INTEGRATED ACTIVITY FLAG:

This activity is related to HIVCare activities in CT (#7988), ARV Services (#7312), and ARV Drugs (#7311). 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:

HIVCare will use FY 2007 funds to work with the Free State Department of Health (FSDOH) to provide antiretroviral treatment and care in private health facilities to patients who do not have medical insurance, either through referrals from the public sector, or self-referrals. The Free State has mainly a rural population, with only two major metropolitan areas (Bloemfontein and Welkom). In addition, the government rollout of HIV care and treatment has been geographically limited, with only one site in each of the five districts.

The major emphasis area for this program will be the development of networks, linkages and referral systems, with minor emphasis given to quality assurance & supportive supervision, food and nutrition support as well as commodity procurement. The target population includes men and women; families (including infants and children) of those infected and affected factory workers and other employed persons, and government employees - specifically teachers, nurses and other health workers (without medical insurance). A further specific population that will be targeted will be secondary school children. The most significant target group is those persons in the economically active age group of the population that cannot access services in the public health system due to the high demand for services.

BACKGROUND:

Since 2005, the main thrust of the activity was to match the FSDOH with partners from the private sector (in this case Netcare, the largest private sector health provider in South Africa, through their primary health centers) in order to build private sector capacity and absorb some of the burden from state facilities. Many FSDOH centers have waiting lists of people waiting to go on ARV treatment. Patients from these waiting lists who meet the eligibility criteria for this program are referred from those public sector clinics to one of the four HIVCare primary health centers in Bloemfontein and one in Welkom for treatment. The FSDOH is a collaborating partner in this public-private partnership.

The Medicross Medical Centre in Bloemfontein, a well-equipped private primary health center, provides the main resource base and in conjunction with three other sites in Bloemfontein and another one in Welkom, will provide an effective means of distributing antiretroviral treatment (ART) to patients who are either referred from state facilities or who access the sites by word of mouth.

ACTIVITIES AND EXPECTED RESULTS:

The HIVCare treatment sites will provide all medical services related to the delivery of HIV care and treatment. Management and coordination activities will be provided by HIVCare. The majority of patients will be referred from public clinics in the FSDOH network to the five HIVCare centers based on the following criteria:(1) Clinical criteria (CD4 <200 cells/mm3 or WHO stage III or IV); (2) Inability to pay (lack of private insurance or state coverage) and (3) Overcrowding at referring clinic.

Among the non-medical criteria for enrollment (based on the SAG's 'Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa' and a request from the FSDOH), is that the patients have a stable point of contact to assure continued follow-up. HIVCare relies heavily on telephone access to ensure that patients keep scheduled physician visits, collect their medication, and respond to other questions.

Patients referred to the program receive PEPFAR-funded consultations and exams from HIVCare center physicians, who will also order relevant tests and refer patients to expert specialists when necessary. The package of care also includes counseling and testing (for

patients who do not know their status) (described elsewhere in the COP), adherence counseling, and access to short-term nutrition support (as per the national guidelines). Based on the partnership with the FSDOH and the services requested that HIVCare provide, HIVCare centers do not provide free treatment for complex opportunistic infections, although some prophylaxis is provided (e.g. cotrimoxazole) and HIVCare staff will treat minor infections and HIV conditions that do not require investigative procedures or hospitalization. Patients are still able to access public health facilities for more serious opportunistic infections/hospitalizations. Likewise, treatment for tuberculosis (TB) can be obtained from the centers, although due to the high cost of TB medications, most patients are referred back to state-run clinics for TB care and treatment. In these instances, a referral letter is provided from the treatment center to the public clinic with a request for information about the patient's TB regimen. Due to the close working relationship and partnership between HIVCare and the FSDOH facilities, this referral process is seamless.

To provide these services, five additional nursing sisters (registered nurses) and one medical doctor will be trained in HIV care and treatment services including elements of the preventive care package. Case Managers employed by HIVCare provide psychosocial support, treatment management and compliance promotion. This individualized management approach will also include telephone support for patients and their families, information about the condition and its symptoms, nutritional advice and healthy living. Case Managers actively assist patients to identify and utilize the family and community structures that may exist as well as providing information on other available support.

In addition, HIVCare will expand its existing project to target children as part of its continuum of care. This activity targets children of between the ages of six and secondary school age through HIV awareness activities. Older children will be provided with access to HIV care and treatment, as well as psychosocial support services (in line with relevant South African laws and regulations pertaining to healthcare for minors). A teen center catering for the specific needs of this age group has been established and PEPFAR funding will be applied in continuing the treatment started in FY 2006. The funds will be specifically applied in providing ARV treatment to children and some prevention materials (i.e. AB) at a number of schools in order to expand awareness of HIV care and treatment services offered by the program. Other referrals will be made by the FSDOH clinics in the area and through HIVCare's collaboration with other organizations including the Anglican Church and Red Cross Society.

