INTEGRATED ACTIVITY FLAG:

The follow-on to the RHRU Program's activities is part of an integrated program that includes CT (#9445), TB/HIV (#9444), Basic Health Care and Support (#9448) and ARV Services (#9446).

SUMMARY:

The Reproductive Health and HIV Research Unit's (RHRU) PEPFAR-funded program, subsequently referred to as the "Follow-on to the RHRU Program" (FRP), will be re-competed through an Annual Program Statement (APS) for 2007.

The FRP, as part of an outreach project in deprived inner city areas, will provide prevention, clinical and support services to sex workers in the many brothels in Hillbrow, Johannesburg. Activities will include training, workshops and other outreach covering condom usage and negotiation, partner reduction strategies, and HIV risk reduction. The primary emphasis area for these prevention activities is information, education and communication (IEC), with additional efforts in development of network/linkages/referral systems and local organization capacity development. The primary target populations for these interventions are women, men, people living with HIV, HIV-infected women, sex workers and their partners/clients, brothel owners, community-based and non-governmental organizations (CBOs/NGOs).

BACKGROUND:

RHRU, which is affiliated with the University of the Witwatersrand in Johannesburg, currently provides technical support to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa, which includes the national ARV roll-out. Under PEPFAR funding since FY 2004, RHRU has provided regular on-site support, direct treatment, training and quality improvement to Department of Health sites in three provinces. The FRP will continue these activities, and will initiate an inner city program focusing on providing support to a complete up and down treatment referral network. In addition, FRP will continue the provision of counseling and testing (CT), palliative care and prevention services. FRP will seek to develop models of service delivery that can be replicated and expanded, and produces findings from lessons learned and targeted evaluations to disseminate and share with others.

It should be noted that the success of antiretroviral treatment (ART) scale-up depends on the comprehensive approach detailed in other program areas. In particular, the strengthening of referral from other primary healthcare programs such as tuberculosis (TB), family planning and STI treatment is critical. Prevention is an integral part of this system, and the FRP will focus its condoms and other prevention program on high-risk groups such as sex workers and their clients, people infected with HIV, and also on building capacity of the CBOs and NGOs with which it works. FRP will also continue to develop strategies to address underserved communities affected by HIV, such as couples, high risk groups such as young people, and gender-based interventions with women at risk, including pregnant women and sex workers, and men.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: HIV Prevention for Women At Risk

FRP will target a large community of sex workers with prevention and care services, as well as treatment referral. The project will be located in the deprived inner city, which is densely populated, transitory and poor, with high HIV and unemployment rates. All women will be referred for CT, and those with appropriate CD4 counts will be referred for ARV treatment. New treatment sites will be identified in needy areas of the city, and the organization will work with local public sector clinics in the area to sensitize staff to the special needs of this difficult-to-reach group and to provide outreach clinics in local brothels. FRP will also work with brothel owners, and clients and partners of sex workers to increase their awareness and affect a change in their norms and behaviors regarding HIV and AIDS. A specific focus will be on changing gender norms through workshops and trainings, which will include such topics as alternatives to risky behavior, women's rights,

and reduction of gender-based violence.

The project will provide prevention outreach services including sexually transmitted infection (STI) management provision of condoms, contraception and HIV prevention education, as well as support for those who wish to leave sex work. The project will play a critical role in raising awareness of HIV services and prevention through workshops and event days, and by distributing IEC materials. Furthermore, this gender-related project will conduct HIV counseling and testing on high risk and difficult-to-access groups, and will relate to the development of health networks and linkages by providing referral to HIV and TB care and treatment services where necessary. To aid the expansion and sustainability of this program, the local health authority will also contribute to this project.

ACTIVITY 2: Prevention for HIV-Infected People

There is very little focus on prevention in South Africa among people already infected with HIV. Prevention work to encourage safe-sex behaviors and limit infection and re-infection for those already positive is currently being developed by some South African organizations. Innovative prevention methods, the development of which will draw on models that have proven successful in other settings, will be introduced in South Africa. Clinicians will be trained in this specific focus area, and the program will be monitored and evaluated for efficacy. Programs that are proven successful will be expanded into other areas and used as examples for other organizations.

