SUMMARY:

The National Health Laboratory Service (NHLS) will use PEPFAR funds to expand a demonstration project that was implemented with FY 2006 funding. The project is aimed at increasing access to early HIV diagnosis for infants, and developing guidelines for rollout of the project on a national level. This project was specifically requested by the Gauteng provincial Department of Health (DOH), with strong support from the National Department of Health (NDOH) and its Prevention of Mother-to-Child Transmission (PMTCT) Early Diagnosis Committee. Policy and guidelines will be the major emphasis area for this program, with minor emphasis given to commodity procurement, development of networks, linkages, and referral systems (especially between immunization clinics, early infant diagnosis and treatment, care and support), and logistics. The primary target population will include HIV-exposed infants (birth to five years old) and infants who are not infected, and secondary target populations include lab workers, doctors, nurses and South African government policy makers.

BACKGROUND:

Early infant diagnosis of HIV is vital for monitoring PMTCT programs and identifying HIV-infected children to receive care. Diagnosing HIV in children is more complex than in adults because of the interference of maternal HIV antibodies during infancy and ongoing exposure to the virus during breastfeeding. To date, HIV diagnostic services for children in low resource settings have been neglected and healthcare workers are not familiar with its theory or practice.

About five million people in the country are HIV-infected and it is estimated that about 500,000 of these, which include 60,000 children, are in urgent need of antiretroviral (ARV) therapy. One frequently cited reason for so few children accessing treatment is the fact that mechanisms to diagnose infants early are not in place. Although NDOH Guidelines have made provisions for early diagnosis with HIV DNA PCR, in most places this has not yet replaced the previous protocol of using HIV ELISA tests at 12-months of age. In reality, infants are not followed up and either die before accessing care or only present once they are already ill with their first HIV-related illness. Lack of early diagnosis for exposed infants and the integration of PMTCT services with services providing ARV drugs have been identified as keys to improving access to care for HIV-affected children and their families, and thereby increasing the number of HIV-infected people receiving treatment.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Technical assistance and scale up of early infant diagnosis

This activity aims to assess the implementation challenges and develop guidelines to scale-up early infant diagnosis for infants born in PMTCT programs. Technical assistance will be provided to the province to help facilitate the rollout of early infant diagnosis services. This project was specifically requested by the Gauteng province DOH, with strong support from NDOH and its PMTCT Early Diagnosis Committee. Technical assistance will be provided to improve lab infrastructure to conduct early infant diagnosis and scale up these services around the province. Technical assistance will be provided to establish dried blood spot testing in all HIV DNA PCR laboratories; to make monthly PCR test statistics available, e.g., to "Concerned Pediatricians" to monitor progress; and to establish a system for feedback from clinics for central monitoring, e.g., service issues, quality control, etc.

ACTIVITY 2: Capacity Building

NHLS will facilitate training of clinic healthcare workers including nurses, doctors and lab technician in the area of early infant diagnosis. The training will ensure that infants exposed to HIV accessing immunization clinics at 6 weeks of age are offered PCR testing. Training will help facilitate an average increase in test volumes from 2,000 to 3,000 per month.

ACTIVITY 3: Linking the expanded program for immunizations (EPI) at primary healthcare clinics (PHC) with early infant diagnosis

NHLS will take advantage of the well-established EPI program at a PHC level as an entry point for HIV-affected children by identifying HIV-infected children (and other family members) for comprehensive HIV medical care including referral between PHC and hospital facilities. To accomplish this, NHLS will institute a sustainable HIV diagnostic service at Discoverers EPI clinic for 6-week-old infants of HIV-infected women including training current PHC clinic staff to provide this service. Older children will also have access to this service. In addition, NHLS will work with the clinic to ensure systems for follow up testing of breastfed infants at least 6-weeks after breastfeeding has been discontinued (through education of healthcare workers; appropriate counseling of primary caregivers; clinic bookings available for testing and giving results).

