INTEGRATED ACTIVITY FLAG: This Human Science and Research Council (HSRC) PMTCT activity relates to other HSRC activities in Strategic Information (#7313), Injection Safety (#7316), Counseling and Testing (#8276) and Other Prevention (#7314) program areas.

SUMMARY: HSRC will provide technical support, including monitoring and evaluation (M&E) of prevention of mother-to-child transmission (PMTCT) activities in 50 antenatal care clinics (ANCs) and surrounding communities in the Eastern Cape and Mpumalanga. Once the PMTCT program in the Eastern Cape is running smoothly, HSRC will embark on similar activities in an underserved district in Mpumalanga (to be determined).The major emphasis area will include quality assurance and supportive supervision, with community mobilization, local organization capacity development, strategic information, and training as minor emphases. The primary target populations include pregnant women, people living with HIV and AIDS (PLHIV), families affected by HIV and AIDS, public and private healthcare workers, community-based organizations (CBOs), faith-based organizations (FBOs), and non-governmental organizations (NGOs).

BACKGROUND: This project will contribute to the PEPFAR objective of preventing HIV infections in the PMTCT priority area. The project was in the FY 2006 COP, but has not been implemented since the Cooperative Agreement with HSRC has not been awarded. Implementation will begin as soon as the award has been made. In partnership with provincial and district health authorities, HSRC will provide technical support for the implementation of PMTCT services according to national guidelines, and will seek to actively engage communities served by the specified ANCs. HSRC will also seek to establish partnerships with relevant CBOs and NGOs conducting HIV-related work in the area, develop reciprocal referral networks and set up peer support group systems to enhance family support (especially husbands, partners, mothers and mothers-in-law) and support from traditional birth attendants (TBAs) for the PMTCT program.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Systems Strengthening Once partnerships have been established with local and provincial health authorities, program strengthening activities will commence. Training activities will be directed towards ANC staff (both nurses and lay counselors), traditional birth attendants, community health workers and district health officials. Envisaged training activities may include basic education about PMTCT and its benefits, infant feeding options (breast versus formula), risk-reduction counseling, the benefits of antiretroviral therapy (ART), disclosure counseling and encouraging partner testing, and training to address HIV-related stigma.

HSRC will promote the use of health facilities for newborn delivery among pregnant women, their families (including mothers and mothers-in-law, husbands or partners), but will implement ART delivery systems (e.g., home nevirapine kits) for HIV-infected women who choose to deliver at home, and their infants. All pregnant women attending the 20 antenatal clinics in Region E of the Eastern Cape will be encouraged to have confidential counseling and testing (CT) for HIV infection during pregnancy. Women who test HIV-positive will be referred to the nearest accredited ART site for clinical staging, a CD4 count, and initiation of ART, if indicated (according to the national ART guidelines). Women who do not meet the criteria for initiation of ART, will be referred to a wellness program and/or relevant social support services. HIV-infected pregnant women will be counseled about disclosure, and encouraged to refer their partners for HIV testing. Women identified as HIV-infected during pregnancy (and who do not have long-term ART initiated prior to delivery), and their infants, will be given a course of nevirapine (NVP) prophylaxis at delivery for PMTCT. Infants born to HIV-infected mothers will be tested for HIV 6 to 14 weeks after delivery using PCR, and at 15 to 18 months using appropriate tests to determine their HIV infection status. Infants found to be infected with HIV will be referred to the local health services for follow-up. Most of the programmatic work will be done by staff already employed by district health services, or by traditional birth attendants in the target communities.

ACTIVITY 2: Technical Assistance HSRC will provide technical assistance to strengthen M&E systems and will seek to coordinate the M&E and PEPFAR-related reporting activities with routine district health M&E activities to minimize any unnecessary duplication of work. At the clinic level this will be paper-based. HSRC will employ a dedicated M&E specialist and a community engagement and outreach activity specialist. HSRC will mobilize community leaders, FBOs, CBOs, district councils, traditional leaders and traditional birth attendants in the region to support PMTCT interventions.