ACTIVITY 3: Community-Based Prevention

FRP will extend care and support services further into inner city areas, and incorporate prevention and behavior change into their activities. With a combination of private sector and PEPFAR funding, FRP will run an information and support centre in a high-risk area, the location of which is to be determined. A team of counselors and caregivers will be launched from this centre into the surrounding community. Team members will link with 30 households a week, with the primary purpose of educating them on HIV prevention and understanding risk. Using prevention messages as the entry to the household they will also assist them as needed with home-based care, reaching orphans and vulnerable children, men and women, as well as contributing to the destigmatization of HIV and AIDS.

FRP will contribute to PEPFAR's 2-7-10 goals by providing prevention services to a most-at-risk population in a densely populated, poor, and highly transient inner city community.

INTEGRATED ACTIVITY FLAG:

This activity relates to The Follow-on to the RHRU Program's activities in Other Prevention (#9449), CT (#9445), TB/HIV (#9444), and ARV Services (#9446). 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 Reproductive Health and HIV Research Unit's (RHRU) PEPFAR-funded program, subsequently referred to as the "Follow-on to the RHRU Program" (FRP), will be re-competed through an Annual Program Statement for 2007.

The FRP's Basic Care and Support activities will be part of an integrated program and will specifically include: (1) palliative care arising from clinical (both ARV and non-ARV) services rendered by FRP staff through the activities described under the ARV Services program area; (2) the provision of psychosocial support to sex workers, (3) the provision of support, home-based care and referral; and (4) the implementation of health provider training in all aspects of palliative care. The major emphasis area for these activities is quality assurance and supportive supervision, with additional focus on human resources, development of network/linkages/referral systems, and training. Populations targeted for these interventions include PLHIV (children, youth and adults), HIV-affected families, commercial sex workers, refugees, and public doctors, nurses, pharmacists, and other health care workers.

BACKGROUND:

RHRU, which is affiliated with the University of the Witwatersrand in Johannesburg, currently provides technical support to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa, which includes the national ARV roll-out. Under PEPFAR funding since FY 2004, RHRU has provided regular on-site support, direct treatment, training and quality improvement to DOH sites in 3 provinces. The FRP will continue these activities, and will initiate an inner city program focusing on providing support to a complete up and down treatment referral network. In addition, FRP will continue the provision of counseling and testing (CT), palliative care, and prevention services. FRP will seek to develop models of service delivery that can be replicated and expanded, and produces findings from lessons learned and targeted evaluations to disseminate and share with others.

It should be noted that the success of ARV treatment scale-up depends on the comprehensive approach detailed in other program areas. In particular, the strengthening of referral from other primary healthcare programs such as TB, family planning and STI treatment is critical. Basic Health Care and Support is an integral part of this system, and the FRP will focus this part of its program on PLHIV, in impoverished areas such as the Hillbrow neighborhood in Johannesburg, by delivering high quality palliative care, psychosocial support, and intensive training of doctors, nurses, and other health care professionals. Furthermore, FRP will continue to develop strategies to address underserved communities affected by HIV, such as couples, high risk groups such as young people, and gender-based interventions with women at risk, including pregnant women and sex workers, and men.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Provision of Palliative Care

Through comprehensive support and quality improvement programs to the Johannesburg inner city and through Mobile Clinical Support Teams operating in North West, KwaZulu-Natal (KZN) and Gauteng provinces, FRP will continue to provide the preventive care package and opportunistic infection prevention and treatment, screening for syndromic STIs, provision of regular CD4 counts, and pain and symptom management in conjunction with ARV treatment to adults and children in partnership with the DOH. In addition, STI treatment will be provided to HIV-infected patients at a network of local

health authority sites in the inner city of Johannesburg, and via the gender-related projects described in the Other Prevention program area. Furthermore, health care and support will be provided to in-patients at a step-down and palliative care facility in KwaZulu-Natal. Lastly, as described in the Other Prevention section, FRP will provide home-based care in the deprived inner city suburb of Hillbrow through its new program of community outreach.

