INTEGRATED ACTIVITY FLAG:

This McCord Hospital PMTCT activity relates to other McCord Hospital activities in CT (#7907), Basic Health Care and Support (#7912), TB/HIV (#7910), ARV Drugs (#7908) and ARV Services (#7909), described elsewhere in the COP.

SUMMARY:

The McCord Hospital/Zoe Life's overall activities relate to building capacity at four municipal clinics in the Outer West area of Durban (KwaZulu-Natal province) to provide a strengthened and integrated prevention of mother-to-child transmission (PMTCT) service which is linked with tuberculosis (TB) and HIV care and treatment. Activities will strengthen services including opt-out counseling and testing of all pregnant women attending the antenatal clinics, testing of partners and children of the index patient where possible, TB screening of HIV-infected pregnant women with referral for treatment where needed, antiretroviral (ARV) prophylaxis for HIV-infected women and newborns, maternal nutrition and infant feeding counseling and infant follow-up. Emphasis areas include local organization capacity development, strengthening of referral networks between PMTCT and other vertical programs, human resource development through training, mentorship and supervision of PMTCT staff, quality assurance and improvement through supportive supervision, technical assistance and mentoring during site visits and strategic information strengthening through development of a simple integrated monitoring and evaluation system. The primary target populations are pregnant women, HIV-infected pregnant women, and their infants.

McCord Hospital currently receives funding for PMTCT and ARV treatment through the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). This program described here focuses on strengthening the capacity of public sector facilities, and it is distinct from the hospital-based program funded by EGPAF.

BACKGROUND:

The South African Government (SAG) recently published results of the PMTCT program per province (2005 Antenatal HIV and Syphilis Prevalence Survey). Results of this survey show that KwaZulu-Natal continues to have the highest antenatal prevalence of HIV at 39.1%. This is 9% higher than the national prevalence of 30.2%. Current statistics at the four municipal clinics in the Outer West area of Durban show suboptimal uptake of PMTCT and poor follow-up of infants from the PMTCT program. There are currently no statistics to indicate the success of infant feeding interventions, infant follow-up rates or involvement of partners.

This is a new activity designed to strengthen PMTCT services within the framework of a decentralization and integration of HIV care and treatment program. This project is supported by both municipal and provincial government. All protocols followed will be in line with the Provincial Treatment Guidelines, and outcomes of the program will be reported to the eThekwini (Durban) municipality as well as to the KwaZulu-Natal Department of Health. The implementing organizations, McCord Hospital and Zoe Life, will strengthen capacity of staff employed by the municipal government (eThekwini Municipality) at the four clinics to optimize current PMTCT services.

ACTIVITES AND EXPECTED RESULTS:

An emphasis on gender equity (key legislative issue) in this program area will focus on optimizing the number of pregnant women who receive care, support and prophylaxis, as well as developing strategies to include partners of pregnant women in decision-making and issues relating to PMTCT. Partners will be encouraged to test for HIV, and infected partners or family members will be integrated into the HIV palliative care and antiretroviral treatment (ART) services program areas. Access to couple counseling will be increased, with focus areas around family planning, risk reduction, infant feeding choices and testing of family members included in the counseling and support.

ACTIVITY 1: Human Resources Strengthening

PEPFAR-funded staff with PMTCT expertise will provide onsite mentorship and supervision of staff of the PMTCT program at the four facilities to improve quality of PMTCT care; training and onsite mentorship of counselors at the four facilities to increase skills in couple counseling and integration of partners into PMTCT related decision making; training of counselors and nurses in infant feeding choices and maternal nutrition; and training of nurses to draw blood from infants to increase access to infant testing.

ACTIVITY 2: Monitoring and Evaluation

This activity will focus on the development of a monitoring and evaluation (M&E) system that can integrate data from ART, TB, palliative care and PMTCT services. This M&E system will optimize the provincial PMTCT data protocols and ensure smooth referrals into other vertical programs.

ACTIVITY 3: Technical Support in Response to M&E Results

PEPFAR-funded staff will provide regular onsite technical support and training of staff to understand the outcomes of the M&E to improve quality of care and to highlight areas where necessary.

ACTIVITY 4: Follow-up of Infants

This activity will focus on the development of sustainable strategies to improve follow-up of infants using M&E tools and optimization of routine infant clinic visits (e.g., for immunizations, weighing).

Sustainability is addressed through the capacity building focus of this program area. PEPFAR-funded staff will not be permanently assigned to these clinics but will lend support and build capacity until South African Government-funded staff are able to sustain the program without assistance. The M&E system developed will be offered to the municipal and provincial government if it is useful within this context.

