INTEGRATED ACTIVITY FLAG:

This activity relates to Catholic Relief Services (CRS) activities in TB/HIV (#7953), CT (#7488), ARV Drugs (#7489) and ARV Services (#7487). 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:

Activities support the provision of palliative care under the comprehensive antiretroviral treatment (ART) program carried out by Catholic Relief Services (CRS) in 25 field sites in 8 provinces in South Africa. The area of emphasis is the improvement of quality of life to people living with AIDS who are not yet on antiretroviral treatment (ART), ensuring their wellness to delay the necessity of commencing the ART for as long as possible, ensuring optimal health for persons on ART, and ameliorating pain and discomfort for those in the terminal stages of the disease. The field sites target those in need of these services, who live in the catchment area of the site, and who lack the financial means to access services elsewhere. The major emphasis area is Linkages with other sectors and initiatives. Minor emphasis areas are community mobilization/participation, development of networks/linkages/referral systems, and human resources. The main target populations are HIV-infected individuals and their families as well as caregivers.

BACKGROUND:

AIDSRelief (the Consortium led by CRS) received Track 1 funding in FY 2004 to rapidly scale up ART in nine countries, including South Africa. In FY 2005 and FY 2006, Track 2 (South Africa) funding was received to supplement central funding, with continued funding applied for under COP 2007. The activity is implemented through two major in-country partners, Southern African Catholic Bishops' Conference (SACBC) and the Institute for Youth Development South Africa (IYD-SA).

All sites operate under the terms of a Memorandum of Understanding (MOU) with the provincial Department of Health (DOH) in which they operate, observing the national and provincial treatment protocols. There is a concerted effort at each site to ensure coordination with the South African Government (SAG) and sustainability by either having the SAG provide antiretroviral drugs, or by referring stable patients in to the SAG treatment plan. Progress made in this regard is discussed below under activities and expected results.

Contrary to initial expectations, the most difficult issue has been ensuring that men access HIV care and treatment services. Currently, only a third of patients on ART in the program are men.

ACTIVITIES AND EXPECTED RESULTS:

With funding provided in FY 2007, AIDSRelief will continue implementing activities in support of the South African national ARV rollout. Of the 25 existing field sites activated in March 2004, two have transferred all their ART patients into SAG sites, and have ceased providing treatment. Three new field sites will have been activated in FY 2007 to enroll additional ART patients in support of the SAG rollout plan.

Utilizing technical assistance from AIDSRelief staff members and South African experts, ongoing support and guidance will be provided to sites in the form of appropriate refresher medical training courses, patient tracking and reporting, monitoring and evaluation mechanisms and other necessary support.

Basic palliative care services including elements of the preventive care package will be provided by the 25 field sites to patients through clinic-based and home-/community-based activities aimed at optimizing quality of life for HIV-infected clients and their families throughout the continuum of illness, by means of pain and symptom diagnosis and relief; psychological and spiritual support; clinical monitoring, related laboratory services, management of opportunistic infections and other HIV and

AIDS-related complications (including pharmaceuticals); and culturally-suitable and religiously-appropriate end-of-life care. Patients within the CRS home-based care network are not given cotrimoxazole prophylaxis within the home but are referred when necessary. Effort will be made to ensure equitable access to care services for both males and females (key legislative area).

The home-based carers are recruited through parish networks, and are deployed in the areas they live in, with the intention that they should serve patients who live within the walking distance of their homes. All provincial DOHs pay stipends to their caregivers. Home-based carers within the CRS network tend to pay their caregivers the same stipend that the DOH pays theirs, as the training that they undergo is the same, as is the workload. Stipends paid to caregivers vary from one site to another according to the differences in stipends paid by different provinces. Caregivers are also reimbursed for transport expenses.

AIDS is stigmatized in many South African communities because of the association with death. This is because of the belief that AIDS inevitably leads to death. As the number of patients on treatment grows, and as communities see that those on treatment are living normal, healthy lives, stigma is decreasing visibly and more and more patients are presenting themselves to be tested, either in CT, or if they know that they are positive, to have their CD4 counts tested and see whether they qualify for treatment. This process has been accelerated by the way in which patients on treatment at each site are used as community peer educators and counselors.

All activities will continue to be implemented in close collaboration with the SAG HIV and AIDS directorate and the respective provincial authorities to ensure coordination and information sharing, thus directly contributing to the success of the SAG's own rollout and the goals of PEPFAR. These activities are also aimed at successful integration of AIDSRelief activities into those implemented by the SAG, thus ensuring long-term sustainability.