ACTIVITY 2: Psychosocial Support

FRP or its sub-partners will provide psychosocial support through counseling, wellness programs and befriending. FRP will assist with income generation, material support programs, and support group facilitation. FRP will be key in the strengthening of adherence initiatives through their work in HIV treatment sites and within the community. FRP will also assist the DOH in providing continuity and support to the down referral process that must take place to enable ARV program scale-up. Currently men are under-represented in seeking ARV treatment, and a family-based approach to care ensures all family members are provided with treatment and prevention initiatives where appropriate. Therefore, FRP will also address gender issues by developing and providing specialized services such as family clinic days 3 days per week, male clinic 5 days per week for CT and ART, and male only support groups for families and men in order to improve access for these two key groups (key legislative area). In addition, work with antenatal and postnatal clinics, FRP will provide psychosocial support and specialized adherence counseling for HIV-infected pregnant women and new mothers. Refugee populations, often a neglected, overlooked group, will also be targeted with services provided by FRP. A special program for the care of refugees (key legislative area) will be expanded to include more systematic identification of refugees seeking assistance through public facilities. These individuals will be counseled and provided full referral and follow up services to the NGO and private sectors to receive care, treatment and support if they are ineligible to receive services through the public sector programs.

ACTIVITY 3: Human Capacity Development

The objective of the training is to increase skills in the delivery of quality palliative care services including elements of the preventive care package. FRP will provide on-site and didactic training to DOH and NGO doctors, nurses and counselors, and will specifically target ARV and non-ARV sites that need to be able to care for, manage and appropriately refer HIV-infected clients. FRP will also provide mentoring to DOH staff via bedside teaching, case reviews, the sharing of quality improvement approaches, and support during consultations. FRP's Primary Health Care Project will provide tools, training and on-site guidance to DOH staff in primary healthcare sites relating to quality improvement of primary healthcare services, including palliative care. This project will also provide to support to ARV treatment and is described in the ARV Services section.

These activities contribute significantly to both the vision outlined in the USG Five-Year Strategy for South Africa and to the 2-7-10 objectives by ensuring that HIV-infected individuals and their families are able to access comprehensive care, and by expanding access to these services in both the public and private sector.

INTEGRATED ACTIVITY FLAG:

FRP's TB/HIV activities are part of an integrated program that includes Other Prevention (#9449), CT (#9445), Basic Health Care & Support (#9448), and ARV Services (#9446).

SUMMARY:

The Reproductive Health and HIV Research Unit's (RHRU) PEPFAR-funded program, subsequently referred to as the "Follow-on to the RHRU Program" (FRP), will be re-competed through an Annual Program Statement for 2007.

This section describes the provision of TB clinical services and the expansion of referral networks and service integration in a deprived inner city area of Johannesburg, South Africa. In addition, FRP will support commencement of ARV services in two TB hospitals in KwaZulu-Natal (KZN). The major emphasis area is the development of network/linkages/referral systems, with additional emphasis in training and quality assurance and supportive supervision. Target populations for the TB/HIV work include men, women, PLHIV (adults) and public health doctors, nurses, and other health care workers.

BACKGROUND:

RHRU, which is affiliated with the University of the Witwatersrand in Johannesburg, currently provides technical support to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa, which includes the national ARV roll-out. Under PEPFAR funding since FY 2004, RHRU has provided regular on-site support, direct treatment, training and quality improvement to DOH sites in 3 provinces. The FRP will continue these activities, and will initiate an inner city program focusing on providing support to a complete up and down treatment referral network. In addition, FRP will continue the provision of counseling and testing (CT), palliative care, and prevention services. FRP will seek to develop models of service delivery that can be replicated and expanded, and produces findings from lessons learned and targeted evaluations to disseminate and share with others.