This program area expects to add quality to and to increase uptake of PMTCT services in four municipal clinics. Uptake of PMTCT services is expected to increase by 30-50%. Zoe Life and McCord Hospital expect to provide additional counseling services such as couple counseling, partner counseling and testing, and maternal nutrition testing. A follow-up system for infants will be developed which will capitalize on the routine immunization schedules, and an increase in infant and sibling testing is expected. HIV-infected infants or children will be supported according to the provincial pediatric treatment guidelines. Referral systems will be strengthened to ensure continuity of care. Infected infants will be referred for initiation of treatment and referred back to the ARV services program area for ongoing care once stabilized. This program area will thus increase access to treatment for infants and children.

The McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year Strategic Plan by integrating PMTCT and HIV services, strengthening the public sector and expanding access to care and treatment.

ACTIVITY 5: Pregnant Women and Pediatric ART

Plus up funding will be used to continue to provide ART to pregnant women with CD4 counts over 200 at McCord hospital and where possible at clinic sites. This will ensure that women receiving care at McCord hospital are treated optimally with ARVs, and will simplify integration into the clinic HIV care and treatment programs. In addition Plus up funding will enable the development of a community outreach and psychosocial program in partnership with an organization called BigShoes, aimed at testing vulnerable children in places of care (this may include children's home or schools) who will then be linked to receive HIV care and treatment in the municipal or NGO sites. This outreach will focus on capacity building of organizations and caregivers, as well as providing psychosocial support to HIV infected children. A psychosocial team will access children at risk of HIV and provide increased case finding and psychosocial services to both the children and their caregivers outside of the clinic setting.

INTEGRATED ACTIVITY FLAG:

This activity also relates to McCord Hospital/Zoe Life activities in CT (#7907), PMTCT (#7906), TB/HIV (#7910), ARV Drugs (#7908) and ARV Services (#7909). 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:

The McCord Hospital/Zoe Life activities in this area will build capacity in four municipal clinics, three NGOs, and businesses in Durban, KwaZulu-Natal, to provide a comprehensive range of care and support services for HIV-infected clients and their families. These services will be available to adults and children from the time of CT, and will support sustained wellness for clients not on ART as well as those receiving treatment. Services will extend to end-of-life care with referral linkages to community-based care services where available. Emphasis areas include community mobilization (church or community groups) to augment spiritual and psychosocial services; development of linkages and referrals, particularly with regard to end of life, spiritual support and community-based care; human resource development with regard to training, mentorship and supervision of staff to provide sustainable services; organizational capacity development by training key personnel to manage sustainable palliative care systems at each site; and quality assurance and improvement through the development of an integrated monitoring and evaluation (M&E) system. The primary target groups are the general population; refugees and asylum seekers; and the private sector.

McCord Hospital receives funding for PMTCT and ARV treatment through the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). This program focuses on strengthening the capacity of public sector facilities, and it is distinct from EGPAF's hospital-based program.

BACKGROUND:

Only five years ago, very few opportunities existed for treatment. In the past three years, ART has become a reality for many. However, the concept of HIV as a chronic manageable disease is not yet a mainstream health belief. Compounded by ongoing stigma and access issues, only the very sick access treatment services, which are largely designed for only ARV provision. This stems from a belief that HIV care equates to ARV treatment, and is an end-of-life privilege to be sought at specialist level.

This project seeks to address health seeking behavior by helping communities access comprehensive HIV care proactively in a primary health setting, encouraging HIV-infected individuals and their family members to access care as early as possible, and in so doing emphasize sustained wellness, quality of life and productivity for as long as possible. Palliative care services offered by a multidisciplinary team will play an integral part in this health behavior change model of care and improve palliative care services within the context of both an HIV wellness program and ARV services. Clinical services will be nurse-led, with only complex clinical issues referred to a clinician or secondary level facility. The emphasis on wellness will promote screening for pain and symptoms, prophylaxis and prompt treatment of opportunistic infections (OIs), with well established referral systems for tuberculosis (TB) screening and treatment. Psychosocial services are essential to promote early engagement with health services, family-centered care, and the chronic health model. Increasing access to care and treatment for men is a critical gender issue for the success of this program. This will be addressed through access to couple counseling, family centered services and mobile services offered in the workplace to employed men (and women) (key legislative area). This project is supported by both municipal and provincial government. All protocols followed will be in line with the provincial treatment guidelines, and outcomes of the program will be reported monthly and quarterly to the eThekwini municipality (Durban) as well as to the KwaZulu-Natal Department of Health (KZNDOH).

