INTEGRATED ACTIVITY FLAG:

This activity relates to St. Mary's Hospital activities in ARV Services (#8264). Plus Up funds will be used to maintain St. Mary's Hospital's current PMTCT program as well as expand and offer services to more HIV positive pregnant mothers in the community surrounding St. Mary's Hospital.

SUMMARY:

The proposed St. Mary's Hospital PMTCT project addresses comprehensive and holistic preventative HIV treatment and care of pregnant women, including the provision of antiretroviral treatment (ART) through clinic-based and home/community-based activities. The major emphasis area for this project is human resources. A minor focus will be on linkages with other sectors, and training. The primary target populations are infants and pregnant women (both HIV-positive and HIV-negative), and clinicians providing services to them.

BACKGROUND:

Since 2001 St. Mary's Hospital has successfully implemented a PMTCT program, named ‘Born to Live' and was initially funded by CMMB. This funding has subsequently ceased. Since FY 2005, the USG has added additional funding to St. Mary's Hospital to focus on pregnant women. St. Mary's serves a district of 750,000 people, which is the Inner/Outer West Sub-Districts of the Ethekwini Metropolitan area in KwaZulu-Natal (KZN) province. It is estimated that 50-60% of all women that attend the antenatal clinic at St. Mary's are HIV-positive, and would require preventative treatment. Just over 8,500 pregnant mothers have attended counseling and testing through this program since its inception, and around 4,000 positive mothers have received antiretroviral treatment. The program has a 96% success rate in terms of preventing HIV being passed from mother to child.

ACTIVITIES AND EXPECTED RESULTS:

As an accredited SAG antiretroviral (ARV) rollout site and as an extension of the service level agreement the Hospital has with the Department of Health, St. Mary's will contribute to a greater extent to the success of the SAG ARV rollout plan through this project. The funding will allow St. Mary's to maintain and extend their existing PMTCT numbers.

Activity 1: Clinical Service Provision PMTCT services are provided to pregnant women at the primary health care clinic. These services include group counseling, individual VCT, CD4 blood counts, and weekly/fortnightly/monthly counseling. In addition there will be a focus on counseling the male partners of the pregnant mother, with the aim to address antiretroviral treatment if required.

The program ensures that pregnant women who have a CD4 count of below 200 have access to antiretroviral drugs (HAART); and preventative antiretroviral drugs are provided to mothers who have a CD4 count above 200. Within the antenatal clinic, patients who have received PMTCT are followed up post-delivery and if clinically appropriate, placed on antiretroviral treatment. This is a seamless program which also places the children of HIV-infected mothers on ART if clinically appropriate.

Activity 2: Community-based Services The hospital and referring clinics are involved in HIV and AIDS community mobilization activities. Home-based care networks will follow-up and support patients to ensure linkages to treatment and monitoring of exposed infants. This is the primary function of the therapeutic counselors.

Activity 3: Training All health care providers and administrative staff are trained to implement the program, but additional training that focuses on HIV and AIDS and TB management will be provided to all clinical staff through the track 1 Catholic Relief Services funding that is due to commence in May 2007.

Activity 4: Lab Services Emergency Plan funding will also support lab services, which are outsourced to a private provider, Toga Laboratories. Blood is drawn at the site and collected via a courier service and delivered to the laboratories. Results are confidentially e-mailed or faxed back to the site within 48 hours of the laboratory receiving the blood samples.

Activity 5: Support Services A comprehensive nutrition program will be implemented to boost immunity with the patient cohort which will be the responsibility of the dietician employed at St. Mary's Hospital, and is supported via a partnership with the Kwazulu-Natal Department of Health (DOH). As an accredited ARV rollout site this is a vital component to the success of the treatment program. In addition there are other support services provided from the rehabilitation department and the social worker. The rehabilitation department will provide physiotherapy to any exposed babies that require support post delivery.

These activities contribute directly to the overall PEPFAR objectives of 2-7-10 as HIV-infected women will be identified, appropriately treated, cared for and supported. It is further enhanced as the program is working in a hospital, primary health care and antenatal setting. All activities will continue to be implanted in close collaboration with the KwaZulu-Natal Department of Health to ensure coordination and information sharing, ensuring the success of the program.

INTEGRATED ACTIVITY FLAG:

This activity relates to St. Mary's Hospital activities in ARV Services (#8264). 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:

St. Mary's Hospital in Durban, KwaZulu-Natal will implement palliative care activities that encompass human resources, training and consumables. A dedicated palliative care team will identify and provide clinical, spiritual, psychosocial and preventive support to the HIV-infected client and family. A hospital-wide education program will be initiated to enhance knowledge of palliative care practice. In addition a number of consumable items will be purchased to assist in managing pain and symptoms related to HIV and AIDS and ensuring comfort of people living with HIV (PLHIV). The emphasis areas of the project are related in particular to human resource support for the palliative care team, training, commodity procurement and the development of networks/linkages/referral systems. The primary target population is people affected by HIV and AIDS and healthcare providers.