It should be noted that the success of ARV treatment scale-up depends on the comprehensive approach detailed in this and other program areas. In particular, the strengthening of referral from other primary healthcare programs such as TB, family planning and STI treatment is critical. In FY 2007, FRP will continue to focus on further strengthening DOH adult and pediatric treatment, and to develop a family-based approach to TB/HIV care and treatment in the public sector. Furthermore, FRP will continue development of strategies to address underserved communities affected by HIV, such as couples, high risk groups such as young people, and gender-based interventions with women at risk, including pregnant women and sex workers, and men.

Although approximately 60% of TB patients in South Africa are HIV-infected, published data have shown that a low number of patients are referred from surrounding TB sites to ARV services. A large percentage of these patients will qualify for immediate ARV treatment, and represents an untapped population requiring immediate access to ARVs. FRP will work with the local authority to provide TB clinical services and training, with the support of PEPFAR-funding. FRP will integrate TB screening and treatment into general palliative care training. In addition, FRP programs will assist in treating hundreds of HIV-infected people for TB. In FY 2007, FRP will train healthcare providers, and emphasize TB and HIV integration as part of on-site technical support to ARV treatment sites and primary healthcare clinics and their referral facilities.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: TB Treatment Support, Integration, and Referral

TB treatment represents an ideal opportunity for entry into an ARV program. Patients being treated for TB have to deal with the public health system entry, daily adherence, drug toxicity, and regular follow-up evaluation, all of which are also key components of the ARV program. Helping healthcare workers understand that referral from TB sites

should be seamless, and encouraging patients to test for HIV through the DOH program, will ensure a constant stream of well-prepared co-infected patients entering the system.

FRP will work within the existing TB services in 3 provinces to expand CT, CD4 staging, initiation of opportunistic infection prophylaxis (cotrimoxazole) and preliminary ARV adherence advice. Counseling and Testing of TB Patients is covered in the CT narrative as well. FRP works in the Department of Health (DOH) facilities and its staff will facilitate direct referral of correctly staged patients into ARV treatment sites, and ensure that other patients accessing ARVs in FRP sites in the 3 provinces are referred for TB treatment where necessary. This will include programs such as ante-natal care/post-natal care (ANC/PNC), women at risk, and programs increasing male health seeking behaviors. Additionally, in the case of very immuno-compromised patients with TB who require ARVs relatively quickly, FRP staff will train DOH workers in terms of the national guidelines, to recognize this urgency and refer the patients to appropriate clinics, while working with accepting ARV sites to similarly treat these cases with urgency.

ACTIVITY 2: Human Capacity Development

FRP will develop and scale-up TB/HIV training programs for TB service providers operating at all levels of facilities in the provinces in which FRP works. The primary focus will be on increasing access to ARV services from TB services through continual training and engagement with TB managers. This approach will maintain a steady stream of patients into their ARV programs (see ARV Services section for more information).

Although approximately 60% of TB patients in South Africa are HIV-infected, published data have shown that a low number of patients are referred from surrounding TB sites to ARV services. Plus up funds will be used by the RHRU to improve referral systems that include the tracking of individual TB patients through counseling and testing, wellness services, and ART. The RHRU will work with the local authority to expand TB clinical services and training and will integrate TB screening and treatment into general palliative care training. TB treatment represents an ideal opportunity for entry into an ARV program. Patients being treated for TB have to deal with the public health system entry, daily adherence, drug toxicity, and regular follow-up evaluation, all of which are also key components of the ARV program. Helping healthcare workers understand that referral from TB sites should be seamless, and encouraging patients to test for HIV through the DOH program, will ensure a constant stream of well-prepared co-infected patients entering the system. In addition, the RHRU will expand treatment of TB for HIV infected patients.