ACTIVITES AND EXPECTED RESULTS:

The areas of legislative interest addressed in this program area is increasing gender equity

as described in the summary above, and increasing women's access to income and productive resources through linkages with the three NGO income-generating programs.

ACTIVITY 1: Human Capacity Development

This activity will focus on human capacity development through training multidisciplinary teams in each site to provide comprehensive palliative care services. Clinical staff will be trained to provide prophylaxis, screening and treatment for opportunistic infections; training of counselors, community workers and spiritual supporters to provide augmented counseling and support services to adults and children.

Clinical and psychosocial staff will support and mentor staff to develop skills and confidence to provide the following services: couple counseling, psychosocial support for children, family centered counseling, wellness literacy for adults, children and caregivers, clinical care (including screening and prophylaxis of OIs) and treatment of primary health level OIs.

ACTIVITY 2: Psychosocial services

McCord/Zoe Life will establish community linkages to strengthen community referrals and to utilize existing community-based psychosocial services (such as home-based care, church-based counseling and support groups).

McCord/Zoe Life will develop and implement sustainable psychosocial support services, including a support group for children at two clinics and one NGO site.

ACTIVITY 3: Monitoring and Evaluation

McCord/Zoe Life will develop a monitoring and evaluation (M&E) system for palliative care services for use in quality improvement and capacity building at local and provincial level.

ACTIVITY 4: Care services for refugee and asylum seekers

McCord/Zoe Life will provide appropriate palliative care services for refugees and asylum seekers in the Durban central area in collaboration with the United Nations High Commission for Refugees (UNHCR) and KHWEZI AIDS Project. These services will be provided in French and Swahili.

ACTIVITY 5: Mobile services

A range of onsite palliative services will be provided for employees in industry who do not have access to medical aid. PEPFAR will fund staff, drugs and laboratory tests to provide mobile onsite services such as counseling, wellness literacy, CD4 count monitoring, screening, prophylaxis and treatment for OIs where possible.

Sustainability at the municipal clinic sites will be addressed by assisting sites to become accredited with the KZNDOH, and thus making all direct costs of maintaining a quality palliative care service the responsibility of the KZNDOH. This project will build capacity in these sites to effectively manage the program without ongoing technical assistance. The NGO sites will be assisted to build infrastructure and referral networks to ensure sustainability of services. The long-term plan for the NGO sites is to build strong relationships with nearby clinics with the intent of building clinical capacity to take over the clinical aspects of palliative care services. This project will later build capacity with these institutions to become accredited sites. Staff will assist the NGOs to source alternative funding. The services for workers in an industrial setting will be funded as a part of a public-private partnership.

The McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.

INTEGRATED ACTIVITY FLAG:

This activity also relates to McCord/Zoe Life activities described in CT (#7907), Basic Health Care & Support (#7912), PMTCT (#7906), ARV Drugs (#7908) and ARV Services (#7909).

SUMMARY:

McCord/Zoe Life activities will build capacity in four municipal clinics, three non-government organizations (NGOs) and a corporate outreach program in Durban to provide proactive and integrated TB/HIV services within the framework of a primary health decentralized HIV care and treatment program. Emphasis areas include: development of referral systems between vertical HIV-related programs and other health services; local organization capacity development; and development of a workplace program.

BACKGROUND:

The prevalence of tuberculosis (TB) in KwaZulu-Natal (KZN) is high, with 60% of TB clients co-infected with HIV. Local TB programs are vertical programs that do not integrate HIV and TB care. An outbreak of multi-drug resistant tuberculosis (MDR-TB) along with poor treatment completion rates highlights the challenges of TB management in KZN. The tools used for diagnosis of TB where an estimated 75% of active TB is extrapulmonary and/or sputum negative pulmonary TB are limited to sputum microscopy for AFB. Chest x-rays (CXR) do help with diagnosis, but is not confirmatory, and the CXR picture of pulmonary TB in HIV is not the classic picture. Diagnosis is often complicated by other infections such as pneumocystis carinii pneumonia (PCP). The yield on sputum culture for TB is higher, especially with sputum negative on microscopy, and the yield of AFB on blood cultures in extrapulmonary and sputum negative TB is also fairly high. The best tool at this stage, however, is the clinician with a high index of suspicion for TB. Effective management of TB is one of the most important upcoming fields of care in South Africa. This new project will be implemented by the McCord/Zoe Life team and seeks to integrate HIV and TB care using National Department of Health (NDOH) guidelines and best practice models to provide a seamless continuum of care to clients co-infected with TB and HIV. Gender (key legislative issue) will be addressed by increasing access to TB screening in the workplace, increasing TB screening for women in PMTCT projects and in women's income generating projects run through the NGOs. The project will also provide TB/HIV care to refugees (key legislative issue).

