SUMMARY: The PATH prevention of mother-to-child transmission (PMTCT) project will improve the quality, availability, and uptake of comprehensive PMTCT services in Eastern Cape by strengthening National Department of Health (NDOH) systems that support the delivery of high-quality, comprehensive PMTCT services, building the capacity of health facilities and staff to provide comprehensive PMTCT services, and increasing community engagement and leadership in promoting, supporting, and utilizing PMTCT services. Major emphasis areas are training and community mobilization/participation, with minor emphasis on quality assurance and supportive supervision. Primary target populations include, people living with HIV (PLHIV), pregnant women, HIV-exposed and infected infants, South African based volunteers and nurses, and provincial and district HIV and PMTCT coordinators.

BACKGROUND: This is a new activity. The Eastern Cape Department of Health (ECDOH) has been actively involved in program design and preparation and has provided direction on geographical focus. The program supports the South African Government's HIV/AIDS Strategic Plan, the Eastern Cape's Comprehensive HIV/AIDS/STI/TB Program, and the Strategic Plan for US-SA Cooperation. PATH, the managing partner, will provide technical, programmatic, and financial leadership. The ECDOH will be the largest partner, providing all the facilities, systems, and local personnel. Health Information Systems Programme (HISP) will be responsible for monitoring and evaluation. South African Partners, an NGO, will lead the community support and mobilization interventions. There will also be a small grants program for community-based organizations. PATH will address the root causes of gender inequity by examining values and norms (a key legislative issue). The project will provide information and support for infant feeding choices and will help clients assess their needs, considering issues such as the risk of stigma and discrimination associated with not breastfeeding. The project will provide holistic psychosocial support to HIV-infected women. The project's emphasis on community mobilization will be led by PLHIV leaders- -the majority of whom are women, will increase knowledge about PMTCT, promote understanding of PMTCT as the equal responsibility of men and the community, and work toward transforming current norms, stigma and discrimination that hold women solely responsible for having HIV and transmitting HIV to children.

ACTIVITIES AND EXPECTED RESULTS: The program goals are to increase utilization of high-quality, comprehensive PMTCT services in EC. This project will strengthen the ability of current PMTCT facilities to provide a minimum package of services, enable the ECDOH to expand PMTCT services by training and supporting providers such that they can provide comprehensive services, and raise awareness of and support for PMTCT service use within communities. The project is focused on the public sector and dependent communities only. The project will use three strategies to meet its goals, each working at a different level of health service delivery.

ACTIVITY 1: Systems strengthen This strategy will address critical higher-level NDOH systems that influence access to and provision of high-quality, comprehensive PMTCT services. Interventions will strengthen human resource capacity: training existing but untrained facility staff (e.g., nurses, midwives, lay counselors) to provide PMTCT services, reinforcing the skills of current PMTCT staff, and orienting other staff (e.g., child/wellness clinic nurses, community health workers) who help ensure a continuum of care. Training will focus on HIV counseling and testing, measuring CD4 cell counts, clinical staging, psychosocial support, antiretroviral treatment (ART), and follow up and care for the exposed child, including piloting polymerase chain reaction (PCR) testing. A second set of interventions will ensure that monitoring and supervision systems are fully operational at all levels (district, local service area, facility), providing on-site technical support as needed. A third set of interventions will strengthen ECDOH data and logistic systems, improving the quality of data recorded, collected, reported, and used at all levels. The project will also work with the ECDOH to address specific policy and guideline issues that directly affect PMTCT services. Finally, the project will improve referral systems, especially referral of pregnant or postpartum women and their children to antiretroviral (ARV) care and treatment sites and pediatric centers.

ACTIVITY 2: Capacity building The project will work at all levels of service delivery to strengthen the provision of high-quality, comprehensive PMTCT services. The project will focus on priority hospitals

and select feeder-community health centers and clinics to ensure women have access to the full continuum of PMTCT services, from the first antenatal care visit through follow-up of the mother and baby after birth. The package of interventions will be tailored to each facility's needs and may include training in essential PMTCT skills, monitoring and supervision to maintain high-quality services and upgrade staff skills, data management for ongoing corrections and decision-making, integration of services to give women and babies necessary care and treatment, and linkages to the community so that PMTCT is accepted and used widely.

ACTIVITY 3: Increasing community engagement and leadership One of ECDOH's priorities is to broaden the role of the community in promoting, supporting, and utilizing PMTCT services. This includes providing health education, reducing stigma (a key legislative area), generating demand for services, working with the partners and families of HIV-infected women to increase support for PMTCT, developing community networks for client follow-up, and strengthening tangible links between the community and the facility. Underlying these interventions is the need to build capacity of community networks and organizations to implement and monitor programs. Interventions will strengthen HIV prevention programs, provide PMTCT information, reduce stigma; strengthen peer support for HIV-infected pregnant women; and improve community-facility collaboration to increase local ownership and utilization of services.