ACTIVITY 3: Expansion The impact of the project on the PMTCT delivery system in region E will be monitored, and when service delivery quality is satisfactory, support will gradually phase out and similar program implementation and support service activities will be initiated in a new geographic region in an underserved area of Mpumalanga province. The area will be selected based on discussion with the provincial department of health, and an analysis of key PMTCT indicators by district. The district with the most need will be selected. This activity will increase gender equity in HIV and AIDS programs by increasing women's access to HIV information, treatment, care and support.

This project will contribute to the PEPFAR 2-7-10 objectives by increasing the number of health workers trained to provide CT services and to administer NVP; increasing the number of pregnant women who receive confidential HIV CT and receive their results; and increasing the number of pregnant women and their infants provided with a complete course of NVP. In addition, the project will ensure that HIV-infected infants are referred to treatment programs, and hence increase pediatric ART enrollment.

This activity was proposed in the original COP submission on 09/30/06. However, on 12/12/06 funds were reprogrammed to HSRC's PMTCT activities.

INTEGRATED ACTIVITY FLAG:

In addition to Other Prevention activities, Human Sciences Research Council (HSRC) also implements activities described in the Strategic Information (#7313), Injection Safety (#7316), PMTCT (#7315) and CT (#8276) program areas.

SUMMARY:

The HSRC plans to use PEPFAR funds to implement and determine the effectiveness of two prevention-with-positives interventions to reduce HIV transmission risks for their partners.

The prevention-with-positives (PwP) activity will adapt and pilot an existing CDC intervention for promoting HIV status disclosure and behavioral risk-reduction strategies among people living with HIV (PLHIV). This intervention is known as Healthy Relationships. It is a support-group-based intervention designed to reduce HIV transmission risks for PLHIV and their partners using an interactive approach that includes educational, motivational, and behavioral skill building components. Once this intervention has been piloted, a second individualized intervention will be developed and pilot-tested for effectiveness. Both interventions will include messages on condom use for PLHIV. The major emphasis area for the activity is information, education and communication, with minor efforts in community mobilization and participation, targeted evaluation, development of networks/linkages/referral systems, and policy development. Target populations include men and women of childbearing age, National AIDS Control Program staff, HIV-infected pregnant women and healthcare workers, doctors, nurses, CBOs, FBOs and NGOs.

BACKGROUND:

Among adults, the predominant mode of HIV transmission in South Africa is through heterosexual intercourse. PLHIV are an important group to target for HIV prevention activities (both to prevent re-infection with other HIV strains, and to prevent transmission to others), but to date prevention in this group has received little attention. Behavioral risk-reduction interventions targeting PLHIV will reduce new HIV infections and will complement behavior change prevention, including condom usage, efforts currently targeting uninfected people. Until now, people who knew they were infected with HIV had been largely ignored by HIV risk-reduction strategies in South Africa. There is an urgent need to develop behavioral and other supportive interventions to assist PLHIV to manage sexual situations, avoid acquiring new sexually transmitted infections, and to prevent the transmission of HIV to uninfected sexual partners. For behavioral risk-reduction to be successful among PLHIV, de-stigmatization must be an integral part of the intervention. Although there is also a need for broad-based stigma-reduction interventions at a community/population level, interventions for PLHIV can assist in managing the adverse effects of HIV-related stigma, including the hazards of disclosure of their HIV-infected status. The Healthy Relationships intervention is a small (support) group-based intervention which has been packaged and disseminated as part of CDC's Replication Project (REP). It has been implemented successfully in several U.S. states as part of an initiative by the CDC to provide HIV prevention interventions for PLHIV. This intervention has not previously been used in South African populations, and will need to be adapted slightly prior to implementation. A second individualized intervention is being considered as many PLHIV have not yet reached a point when they are willing to disclose their status to others (including other PLHIV). The second intervention will focus on individual (one-on-one) positive prevention activities.