Furthermore, NHLS will pilot a patient-held record to document HIV care and facilitate communication between the PHC clinic and hospital based facility and build relationships and identify effective systems for referral between the PHC clinic and the hospital facility based at Coronation Women and Children's Hospital by working at both sites (e.g., mechanisms for providing clinical and educational support to PHC staff) to capacitate existing PHC clinic staff to provide comprehensive HIV care to stable HIV-infected children on or off ARV therapy. Lastly, NHLS will identify requirements for facilitating access to HIV care for family members accompanying the index infant using the immunization clinic as an entry point.

The NHLS early infant diagnosis demonstration project directly contributes to PEPFAR's 2-7-10 goals by increasing the number of infants accessing treatment in Gauteng, and serving as a platform for expansion of early infant diagnosis programs throughout the country. These activities support the PEPFAR Five-Year Strategy for South Africa by supporting government efforts to improve quality of and access to care and treatment for HIV-infected children.

SUMMARY

CARE is an umbrella organization for CDC in South Africa. CARE will support the Muslim AIDS Program (MAP) for these activities. MAP is a faith-based organization working primarily with youth populations to promote healthy norms and behaviour amongst individuals within communities and to promote the preservation of productive and contented families. The AB programs will target youth between 10 and 21 years. Our target areas are primary schools, secondary schools, universities, out of school youth and vernacular classes) in the four provinces viz. Western Cape, Kwa Zulu Natal, Gauteng and Mpumalanga. MAP will recruit and train young adults to work in the programs as peer group trainers and facilitators. The emphasis area for this program will be information, education and communication with a view to community mobilization and training. It would target the in and out of school youth, orphans and vulnerable children, disabled population community and religious leaders and other faith and community-based organizations. The target audience for this project is youth attending schools. The project will target both girls and boys up to the age of 21. The project will be implemented in close collaboration with the Department of Health in each of the four target provinces.

BACKGROUND

MAP lifeskills program is an initiative of the Islamic Careline, Jamiatul-Ulama and the Islamic Medical Association. One of our key objectives is to aid the development of our children and youth in becoming responsible members of our community. As such we have developed a series of lifeskills programs and continue to provide training for the facilitation of such programs. MAP has been receiving National Department of Health funding since 2001, this has been supplemented by PEPFAR through the CDC Cooperative agreement since 2005. In FY2007, PEPFAR will continue to support MAP, however the funding mechanism will change, and MAP will become a sub-partner of CARE.

ACTIVITIES AND EXPECTED RESULTS

Activity 1 (AB training) MAP's AB activities are aimed at promoting behavior change. This will be achieved through workshops aimed at empowering youth. MAP will also target women's organizations and educational institutions (secular and religious) with counseling, training and AB lifeskills programs. The abstinence based messages are designed to assist youth out of school aged 18 to 21 and encourage them to delay sexual debut until marriage. For youth in this age group who may already be marriage the messaging is focused on being faithful within a marriage. In order to empower and train youth, MAP had developed a methodology that targets women/mothers. MAP understands that women/mother need to be the target of interventions dealing with youth as in most cases, within the communities in which MAP works, it is the mothers who are responsible for being the primary caregivers of youth. By training mothers, these mothers will be better equipped to deal with their children's sexuality issues and the mothers' can play a role in empowering their children around the issues of abstinence. In order to ensure that all the above training is carried out appropriately, MAP will facilitate AIDS Educator training workshops. Once these facilitators begin implementing workshops, MAP will monitor the quality of the workshops.

Activity 2 (Lifeskills Training and Peer Education in Schools)

MAP will train young university students and youth that are unemployed. The "Free Teens" program is abstinence based and encourages young people to make informed choices about their future through interactive discussion on pertinent topics. The program covers HIV and AIDS, STI's and as well as a teenage pregnancy prevention program.

Our facilitators are well trained in the program as well as working with young people. There is no doubt that learners will benefit a great deal from their expertise and from the essential topics covered in the program.

The "No Apologies" program will be implemented with youth from grade 7-12, and youth out of school. The program is a character based, abstinence until marriage program.

Topics covered include: Healthy Relationships, Media Literacy, Pre-Marital sex has consequences, Why abstinence works, Drugs and Alcohol as it relates to abstinence.

