INTEGRATED ACTIVITY FLAG:

JHPIEGO has related activities in Basic Care and Support (#7887) and ARV Services (#7629), and coordinates closely with Family Health International (#7584) and Academy for Educational Development (#7508), in PMTCT.

SUMMARY:

JHPIEGO will continue conducting monitoring and evaluation (M&E) training in PMTCT for staff from National Department of Health (NDOH) and provinces. In addition to the geographic breadth of training, JHPIEGO will increase its geographic depth by introducing a model PMTCT facility that will link essential PMTCT services among six feeder primary healthcare clinics (PHC) and the district hospital in a targeted district in North West province. This program will be used as a model of best practice for the province, and will be expanded to other districts in FY 2008. JHPIEGO will also expand the Training Information Monitoring System (TIMS) to three additional provinces. Emphasis areas are training, human resources, quality assurance and supportive supervision, and strategic information. Target groups include adults, family planning clients, people living with HIV, HIV-infected infants, public health workers and policy makers.

BACKGROUND:

JHPIEGO has provided M&E training to the NDOH since FY 2004. In FY 2007, support and technical assistance will be provided to introduce an integrated model to adopt and support a PMTCT service delivery facility in North West province. In most cases, antenatal care services are provided only at antenatal facilities. JHPIEGO proposes that the integrated PMTCT model combine antenatal care (ANC)/delivery services at the district hospital level inclusive of its feeder clinics, thereby increasing access and standardizing services. Currently, adequate referral systems between the PHC feeder sites and district hospital are lacking. This model will improve comprehensive PMTCT by addressing each pillar of the World Health Organization's (WHO) framework for PMTCT services, including 1) primary prevention of HIV infection, 2) prevention of unintended pregnancy among HIV-infected women, 3) prevention of transmission from HIV-infected women to their infants, and 4) care, treatment, and support for HIV-infected women and infants.

JHPIEGO will work closely with the North West province department of health (NWDOH) HIV and AIDS directorate, and district health authorities to develop an implementation plan that will include eventual transition away from donor funding and to full support by the NWDOH. JHPIEGO may cover initial salaries of additional staff but will work with DOH authorities to ensure that required positions are created and budgeted for. This will ensure sustainability by permitting the NWDOH to eventually absorb these positions. JHPIEGO will also work with the district hospital and the six feeder clinics to ensure adequate forecasting of required drugs and supplies. As cross-cutting support to address sustainability, JHPIEGO will introduce standards-based management and recognition (SBM-R) for PMTCT that will encompass those interventions mentioned above as well as others. JHPIEGO will also support the rollout of couple counseling in this model program in an attempt to increase men's role in PMTCT services.

Although working at different sites with the Northern Cape, KwaZulu-Natal and Mpumalanga, JHPIEGO will coordinate PMTCT activities with FHI and AED.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Referrals & Linkages

The objective of this activity is to build strong linkages and referral systems between women's healthcare services and PMTCT programs, thus eliminating missed opportunities for women and their families to access PMTCT services.

JHPIEGO will work to ensure that counseling and rapid testing services focusing on risk reduction will be available to all PHC clients and their partners. JHPIEGO will mentor and support personnel in PMTCT counseling and clinical interventions to reduce the risk of transmission during ANC, postnatal care, labor and delivery. JHPIEGO will link with the

provincial and national departments of health to ensure that all providers who have not received adequate training are enrolled in the national PMTCT and Infant Feeding Training. After providers have attended training, JHPIEGO will offer supportive supervision and mentoring at the facility level and will facilitate the implementation of clinical staging for antiretroviral treatment (ART) so eligible HIV-infected pregnant women can be immediately referred to ART services. In accordance with South African Government PMTCT guidelines, JHPIEGO will ensure that all providers are equipped with adequate knowledge on nevirapine administration for PMTCT. In addition, JHPIEGO will ensure that HIV-infected women and infants are not only referred for treatment but are tracked so they do not fall through the cracks after delivery. Services provided in the postpartum period will include ongoing monitoring for opportunistic infections, linkages with well-baby visits, HIV testing for infants and appropriate referrals to treatment, care and support. Finally, women will be referred back to family planning counseling. To increase men's role (key legislative issue) in PMTCT, JHPIEGO will work with facility staff to incorporate couple counseling, including prevention for positives. JHPIEGO will link with Kagisio Educational Television, which implements the "Grassroots Male Involvement in PMTCT" campaign, to include men in the catchment areas.

To foster linkages between the CT, PMTCT, treatment and family planning aspects of these programs, JHPIEGO will work with community health workers, community-based organizations, and social services to strengthen linkages and referral systems, including referral for infant feeding programs and mother to mother-to-be support groups.

JHPIEGO will work with facilities to measure performance, identify performance gaps and develop action plans to address challenges in implementation. JHPIEGO will work with staff and health authorities to use this tool as an internal and external supervision tool that can be used to improve quality and sustainability of services. JHPIEGO will use its PMTCT performance and quality improvement tool, which was developed to improve M&E from the service delivery level to the district level. This will serve to strengthen data capture, monitoring, and evaluation allowing the NWDOH to use data to strengthen PMTCT services in the province.