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training

Counselors will be trained in provider-initiated CT, and this service will be offered to all TB-infected clients accessing care at the municipal clinics, and to TB patients accessing services at NGO sites. Counselors will be trained to enroll all HIV-infected clients into wellness/ARV services and to refer for CD4 screening. Counselors will be trained to screen for TB during any contact with an HIV-infected client and to refer appropriately. Nurses working in prevention of mother-to-child transmission (PMTCT) or sexually transmitted infections (STI) NGOs will be cross-trained to screen all HIV-infected clients at each contact and to refer appropriately for quick diagnosis, treatment and CD4 monitoring. They will be trained to provide focused wellness and adherence counseling to patients co-infected with TB and HIV. Staff working within clinic-based TB programs will be trained in integrated TB/HIV management and reporting, including provision of cotrimoxazole. Staff at NGOs will be trained to screen for TB in community settings and provide community-based wellness training, dual testing for TB/HIV, and household adherence support for TB/HIV.

ACTIVITY 2: Increase screening of TB in all HIV-related settings including community

This activity will provide technical support for counselors, community workers and nurses to routinely screen for TB in PMTCT, CT, palliative care and ARV services using a simple symptom-based screening tool. Additional funding will be sought to purchase laboratory equipment for more rapid microscopy and culture of sputum.

ACTIVITY 3: Mentorship and supervision of staff

Mentorship and supervision of staff will provide integrated active case management of TB/HIV with multidisciplinary service provision in palliative care and ARV services where required. Staff will be assisted to integrate all patients with TB/HIV into comprehensive HIV management services with contact tracing, screening and partner/family testing encouraged as standard of care. Sites will be assisted to provide cotrimoxazole to all TB/HIV clients.

ACTIVITY 4: Linkages and referrals

McCord/Zoe Life will assist in strengthening linkages and referrals to ensure full range of HIV care and treatment services (including extrapulmonary TB) are available without loss of continuity of care or patients lost to follow-up.

ACTIVITY 5: Development of workplace program and mobile clinic

Staff and employees participating in the HIV workplace program will be trained to understand the link between HIV and TB. Employees accessing the workplace CT services will be screened for TB by history and symptom screening. Occupational nurses will be trained to screen for TB per protocol in the management of HIV. Additional funding will be sought to equip a mobile clinic with a mobile X-ray machine and microscopy. This unit will be used to provide TB and HIV screening and diagnosis to all workers accessing the workplace wellness program. Funding will be sought through industry and international funding to purchase this equipment which is vital to managing TB in the workplace. Until this is a reality, linkages between workplace programs and referral centers for treatment will be established. Where possible, TB treatment will be initiated onsite and TB rates reported to the district TB program.

ACTIVITY 6: Development and strengthening of M&E system

An M&E system should have the capacity to track HIV-infected clients receiving TB treatment, to ensure tracking of visits, active case management and retrieval of TB patients. The system will require strengthening of linkages between the municipal clinics, the Durban TB clinic and the DOTS workers. A patient-held record for communication between health facilities will be used in conjunction with the pharmacies and providers at the health facilities to ensure continuity of care in all services.

ACTIVITY 7: Sharing best-practices

McCord/Zoe Life will engage with provincial and district TB coordinating bodies to share best-practices to improve services. This includes revisiting diagnostic algorithms, accessing funding to pilot better diagnostic testing algorithms and expanding treatment centers.

Sustainability is addressed through development of integrated services within existing public health facilities, establishment of linkages and referral pathways making access to diagnosis of TB easier, and through cost sharing in workplace programs.

Through integrated TB/HIV services, McCord Hospital/Zoe Life expects to increase provider-initiated HIV testing through the municipal TB services to all TB patients, expecting 40-60% of TB patients to be HIV infected. Any HIV-infected client on TB treatment will be offered the full spectrum of palliative care services and be referred to for ARV services according to provincial treatment guidelines. All HIV-infected clients will be screened for TB. It is expected that 20% of all HIV-infected clients will require TB treatment. In the NGO setting the goal is to increase community-based referral for TB screening, adherence support and strengthening of referral systems. In the workplace, the goal is to increase workplace screening, diagnosis and treatment of TB in the HIV workplace program through mobile onsite services.

