SUMMARY:

JHPIEGO will continue conducting monitoring and evaluation (M&E) training in PMTCT for staff from

National Department of Health (NDOH) and provinces. In FY 2007, JHPIEGO would have implemented

activities to strengthen PMTCT services in North West province. JHPIEGO will increase its geographic

depth by expanding the model PMTCT facility that will link essential PMTCT services among six feeder

primary healthcare clinics (PHC) and the district hospital in a targeted district in North West province. This

program will be used as a model of best practice for the province, and will be expanded to other districts in

FY 2008. JHPIEGO will also expand the Training Information Monitoring System (TIMS) to three additional

provinces. Emphasis areas are training, human resources, quality assurance and supportive supervision,

and strategic information. Target groups include adults, family planning clients, people living with HIV, HIV-

infected infants, public health workers and policy makers.

BACKGROUND:

Using PEPFAR funding, JHPIEGO has provided M&E training to the NDOH since FY 2004. In FY 2007,

JHPIEGO provided support and technical assistance to introduce an integrated model to adopt and support

a PMTCT service delivery facility in North West province. JHPIEGO will continue this work in FY 2008, and

will also expand this support to an additional district in the NWP. JHPIEGO proposes that the integrated

PMTCT model combine antenatal care (ANC)/delivery services at the district hospital level inclusive of its

feeder clinics, thereby increasing access and standardizing services. Currently, adequate referral systems

between the PHC feeder sites and district hospital are lacking. This model will improve comprehensive

PMTCT by addressing each pillar of the World Health Organization's (WHO) framework for PMTCT

services, including (1) primary prevention of HIV infection, (2) prevention of unintended pregnancy among

HIV-infected women, (3) prevention of transmission from HIV-infected women to their infants, and (4) care,

treatment, and support for HIV-infected women and infants. JHPIEGO will work closely with the North West

province Department of Health (NWDOH) HIV and AIDS directorate, and district health authorities to

develop an implementation plan that will include eventual transition away from donor funding and to full

support by the NWDOH. JHPIEGO may cover initial salaries of additional staff but will work with DOH

authorities to ensure that required positions are created and budgeted for. This will ensure sustainability by

permitting the NWDOH to eventually absorb these positions. JHPIEGO will work with the district hospital

and the six feeder clinics to ensure adequate forecasting of required drugs and supplies.

As cross-cutting support to address sustainability, JHPIEGO will introduce standards-based management

and recognition (SBM-R) for PMTCT that will encompass those interventions mentioned above as well as

others. JHPIEGO will support the rollout of couple counseling in this model program in an attempt to

increase men's role in PMTCT services. JHPIEGO will coordinate PMTCT activities with FHI, AED, and

other PEPFAR partners working in the same geographical area. Family planning, infant and young feeding

practices, and monitoring and evaluation topics are synthesized into the three respective training

curriculums so that the topics are not repeated and to ensure that clinic staff are not pulled off of the clinic

for redundant training.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Referrals & Linkages

The objective of this activity is to build strong linkages and referral systems between women's healthcare

services and PMTCT programs, thus eliminating missed opportunities for women and their families to

access PMTCT services. JHPIEGO will work to ensure that counseling and rapid testing services focusing

on risk reduction will be available to all PHC clients and their partners. JHPIEGO will mentor and support

personnel in PMTCT counseling and clinical interventions to reduce the risk of transmission during ANC,

postnatal care, labor and delivery. JHPIEGO will link with the provincial and national departments of health

to ensure that all providers who have not received adequate training are enrolled in the national PMTCT

and Infant Feeding Training. After providers have attended training, JHPIEGO will offer supportive

supervision and mentoring at the facility level and will facilitate the implementation of clinical staging for

antiretroviral treatment (ART) so eligible HIV-infected pregnant women can be immediately referred to ART

services. In accordance with South African Government PMTCT guidelines, JHPIEGO will ensure that all

providers are equipped with adequate knowledge on ART prophylaxis for PMTCT. In addition, JHPIEGO will

ensure that HIV-infected women and infants are not only referred for treatment but are tracked so they do

not fall through the cracks after delivery. Services provided in the postpartum period will include ongoing

monitoring for opportunistic infections, linkages with well-baby visits, HIV testing for infants and appropriate

referrals to treatment, care and support. Finally, women will be referred back to family planning counseling.