BACKGROUND:

This is a new program funded in FY 2007, although St. Mary's has received previous PEPFAR funding as a sub-partner to CRS. The project is an expansion of the current palliative care program that functions at St. Mary's Hospital. The hospital, established in 1927, serves a peri-urban/rural community of 750,000 people, a third of which are HIV-infected. The community has a high unemployment rate of around 60% and an estimated 25,000 people in the community require ART. On an annual basis approximately 3,000 of St. Mary's inpatients require end-of-life palliative care support, 35,000 require palliative care, and over 2,000 patients are currently on ART at the hospital, who by definition fall into the category of people requiring palliative care including ART adherence support.

ACTIVITIES AND EXPECTED RESULTS:

Two activities will be carried out in this program:

ACTIVITY 1: Dedicated Palliative Care Team and Trained personnel to Ensure Delivery of Quality Services

The overall objective of this activity is to ensure that patients who require palliative care and their affected families are adequately supported in the hospital and in their surrounding communities; including clinical, spiritual, psychological and social support.

Patients and families requiring palliative care will be identified in the inpatient, outpatient and ART clinic and hospice care settings. The HIV-related services offered by the hospital and its hospice service is based on the belief that the palliative care activity is central and automatically provides a network of services, from counseling and testing, stigma reduction, ART and adherence, counseling and support to the individual and family, end of life care, referral to other organizations and continuous education and support thereafter to all concerned. The palliative care team will work with other facility-based health providers to ensure that HIV-infected adults and children in all facility settings are either provided or referred (with follow-up) for evidence-based preventive care interventions which include the following: OI screening and prophylaxis (including cotrimoxazole, TB screening/management), counseling and testing for clients and family members, safe water and personal hygiene strategies to reduce diarrheal disease, HIV prevention counseling, provision of condoms, referral for family planning services for HIV-infected women, appropriate child survival interventions for HIV-infected children and nutrition counseling, clinical measurement, nutrition monitoring and targeted support based on WHO criteria for severely malnourished PLHIV. The package of services also includes basic pain and symptom management and facility-based support for adherence to OI medications (including cotrimoxazole prophylaxis and TB treatment) and antiretroviral therapy (ART). Community and home-based psychological support, stigma reduction

strategies and adherence support for OI medications and ART will be provided by therapeutic counselors who are trained PLHIV, employed by the hospital that visit the patients and their families in the community. Attention will be given to increasing the gender equity in the HIV and AIDS programs, increasing male involvement in the program, addressing stigma and discrimination, and partnerships with local NGOs, FBOs and CBOs. In addition to care for PLHIV, therapeutic counselors and hospital staff will also expand their provision of psychological, spiritual and social support of affected family members. A complex referral network to a number of organizations, inter alia the KwaZulu-Natal Department of Health, the Ethekwini Metropolitan (Durban), other NGOs, the Highway Hospice, and the Dream Centre exists and is used on a proactive basis. A dedicated palliative care professional nurse and pastoral care worker will manage this activity, with additional involvement of other members of the palliative care multi-disciplinary team including hospital doctors and nurses, a social worker and the community outreach coordinator. The palliative care program is managed and administered via the organizational arrangements pertaining to the hospital itself and relies on a multi-disciplinary team approach for service delivery.

Training & Volunteer Engagement: The program relies on both volunteer and fulltime qualified and registered healthcare professionals who require technical support and training. St. Mary's hospice care program is a member of the PEPFAR-funded Hospice and Palliative Care Association (HPCA) who is supporting St. Mary's with critical areas including staff training and clinical protocols so St. Mary's may meet the HPCA accreditation requirements essential to providing holistic quality health care to patients. In FY 2007, St. Mary's will scale up its palliative care training for all health professionals, volunteers and PLHIV therapeutic counselors involved in palliative care service delivery with training materials from HPCA and from the World Health Organization's (WHO) Integrated Management of Adolescent Illnesses' (IMAI) program. All modules of IMAI will be utilized, however, the IMAI module on palliative care which will be made available to all the nursing students and staff at St. Mary's who will be directly involved in palliative care. Clinical protocols designed and approved by the HPCA are used for support and clinical services for opportunistic infections and pain assessment and management.

St. Mary's has a number of partnerships with US universities and interest and support from US-based volunteers. On average, four to six U.S. volunteers will be accommodated by St. Mary's on a monthly basis (supported with non-PEPFAR funds).

ACTIVITY 2: Commodity Procurement

Provision has been made for palliative care medications and commodities except for items which directly improve the comfort of PLHIV and adequate pain and symptom control, including medications for appropriate pain and symptom control (additional morphine for pain control, syringe drivers, anti-nausea medications and other drugs for symptom control). Provision for such palliative medications and supplies are included in this activity and are vital to the overall success of the program.