The McCord Hospital activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.

INTEGRATED ACTIVITY FLAG:

This McCOrd Hospital and Zoe Life (McCord/Zoe Life) activity also relates to TB/HIV (#7910), Basic Health Care and Support (#7912), PMTCT (#7906) and ARV Drugs (#7908) and ARV Services (#7909), described elsewhere in the COP.

SUMMARY:

McCord/Zoe Life aim to increase capacity to expand integrated counseling and testing (CT) services within the framework of a comprehensive HIV care and treatment program in seven sites-- four municipal clinics and three non-governmental organizations (NGOs). Capacity will be developed by (a) training of voluntary lay counselors at the NGOs to provide best-practice services, (b) mentorship of NGO and municipal counselors to provide integrated, provider-initiated CT services, and (c) strengthening continuity of care post-CT through referral of HIV-infected clients by counselors to the HIV care and treatment services. The emphasis areas are the development of referral systems between vertical programs, human resource support, development of a training curriculum aimed at CT of children, strengthening the local organizational capacity to increase CT services, quality improvement, supportive supervision, and in-service training of staff. Specific target populations are the general population, refugees and internally displaced persons (through the KHWEZI AIDS Project in central Durban), and workers within the business community. Counseling and testing will be provided in French and Swahili in the KHWEZI AIDS project to reach refugees and asylum seekers (key legislative issue) from Central and West Africa who currently reside in the Durban area.

McCord Hospital receives funding for PMTCT and ARV treatment through the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). This program described here focuses on strengthening the capacity of public sector facilities, and it is distinct from the hospital-based program funded by EGPAF.

BACKGROUND:

Counseling and testing is the entry point to prevention, care, treatment and support of HIV-infected persons. If access to care and treatment is to be accelerated, then access to CT should be aggressively pursued. In KwaZulu-Natal, lay counselors in municipal and local health authorities have traditionally provided a stand-alone vertical service to persons requesting HIV testing. Uptake of VCT services has largely been a result of the PMTCT program, with referral from other programs (sexually transmitted infections (STI) and tuberculosis (TB)) and self-referral contributing a small percentage to the uptake of CT. In the NGO setting, patients are largely referred for CT from community health workers who suspect advanced HIV disease. Thus, apart from PMTCT where CT is provider-initiated, the bulk of CT services are requested by clients who are already symptomatic with AIDS and who require a definitive diagnosis and ARV treatment.

The emphasis of this new project would be to shift the trend of voluntary counseling and testing (VCT) to a more universal, provider-initiated opt-out service designed to increase uptake of services and to promote early diagnosis of HIV while patients are still well enough to access wellness and health promotion services. This project would also emphasize increasing opportunities to counsel and test children. In addition to increasing uptake of CT, this project seeks to ensure that clients who learn of their HIV status will be seamlessly integrated into care, support and treatment services. Lastly, this project seeks to take CT into the business community to workers who would not otherwise have an opportunity to be counseled and tested. These activities are supported by the KwaZulu-Natal Department of Health (KZNDOH). Activities within the municipal clinics will be undertaken with the support of the eThekwini (Durban) Municipality. Gender issues (key legislative issue) will be addressed by taking VCT services into the business community, where many employed men have no access to services. In addition, counselors will proactively encourage partners of women tested in PMTCT services to access testing. Where possible, the technical support team will investigate the possibilities of extended hours of CT services to include weekends or evenings.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training

McCord/Zoe Life will work with three NGOs currently providing psychosocial support to HIV-infected clients in their communities using voluntary lay counselors. These voluntary lay counselors have been trained by a variety of organizations. In order to standardize the quality of counseling which will be offered through this project, McCord will train all participating lay counselors. Training will be conducted over 10 days according to the South African national counseling guidelines (minimum standard). Lay counselors employed by the four municipal clinics will have benefited from the 10-day training course as a pre-employment requirement and will not require further training in CT. Staff from all seven sites will be trained in VCT of children to increase confidence and skill in this area. Counselors will be trained to conduct pre- and post-test counseling with caregivers and children where appropriate. Clinical staff will be trained in testing of children, which includes skills to draw blood from small children or babies. This is currently a barrier to widespread testing of small children outside of a hospital setting. Counselors who have not already had exposure to training in couple counseling will be trained and urged to encourage partner or family attendance at clinic or NGO activities with the view of encouraging testing and other palliative care services.