ACTIVITIES AND EXPECTED RESULTS:

The HSRC will use PEPFAR funding to adapt and implement the Healthy Relationships Program in the area around Mthatha in South Africa's Eastern Cape province. Funds will be used to employ ten support group facilitators and an administrative staff person to undertake formative evaluations at baseline and at one, three and six months after enrollment, and to develop or purchase training materials and videos. HSRC hopes to provide the intervention to PLHIV in Region E of the Eastern Cape in the future. Each group of ten PLHIV participating in the Healthy Relationships intervention will attend five

sessions of two hours each over a 1 to 2 month period. The effects of the intervention will be evaluated using before and after comparisons, and by comparisons to PLHIV who have not yet taken part in the intervention. A process evaluation will also be conducted. In addition to adapting and piloting the Healthy Relationships intervention as a small group intervention, HSRC proposes to develop or adapt another intervention to be delivered as an individual intervention by lay counselors; because issues of stigma and fear to disclose one's HIV serostatus may serve as barriers to participation in a group-based intervention for PLHIV. This will be conducted with 400 PLHIV. This individual intervention is likely to consist of three one-hour individual sessions with a lay counselor over a one month period.

The project will establish how well these interventions work in a rural under-resourced South African setting and will also determine the feasibility of scaling-up these interventions in other rural areas with a high HIV prevalence. The interventions will be framed by the challenges PLHIV face in establishing and maintaining satisfying relationships, with special emphasis on strategies for disclosing HIV positive status to a sex partner (reducing violence and coercion, key legislative issue). Skills for making effective HIV disclosure decisions will be taught for disclosing HIV status to non-sex partners, particularly family members, friends, and employers (stigma and discrimination, key legislative issue). The interventions will also address building skills for reducing HIV transmission risk through behavior change with a particular focus on one of the key legislative issues: male norms and behavior. Risk-reduction strategies arise naturally in the context of disclosing HIV status, with different implications for practicing protected and unprotected sex with HIV-infected partners, HIV-negative partners, and partners of unknown HIV status. An advocacy component will be incorporated to train participants to advocate for HIV testing and risk behavior reduction among partners, family members, and friends. In this way, the impact of the intervention will be spread among their social and sexual networks, and hence increasing gender equity in HIV and AIDS programs. Participants in both field tests will be assessed at baseline, immediately post-intervention, and at one, three and six months after completion of the intervention. Once the evaluation of these two interventions has been completed, they will be further adapted if necessary and expanded throughout Region E of the Eastern Cape. Expansion to other regions and provinces is also anticipated. The HSRC will train an additional 50 lay counselors and other healthcare workers working in the public sector or for local NGOs, community-based organizations or faith-based organizations, in the delivery of positive prevention interventions, and will undertake monitoring and evaluation of the program.

This activity will contribute to the PEPFAR goals by developing prevention strategies for PLHIV and their partners, thus having an impact on prevention of new infections.

INTEGRATED ACTIVITY FLAG:

This Human Sciences Research Council (HSRC) activity also relates to HSRC's activities described in the PMTCT (#7315), Injection Safety (#7316), Condoms and Other Prevention (#7314) and Strategic Information (#7313) program areas.

SUMMARY:

HSRC will use PEPFAR funds to conduct a targeted evaluation of counseling and testing (CT) activities in South Africa. The purpose of this activity is to obtain information on current CT practice, with a view to promote good program practices. The targeted evaluation will consist of two components: (1) a survey of current CT practices among a purposive sample of CT providers; and (2) an evaluation of different models of delivery of CT. Once the evaluation has been completed, the HSRC will host a one day symposium for CT program managers and policymakers to discuss the results and to plan for appropriate action based on the findings. At this symposium, the HSRC will facilitate the development of an implementation plan to ensure that the results of the targeted evaluation are turned into action. This targeted evaluation will provide strategic information on CT practices in South Africa and will inform policy and guidelines relating to CT. Specific target populations are policy makers, including national, provincial and local government, and those providers (nurses, doctors, counselors) and managers responsible for CT program implementation at all levels working in the public sector, private sector, or for voluntary organizations.