These activities contribute directly to the overall PEPFAR objectives of 2-7-10 as HIV-infected people will be identified, appropriately treated, cared for and supported. Family members affected will benefit directly from counseling and support within the hospital environment as well as within the community setting during home visits.

INTEGRATED ACTIVITY FLAG:

This activity is part of an integrated approach to the treatment of HIV and AIDS and associated conditions, which is also addressed in St. Mary's Hospital Basic Health Care and Support (#8262) narrative.

SUMMARY:

The proposed St. Mary's Hospital project addresses comprehensive and holistic HIV care and treatment, including antiretroviral treatment (ART) within a hospital setting, with a large focus on training at a community clinic level to ensure that stable patients, once down-referred from the hospital can be treated on a continuous basis at a community level. The major emphasis area for this project is human resources and the development thereof. A minor focus will be on community participation, and linkages with other sectors, and the capacity development of local organizations. The primary target populations will be the general population, people affected by HIV and AIDS, discordant couples in special populations, the community, the South African Government (SAG), healthcare providers and other groups and organizations.

BACKGROUND:

Since 2003 St. Mary's hospital has successfully implemented an ART program based on holistic and comprehensive treatment of HIV and AIDS patients. This program was funded through another PEPFAR partner, Catholic Relief Services (CRS) as part of their Track 1 program. Since FY 2005, the USG has added additional funding to St. Mary's Hospital to focus on pregnant women. Successful treatment of HIV and AIDS requires that patients maintain adherence to medication, incorporating overall wellbeing, including nutrition. Patients on ART at St. Mary's have maintained average adherence of 90%, which is largely due to a patient-centered model of care. In the district that St. Mary's serves, an estimated 25,000 patients require immediate treatment. Just over 2,000 patients are currently on treatment at the hospital.

ACTIVITIES AND EXPECTED RESULTS:

As an accredited SAG antiretroviral (ARV) rollout site and as an extension of the service level agreement the Hospital has with the Department of Health, St. Mary's will contribute to a greater extent to the success of the SAG ARV rollout plan through this project. The funding allows St. Mary's to continue to initiate patients on ART, and once stable, down refer them to the community clinics in the area. St. Mary's will assist with the training of health workers at clinic level to facilitate this. St. Mary's has identified local partners as well as the World Health Organization's Integrated Management of Adult Illnesses (IMAI) training toolkit as a vehicle for training. The toolkit makes use of people living with HIV (PLHIV) as expert trainers which are directly aligned to the success of St. Mary's ART program. All three sites within St. Mary's Hospital strongly emphasize human capacity development. Within the entire Hospital setting (including the three ART sites) patients who have tested HIV positive but whose CD4 counts and staging preclude them from treatment form part of a wellness program. Opportunistic infections are treated at every point of care, service and nutrition interventions made, as per government protocols and guidelines. Social support services, which may take the form of social grants in accordance with the SAG guidelines, are also initiated as appropriate, providing access for patients to financial resources.

As stated previously, St. Mary's is a Department of Health accredited ARV rollout site and the partnership will be enhanced and expanded through the additional PEPFAR funding. CRS funds staffing in the St. Mary's treatment sites, with the exception of the PMTCT site for which the staffing is funded through a grant from CDC (currently but has been included into the targets 2007 and 2008). Within the antenatal clinic, patients who have received PMTCT are followed up post-delivery and if clinically appropriate, placed on antiretroviral treatment. This is a seamless program which also places the children of HIV-infected mothers on ART if clinically appropriate. The program also provides education and nutrition support in partnership with the KwaZulu-Natal Department of Health. Pediatric HIV care is strengthened through early testing and diagnosis. The main challenge is polymerase chain reaction (PCR) testing and follow-up in this area, given that 19 clinics

are being supported in the process.

The community clinics surrounding St. Mary's will be linked into St. Mary's via the referral patterns already established. The implementing organization will be St. Mary's Hospital and local partners will be recruited to assist with the WHO ART training modules. Gender issues will be addressed throughout the project as well as stigma and discrimination, twinning, the use of US-based volunteers from a training perspective, as stated in the palliative care activity narrative. Gender equity will become an increased focus as women are provided with resources (grants, nutrition) and capacitated to become self sufficient. Through a partnership with the Treatment Action Campaign (TAC) male norms and behaviors will be addressed directly through patient education, encouraging prevention, 'know your status', and promoting family values. A comprehensive nutrition program will be implemented to boost immunity with the patient cohort which will be the responsibility of the dietician employed at St. Mary's Hospital, and is supported via a partnership with the Kwazulu-Natal Department of Health (DOH). As an accredited ARV rollout site this is a vital component to the success of the treatment program.

By strengthening the down-referral system and providing technical assistance to the public sector, St. Mary's hospital is contributing to the PEPFAR 2-7-10 goals.