Holistic palliative care services are provided to all people who come to the field sites irrespective of their age, gender, nationality, religious or political beliefs. Historically, adults with HIV of both genders (children to a lesser extent) have been admitted for palliative care services in partner field sites providing such services. Palliative care services are provided by SACBC and IYD-SA at their respective sites, through the provision of services aimed at optimizing quality of life for HIV-infected patients and their family members, psychological support, management of opportunistic infections (where necessary), other HIV and AIDS related illnesses, and end-of-life care provided either at the clinic level (where available) or through home-based care mechanism. Field sites managed by SACBC provide a vast range of services, ranging from basic (home-based care) palliative support, to in-house, facility-based beds and full palliative care services, depending on the specifics of each site. IYD-SA also provide a different range of palliative care services, ranging from referral to other SAG clinics in the area, to home-based carers who provide compassionate and valuable services to palliative care patients.

This activity will directly contribute towards the 10 million people in care component of the 2-7-10 PEPFAR goals by increasing the quality and access to care.

INTEGRATED ACTIVITY FLAG:

Catholic Relief Services (CRS) provides a comprehensive service including activities described in Basic Health Care & Support (#7490), CT (#7488), ARV Drugs (#7489) and ARV Services (#7487).

SUMMARY:

Activities are implemented to support provision of TB diagnosis under the comprehensive antiretroviral treatment (ART) program carried out by Catholic Relief Services (CRS) in 25 field sites in 8 provinces in South Africa. The area of emphasis is on diagnosing patients with TB so that they can be referred to the South African Government TB program for treatment, and commence with ART while on TB treatment as soon as the doctor at the site sees this as being medically feasible. The field sites target those in need of these services, who live in the catchment area of the site, and who lack the financial means to access services elsewhere.

BACKGROUND:

AIDSRelief (the Consortium led by Catholic Relief Services) received Track 1 funding in FY 2004 to rapidly scale up antiretroviral therapy in nine countries, including South Africa. In FY 2005 and FY 2006, Track 2 South Africa PEPFAR funding was received to supplement central funding, with continued funding applied for in FY 2007. The activity is implemented through two major in-country partners, Southern African Catholic Bishops' Conference (SACBC) and the Institute for Youth Development South Africa (IYD-SA).

All sites operate under the terms of a Memorandum of Understanding (MOU) with the provincial Department of Health (DOH) in which they operate, observing the national and provincial health protocols. There is a concerted effort at each site to ensure coordination with the South African Government (SAG) and sustainability by diagnosing TB in potential ART patients, referring them to nearby SAG TB treatment facilities, and commencing ART once the patients are ready.

ACTIVITIES AND EXPECTED RESULTS:

With funding provided in FY 2007 AIDSRelief will continue implementing the activities in support of the South African national ARV rollout. Of the 25 existing field sites, activated in program year 1 (Mar '04 - Mar '05), two have transferred all their ART patients to SAG rollout facilities, and have ceased providing treatment. Three new field sites will have been activated in FY 2007 to enroll additional ART patients in support of the SAG rollout plan.

Utilizing technical assistance from AIDSRelief staff members and South African experts, ongoing support and guidance will be provided to sites in the form of appropriate refresher medical training courses, patient tracking and reporting, monitoring and evaluation mechanisms and other necessary support.

All TB treatment in South Africa is provided for free by the SAG. Screening of TB patients is problematic in NGO sites, but this programmatic area is strengthened with CDC-Atlanta support and increased focus in FY 2007. AIDSRelief will screen all patients who present themselves to field sites for TB, and will perform laboratory smear microscopy and culture (if indicated according to NDOH algorithms) on those suspected of having TB. If laboratory tests are positive, they will be referred to the SAG TB program for treatment. This activity includes additional training and commodities for the vast network of home-based carers to implement a single TB screening algorithm.

As part of the home-based care training, all home-based carers have to complete a module in TB DOTS. Most of them were selected as ART adherence monitors in the first place because of the considerable experience they have gained over the years in implementing the TB DOTS program.

AIDS (in itself and its relation to TB/HIV) is stigmatized in many South African communities because of the association with death. This is because the perception exists that AIDS inevitably leads to death. As the number of patients on treatment has grown,

and as communities see that those on treatment are living normal, healthy lives, stigma is decreasing visibly and more and more patients are presenting themselves to be tested, either in VCT, or if they know that they are positive, to have their CD4 counts tested and see whether they qualify for treatment. This process has been accelerated by the way in which patients on treatment at each site are used as community peer educators and counselors.