To increase men's role in PMTCT, JHPIEGO will work with facility staff to incorporate couple counseling,

including prevention with positives. JHPIEGO will link with Kagiso Educational Television, which implements

the "Grassroots Male Involvement in PMTCT" campaign, to include men in the catchment areas and to

foster linkages between the CT, PMTCT, treatment and family planning aspects of these programs,

JHPIEGO will work with community health workers, community-based organizations, and social services to

strengthen linkages and referral systems, including referral for infant feeding programs and mother to

mother-to-be support groups. JHPIEGO will work with facilities to measure performance, identify

performance gaps and develop action plans to address challenges in implementation. JHPIEGO will work

with staff and health authorities to use this tool as an internal and external supervision tool that can be used

to improve quality and sustainability of services. JHPIEGO will use its PMTCT performance and quality

improvement tool, which was developed to improve M&E from the service delivery level to the district level.

This will serve to strengthen data capture, monitoring, and evaluation, allowing the NWDOH to use data to

strengthen PMTCT services in the province.

By strengthening PMTCT services and building the capacity of healthcare workers, these activities

contribute to PEPFAR 2-7-10 goals, averting new infections among infants exposed to HIV as well as

increasing access to treatment care and support for HIV-infected women and their infants.

SUMMARY:

JHPIEGO, with approval from the South African National Department of Health (NDOH) will implement male

circumcision (MC) activities by supporting a male circumcision technical advisor to the NDOH to help

spearhead and coordinate MC within the NDOH, and to continue piloting modules of the WHO MC tool-kit.

BACKGROUND:

For nearly two decades, researchers have been interested in the preventive effect that male circumcision

has on the risk of STIs, particularly chancroid and syphilis, as well as penile and cervical cancers.

Increasing attention and research has been devoted to the potential preventive effect MC has on HIV

transmission. From the interim results of three clinical trials that were conducted in South Africa, Kenya and

Uganda, it has been concluded that MC reduces HIV transmission from women to men, by 60% on

average. All three trials were interrupted before planned completion for ethical reasons once it was

established that a clear protective effect existed between circumcision and contracting HIV, so that the men

in the control groups could access this potentially life-saving intervention. Male circumcision is now

accepted by the global normative bodies as one aspect of an effective HIV prevention strategy. Modeling

studies estimate that making MC universal in Africa would prevent 5.7 million new infections and 3 million

deaths over the next 20 years.

JHPIEGO has been supporting MC/Male Reproductive Health services in Zambia since 2003. The work in

Zambia informed the WHO/UNAIDS programs and the WHO toolkit. JHPIEGO is a co-author with WHO and

UNAIDS of the Training Manual for Male Circumcision under Local Anesthesia. In Mozambique, JHPIEGO,

through the FORTE Saúde Consortium led by Chemonics and funded by USAID, has been recently asked

to be the technical leader in the implementation of initial MC activities in Mozambique

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1:

It is expected that during FY 2007, JHPIEGO and the South African Government will reach agreement on

the placement of a male circumcision technical advisor within the NDOH. FY 2008 funds will be used to

continue JHPIEGO’s technical assistance work with the NDOH. It is expected that the advisor will assist

the NDOH with coordinating MC activities among the various relevant portfolios within the NDOH and will

assist in the development of policies and guidelines that can be rolled out nationally. The technical advisor

will work closely with the NDOH TBD activities supported by CDC on the development of linkages between

traditional healers/surgeons and safe clinical male circumcision.

ACTIVITY 2:

It is expected in FY 2007 that JHPIEGO will be engaged in field testing various modules of the WHO MC

toolkit and implementing capacity building activities that take into account political and cultural sensitivities

of MC. The testing of these modules is based on ongoing consultation with the NDOH and UNAIDS. FY

2008 funds will be used to continue these activities in coordination with the NDOH and other relevant

stakeholders

ACTIVITY 3:

Development of a standard MC training curriculum. Only with the express consent of the NDOH will training

and service delivery of MC activities be undertaken. In preparation, and in consultation with the NDOH, a

training course will be designed for clinical service providers (physicians, nurses, nurse-midwives) and

aimed at producing individuals qualified to provide male circumcision and reproductive health counseling

services. The course will consist of classroom and practical sessions focusing on Male Circumcision and

reproductive health. Qualification will be based on participants’ achievement in two areas: Knowledge -

score of at least 80% in the end of course knowledge assessment and Skills - satisfactory performance of

recommended procedures during simulated clinical practice and with clients. The course is designed for five

days but could be extended to 10 days in low-volume circumcision clinics so that the participants can

acquire adequate guided clinical practice. Topics will include anatomy and physiology, male reproductive

health needs, health education, counseling, male circumcision methods, management of adverse events

resulting from MC, infection prevention and organizing and managing a male reproductive health clinic. The

training will be provided by qualified MC clinical trainers.

These activities will contribute to the 2-7-10 goals of PEPFAR by creating policies and guidelines that will

lead to increased prevention within South Africa.