This activity will contribute to both the vision outlined in South Africa's Five-Year Strategy and to the 2-7-10 goals by identifying and directing more people to ART, and by increasing access to care.

INTEGRATED ACTIVITY FLAG

This activity also relates to activities described in the Condoms and Other Prevention (#9449), TB/HIV (#9444), Basic Health Care & Support (#9448), and ARV Services (#9446).

SUMMARY:

The Reproductive Health and HIV Research Unit's (RHRU) PEPFAR-funded program, subsequently referred to as the "Follow-on to the RHRU Program" (FRP), will be re-competed through an Annual Program Statement for 2007.

PEPFAR funds will support FRP to continue to directly provide voluntary counseling and testing (VCT) services, and to expand services tailored to target groups such as couples, children, and families, as part of an integrated prevention, care and treatment program. FRP will provide training and mentoring in voluntary counseling and testing to Department of Health (DOH) staff, to ensure that VCT is integrated into TB, STI and contraceptive services at all levels. Major emphasis in this program area is on quality assurance and supportive supervision, with additional emphasis on the development of network/linkages/referral systems, human resources, and training. These activities target HIV-affected families (children, youth and adults), sex workers, men, pregnant women, discordant couples and public health workers.

BACKGROUND:

RHRU, which is affiliated with the University of the Witwatersrand in Johannesburg, currently provides technical support to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa, which includes the national ARV roll-out strategy. Under PEPFAR funding since FY 2004, RHRU has provided regular on-site support, direct treatment, training and quality improvement to DOH sites in three provinces (Gauteng, KwaZulu-Natal and North West). The FRP will continue these activities, and will initiate an inner city program focusing on providing support to a complete up and down treatment referral network. In addition, FRP will continue the provision of VCT, palliative care and prevention services. FRP will seek to develop models of service delivery that can be replicated and expanded, and produces findings from lessons learned and targeted evaluations to disseminate and share with others.

It should be noted that the success of ARV treatment scale-up depends on the comprehensive approach detailed in other program areas. In particular, the strengthening of referral from other primary healthcare programs such as TB, family planning and STI treatment is critical. In FY 2007, FRP will continue to focus on further strengthening DOH adult and pediatric treatment, and on continuing the development of a family-based approach to HIV care and treatment in the public sector. Furthermore, FRP will continue to develop strategies to address underserved communities affected by HIV, such as couples, high risk groups such as young people, and gender based interventions with women at risk, including pregnant women and sex workers, and men. FRP will place a strong emphasis on quality assurance for all interventions supporting VCT and will draw on the tools that have a proven track record in terms of improving quality of care, such as pocket reminders for counselors, wall charts with trigger messages for clients and counselors, and routine performance assessments.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Voluntary Counseling and Testing

PEPFAR funds will support FRP to continue to directly provide VCT services, and to expand services tailored to target groups such as couples, children, families, men, pregnant women, and sex workers as part of an integrated prevention, care and treatment program. Discordant couples will be targeted for prevention education, and concordant couples can benefit from referral to a wellness program. Both groups will benefit from fertility and family planning advice. FRP will work closely with the national DOH and will seek to ensure that VCT is integrated into other health programs at all levels. In addition, FRP will focus on integrating VCT into TB, STI and family planning services.

ACTIVITY 1.1: Gender-based Voluntary Counseling and Testing

Approximately 70% of individuals currently accessing ARVs are women. FRP will develop a program which aims to address this gender inequality, and to increase the number of men who obtain HIV services. This will be done through the development of male-friendly VCT methods, such as family-centered counseling and testing, and interventions to encourage health-seeking behaviors. This program will contribute towards increasing gender equity in HIV and AIDS programs.

ACTIVITY 1.2: Family-Centered Testing

Children and families have special needs that will be addressed in the program. Previous work in antenatal clinics and in pediatric treatment will have given FRP the opportunity to promote family testing to DOH staff and community social workers, and to develop approaches to this activity. A youth-friendly VCT model will be developed and implemented in the inner city of Johannesburg. Age-appropriate counseling and testing techniques will be developed, and opportunities to scale-up counseling and testing of this group will be identified and interventions implemented accordingly.

