systems

The Africa Centre will establish clinic-based ART drug resistance surveillance. In order to choose the best second-line therapy, information about the drug resistance in the case of first-line therapy is needed. Routine ARV drug resistance testing is not part of the South African treatment plan. Including drug resistance testing in the ACHART program will directly benefit the patients. The findings may benefit other sites in resource-limited settings. If the Africa Centre finds that most treatment failures are due to resistance against stavudine (and not lamivudine or nevirapine), the overall quality of choice of second-line drugs may be improved without genetic drug resistance testing. PEPFAR funding will finance laboratory equipment and transport costs to set up ART drug resistance surveillance.

Africa Centre contributes to PEPFAR's 2-7-10 goals for South Africa by increasing community access to ART services by facilitating scale-up of the SA Government efforts.