ACTIVITY 2: Workshop in Provider-Initiated Counseling and Testing Within a Multidisciplinary Team

All staff who participate in this project will attend a preparatory workshop on the concept, advantages and implementation challenges of provider-initiated or opt-out CT services. During this workshop, the seven sites will be assisted in formulating an approach to implementing provider-initiated CT or opt-out counseling as an augmentation to their current services, which would include PMTCT, STI, TB, children's clinic, immunization services. Staff will be assisted to include lay counselors into a multidisciplinary team which will span across vertical programs. Staff will be assisted to develop referral systems which are effective and ensure continuity of care between VCT, HIV care and treatment and the other programs. Special attention will be paid to increasing confidence in counseling and testing of children.

ACTIVITY 3: Technical Support to Implement Provider-Initiated or Opt-Out CT

All sites will be supported technically to implement provider-initiated or opt-out CT through weekly mentorship of counselors, facilitation of multidisciplinary and inter-program referrals, and problem solving. McCord/Zoe Life will assist sites to strengthen monitoring and evaluation systems linked to CT. Information relating to the implementation of CT services will be reviewed and fed back to staff at the sites for ongoing quality control and problem solving. Counselor mentors will monitor quality of counseling, assist with complex cases and strengthen referrals. Clinical support will be given to staff that require assistance with testing of children.

ACTIVITY 4: Human Resource Augmentation

In sites where uptake of CT exceeds the staff capacity, PEPFAR-funded counselors will be employed to increase capacity whilst the organization motivates for increasing human resources from the KZNDOH or from other funding sources.

The McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.

INTEGRATED ACTIVITY FLAG:

This activity also relates to McCord Hospital's activities in Counseling and Testing (#7907), Basic Health Care and Support (#7912), PMTCT (#7906), TB/HIV (#7908) and ARV Services (#7909), described elsewhere in the COP.

SUMMARY:

McCord Hospital and Zoe Life (McCord/Zoe Life) will support and provide technical assistance in the delivery of antiretroviral (ARV) drugs to patients at seven sites - four municipal clinics and three non-governmental organizations (NGOs). The activity will also extend to participating industry sites for workers without medical insurance in Durban, KwaZulu-Natal.

The emphasis areas are commodity procurement (for NGO sites/industry sites); human resources; local organization capacity development; and quality assurance and improvement. The primary target populations are the general population, refugees and asylum seekers, and business community. Refugees and asylum seekers are an important target group, as they cannot access free antiretroviral treatment in the public sector.

McCord Hospital receives funding for PMTCT and ARV treatment through the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). This program described here focuses on strengthening the capacity of public sector and NGO facilities, and it is distinct from the hospital-based program funded by EGPAF.

BACKGROUND:

This is a new project which will be implemented by the McCord/Zoe Life team in partnership with the eThekwini Municipality (Durban), three NGOs and private sector sites, to decentralize antiretroviral treatment (ART) provision to primary health settings. Stable patients initiated on ART at local hospitals will be referred to the above sites for ongoing follow-up and for monthly ART dispensing. New stable patients will be initiated on ART at the decentralized sites and continue follow-up and ART dispensing at these sites.

McCord Hospital currently dispenses ART to approximately 2000 patients, and has now become an accredited site with the KwaZulu-Natal Department of Health (KZNDOH). The project described here to support public sector and NGO sites is supported by the metropolitan and provincial health departments. KZNDOH ARV guidelines will be used in the provision of ARVs wherever appropriate. Gender issues will be addressed through increasing access to ART in workers (assuming most are men) in a workplace program, and by ensuring that a family-centered treatment approach is offered to partners and family members of index patients via access to couple counseling, community-based referrals, provider-initiated palliative care for partners and active case management of families. The project will also increase access to ART for refugees.

ACTIVITES AND EXPECTED RESULTS:

ACTIVITY 1: Site accreditation

McCord/Zoe Life will support a process of site accreditation at four metropolitan clinics through negotiation with the metropolitan and provincial health departments to ensure sustainability and ensure ongoing provision of ART drugs to these sites.

ACTIVITY 2: Accreditation guidelines

McCord/Zoe Life will assist the KZNDOH to develop accreditation guidelines for NGOs and workplace programs to ensure ongoing provision of ART to these sites.

ACTIVITY 3: ART to decentralized sites

This activity will support and strengthen systems onsite to provide ART efficiently at decentralized sites.