ACTIVITY 4: Producing Job-AIDS to assist women in decision making around infant feeding choices PATH will develop a series of job aids and materials for health workers and mothers such as handouts on feeding options, flip chart and counseling cards for infant feeding counselors on feeding options, AFASS, lactation and breastfeeding, basic maternal nutrition guidance, wall charts A final determination of the exact materials needed, languages and quantities will be determined at the assessment stage.

The new HIV & AIDS and STI Strategic Plan for South Africa calls for a new policy on the drug regimen used in PMTCT, suggesting that the policy should be updated according to the WHO Guidelines. PATH will establish a pilot project in ten sites in the Eastern Cape Province and implement dual therapy for PMTCT services. This project will be used to establish a "best practice" model for the Eastern Cape, whereby activities can be rolled out to other districts and facilities. These sites will be determined after formative and baseline research is conducted. The pilot will be set up at sites which are already providing ARVs. In year one, appropriate sites will be identified, a protocol will be developed, staff will be trained, and services will be delivered.

SUMMARY:

PATH proposes to support prevention and control of MDR-TB and XDR-TB in the Southern African region and thus reduce the potential for accelerated mortality in HIV-infected individuals especially through activities targeting gaps in several specific areas of need: improved infection control practices, improved laboratory practices, and improved capacity for planning and implementing strategies to address MDR-TB and XDR-TB in the medium term.

BACKGROUND:

South Africa ranks seventh in the world in burden of tuberculosis and second in the burden of HIV. The recent emergence of extensively drug resistant TB (XDR-TB) outbreaks in South Africa with extremely high mortality among HIV-infected cases has made addressing the threat of MDR-TB and XDR-TB in this high-HIV setting a priority for South Africa and the international TB control community. The Global MDR-TB and XDR-TB Response Plan 2007-2008 ranks South Africa as fourth on the priority list of countries for action on MDR/XDR-TB, estimating a current burden of 10,348 MDR-TB cases among all cases, or 2.6% of total TB cases. WHO's Global TB Report in 2007cited better drug resistance surveillance, more effective patient support, and improved infection control as urgent responses to contain drug resistance and prevent development of new drug-resistant cases in South Africa. The Global MDR-TB and XDR-TB Response Plan supports these priorities. Objective 5 of the Plan is to "foster sound infection control measures to avoid MDR-TB and XDR-TB transmission to protect patients, health workers, others working in congregate settings, and the broader community, especially in high HIV prevalence settings."

ACTIVITIES AND EXPECTED RESULTS:

In recognition of the extensive work that is already underway or has been planned in the areas of infection control, laboratory capacity, and MDR-TB control planning in the region by a large number of organizations, PATH proposes to play a primarily catalytic role in moving MDR-TB control activities forward by working with the government of South Africa and all other stakeholders to craft coherent strategies that promote a unified approach to infection control, laboratory capacity-building, and MDR-TB response planning and that take advantage of each partner's strengths. In coordination with all partners, PATH will document best practices and lessons learned, identify areas that require further study, support country- and provincial-level action planning, and coordinate technical assistance as requested to strengthen the region's response to the dual epidemics of TB and HIV and the threat of MDR-TB/XDR-TB.

ACTIVITY 1: Support the government of South Africa to build capacity for the provision of standardized infection control

1) Establish a multi-sectoral network of key infection control stakeholders for a more strategic and coordinated response, to share best practices and lessons learned, leverage programmatic resources, and identify priority areas for operations research. 2) Engage all partners, including the South African Government in developing a training strategy and plan, adapting existing materials and resources to create standardized training materials that support the infection control policies and guidelines developed by the South African Government and the WHO. 3) Strengthen local capacity to implement a comprehensive infection control training program designed above.

ACTIVITY 2: Support the government of South Africa to build capacity to identify and effectively manage drug-resistant TB cases though support for laboratory strengthening and implementation of strategies to combat drug resistant TB.

1) In collaboration with in-country partners, pilot test the new MDR-TB/XDR-TB Country Assessment Tool being developed by PATH in conjunction with Stop TB, GLC, and others to inform action planning for MDR-TB control and identify additional technical assistance needs.

2) Organize a consultation to review, and adapt as needed, guidelines for management of drug-resistant TB and discuss next steps needed to manage mobile and cross-border TB cases effectively. 3) Establish a learning network that will focus on the management of drug-resistant TB to serve as a forum for peer exchange among SADC countries and will capture successful regional approaches and challenges that need to be addressed.

ACTIVITY 3: Provide technical assistance to Eastern Cape Province to strengthen their TB/HIV programs with a particular emphasis on data collection and utilization and monitoring and evaluation.

ACTIVITY 4: Coordinate an evaluation to assess implementation of enhanced diagnostic techniques for multidrug-resistant TB (MDR-TB) in HIV-infected TB patients. In selected high HIV-prevalence sites, all HIV-infected TB patients will undergo early culture and drug susceptibility testing at diagnosis to enable earlier detection of MDR-TB to shorten time to delivery of life-saving anti-TB and antiretroviral medication.

There will be no direct targets associated with this activity as PATH will be supporting system strengthening at the national level.