ACTIVITY 2: Human Capacity Development

FRP will train counselors, doctors, nurses, and other healthcare workers to provide comprehensive and appropriate VCT services, in line with South African guidelines. This includes appropriate referral, and updates on new practice and current debates in an evolving field. In addition, FRP staff will provide mentoring to local NGOs, lay counselors, and DOH staff in the public sector facilities in which they work, through weekly supportive supervision sessions with all counselors and regular meetings to discuss the development and application of new practices.

PEPFAR Plus Up funds will support RHRU to continue to directly provide VCT services, and to expand services tailored to target groups such as couples, children, families, men, pregnant women, and sex workers as part of an integrated prevention, care and treatment program. Discordant couples will be targeted for prevention education, and concordant couples can benefit from referral to a wellness program. Both groups will benefit from fertility and family planning advice. RHRU will work closely with the national DOH and will ensure that VCT is integrated into other health programs at all levels. RHRU will focus on integrating VCT into TB, STI and family planning services. RHRU will train counselors, doctors, nurses, and other healthcare workers to provide comprehensive and appropriate VCT services, in line with South African guidelines, and will encourage provider initiated CT in all government assisted sites.

These activities expand VCT services to important high risk populations, and serve as a critical entry point into HIV care and treatment programs, thus contributing to the 2-7-10 goals by enabling access to treatment and prevention for those who test.

INTEGRATED ACTIVITY FLAG:

These activities are part of an integrated program that also includes OP (#9449), TB/HIV (#9444), Basic Health Care & Support (#9448), and CT (#9445).

SUMMARY:

The Reproductive Health and HIV Research Unit's (RHRU) PEPFAR-funded program, subsequently referred to as the "Follow-on to the RHRU Program" (FRP), will be re-competed through an Annual Program Statement (APS) for FY 2007.

The FRP will provide ARV rollout support services with DOH partners in over 30 facilities in 3 provinces. The major emphasis area is human resources, and minor areas include quality assurance and supportive supervision, local organization capacity development, and training. Services target people living with HIV (PLHIV) and their families, including children, pregnant women, caregivers, doctors, nurses, traditional healers, and other healthcare workers.

BACKGROUND:

RHRU currently provides technical support to the South African Government (SAG) that includes the national ARV rollout. With PEPFAR funding since FY 2004, RHRU has provided regular onsite support, direct treatment, training and quality improvement to provincial departments of health (DOH) sites in Gauteng, North West and Kwazulu-Natal (KZN). The FRP will continue these activities and an inner city program in Johannesburg. Up and down treatment referral systems are being improved in all provinces. In addition, FRP will continue the provision of counseling and testing (CT), palliative care, and prevention services. FRP will develop service delivery models that can be replicated and expanded, and produces lessons learned to share with others.

An effective, sustainable ARV treatment (ART) program is founded on strong partnerships with local public sector treatment sites. The needs of each facility vary, and successful incorporation of ARV services at facilities requires a thorough facility-based situation analysis. FRP's aim is to deliver decentralized HIV care or up and down referral between hospitals and related primary care clinics. ARV clients will be identified, screened, prepared and initiated on ARV treatment with access to future care at up or down referral sites. This system reduces congestion at primary treatment sites and improves patient access to care.