The McCord hospital pharmacy currently manages the ART supply chain for more than 2,000 patients. This project will hire staff to expand this service to decentralized sites and strengthen current systems. ARVs will be selected from national regimens according to trends from previous forecasting. Drugs will be procured, stored and regulated by the McCord Hospital Dispensary which is registered as a hospital pharmacy. As McCord Hospital is accredited with the KZNDOH, ARVs will be ordered from and supplied by the central Department of Health Pharmacy. If the NGO or industry sites are not accredited by the time this project begins, ARVs will be separately procured. In this case, brand name drugs and generics registered with the Medicines Control Council of South Africa (MCC) and FDA will be procured from distributors such as International Health Care Delivery (IHD) and Kinesis, as well as directly from the pharmaceutical companies. In FY 2007, exploratory discussions will be held with the Partnerships for Supply Chain Management (PFSCM), a PEPFAR partner, to support commodity procurement of the most cost-effective brands at the NGO and corporate sites.

All drugs received by the pharmacist will be stored in the McCord Hospital dispensary under the care of the pharmacists who adhere to good pharmacy practice conditions. Drugs will be ordered twice a month. Systems are in place to select, procure, store, track and distribute the drugs privately. If there is a delay from tendered companies, drugs can be sourced from wholesalers (same day delivery but increased cost). GlaxoSmithKline (GSK) does forecasting based on use, and is obligated to ensure adequate supplying. McCord Hospital has two purchasing systems currently in operation: Rolling Forecast System where the GSK Access program drugs are purchased monthly according to a three-month commitment, and nine-month open forecast that is updated monthly. This forecast is determined by the present ART clinic batch system. The Demand Dependant System is a 24-hour order to delivery system, is based on demand and maintained with minimum and maximum stock levels. Monitoring of purchases and distribution is done both manually and electronically. If stock-outs (less than five days) occur, stock will be purchased from an alternative source.

A PEPFAR-funded pharmacist will liaise with the pharmacists at municipal, NGO and industry sites to forecast ARV needs on a weekly basis. ARVs will be prepackaged for the decentralized sites and delivered weekly to each site. Pediatric formulations will also be delivered to sites weekly. The McCord/Zoe Life team will provide technical support to ensure that onsite storage and dispensing systems are in place before ARVs are dispensed. Scripts will be written by dispensing nurses at the decentralized sites and kept in a register in the pharmacy. In clinics without a pharmacy, drugs will be stored in a secure cupboard. A register of scripts and drugs dispensed will be maintained at each clinic by a senior dispensing nurse. Records will be captured in the logistics database on a weekly basis. Excess or expired medicines are disposed of through a waste management company.

Sustainability is addressed at provincial level through accreditation of municipal sites and development of accreditation policies for NGO and corporate sites.

Human capacity development is strengthened through technical support and mentorship of pharmacists and senior nursing staff at the sites to improve logistics management regarding ARV supply. Staff will be trained in monitoring and evaluation to strengthen the efficiency of the systems, and to optimize tracking of missed drug pick up, liaising with the multidisciplinary team who will follow up these clients.

The McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.

INTEGRATED ACTIVITY FLAG:

This activity also relates to McCord Hospital's activities in Counseling and Testing (#7907), Basic Health Care and Support (#7912), PMTCT (#7906), TB/HIV (#7910), and ARV Drugs (#7908).

SUMMARY:

The McCord Hospital/Zoe Life activities of this program area relate to strengthening capacity at four municipal clinics and three non-governmental organizations (NGOs) to provide comprehensive antiretroviral treatment (ART) services in a primary healthcare setting as part of a decentralization plan. A mobile service will provide ART to infected workers as part of a workplace program. Emphasis areas are development of referrals across vertical programs (CT, PMTCT, TB/HIV), community programs and to secondary and tertiary facilities; local organization capacity building (major emphasis); quality assurance, improvement and supportive supervision; strategic information; training; and workplace programs. The primary target populations are the general population, people affected by HIV and AIDS, refugees and the private sector (workers without health insurance).

McCord Hospital receives funding for PMTCT and ARV treatment through the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). This program described here focuses on strengthening the capacity of public sector facilities, and it is distinct from the hospital-based program funded by EGPAF.