ACTIVITY 2: Monitoring and Evaluation

Since FY 2004, JHPIEGO has supported the implementation of TIMS at the Regional Training Center at the University of Transkei in Eastern Cape, Hope Worldwide, and National tuberculosis (TB) and PMTCT units. During FY 2006, JHPIEGO supported expansion of TIMS to three additional regional training centers and assisted in organizing the flow of PMTCT training data from provincial PMTCT departments to the national PMTCT unit where data can be entered and aggregated.

Building on the expansion of TIMS in FY 2006 to the National PMTCT Unit, Northern Cape, and North West provinces, JHPIEGO will continue to support TIMS in FY 2007 by providing technical assistance with intermittent troubleshooting to the provinces. As a result of this activity, the NDOH PMTCT and TB units and three regional training centers in Gauteng, Mpumalanga and Limpopo will be able to capture training data on both national and provincial levels. This data will permit them to assess their progress and ongoing needs for capacity building. TIMS allows program planners to determine where training needs are greatest and prioritize their investment of training resources accordingly.

By strengthening PMTCT services and building the capacity of healthcare workers, these activities contribute to PEPFAR 2-7-10 goals, averting new infections among infants exposed to HIV as well as increasing access to treatment care and support for HIV-infected women and their infants.

INTEGRATED ACTIVITY FLAG:

JHPIEGO also has related activities in PMTCT (#7888) and ARV Services (#7629). 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:

Since 2004, JHPIEGO has been working in HIV and AIDS service delivery areas, supporting human capacity development strategies which include health care worker training and quality assurance that improve provider performance. In FY 2007, JHPIEGO will support the expansion of palliative care services through the provision of clinical and social care services for people living with HIV and AIDS (PLHIV) with an emphasis on opportunistic infections and cancers in service delivery settings and social and legal care at the NDOH. JHPIEGO will provide technical support to the NDOH by placing a HIV and AIDS Care Technical Advisor and training within the NDOH HIV and AIDS Care and Support Unit. The major emphasis areas of these activities are: 1) training, 2) networks/linkages/referral systems, and 3) human resources. Specific target groups are HIV-infected individuals and their families, women of reproductive age, family planning clients, pregnant women, and health care workers.

BACKGROUND:

The JHPIEGO palliative care program is continuing from FY 2006 to provide technical support to the NDOH and to train health workers in state of the art HIV-related care issues. Despite social and legal program successes in South Africa, technical support is required in the NDOH to address national-level social and legal inequities and program gaps for PLHIV. In FY2007 JHPIEGO will also focus its support on training and health worker skill for screening for opportunistic infections and AIDS-associated malignancies, particularly cervical cancer. Protocols and materials for prophylaxis and treatment of OIs are widely available throughout clinics in South Africa; however, training support is needed at primary health care levels throughout the country. Given the high burden of HIV in South Africa, prevalence of AIDS-related malignancies and the corresponding high incidence of cervical dysplasia among HIV-infected women a gap exists in screening and treatment for AIDS-related cancers, especially cervical cancer. Recently published studies (Moody et al. 2006) document an increased risk for squamous intraepithelial lesions (SIL), the precursor to invasive cervical cancer, among HIV-infected women in Western Cape, confirming data from other international studies. Cancer of the cervix continues to be the second commonest cancer among South African women and is included as one of the defining conditions of the AIDS in South Africa. Studies and clinic experience in South Africa continue to underscore the importance of developing locally relevant cervical screening and management guidelines for HIV-infected women in South Africa. In collaboration with the North West province provincial Department of Health, JHPIEGO will provide training and technical support for OI prophylaxis and care for PLHIV and screening for cervical cancers in HIV-infected women (key legislative area) at primary health care centers.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Support for National Department of Health

JHPIEGO will continue to provide technical support to the NDOH by placing a HIV and AIDS Care Technical Advisor within the NDOH HIV and AIDS Care and Support Unit to support and expand the government's programs for care of PLHIV. At the request of the NDOH, emphasis is needed to support and expand legal and social support activities for PLHIV. Activities in FY2007 including development of a legal support database for PLHIV in South Africa, development of a national strategy to mitigate HIV and AIDS stigma in partnership with PLHIV, and develop a human rights workbook for PLHIV that is targeted for paralegals. The advisor will have the full access to technical experts at JHPIEGO and the experts based at Johns Hopkins University. This technical advisor will work closely with a JHPIEGO sponsored advisor focusing on accreditation of primary health care facilities.