This program area will promote the public-private partnership between HIVCare/Medicross and the FSDOH. This partnership strengthens the system of both parties and allows for the sharing of knowledge and skills. This public-private partnership has been ongoing for a number of years and includes the greater Netcare Group in the Free State.

By providing HIV care services to a significant population of people without private insurance and school age children, HIVCare is contributing to the PEPFAR goals of providing care for 10 million others who are infected with HIV. These activities also support care and treatment objectives outlined in the USG Five-Year Strategy for South Africa by expanding public-private partnerships and expanding care to an underserved population.

INTEGRATED ACTIVITY FLAG:

This HIVCARE activity also relates to activities described in Basic Health Care and Support (#7989), ARV Services (#7312), and ARV Drugs (#7311).

SUMMARY:

HIVCare will use FY 2007 funds to work with the Free State Department of Health (FSDOH) to provide antiretroviral treatment in private health facilities to patients who do not have medical insurance (either through referrals from the public sector, or self-referral). The Free State has mainly a rural population, with only two major metropolitan areas (Bloemfontein and Welkom). In addition, the government rollout of HIV care and treatment has been geographically limited with only one treatment site in each of the five districts.

The Medicross Medical Centre, a well equipped private primary health center, provides the main resource base in conjunction with three other sites in Bloemfontein and another one in Welkom. The center will provide an effective means of providing HIV care and treatment to patients who are either referred from state facilities or who access the sites by word of mouth. The major emphasis area for this program will be commodity procurement, with minor emphasis given to logistics and the development of networks, linkages and referral systems, quality assurance and supportive supervision. The target population includes men and women; families (including infants and children) of those infected and affected factory workers and other employed persons, and government employees - specifically teachers, nurses and other health workers. A further specific population that will be targeted will be secondary school children. The most significant target group is those persons in the economically active age group of the population that cannot access services in the public health system.

BACKGROUND:

The HIVCare project began in June 2005 with PEPFAR funding. The main aim of the program was to match the FSDOH with partners from the private sector (in this case Netcare, the largest private sector health provider in South Africa, through their primary health centers) in order to build private sector capacity and absorb some of the burden from state facilities. Many FSDOH centers have waiting lists of people for ARV treatment. Patients from these waiting lists who meet the eligibility criteria for treatment, are referred from those public sector clinics to one of the HIVCare primary health centers in Bloemfontein or Welkom for care and treatment. HIVCare will be able to serve the population in need through its four sites in Bloemfontein and single site in Welkom. The FSDOH is a collaborating partner in this public-private partnership.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Provision of Medical Services

The HIVCare treatment sites will provide all medical services related to the delivery of HIV care and treatment. In addition they will provide voluntary counseling and testing (VCT) services. Management and coordination activities will be provided by HIVCare. Active marketing of VCT service will only be done within local secondary schools as part of an HIV awareness and prevention strategy although it is expected that word of mouth and the central location of the sites will provide the desired accessibility for the public and will furthermore ensure that the required patient numbers are achieved. In addition to clinic referrals, Free State government employees will be encouraged to make use of the HIVCare services. The HIVCare centers specifically are being promoted among government employees (who do not have medical insurance) in the Bloemfontein area as independent testing and treatment sites where confidentiality can be ensured.

ACTIVITY 2: VCT

Patients attending the center for testing receive comprehensive voluntary counseling and

testing. Persons testing positive, with their consent, are screened for treatment and care options including staging tests (e.g. CD4) to determine the level of disease progression. Those that meet the clinical criteria will be referred to the treatment program. In order to provide these services, five additional nursing sisters (registered nurses) will be trained in VCT services. Persons participating in VCT will be provided with a call center number which they will be able to use to access further advice and /or information. Literature on HIV and related matters will also be provided.

ACTIVITY 3: Public Private Partnership

This program area will promote the public-private partnership between HIVCare/Medicross and the FSDOH. This partnership strengthens the system of both parties and allows for the sharing of knowledge and skills. This public-private partnership has been ongoing for a number of years and includes the greater Netcare Group in the Free State.