This activity was approved in the FY 2007 COP, was funded with FY 2007 PEPFAR funds, and is included

here to provide complete information for reviewers. The funding mechanism from field support to a local

agreement for JHPIEGO is changing in October 2008 therefore a COP entry is being made to reflect this

change in mechanism and activity number only. JHPIEGO activities under HBHC are expected to continue

under the FY 2008 COP and funds are being requested in the new COP entry.

SUMMARY:

Since 2004, JHPIEGO has been working in HIV and AIDS service delivery areas, supporting human

capacity development strategies which include health care worker training and quality assurance that

improve provider performance. In FY 2008, JHPIEGO will support the expansion of palliative care services

through the provision of clinical and social care services for people living with HIV and AIDS (PLHIV) with

an emphasis on opportunistic infections and cancers in service delivery settings and social and legal care at

the NDOH. JHPIEGO will provide technical support to the NDOH by placing a HIV and AIDS Care Technical

Advisor and training within the NDOH HIV and AIDS Care and Support Unit. The major emphasis areas of

these activities are: 1) training, 2) linkages and referral systems, and 3) human resources. Specific target

groups are HIV-infected individuals and their families, women of reproductive age, family planning clients,

pregnant women, and health care workers.

BACKGROUND:

The JHPIEGO palliative care program is continuing from FY 2006 to provide technical support to the NDOH

and to train health workers in state of the art HIV-related care issues. Despite social and legal program

successes in South Africa, technical support is required in the NDOH to address national-level social and

legal inequities and program gaps for PLHIV. In FY 2008 JHPIEGO will continue to also focus its support on

training and health worker skill for screening for opportunistic infections and AIDS-associated malignancies,

particularly cervical cancer. Protocols and materials for prophylaxis and treatment of OIs are widely

available throughout clinics in South Africa; however, training support is needed at primary health care

levels throughout the country. Given the high burden of HIV in South Africa, prevalence of AIDS-related

malignancies and the corresponding high incidence of cervical dysplasia among HIV-infected women a gap

exists in screening and treatment for AIDS-related cancers, especially cervical cancer. Recently published

studies (Moody et al. 2006) document an increased risk for squamous intraepithelial lesions (SIL), the

precursor to invasive cervical cancer, among HIV-infected women in Western Cape, confirming data from

other international studies. Cancer of the cervix continues to be the second commonest cancer among

South African women and is included as one of the defining conditions of the AIDS in South Africa. Studies

and clinic experience in South Africa continue to underscore the importance of developing locally relevant

cervical screening and management guidelines for HIV-infected women in South Africa. In collaboration with

the North West province provincial Department of Health, JHPIEGO will provide training and technical

support for OI prophylaxis and care for PLHIV and screening for cervical cancers in HIV-infected women at

primary health care centers.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Support for National Department of Health

JHPIEGO will continue to provide technical support to the NDOH by placing a HIV and AIDS Care Technical

Advisor within the NDOH HIV and AIDS Care and Support Unit to support and expand the government's

programs for care of PLHIV. At the request of the NDOH, emphasis is needed to support and expand legal

and social support activities for PLHIV. Activities in FY 2008 include activities to mitigate HIV and AIDS

stigma in partnership with PLHIV, and training paralegals on human rights for PLHIV. The advisor will have

the full access to technical experts at JHPIEGO and the experts based at Johns Hopkins University. This

technical advisor will work closely with a JHPIEGO sponsored advisor focusing on accreditation of primary

health care facilities.

ACTIVITY 2: Training and technical support for OI prophylaxis and care for PLHIV and screening for

cervical cancers in HIV-infected women at primary health care centers

In FY 2008, JHPIEGO will expand care program in the North West province and work collaboratively with

Columbia University in Eastern Cape and KwaZulu-Natal. JHPIEGO will train facility-based health care

workers on OI prophylaxis and care (emphasis on cotrimoxazole prophylaxis, TB screening and OI

treatment) and will include all elements of the evidence-based adult and pediatric preventive care package,

ART adherence and basic pain and symptom management within the training program. Facility-based care

also creates an entry point for screening and treatment of human papilloma virus (HPV, the cause of 95% of

cases of cervical dysplasia), other sexually transmitted infections, cervical cancer itself and other AIDS-

associated cancers which are often overlooked in clinic settings. JHPIEGO will train and support district and

primary health care level health professionals working with PLHIV to appropriately screen, diagnose, treat

and educate PLHIV and their partners about HPV, other STIs, cervical dysplasia and other AIDS-associated

malignancies as a component of comprehensive care services for PLHIV. Protocol and material

development, training, supportive supervision and follow-up technical support will be provided. The program

will be developed and implemented in partnership with the North West province provincial Department of

Health and is intended to improve the capacity of the South African health system to provide holistic care of

PLHIV, especially women infected or at risk for both HIV and cervical cancer. This activity addresses

gender issues by promoting equal access to OI, STI and cancer care for both males and females and

equipping health care workers with skills to address HPV and cervical dysplasia in women, an important

element of HIV and AIDS care for HIV-infected women that is largely overlooked. Screening, messaging

and referral on gender-based violence will also be integrated into the program.