BACKGROUND:

Currently an estimated 5.5 million people in South Africa are infected with HIV. CT service utilization is low, partly due to low risk perception, denial and stigma associated with HIV and AIDS. Health service factors such as availability and accessibility, confidentiality of services and health staff attitudes may also contribute to low HIV CT uptake. In South Africa, the majority of people who are infected with HIV are not aware of their infection status. In a national household survey of HIV conducted by the HSRC in 2005, >50% of those who tested HIV-positive did not perceive themselves to be at risk. A substantial portion of people who test HIV-positive already have advanced HIV disease at the time of testing, and consequently do not access ART until it is too late. Among HIV-infected persons and at risk HIV-negative persons, CT is a point of accessing prevention programs. Knowing one's HIV status can serve as an incentive to practice safer sexual behavior, especially if HIV testing is combined with quality HIV prevention counseling. Be faithful is one of the primary components of behavioral HIV prevention strategies, yet many people in discordant partnerships become infected with HIV by being faithful to HIV-infected partners who don't know, or who don't disclose, their HIV status. It is thus critical for the use of CT services in South Africa to be scaled-up in order for HIV prevention, treatment and care initiatives to be more effective. Currently there is consensus that HIV testing should only be done with consent, but there are no national guidelines for providing effective quality CT services. CDC guidelines for counseling and testing recommend routine (opt-out) testing as a means to identify undiagnosed HIV-infected people and referring them for care and positive prevention programs. Botswana has a national policy of routine HIV testing. However there is resistance to adopting routine HIV testing in South Africa, primarily because of confidentiality concerns and fear that people may be tested without consent. A number of service providers have taken initiatives to improve HIV testing and counseling services in South Africa by providing community-based or mobile services, and by introducing couple counseling. Current HIV testing and counseling practices in South Africa are not well documented.

ACTIVITIES AND EXPECTED RESULTS:

This new project will carry out a targeted evaluation of a purposive sample of CT services in South Africa. The HSRC will include services that have a reputation for best practice or for offering innovative forms of CT including mobile CT, home-based CT, and couple CT. The sample will also select CT services that differ by type of provider (public, private, NGO); models of delivery; and that include a range of geographic settings throughout South Africa, both urban and rural. The HSRC will request permission from the appropriate authorities in advance. This project will be conducted by the HSRC in collaboration with

CDC partners and with the National Department of Health (NDOH).

The HSRC will evaluate models of delivery in terms of structure (design), processes, and performance. The framework will assume that effectiveness or performance of a delivery model is a function of supply side or provider factors (e.g. facilities, quality, access) and demand or user factors (e.g. attitudes, knowledge, practices) and underlying factors such as socioeconomic status, culture, geographic setting etc. Structured and semi-structured interviews and field observations will be conducted with service managers, frontline service providers, and clients. Statistics will be gathered on numbers of clients tested, reasons for testing, HIV seroprevalence among clients, and client demographics (gender, age). Information will be collected on charges for services (if applicable), staff training, staff supervision, quality assurance practices (for counseling as well as testing), types of HIV tests used (rapid or slow ELISA), counseling models used and whether the model is theory-based and/or evidence-based, social marketing and outreach activities, policies and practices relating to consent and disclosure, and integration and linkages with other relevant health and social services. For a limited number of services using different models of delivery, more in-depth information, including cost information, will be gathered for purposes of a comparative evaluation. The HSRC will try to include examples of integrated, stand-alone, and mobile or home-based services in the evaluation, as well as different forms of counseling delivery (e.g. individual, couples, and small group).

The study results will be written up in the form of a report published by the HSRC Press and a copy will be available on the HSRC website. In addition, HSRC will develop a policy brief for government use. Once the study has been completed, a one-day symposium, directed at CT policymakers and providers will be held to present and discuss the results and to plan for appropriate action based on the findings. Select CT providers that are examples of best practices or innovative CT strategies will be invited to speak at the symposium. The HSRC will also investigate the need for the production of short briefing documents.

This activity will gather evidence relevant for effective and cost-effective scaling up of CT services in South Africa, thus contributing indirectly to the overall 2-7-10 PEPFAR objectives (2 million individuals on treatment, 7 million infections averted and 10 million people in care). The results of this activity will be used to improve quality of CT services, which should impact indirectly on the number of people tested and referred to treatment, care and support.

INTEGRATED ACTIVITY FLAG:

In addition to the Strategic Information (SI) activities, Human Science Research Council (HSRC) also implements activities described in the PMTCT (#7315), Injection Safety (#7316), Counseling and Testing (#8276) and Other Prevention (#7314) program areas.