BACKGROUND:

There are a number of constraints to the rapid rollout of ART in the public sector. This is largely due to the lack of human and infrastructural resources, and that ART is generally offered at secondary or tertiary care level. McCord Hospital has over 2,000 patients on ART, and it is not sustainable to continue the follow-up of stable patients at this or any other hospital. This new activity will be implemented by the McCord/Zoe Life team in partnership with the eThekwini Municipality (Durban), three NGOs and participating corporate bodies. The project will build capacity at primary health care (PHC) level to continue follow-up of down referred stable patients on ART (initiated at hospital level) and to increase skill at PHC level to provide ART services (including initiation of ART in patients who are stable). This project is supported by metropolitan and provincial health departments. Provincial ART guidelines are followed. Gender issues will be addressed through increasing access to ART in workers (assuming most are men) in a workplace program, and by ensuring that a family-centered treatment approach is offered to partners and family members via access to couple counseling, community-based referrals, provider-initiated palliative care for partners and active case management of families.

ACTIVITES AND EXPECTED RESULTS:

ACTIVITY 1: Site accreditation

This activity will support site accreditation at four metropolitan clinics through negotiation with metropolitan and provincial health departments to ensure sustainability and ongoing provision of staff and commodities for ART services.

ACTIVITY 2: Human capacity development

Nurse-led multidisciplinary teams at each site will be trained to provide comprehensive ARV services at clinics. Training will include adult and pediatric clinical services, psychosocial support/adherence counseling, pharmacy management and monitoring and evaluation (M&E). Teams will initially be trained to follow up down referred patients on ART, and will later be supervised to initiate stable clients on ART. Counselors will be trained to provide routine focused HIV prevention counseling to clients on ART. This will also be included in routine treatment readiness training for patients. Staff will be trained to provide services with a French/Swahili interpreter to increase access to refugees/asylum seekers.

ACTIVITY 3: Pharmacy systems

Pharmacy systems will be strengthened to support drug chain management. Commodity procurement will be largely the responsibility of the provincial government, and McCord Hospital has been accredited as a KwaZulu-Natal Department of Health (KZNDOH) site, with the result that decentralized ARV service sites will also fall under the KZNDOH. Provision of ARV drugs, test kits and labs will be supplied by the DOH as a cost-share. Exploratory discussions are being held with Partnership For Supply Chain Management (PFSCM), a PEPFAR partner, to support commodity procurement at the NGO and corporate sites whilst accreditation of these sites is being negotiated with the KZNDOH.

ACTIVITY 4: Technical support

These activities will build capacity through technical support, mentorship and supervision to implement a comprehensive care and treatment program. This project will provide experienced staff to each site on a weekly basis to ensure that ARV services are seamlessly linked with wellness services, TB/HIV and PMTCT to strengthen continuity of care and patient retention. This will be supported by development of referral tools and regular M&E feedback with problem solving support.

ACTIVITY 5: Pediatric ART

McCord/Zoe Life will provide technical support to increase provision of ART to children. Staff from the municipal and NGO sites will attend a preparatory workshop in which an approach to increasing pediatric services will be formulated. Technical support will be offered to integrate ARV services into current vertical services such as PMTCT, TB, children's clinic, immunization services and community-based psychosocial services. Staff will be encouraged to implement routine testing of children, and assistance will be given to develop effective systems which ensure referral of infected children to voluntary counseling and testing, HIV care, and other programs.

ACTIVITY 6: Referrals

McCord/Zoe Life will assist in strengthening referrals and linkages by establishing a system of up referral for specialized or hospital-based care, and down referral from any accredited ARV site to the municipal clinics and NGO sites for patients living in the area; and establish referrals for workers receiving ART (workplace program).

ACTIVITY 7: Adherence

A strong community-based family-centered adherence component with existing and new role-players for continuity of care between facility and community will be developed. Where possible, treatment readiness and adherence support programs will be decentralized further into community facilities.

ACTIVITY 8: M&E

The project will develop and implement a model of M&E that can be integrated into, as well as strengthen the current data collection systems for partners across both community and vertical programs and up to the secondary and tertiary level. This will improve quality, ensure a multidisciplinary continuum of care and manage referral pathways.

ACTIVITY 9: Staff programs

Partnerships will be developed to provide ARV services to employees who do not have access to medical insurance.

Sustainability at the municipal clinic sites is addressed by assisting sites to become accredited with the KZNDOH. This project will build human capacity to effectively manage the program without ongoing technical assistance. NGO sites will be assisted to build infrastructure and referral networks to ensure sustainability of services. The long-term plan for the NGO sites is to build strong relationships with nearby clinics where clinical capacity can be increased to take over clinical aspects of decentralized ART. These

institutions will be included in FY 2008 funding to become accredited sites. NGOs will be assisted to source other funding. The workplace services will be funded as a public-private partnership. Where possible, corporate occupational health clinics will be assisted to become accredited KZNDOH sites.

The McCord Hospital activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.