The program is further enhanced with the Ladies Lifeskills/Parenting skills which promotes constructive communication between the youth and caregiver (parents)

The Rutanang Peer Education concept will be implemented within the existing program, as our facilitators have already been trained as master trainers.

Activity 3: (Creative Education)

MAP incorporates entertainment in the form of role plays, drama, dancing and singing to reinforce the AB message. In the OVC program, lifeskills is modified to suit the needs of these learners. In some cases the program is translated for easy understanding by learners.

The use of holiday camps is rapidly becoming a means of intervention whereby parent-child interaction is enhanced and promoted.

Activity 4 (Capacity Building)

Interns and volunteers are recruited to facilitate the implementation of the above mentioned programs. Scope for further empowerment and enhancement with the program is realized continuously. The volunteers are capacitated with training and opportunities to improve skills.

MAP also provides technical assistance is provided to 4 CBOs for capacity building, which includes program management, training and mentoring.

MAP's contribution to the program will assist in the reduction of high-risk behaviour amongst the youth and the most vulnerable. The organization is also confident that it will contribute and support the prevention goals as outlined in the USG Five Year Strategy for South Africa to avert 7 millions new infections.

SUMMARY:

CARE will continue its work in building HIV and AIDS competence of civil society organizations (CSOs) who deliver HIV-related care services in South Africa. CARE aims to scale up palliative care by increasing technical and organizational capacity, targeting local and indigenous CSOs and faith-based organizations (FBOs) in South Africa. This is accomplished by administering and managing 18 small grants and targeted technical assistance to identified grantees to scale up HIV-related palliative care services in organizations that are unable to receive direct funding due to limited capacity. Minor emphasis activities include community mobilization, training and development of networks.

BACKGROUND:

The CARE Letsema project is part of a five-year project, which started in October 2005 and aims to support HIV and AIDS activities in South Africa, Lesotho and Swaziland. This narrative describes activities in two South African provinces -- the Free State and Limpopo. The project extends organizational and technical capacity strengthening and mentoring support activities to three CSOs and will soon expand to support four additional CSOs. CARE provides these organizations with small grants to build their capacity to improve service delivery. CARE will continue to work with and provide technical support to sub-partners to strengthen the quality of their services and provide institutional support so that sub-partners can develop into sustainable local organizations. CARE works in collaboration with South African government departments to enable the targeted population (both organizations and beneficiaries) to enhance and coordinate access to support services. CARE plays a largely facilitative role in ensuring that resources reach smaller community-based initiatives, while providing a supportive capacity building curriculum to enhance organizational and technical service delivery. Direct organizational development will be implemented through participatory processes to build the long-term sustainability of CARE's sub-partners. Technical program areas are supported by small grants and technical assistance for that program area, directly through CARE, as well as through identified Sectoral Education and Training Authority (SETA) accredited partners with specialized expertise in HIV-related palliative care and support.

In FY 2006, Letsema has been working primarily in the eastern Free State near the Lesotho border and will continue to work in this area. In FY 2007, the project will also expand to several districts in Limpopo because the province has been identified as under-resourced and CARE has already established relationships with the provincial government.

ACTIVITIES AND EXPECTED RESULTS:

CARE will carry out three activities in this program area.

ACTIVITY 1: Strengthen delivery of quality HIV-related palliative care services

Targeted training and mentoring support will be provided to selected organizations to address the clinical, physical and psychological care of HIV-infected individuals, and the psychological, spiritual and social care of affected family members. Technical emphasis will be supporting CSOs to appropriately message, provide and/or refer for elements of the basic preventive care package. The aim of this activity is to build a more integrated HIV response that responds to the family as a whole and promotes increased coordination of services within the community, facilitating greater uptake and utilization of health and social government services such as HIV counseling and testing, treatment and social assistance. CARE aims to strengthen the referral network within each of the organizations it supports. This is an integrated response that promotes community mobilization, awareness and implementation of HIV prevention, care and treatment support activities as a continuum.