SUMMARY:

HSRC proposes to use PEPFAR funding to support the South Africa 2008 national population-based HIV prevalence and behavioral risk survey. The survey will use state-of-the art survey and epidemiologic methods to collect and analyze data. These data will also be used to enhance national HIV and AIDS program indicators and compare South Africa's HIV epidemic to the global pandemic. The major emphasis area of this project is a population survey, with a secondary emphasis on HIV Surveillance Systems. Additional information on behavioral risk factors for HIV infection among youth aged 15 to 24 years will be collected. The entire population of South Africa will benefit from this survey. The target population for this project will also include the South African Government as the survey results will inform national policy and planning.

BACKGROUND:

To implement effective HIV and AIDS prevention, care and treatment programs in South Africa, it is vital to have accurate data and a comprehensive understanding of the epidemic. UNAIDS (2000) advocates for the development and use of data sources beyond antenatal care (ANC) HIV prevalence data to enhance a country's understanding of the epidemic's dynamics and its impact on the population. HIV prevalence estimates derived from population-based samples yield different and complementary information on HIV transmission dynamics in a country. Often times ANC HIV surveillance data leads to overestimates of national prevalence rates. The data will be used to compare estimates derived from ANC sentinel site surveys. The results of the previous two surveys have been influential in drawing attention to gender inequalities in the HIV epidemic in South Africa. By triangulating these data, along with data on risk behaviors, countries can obtain a more accurate picture of epidemic levels and trends.

Preparatory activities for this survey will be done in 2007 and the fieldwork will begin in early 2008. The 2008 national household survey on HIV will be the third such survey conducted in South Africa. The first and second surveys were conducted in 2002 and 2005 by the HSRC and its partners were funded by the Nelson Mandela Foundation, the Nelson Mandela Children's Fund, the Swiss Agency for Development and Cooperation, and the HSRC. In the 2005 survey, HSRC also received support from PEPFAR and the South African National Institute for Communicable Diseases (NICD) for conducting HIV incidence testing on dried blood spot samples (using the BED assay). This enabled HIV incidence to be estimated for the first time in a national population-based sample of the general population. HSRC plans to seek co-funding for the 2008 survey from other sources. HSRC is also considering a couples sub-study as part of the 2008 national household survey to obtain an estimate of the prevalence, patterns, and factors associated with discordant HIV serostatus among people in established sexual partnerships. This sub-study will be contingent on mobilizing adequate funding and human resources, and devising a sampling strategy that does not compromise the main survey.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: 2008 HIV Prevalence Survey

HSRC will use PEPFAR funds to conduct the 2008 national population-based HIV prevalence survey in South Africa. The survey will include children 2 years and older, as well as youth and adults of all ages. Funds will be used to: train fieldworkers and conduct fieldwork; for staff support; field allowances; quality assurances procedures; development and printing of data collection and processing forms; and the shipment (by courier) of specimens to the selected laboratories from the field. A large portion of funding will be devoted to HIV antibody testing and other related tests at an accredited national laboratory. Funds will also be used to support the analysis and write-up of the results and the publication of a report, scheduled for release on 1 December 2008 (World AIDS Day).

Results will be analyzed by gender, thus providing information for increasing equity in HIV and AIDS programs (an area of legislative interest). In addition, a more detailed risk assessment will be conducted on a sample of youth, which will provide information on male norms and behaviors (an area of legislative interest).

Following the publication of the report, additional secondary analyses will be conducted using data from the 2002, 2005 and 2008 surveys. Funding will also support the development of human capacity in the area of HIV and AIDS-related strategic information. Capacity in strategic information will be enhanced among HSRC staff and new trainees through their participation in planning, fieldwork, analysis and reporting of the results of the 2008 national household survey. In addition HSRC plans to conduct a workshop on second generation surveillance in 2008 to train government and public health sector staff in strategic information.

The 2008 national household survey will provide behavioral, communication, socio-cultural and up-to-date data on HIV for South Africa. This will enable trends in HIV and behaviors associated with HIV transmission since 2002 to be compared. The 2008 national household survey will also help to determine provincial dynamics and will inform resource allocation and effective interventions.

This activity will provide vital information that can be used for program improvement, and ultimately achieve the 2-7-10 goals.