ACTIVITY 3: Development of linkages between facilities and services

To improve overall program effectiveness and integrate elements of social care to the clinical care program

(Activity #2 above), JHPIEGO will support and work with one district DOH in North West province to

formalize referral systems and develop linkages between health facilities, and within health facilities (service

-to-service) as well referral and counter-referral between the health system and social services as it relates

to HIV-related palliative care services.

Activity Narrative:

These results contribute to the PEPFAR 2-7-10 goals by improving access to and quality of palliative care

services that were not previously provided.

This activity was approved in the FY 2007 COP, was funded with FY 2007 PEPFAR funds, and is included

here to provide complete information for reviewers. The funding mechanism from field support to a local

agreement for JHPIEGO is changing in October 2008 therefore a COP entry is being made to reflect this

change in mechanism and activity number only. JHPIEGO activities under HTXS are expected to continue

under the FY 2008 COP and funds are being requested in the new COP entry.

SUMMARY:

JHPIEGO's activities support efforts by the National Department of Health (NDOH) and public sector

antiretroviral therapy (ART) sites in Gauteng to ensure access to and quality of ART services. The

emphasis areas include human capacity and development (including task shifting for nurse managed ART

services), and local organization capacity building. Specific target groups include people living with HIV

(PLHIV).

BACKGROUND:

JHPIEGO has been working with the NDOH since FY 2004 to improve institutional capacity through training

and dissemination of national HIV and ART guidelines and through support of a treatment technical advisor

to the NDOH. In FY 06 and FY07, JHPIEGO partnered with the Foundation for Professional Development

(FPD) (a PEPFAR-funded partner) to initiate a standards-based management and recognition approach for

improving ART services. In FY 2008, JHPIEGO will continue to implement these interventions, aimed at

improving access to and quality of HIV and AIDS service delivery. In FY 2007 JHPIEGO supported

implementation of the NDOH's model for nurse-initiated and managed ART through an approach that will

encourage a healthcare culture supportive of nurse-initiated and managed ART; a policy environment that

will ensure that these frontline nurses have the training, funding, and ongoing support they require; and

ensure that South African training institutions are strong partners in the efforts to achieve the ambitious

targets set in the HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011 for increasing the

proportion of adults and children started on ART by nurses. These activities will continue in FY 2008.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Performance Standards

Standards-based Management and Recognition (SBM-R) is a practical management approach for

improving the performance, efficiency and quality of health services. It consists of the systematic utilization

of performance standards as the basis for the implementing organization and related service delivery.

Compliance with standards is recognized through formal mechanisms and is in line with NDOH standards

and guidelines. In FY 2005 and FY 2006, JHPIEGO developed detailed performance standards for ART and

introduced this process at four FPD-supported ART sites. Performance standards focused on twelve

different areas of ART service delivery including pre-treatment, treatment commencement, and

management of complications for both children and adults; pharmacy services; laboratory services;

information, education and communication; health information systems; infrastructure; and human

resources.

Based on the initial work by the South African Government in FY 2007, JHPIEGO will support scale-up of

this process to other NDOH sites in the Northern Cape, especially those where ART will be integrated into

primary healthcare services. JHPIEGO will coordinate with other PEPFAR treatment partners in the

accreditation process. JHPIEGO will support scale-up of SBM-R for ART in the Gauteng province, or other

provinces as requested by the NDOH. As a result of these interventions, access to and quality of ART

services will improve for both children and adults.

ACTIVITY 2: Strengthening Nurse-Managed Antiretroviral Therapy and Comprehensive HIV and AIDS

Services

In FY 2008, JHPIEGO will continue to support implementation of the NDOH's model for nurse-initiated and

managed ART through an approach that will encourage a healthcare culture supportive of nurse-initiated

and managed ART; a policy environment that will ensure that these frontline nurses have the training,

funding, and ongoing support they require; and ensure that South African training institutions are strong

partners in the efforts to achieve the ambitious targets set in the HIV & AIDS and STI Strategic Plan for

South Africa, 2007-2011 for increasing the proportion of adults and children started on ART by nurses.