As of June 2006 RHRU-assisted sites were treating over 16,000 people with ART, and over 2,000 health providers had been trained in ART. FRP will continue assistance in existing sites and expand services to several new sites. Pediatric support will be expanded. In addition, FRP will initiate an HIV Maternal Health Outreach Service, and provide planning, training and technical assistance (TA) to 2 primary healthcare clinic (PHC) networks in Gauteng and KZN (PHC project). This will enable these clinics to receive down-referred patients, and initiate new patients in selected sites. Nurse-based services will be promoted whenever feasible.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Treatment Support

Specialist HIV treatment teams will support urban and rural ARV sites for adults and pediatrics. They will provide TA to new sites, and will develop and facilitate referral networks. Teams will consist of a doctor, nurse, management specialist and counselor and will rotate among a cluster of treatment facilities providing onsite training and management support. The continuum of care will be emphasized including: prevention, healthy lifestyle, responsible behavior, nutrition advice, opportunistic infection prevention/treatment, palliative care, and ART. Materials previously developed to educate healthcare workers and HIV clients about HIV care will be utilized. Outreach teams will provide ARV and referral clinics with TA on up and down referral models. The teams will assist local clinic staff to improve practice, integrate and expand services (including TB, see TB section), and maximize referral for CT, palliative care and ART.

ARV treatment and HIV care for perinatal women will be expanded to provide outreach in maternal services. Family-based and gender-specific services for underserved groups such as men and high-risk women will also be expanded.

ACTIVITY 2: Human Capacity Development

Insufficient skills in HIV care and program management have been a barrier to scale-up of site support. FRP will develop an internal site-based training program to enhance staff skills. FRP will also offer a structured program for young doctors interested in pursuing a career in HIV. All FRP staff involved in the PEPFAR program will become skilled HIV clinicians and program implementers, benefiting the program in the short term, and improving the South African skill base in public health in the longer term.

FRP will provide DOH staff in ARV sites with expert capacity and TA to develop models of effective service delivery using existing infrastructure and resources. It will emphasize clinical training and promotion of quality improvement techniques that can be applied by the DOH staff to develop local solutions to local problems. The teams will provide onsite support to clinical management, referral, patient flow and data management.

Through the PHC project, FRP will assist PHC sites to integrate HIV care into routine service delivery and will support sites with ARV accreditation. Nurses will lead these services, with doctor support when necessary. FRP will conduct formal training courses including foundation courses in adult and pediatric ART for healthcare providers and traditional healers, and HIV management for nurses and doctors.

ACTIVITY 3: Pediatrics

FRP and its partners will expand pediatric services to additional provinces based on a review of needs and requests from provincial authorities. The pediatric clinical support teams will rotate through DOH sites, capacitating and strengthening clinical skills, and supporting the development of referral networks. They will aid collaborations between healthcare facilities and local FBOs, NGOs and CBOs to provide holistic care for children on ART. FRP will play a pivotal role in initiating pediatric ARV services at facilities where no pediatric services exist.

The National Adolescent Friendly Clinic Initiative (NAFCI) supports the public sector to provide quality services geared to youth, and are developing a referral system for HIV-infected adolescents to receive ongoing care and provision of ART. FRP will support services at NAFCI sites in proximity to HIV treatment facilities in Soweto.

ACTIVITY 4: Referral Networks

FRP will provide training, mentoring, management support and consultants across 3 provinces, to assist DOH ART sites with referral processes. This includes increasing referral capacity at secondary sites to channel and monitor stable patients at peripheral sites closer to patient's homes. This mechanism will reduce congestion at primary sites, enable clinics to see more patients, reduce patient transportation costs and increase adherence. FRP will aid capacity development and training of local organizations, as well as develop linkages, referral systems, human resources, information, education and communication, needs assessments, policy and guidelines and strategic information.

ACTIVITY 5: Nutrition

FRP will support several ART sites and TB hospitals in Johannesburg by employing a dietician to provide TA, coordinate supplies of nutritional supplements from the district health office to facilities for pediatric and TB/HIV-infected clients, give nutrition information and counseling support. FRP will provide TA to national and provincial DOH about appropriate nutrition interventions at different stages of disease in people infected with HIV and TB.

These activities directly contribute to PEPFAR's goal of 2 million people on treatment. FRP will support the South Africa 5 year strategy by expanding access to HIV services, improving ARV service delivery, and increasing the demand for and acceptance of ART.