Service delivery will be strengthened, and quality and success rates in accessing government services will be improved by (1) placing salaried professional staff (nursing supervisors or auxiliary social workers) together with sub-partners and contract specialists to train and mentor staff and volunteers to improve the clinical component of home-based care within the government's specified guidelines and curriculum; (2) technical support to

CSOs emphasizing the messaging, delivery and/or referral for evidence-based preventive care interventions which include the following: OI screening and prophylaxis (including cotrimoxazole, TB screening), counseling and testing for clients and family members, malaria prevention with ITNs (where appropriate), safe water and personal hygiene strategies to reduce diarrheal disease, nutrition counseling, HIV prevention counseling, provision of condoms, referral for family planning services for HIV-infected women, and appropriate child survival interventions for HIV-infected children. The package of services also includes basic pain and symptom management, psychosocial support, treatment support for OIs (including cotrimoxazole prophylaxis and TB treatment) and antiretroviral therapy (ART) and psychological, spiritual and social support of affected family members; (3) strengthening collaborations among government departments at district and provincial levels to ensure access to basic healthcare, ART, legal documentation, state income grants, support for staying in school, and volunteer stipends and improved service coordination; and (4) improving psychosocial programs with training and support for staff and volunteers to work with orphans and vulnerable children and their caregivers in groups, individual counseling, peer education programs and home-based care, and develop workplace support and supervision for volunteers.

This activity addresses gender issues through ensuring equitable access to HIV-related care services for both males and females and encouraging male involvement and mobilization of community leaders throughout the program.

ACTIVITY 2: Capacity building

The activity combines organizational development training and mentoring to enhance institutional strengthening identified CSOs to improve organizational functioning and service quality. The program will achieve this through an innovative combination of capacity building approaches including training workshops, mentoring, cross-visits, and organizational technical assistance. The proposed intervention will minimize one-time training and workshops and will develop longer term activities to strengthen CSOs and networks, ensuring sustained capacity building and joint learning. Organizational capacity will be strengthened to improve institutional functioning by (1) undertaking organizational assessments (human resources, policy development, project management, finance and governance) of each of the participating CSOs; (2) developing clear organizational/human development training and mentoring plans to address gaps emerging from the assessment; and (3) providing training in project management, basic book-keeping, narrative and financial reporting, monitoring and evaluation.

ACTIVITY 3: Management of sub-grants

The activity provides and manages sub-grants to 21 CSOs, to sustain operations through improved fundraising and coordination. The activity aims to increase access to resources for small CSOs that do not meet the criteria of government and/or international donors, but that provide valuable care and support services at the community level in a culturally appropriate manner.

This activity will increase civil society organizational capacity to deliver quality basic healthcare and to expand access to quality palliative care services, thereby addressing the priorities set forth in the USG Five-Year Strategy for South Africa. In addition, the people receiving care and support will contribute to the care portion of the 2-7-10 objectives.

None

Table 3.3.06:

SUMMARY: CARE will continue its work in building HIV and AIDS competence of civil society organizations (CSOs) who deliver HIV-related OVC services in South Africa. CARE aims to scale up OVC services by increasing technical and organizational capacity, targeting local and indigenous CBOs and faith-based organizations (FBOs) in South Africa. This is accomplished by administering and managing 18 small grants and targeted technical assistance to identified grantees to scale up HIV-related OVC services in organizations that are unable to receive direct funding due to limited capacity. Minor emphasis activities include community mobilization, training and development of networks.

BACKGROUND: The CARE Letsema project is part of a five-year project, which started in October 2005 and aims to support HIV and AIDS activities in South Africa. This narrative describes activities in two South African provinces -- the Free State and Limpopo. The project extends organizational and technical capacity strengthening and mentoring support activities to three CSOs and will soon expand to support four additional CSOs. CARE provides these organizations with small grants to build their capacity to improve service delivery. CARE will continue to work with and provide technical support to sub-partners to strengthen the quality of their services and provide institutional support so that sub-partners can develop into sustainable local organizations. CARE works in ollaboration with South African government departments to enable the targeted population (both organizations and beneficiaries) to enhance and coordinate access to support services. CARE plays a largely facilitative role in ensuring that resources reach smaller community-based initiatives, while providing a supportive capacity building curriculum to enhance organizational and technical service delivery. Direct organizational development will be implemented through participatory processes to build the long-term sustainability of CARE's sub-partners. Technical program areas are supported by small grants and technical assistance for that program area, directly through CARE, as well as through identified Sectoral Education and Training Authority (SETA) accredited partners with specialized expertise in HIV-related palliative care and support. In FY 2006, Letsema has been working primarily in the eastern Free State near the Lesotho border and will continue to work in this area. In FY 2007, the project will also expand to several districts in Limpopo because the province has been identified as under-resourced and CARE has already established relationships with the provincial government.