In addition, HIVCare will expand its existing project to target children as part of its continuum of care. This activity targets girls and boys of mainly secondary school age through messages of awareness of HIV care and treatment. A teen center catering for the specific needs of this age group has been established and PEPFAR funding will be used to continue the treatment services already started. VCT that takes place at this center will be provided in an environment that is sensitive to the special needs of this group and in line with the South African laws and regulations pertaining to children and HIV.

By providing comprehensive VCT services to patients and promoting ARV services for a significant population (people without private insurance and school age children) HIVCare is contributing to the PEPFAR goals of placing 2 million people on ARV treatment and providing care for 10 million others who are infected with HIV. These activities also support care and treatment objectives outlined in the USG Five-Year Strategy for South Africa by expanding public-private partnerships and expanding care to an underserved population.

INTEGRATED ACTIVITY FLAG:

HIVCare is an integrated program providing Basic Health Care and Support (#7989), Counseling & Testing (#7988) and ARV Services (#7312) as described in other sections of the COP.

BACKGROUND:

PEPFAR funding for the HIVCare project commenced in June 2005. The main thrust of the activity was to match the Free State Department of Health (FSDOH) with partners from the private sector (in this case Netcare, the largest private sector health provider in South Africa) in order to build private sector capacity and absorb some of the burden from public sector facilities. Many FSDOH centers have waiting lists of people for ARV treatment. Patients from these waiting lists who meet the eligibility criteria for this program are referred from those public sector clinics to one of the four primary health centers in Bloemfontein and one in Welkom for treatment. The FSDOH is a collaborating partner in this project.

SUMMARY:

HIVCare will use FY 2007 PEPFAR funds to work with the Free State Department of Health to provide antiretroviral treatment in a private health facility to patients who do not have medical insurance and who are referred from the public sector waiting lists for treatment. The Medicross Medical Centre, a well equipped private primary healthcare center, provides the main resource base and in conjunction with four other sites in Bloemfontein and another one in Welkom, will provide an effective means of properly distributing ART to patients who are either referred from public sector facilities or who access the site by word of mouth. The major emphasis area for this program will be commodity procurement, with minor emphasis given to logistics and the development of network, linkage and referral systems, quality assurance and supportive supervision. The target population includes men and women; families (including infants and children) of those infected and affected, factory workers and other employed persons, and government employees - specifically teachers, nurses and other health workers (who do not have medical insurance). A further specific population that will be targeted will be secondary school children. The most significant target group is those persons that cannot access services in the public health system. All treatment administered is done in strict accordance with South African Government (SAG) guidelines and with due regard to the need to transfer the patients back to SAG facilities when feasible.

ACTIVITIES AND EXPECTED RESULTS:

Drugs and other commodities used in the treatment process are procured through the Netcare purchasing system, the single largest purchaser of medical supplies outside of the South African Government. The drugs, specifically regulated in terms of South African legislation, are distributed to treatment centers via the Netcare pharmacies in Bloemfontein and Welkom and are dispensed to patients by qualified pharmacy staff. All medication issued to patients is done following a prescription issued by the treating physician. All other products are purchased within the procurement system of Netcare with some products being specially packaged for the program.

By providing comprehensive ARV services to patients and promoting ARV services for a large population of underserved people living with HIV (people without private insurance) and school age children, HIVCare is contributing to the PEPFAR goals of placing two million people on ARV treatment and providing care for 10 million others who are infected with HIV. These activities also support care and treatment objectives outlined in the USG Five Year Strategy for South Africa by expanding public-private partnerships and expanding care to an underserved population.

INTEGRATED ACTIVITY FLAG:

HIVCare is an integrated program providing Basic Health Care and Support (#7989), Counseling and Testing (#7988), ARV Services (#7312), and ARV Drugs (#7311) as described in the COP.

SUMMARY:

HIVCare will use FY 2007 funds to work with the Free State Department of Health to provide antiretroviral treatment in a private health facility to patients who do not have medical insurance and who are referred from the public sector facilities waiting lists for treatment. The Medicross Medical Centre, a well equipped private primary health center, provides the main resource base and in conjunction with three other sites in Bloemfontein and another one in Welkom, will provide an effective means of properly distributing ART to patients who are either referred from public sector facilities or who access the sites by word of mouth. The major emphasis area for this program will be the development of networks, linkages and referral systems with minor emphasis given to logistics; commodity procurement; human resources; and quality assurance and supportive supervision. The target population includes men and women; families (including infants and children) of those infected and affected factory workers and other employed persons, and government employees - specifically teachers, nurses and other health workers (who do not have medical insurance). A further specific population that will be targeted will be secondary school children. The most significant target group is those persons that cannot access services in the public health system. All treatment administered is done in strict accordance with South African Government (SAG) guidelines and with due regard to the need to transfer the patients back to SAG facilities when feasible.