As described earlier, all activities will be implemented in close collaboration with the South African Government's health authorities to ensure coordination and information sharing, thus directly contributing to the success of the SAG rollout and the goals of PEPFAR. These activities are also aimed at successful integration of AIDSRelief activities into those implemented by the SAG, thus ensuring long-term sustainability.

INTEGRATED ACTIVITY FLAG:

Catholic Relief Services (CRS) provides a comprehensive service including activities described in Basic Health Care and Support (#7490), TB/HIV (#7953), ARV Drugs (#7489) and ARV Services (#7487).

SUMMARY:

CRS activities are implemented to support provision of voluntary counseling and testing (VCT) under the comprehensive ART program carried out by Catholic Relief Services (CRS) in 25 field sites in 8 provinces in South Africa. The area of emphasis is to establish the HIV status of as many residents of the catchments area of each site as possible, with a view to determine their CD4 counts, so that they can be placed on ART as soon as necessary. Thus major emphasis is placed on community mobilization/participation, with minor emphasis given to the development of network/linkages/referral systems, development of human resources and training. Specific target populations include the general population, people affected by HIV and AIDS, nurses and other healthcare workers.

BACKGROUND:

AIDS Relief (the Consortium led by Catholic Relief Services) received Track 1 funding in 2004 to rapidly scale up antiretroviral treatment (ART) in 9 countries, including South Africa. In FY 2005 and FY 2006, Track 2 (South Africa) funding was received to support central funding, with continued funding applied for under COP 2007. The activity is implemented through two major in-country partners, Southern African Catholic Bishops' Conference (SACBC) and the Institute for Youth Development South Africa (IYD-SA).

All sites operate under the terms of a Memorandum of Understanding (MOU) with the provincial Department of Health (DOH) in which they operate, observing the national and provincial protocols. Many patients present themselves for CD4 tests and/or ART after having undergone VCT at the South African Government (SAG) clinic.

Contrary to initial expectations, the most difficult issue has been ensuring that men benefit from the VCT activities offered. It is mostly women who undergo VCT at the field sites. At each field site, home-based caregivers, who are based in their communities, are vigorously recruiting men to undergo VCT. A problem experienced by all treatment programs in South Africa is the reluctance of males to present themselves for treatment. CRS sites attempt to overcome this by encouraging females to attend adherence sessions with their partners. Once the participation of males has been secured in this way, they are encouraged to undergo VCT and/or CD4 testing.

ACTIVITIES AND EXPECTED RESULTS:

With funding provided in FY 2007 AIDS Relief will continue implementing the activities in support of South African national ARV rollout. Of the 25 existing field sites, activated in program year 1 (March 2004 - March 2005), two have transferred all their ART patients into the SAG rollout, and have ceased providing treatment.

ACTIVITY 1: Support for SAG Roll-Out

Three new field sites will have been activated in FY 2007 period to enroll additional ART patients in support of the SAG rollout plan. Utilizing technical assistance from AIDSRelief staff members and South African experts, ongoing support and guidance will be provided to sites in the form of appropriate refresher medical training courses, patient tracking and reporting, monitoring and evaluation mechanisms and other necessary support.

At each field site, staff are trained in counseling techniques. Trained nurses are employed at each site, and they are able to perform rapid tests. Those patients who are identified as HIV-infected undergo CD4 and viral load tests. If their CD4 count is below 200, they commence with ART. The home-based caregivers provide care to large numbers of patients, many of them not necessarily people living with HIV. The caregivers are trained to be aware of possible symptoms that might be AIDS-related (for example, weight loss or persistent diarrhea). Where a caregiver suspects that illness might be AIDS-related they

give the patients appropriate counseling and advise them to be tested.

In sites with onsite medical services, voluntary counseling and testing will be provided by trained nurses and counselors, though the majority of patients in the AIDSRelief program receive free counseling and testing in public sector facilities. Commodity procurement (test kits) is provided for by Department of Health.

All activities will continue to be implemented in close collaboration with the South African Government's HIV and AIDS Unit and the respective provincial authorities to ensure coordination and information sharing, thus directly contributing to the success of the South African Government's own rollout and the goals of PEPFAR. These activities are also aimed at successful integration of AIDSRelief activities into those implemented by the South African Government, thus ensuring long-term sustainability.