ACTIVITIES AND EXPECTED RESULTS: CARE will carry out three activities in this program area.

ACTIVITY 1: Strengthen delivery of quality OVC services Targeted training and mentoring support will be provided to selected organizations to address the clinical, physical, social and psychological care of OVC. Technical emphasis will be supporting CBOs to appropriately message, provide and/or refer for elements of the OVC package. The aim of this activity is to build a greater response at community level that responds to the needs of the OVC. This includes increased coordination of services within the community, facilitating greater uptake and utilization of health and social government, treatment and social assistance. CARE aims to strengthen the referral network within each of the organizations it supports. This is an integrated response that promotes community mobilization, awareness and implementation of support programs for OVC. This activity will also addresses gender issues through ensuring equitable access to services for both males and females.

ACTIVITY 2: Capacity building The activity combines organizational development training and mentoring to enhance institutional strengthening identified CSOs to improve organizational functioning and service quality. The program will achieve this through an innovative combination of capacity building approaches including training workshops, mentoring, cross-visits, and organizational technical assistance. The proposed intervention will minimize one-time training and workshops and will develop longer term activities to strengthen CSOs and networks, ensuring sustained capacity building and joint learning. Organizational capacity will be strengthened to improve institutional functioning by (1) undertaking organizational assessments (human resources, policy development, project management, finance and governance) of each of the participating CSOs; (2) developing

clear organizational/human development training and mentoring plans to address gaps emerging from the assessment; and (3) providing training in project management, basic book-keeping, narrative and financial reporting, monitoring and evaluation.

ACTIVITY 3: Management of sub-grants The activity provides and manages sub-grants to 18 CSOs, to sustain operations through improved fundraising and coordination. The activity aims to increase access to resources for small CSOs that do not meet the criteria of government and/or international donors, but that provide valuable OVC services at the community level in a culturally appropriate manner. This activity will increase civil society organizational capacity to deliver quality OVC services, thereby addressing the priorities set forth in the USG Five-Year Strategy for South Africa.

SUMMARY: CARE is a CDC Umbrella Grants Management partner who will provide funds to Scientific Medial Research (Pty) Ltd (SMR) (formerly known as Tucker Strategy), a health strategy consulting company that has developed a methodology for assessing the PEPFAR Counseling and Testing (CT) partner activities.

ACTIVITY 1 (Pilot Phase): Under a prior contract, SMR developed a strategy and the Comprehensive HIV and AIDS Quality Assurance (CHAQA) tool. This tool will be used to assess partners so that we identify indicators of success within programs, and identify limitations that may require technical assistance. This assessment will include a review of the project objectives and its relationship to PEPFAR goals, the project's progress to date (including their achievement of targets) and other key issues that contribute to their accomplishments and challenges. SMR will pilot the tool with two selected CDC-funded Counseling and Testing (CT) partners at two selected sites each. The feedback will be given to the South African Government and PEPFAR Activity Managers with recommendations for technical assistance to be provided to the partner. As this initial pilot is focusing on CT partners, it is felt that it could be adapted and used for other activity areas. The validity of the CHAQA tool will be evaluated during the pilot phase.

ACTIVITY 2 (Evaluation for Scale-Up) Upon conclusion of the pilot phase, the tool will be evaluated for its usefulness among all CT partners and in other activity areas. A report from SMR will detail the outcome and challenges encountered with the tool and will state recommendations for wider use. Scale up of the CHAQA tool will occur following approval with COP 08 funding.

SMR's activity strongly supports the vision in the South Africa 5 year strategy to ensure quality of program implementation.