JHPIEGO proposes strengthening both in-service and pre-service education with a focus on training nurses

and providing on-going support to ensure their competency in day-to-day management of patients on ART

and identification and referral of treatment complications from the health center to district hospital level.

This will relieve the heavy client burden on tertiary ART institutions resulting in improved access for current

clients and more clients getting on ART.

ACTIVITY 3: Expand Provincial and District Capacity of Accreditation and Site Readiness

In FY 2008, JHPIEGO will continue to work with the National Department of Health to build the capacity of

the national, provincial and district teams to accredit sites. Activities will include adaptation of the

accreditation tools for primary health care level, training and onsite mentoring of teams. JHPIEGO will also

work with the sub-district level teams by providing support for implementation of site readiness plans and

work with other USAID treatment partners to assist them in receiving ART accreditation for their sites.

These activities will indirectly contribute to the overall PEPFAR objectives by ensuring sustainability and

quality of ART services. Technical experts working with NDOH will indirectly contribute to increased access

to treatment services through site accreditation, and standards-based management of services will indirectly

increase access due to improved quality of service. These activities contribute the PEPFAR goal of putting

two million people on treatment, and support the USG/SA Five-Year Strategy by building capacity for ART

service delivery.

SUMMARY:

JHPIEGO will continue (a) conducting monitoring and evaluation (M&E) training in PMTCT for staff from the

National Department of Health (NDOH) and provinces; and (b) implementing and expansion of the training

information monitoring system (TIMS). In addition, JHPIEGO will also strengthen PMTCT supervision skills

for provincial and district PMTCT program managers.

ACTIVITY 1: Monitoring and Evaluation

Since FY 2004, JHPIEGO has provided technical assistance in strengthening PMTCT M&E and has trained

approximately 250 HIV and AIDS program managers and coordinators from the NDOH and eight provincial

departments of health in M&E fundamentals. In FY 2007, JHPIEGO provided intensive on-site supervision

and follow-up to targeted sites in the Northern Cape using a supervision tool outlining PMTCT M&E

standards. JHPIEGO assisted facility-based health-care workers to implement interventions to improve

M&E capacity. Technical assistance focused on interventions such as record keeping, interpretation of data

and reporting. JHPIEGO encouraged facilities to use the M&E performance tool as an internal method for

supervising their effectiveness for M&E. PEPFAR funding will be used to support technical assistance costs

(M&E expert consultants) to facilitate this process at the site level. The activities will continue in FY 2008

and will be expanded to additional sites.

ACTIVITY 2: Training Information Monitoring System (TIMS)

Building on the expansion of TIMS in FY 2007 to the National PMTCT Unit, Northern Cape, and North West

provinces, JHPIEGO will continue to support TIMS in FY 2008 by providing technical assistance with

intermittent troubleshooting to the provinces and exploring web-based TIMS. As a result of this activity, the

NDOH PMTCT and TB units and three regional training centers in Gauteng, Mpumalanga and Limpopo will

be able to capture training data on both national and provincial levels. This data will permit them to assess

their progress and ongoing needs for capacity building. TIMS allows program planners to determine where

training needs are greatest and prioritize their investment of training resources accordingly.

ACTIVITY 3: Training in PMTCT Supervision

As partners under the USAID Population and Health Integrated Assistance project, JHPIEGO developed

and implemented supervision training for reproductive health supervisors in Kenya, Malawi and Ethiopia. In

FY 2008 JHPIEGO proposes to address training-related PMTCT supervision problems through the

adaptation and implementation of the supervision learning package. Supervision is an essential intervention

to maintain the performance of the healthcare provider, and improved supervision is unanimously

recognized as important for the delivery of quality HIV and AIDS services. The supervisor plays a critical

role in ensuring that members of the community receive quality healthcare services. To perform effectively,

the supervisor not only needs to acquire the knowledge and skills to do the job, but needs to work in an

environment that will allow the supervisor to have a positive effect on the quality of services. Most health

professionals charged with supervision responsibilities in the PMTCT program lack the full range of

knowledge and skills to perform their job effectively. Most supervisors are limited in this capacity because

they have received not received training in this area or any support or reference materials on supervision. In

addition to a lack of knowledge and skills, other causes of poor performance include: insufficient funds for

transportation, lack of supervision tools (to be addressed in part through the development of the supervision

learning package), infrequent supervision visits and inadequate national supervision guidelines. To

maximize the effect of the training interventions, it is essential that these other causes of poor performance

be addressed concurrently with the training of supervisors.

These activities will indirectly contribute to the overall PEPFAR objectives, as supervision will indirectly

increase access due to improved quality of service.