INTEGRATED ACTIVITY FLAG:

Catholic Relief Services (CRS) provides a comprehensive service including activities described in Basic Health Care and Support (#7490), TB/HIV (#7953), Counseling and Testing (#7488), and ARV Services (#7487). This in-country funding is related to ARV Drugs with Track 1 funding (#7485).

SUMMARY:

Activities are implemented to support procurement of antiretroviral (ARV) drugs under the comprehensive ART program carried out by Catholic Relief Services (CRS) in 25 sites. Coverage extends to eight provinces in South Africa (excluding the Western Cape). The target population includes people affected by HIV and AIDS as well as higher risk populations such as migrant workers and refugees.

BACKGROUND:

AIDSRelief (the Consortium led by Catholic Relief Services) received Track 1 funding in FY 2004 to rapidly scale up antiretroviral therapy (ART) in nine countries, including South Africa. Since FY 2005 in-country funding has supplemented Track 1 funding, and this will continue in FY 2007. The activity is implemented through two major in-country partners, Southern African Catholic Bishops' Conference (SACBC) and the Institute for Youth Development South Africa (IYD-SA).

ACTIVITIES AND EXPECTED RESULTS:

With funding provided in FY 2007, AIDSRelief will continue implementing the activities in support of South African Government (SAG) national ART rollout. In the interest of maximizing available funds the focus will be placed on strengthening the existing sites' provision of services rather than on assessing and activating new sites. Utilizing technical assistance from AIDSRelief staff members and South African experts, ongoing support and guidance will be provided to sites in the form of appropriate refresher medical training courses, patient tracking and reporting, monitoring and evaluation mechanisms and other necessary support.

ARV drugs are provided to all qualifying HIV patients who present at the sites, irrespective of their age, gender, nationality, religious or political beliefs. Historically, about 90% of adults and 10% of children with HIV have been receiving ARV drugs through the 25 partner sites.

ARV drugs purchased will be used by the 25 sites to treat ARV patients through clinic-based and home- -based activities aimed at optimizing quality of life for HIV-infected clients and their families. For most of the 25 sites, ARV drugs are currently being purchased centrally through a Johannesburg-based pharmaceutical company, and delivered via courier to the field sites monthly on a patient-named basis. CRS is billed once a month for all site deliveries after verification of drugs delivered to each site. The opportunity of accessing preferential cost drugs is being utilized through cooperation with GlaxoSmithKline where available.

Generic medications purchased comply with the USG PEPFAR Task Force requirement of FDA approval as well as approval from the Medicines Control Council of South Africa.

All activities will continue to be implemented in close collaboration with the South African Government's (SAG) HIV and AIDS Unit and the respective provincial authorities to ensure coordination and information sharing, directly contributing to the success of the South African Government's own rollout and the goals of the President's Emergency Plan. These activities are also aimed at successful integration of AIDSRelief activities into those implemented by the South African Government, thus ensuring long-term sustainability.

All sites operate in terms of a Memorandum of Understanding (MOU) with the Provincial Department of Health in which they operate, observing the national and provincial treatment protocols. There is a concerted effort at each site to ensure sustainability by either having the SAG provide antiretroviral drugs, or by down referring stable patients in

to the public primary healthcare clinics after providing training for the SAG clinic staff. St. Mary's Hospital, which accounts for more than a third of patient numbers, has already been accredited as a SAG rollout site. Sinosizo is receiving drugs from Department of Health due to its status as a down referral clinic for Stanger Hospital. At Centocow and Bethal, all patients are already receiving drugs through the SAG rollout.

Plus Up funds will be used to expand the activities at the existing AIDSRelief sites in South Africa and increase the number of ART patients on treatment by the end of September 2008. Additional ARV drugs will be purchased to support the treatment of these additional patients and thus contribute to reaching the goals of the President's Emergency Plan.

This activity will directly contribute to the goal of 2 million individuals on treatment of the PEPFAR 2-7-10 goals.

INTEGRATED ACTIVITY FLAG:

Catholic Relief Services (CRS) provides a comprehensive service including activities described in Basic Health Care and Support (#7490), TB/HIV (#7953), Counseling and Testing (#7488), and ARV Drugs (#7489). This in-country ARV Services activity is linked to the Track 1-funded ARV Services section (#7484).

SUMMARY:

Activities are implemented to support provision of quality ARV services under the comprehensive antiretroviral treatment (ART) program carried out by Catholic Relief Services (CRS) in 25 sites in 8 provinces in South Africa. Major emphasis will be on human resources, with minor focus on development of network/linkages/referral systems, local organization capacity development, quality assurance and supportive supervision, and training.