BACKGROUND:

The HIVCare project commenced in June 2005 with PEPFAR funding. The main thrust of the activity was to match the Free State Department of Health (FSDOH) with partners from the private sector (in this case Netcare, the largest private sector health provider in South Africa) in order to build private sector capacity and absorb some of the burden from state facilities. Many FSDOH centers have waiting lists of people for ARV treatment. Patients from these waiting lists who meet the eligibility criteria for this program are referred from those public sector clinics to one of the four primary health centers in Bloemfontein and one in Welkom for treatment. HIVCare will be able to serve the population need through its four sites in Bloemfontein and single site in Welkom. The FSDOH is a collaborating partner in this public-private partnership (PPP).

ACTIVITIES AND EXPECTED RESULTS:

The HIVCare treatment sites will provide all medical services related to the delivery of HIV care and treatment. Management and coordination activities will be provided by HIVCare. The majority of patients will be referred from public clinics in the FSDOH network to the five HIVCare centers based on the following criteria:(1) Clinical criteria (CD4 <200 cells/mm3 or WHO stage III or IV); (2) Inability to pay (lack of private insurance or state coverage) and (3) Overcrowding at referring clinic.

Among the non-medical criteria for enrollment (based on the SAG's Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa and a request from the FSDOH), is that the patients have a stable point of contact to assure continued follow-up. HIVCare relies heavily on telephone access to ensure that patients keep scheduled physician visits, collect their medication, and respond to other questions.

Patients referred to the program receive PEPFAR-funded consultations and exams from HIVCare physicians, who will also order relevant tests and refer patients to expert specialists when necessary. The package of care also includes counseling and testing (for patients who do not know their status), adherence counseling, and access to short-term nutrition support as per the national guidelines.

The patients that are on the waiting lists for ARV treatment at the public health facilities are offered the option of attending the HIVCare treatment sites. The patients that then

exercise that choice in favor of the HIVCare program present at the treatment center with a referral letter and other clinical notes (e.g. CD4 count) from the public health center. The patients meeting the clinical criteria are enrolled onto the program. Where patients present directly at the HIVCare treatment center and are found to be in need of TB treatment or treatment of an opportunistic infection requiring specialized treatment, hospitalization or investigative procedures, are referred to the local public facility for care. Similarly radiography and pathology for investigative procedures is provided by the public health facilities. This is based on the request from the FSDOH to provide only a limited range of services, and the HIVCare program is only meant to assist with the unmet demand at the public sector sites, rather than create a parallel health service delivery program. Due to this working relationship, referrals between the HIVCare sites and public sector sites are seamless.

In addition, HIVCare will expand its existing project to target children as part of its continuum of care. This activity targets children of between the ages of six and secondary school age through HIV awareness activities. Older children will be provided with access to HIV care and treatment, as well as psychosocial support services (in line with relevant South African laws and regulations pertaining to healthcare for minors). A teen center catering for the specific needs of this age group has been established and PEPFAR funding will be applied in continuing the treatment started in FY 2006. The funds will be specifically applied in providing ARV treatment to children and some prevention materials (including abstinence and being faithful) at a number of schools in order to expand awareness of HIV care and treatment services offered by the program. Other referrals will be made by the FSDOH clinics in the area and through HIVCare's collaboration with other organizations, including the Anglican Church and Red Cross Society.

In order to provide these services, five additional nursing sisters (registered nurses) and one medical doctor will be trained in HIV care and treatment services. Case managers employed by HIVCare provide psychosocial support, treatment management and compliance promotion. This individualized management approach will also include telephone support for patients and their families, information about the condition and its symptoms, nutrition advice and healthy living. Case managers actively assist patients to identify and utilize the family and community structures that may exist as well as providing information on other available support. In late 2007 HIVCare will co-fund with the Free State University, the Centre for Health Policy, and the Free State Health Department, a roundtable meeting of researchers and policy makers. The purpose of the Roundtable is to provide an opportunity for both researchers and health system implementers to share information and enter into constructive dialogue on ten themes relating to the delivery and scale-up of ART

By providing comprehensive ARV services to patients and promoting ARV services for a large population of underserved people living with HIV, and who do not have private insurance) and school age children, HIVCare is contributing to the PEPFAR goals of placing 2 million people on ARV treatment and providing care for 10 million others who are infected with HIV. These activities also support care and treatment objectives outlined in the USG Five-Year Strategy for South Africa by expanding public-private partnerships and expanding care to an underserved population.