ACTIVITY 2: Training and technical support for OI prophylaxis and care for PLWHIV and screening for cervical cancers in HIV-infected women at primary health care centers

In the North West province, JHPIEGO will train facility-based health care workers on OI prophylaxis and care (emphasis on cotrimoxazole prophylaxis, TB screening and OI treatment) and will include all elements of the evidence-based adult and pediatric preventive care package, ART adherence and basic pain and symptom management within the training program. Facility-based care also creates an entry point for screening and treatment of human papilloma virus (HPV, the cause of 95% of cases of cervical dysplasia), other sexually transmitted infections, cervical cancer itself and other AIDS-associated cancers which are often overlooked in clinic settings. JHPIEGO will train and support district and primary health care level health professionals working with PLHIV to appropriately screen, diagnose, treat and educate PLHIV and their partners about HPV, other STIs, cervical dysplasia and other AIDS-associated malignancies as a component of comprehensive care services for PLHIV. Protocol and material development, training, supportive supervision and follow-up technical support will be provided. The program will be developed and implemented in partnership with the North West province provincial Department of Health and is intended to improve the capacity of the South African health system to provide holistic care of PLHIV, especially women infected or at risk for both HIV and cervical cancer.

This activity addresses gender issues by promoting equal access to OI, STI and cancer care for both males and females and equipping health care workers with skills to address HPV and cervical dysplasia in women, an important element of HIV and AIDS care for HIV-infected women that is largely overlooked. Screening, messaging and referral on gender-based violence will also be integrated into the program.

ACTIVITY 3: Development of linkages between facilities and services

To improve overall program effectiveness and integrate elements of social care to the clinical care program (activity #2 above), JHPIEGO will support and work with one district DOH in North West province to formalize referral systems and develop linkages between health facilities, and within health facilities (service-to-service) as well referral and counter-referral between the health system and social services as it relates to HIV-related palliative care services.

These results contribute to the PEPFAR 2-7-10 goals by improving access to and quality of palliative care services that were not previously provided.

INTEGRATED ACTIVITY FLAG:

JHPIEGO also has related activities in Basic Health Care and Support (#7887) and PMTCT (#7888). JHPIEGO works closely with the Foundation for Professional Development (#7985) in this program area.

SUMMARY:

JHPIEGO's activities support efforts by the National Department of Health (NDOH) and public sector antiretroviral therapy (ART) sites in Gauteng to ensure access to and quality of ART services. The emphasis areas include quality assurance and supportive supervision, and human resources. Specific target groups include people living with HIV (PLHIV).

BACKGROUND:

JHPIEGO has been working with the NDOH since FY 2004 to improve institutional capacity through training and dissemination of national HIV and AIDS ART guidelines and through support of a treatment technical advisor to the NDOH. In FY 2006, JHPIEGO partnered with the Foundation for Professional Development (FPD) (a PEPFAR-funded partner) to initiate a standards-based management and recognition approach for improving ART services. In FY 2007, JHPIEGO will continue to implement these interventions, aimed at improving access to and quality of HIV and AIDS service delivery.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: NDOH Technical Advisor

In support of the NDOH effort to increase access to and quality of ART services, as well as care for PLHIV, JHPIEGO will continue to support two local technical advisors to the NDOH treatment, care and support unit, one specifically as a treatment advisor, and the other in care. The NDOH plans to transfer these technical advisors to the NDOH budget in 2009. The role of the technical expert is to assist with: 1) transfer of learning in the area of ARV treatment; 2) accreditation of sites to provide ARV services, and; 3) evidence-based knowledge for revision and development of national policies for HIV and AIDS service delivery. The advisor will have full access to technical experts at JHPIEGO and the experts based at Johns Hopkins University. As a result of this support, the NDOH will continue to be able to expand accreditation of ART sites, thus increasing overall access to services and the number of persons receiving ART.

Activity 2: Performance Standards

Standards-based Management and Recognition (SBM-R) is a practical management approach for improving the performance, efficiency and quality of health services. It consists of the systematic utilization of performance standards as the basis for the implementing organization and related service delivery. Compliance with standards is recognized through formal mechanisms and is in line with NDOH standards and guidelines. In FY 2005 and FY 2006, JHPIEGO developed detailed performance standards for ART and introduced this process at four FPD-supported ART sites. Performance standards focused on twelve different areas of ART service delivery including pre-treatment, treatment commencement, and management of complications for both children and adults; pharmacy services; laboratory services; information, education and communication; health information systems; infrastructure; and human resources.

At the end of FY 2006, the sites will have used this process for continuous measurement of their actual performance and site supervision improvement, and will have tailored and implemented interventions to reduce performance gaps in ART service delivery. The National Department of Health will begin to accredit primary health care sites as down referral sites to improve access to ART. Based on the initial work by the South African Government, in FY 2007, JHPIEGO will support scale-up of this process to other NDOH sites in the Northern Cape, especially those where ART will be integrated into primary healthcare services. JHPIEGO will coordinate with other PEPFAR treatment partners in the accreditation process. JHPIEGO will support scale-up of SBM-R for ART in the Gauteng Province, or other provinces as requested by the NDOH. As a result of these

interventions, access to and quality of ART services will improve for both children and adults.

These activities will indirectly contribute to the overall PEPFAR objectives by ensuring sustainability and quality of ART services. Technical experts working with NDOH will indirectly contribute to increased access to treatment services through site accreditation, and standards-based management of services will indirectly increase access due to improved quality of service.

These activities contribute the PEPFAR goal of putting two million people on treatment, and support the USG/SA Five-Year Strategy by building capacity for ART service delivery.