BACKGROUND:

AIDSRelief (the Consortium led by Catholic Relief Services) received Track 1 funding since FY 2004 to rapidly scale up antiretroviral therapy (ART) in 9 countries, including South Africa. Since FY 2005 in-country funding was received to supplement central funding. The activity is implemented through two major in-country partners, Southern African Catholic Bishops' Conference (SACBC) and Institute for Youth Development South Africa (IYD-SA).

ACTIVITIES AND EXPECTED RESULTS:

With funding provided in FY 2007 AIDSRelief will continue implementing the activities in support of the South African Government (SAG) national ARV rollout. In the interest of maximizing available funds the focus will be on strengthening the existing sites providing services rather than on assessing and activating new sites. Utilizing technical assistance from AIDSRelief staff members and South African experts, ongoing support and guidance will be provided to sites in form of appropriate refresher medical training courses, patient tracking and reporting, monitoring and evaluation mechanisms and other necessary support.

ARV services will be provided through the 25 sites to ARV patients through clinic-based and home -based activities to optimize quality of life for HIV-infected clients and their families. All the relevant healthcare providers and administrative support staff at the sites will be trained to implement the ART program, using government-approved training curricula. Staff who have already received initial training will undergo refresher courses (either in-house or external), coupled with exchange of training courses and materials between sites with active support from the local training provider, Kimera training center. Treatment adherence training is provided to all patients who are enrolled on the ART program. In most sites home-based care networks will follow-up and support patients. Each site ensures that HIV-infected patients are screened for tuberculosis (TB) prior to placing them on antiretroviral treatment, and are referred to TB treatment if they tested positive. Screening and testing for TB is conducted in a number of different ways, and these testing methods are specific to each site. While screening is conducted by a medical professional at each of the sites, in most cases patients are referred to the nearby SAG medical facility for TB testing and are only enrolled in antiretroviral treatment once they have completed two months of TB treatment, or have been found not to have active TB.

PEPFAR funding will also be used to support laboratory services, which are outsourced to a private provider, Toga Laboratories. A courier service collects blood that is drawn at each site, and delivers these samples to the laboratories. Results are e-mailed or faxed back to the site within 48 hours of the laboratory receiving the blood samples.

The program is designed to improve each site's capacity to implement the national ART program in the long-term, and to strengthen clinical, administrative, financial and strategic information systems. Through linkage with another PEPFAR-funded partner, John Snow Inc. (JSI), CRS is receiving technical assistance and systems support to implement a patient information system that will be based on innovative smartcard technology. Sites will be assisted in developing appropriate policies and protocols and in setting up sound

financial and strategic information systems. Each site will also develop a unique community mobilization plan for the ART program and implement it in collaboration with relevant community organizations and leaders. Many of the sites are already involved in HIV and AIDS community mobilization activities and these will be linked to ART services. These lessons learned will be of value to other partners working in the non-governmental organization (NGO) sector.

All activities will continue to be implemented in close collaboration with the Department of Health HIV and AIDS Unit and the respective provincial authorities to ensure coordination and information sharing, and this will directly contribute to the success of the SAG's own rollout and the goals of PEPFAR. These activities are also aimed at successful integration of AIDSRelief activities with those implemented by the South African Government, thus ensuring long-term sustainability.

All sites operate under the terms of a Memorandum of Understanding (MOU) with the provincial Department of Health in which they operate, observing the national and provincial treatment protocols. There is a concerted effort at each site to ensure sustainability by having the SAG provide antiretroviral drugs, or by down referring stable patients into the SAG's primary healthcare clinics after providing training for the SAG clinic staff. St. Mary's Hospital, which accounts for more than a third of patient numbers, has already been accredited as a SAG rollout site. Sinosizo receives drugs from the National Department of Health due to its status as a down referral clinic for Stanger Hospital, and at a further two sites, Centocow and Bethal, all patients already receive drugs via the SAG rollout. Monthly statistics are shared with the relevant provincial health departments.

There is a concerted effort to include men and children in the program, and all sites have specific plans to increase enrolment, including couple counseling and using a family-based approach. Most sites have clinic-based gardens to assist with nutrition programs, and several sites provide nutrition supplements, as per South African treatment guidelines. All sites provide ART access to non-South Africans, including refugees.

Plus Up funds will be used to support the increase of the overall treatment target by the end of September 2008. These additional patients will receive the same package of services as described above - including HIV care and treatment.

The CRS treatment program supports the PEPFAR goal of treating 2 million people with antiretroviral drugs.