SUMMARY:

Population Council (PC) is using PEPFAR funding to provide technical assistance (TA) to the KwaZulu-

Natal Department of Health (KZN DOH) in the development of a provincial antenatal (ANC) and postnatal

(PNC) policy and evidence-based comprehensive guidelines. These will incorporate aspects of HIV

prevention, counseling and testing (CT), prevention of mother-to-child transmission (PMTCT), antiretroviral

(ARV) and male involvement, which are aimed at providing pregnant women, their partners and infants with

quality comprehensive care during the ANC and PNC period. The target populations for this activity are

people living with HIV and AIDS, HIV-infected pregnant women, and program managers. The emphasis

areas for this activities are local organization capacity development (major), strategic information, and

human capacity development (training and task shifting).

BACKGROUND:

PC currently provides TA using a participatory methodology aimed at ensuring that local, national and

international evidence, and relevant guidance from the vertical HIV related programs (CT, PMTCT, and

ARV) feed into the development of comprehensive and integrated provincial ANC and PNC policies and

guidelines. This ongoing project, which commenced in 2004 with PEPFAR funding, is carried out in

collaboration with the Reproductive Health and HIV Research Unit (PEPFAR funded) and two KwaZulu-

Natal DOH directorates (Maternal Child and Women Health [MCWH]/PMTCT, Sexually Transmitted

Infections [STI]). The KZN MCWH is the lead for the provincial "Core Team". The overall function of the

Core Team is to steer the development of policy and guidelines. To date, multiple stakeholders and the

Core Team have developed drafts of both the policy and guidelines. As part of the process to inform the

development of the policy and guidelines, the Core Team conducted focus group discussions with pregnant

women to identify their maternal health needs. Further resources, including monitoring and evaluation tools,

a set of job aides and training materials had been developed to support the implementation of the policy and

guidelines.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Continued technical assistance to the KZN DOH in support of the implementation of the policy

and guidelines

PC will provide ongoing TA to the KwaZulu-Natal DOH as key drivers of the comprehensive and evidence-

based policy and guideline development. The development of the policy and guidelines has been a

provincial process which has mainly been driven by the MCWH/PMTCT program. As a way of strengthening

integration at district and facility levels and for sustainability of the implementation of the guidelines,

technical assistance will be expanded to other programs which are STI, HIV and AIDS, ART, VCT, TB and

gender. Task teams representing these programs will be formed to assist in driving the implementation of

the policy and guidelines. Specific support will include assistance with the development of district work

plans for implementation, development of health delivery systems as well as continued training on M&E.

Ongoing support will be provided to the relevant programs to identify any implementation issues and further

training will be organized where necessary. PEPFAR funds will be utilized for conducting

feedback/debriefing sessions, facilitating the development of health delivery systems, coordination of the

development of district work plans and training. The target population for this activity involves program

managers and health providers of the six programs listed above.

ACTIVITY 2: Supporting and evaluating the effectiveness of the implementation of the comprehensive

policy and guidelines in improving maternity care at provincial level

In order to improve the implementation of the policy and guidelines, the evaluation will take several forms

(testing the effectiveness of job aides and training materials, M&E tools, training of trainers, assessment of

provider attitudes, as well as ANC and PNC client satisfaction assessment). Based on the outcome of this

evaluation, identified gaps will be addressed and relevant adaptations will be made. PEPFAR funds will be

used for the design of data collection methodology and tools, training of data collectors, collection of data,

data entry, analysis and interpretation of the evaluation data at facility level.

This activity will contribute to the overall PEPFAR goals of preventing 7 million new infections by

strengthening PMTCT programs with policy and guidelines and an implementation plan in the province most

affected by the HIV and AIDS crisis.

TYPE OF STUDY: Continuing.

PROJECT TITLE: Feasibility and Effectiveness of a Comprehensive School-Based Life Skills Curriculum

based on HIV and AIDS Prevention Messages Focused on Abstinence and Being Faithful

NAME OF LOCAL CO-INVESTIGATOR: Mpumalanga Province Department of Education

PROJECT DESCRIPTION: This public health evaluation (PHE) will adapt the existing abstinence and

being faithful (AB) Life Skills curriculum by monitoring and evaluating its implementation in the 8th and 9th

grade classrooms, and then implement the adapted curriculum in nine primary/secondary schools in

Mpumalanga. Process data that relate to dosage and fidelity of implementation in the selected classrooms

will be collected and monitored; the PHE will ensure age appropriateness of materials, and their adherence

to Department of Education (DOE) Learning Outcomes and Assessment Standards. Population Council will

follow the 4,600 learners and 102 teachers who will have received the adapted AB curriculum in the 6th and

7th grade. Follow-up observations focus on sexual behavior outcomes and knowledge, and attitudinal

outcomes around abstinence and faithfulness.

EVALUATION QUESTION: Currently there is little available knowledge on the feasibility and effectiveness

of embedding HIV and AIDS prevention AB messages into a comprehensive life skills school-based

curriculum that begins with the 6th grade learners. This PHE seeks to answer the following research

questions:

(1) Will rigorous process evaluation generate information that leads to an appropriately adapted AB

prevention curriculum?

(2) Will the adapted curriculum be the main causal factor in changed sexual attitudes and behaviors among

the selected learners?

PROGRAMMATIC IMPORTANCE/ANTICIPATED OUTCOMES: For the FY 2007 COP, Population Council

worked on expanding the Life Skills curriculum to 30 schools in Mpumalanga. Population Council developed

this curriculum as a replacement for the current Mpumalanga Department of Education's Life Orientation

Program curriculum. The comprehensive curriculum addresses the Department of Education's Life

Orientation Learning Outcomes and Assessment Standards through the lens of HIV prevention, particularly

focusing on AB. In addition, the curriculum builds negotiation, decision-making, and problem-solving skills

around HIV prevention. This comprehensive curriculum is designed to be seamlessly incorporated into all

6th - 7th grade (11-12 year old learners) Life Orientation Program classrooms across South Africa. These

elements of school-based learning are critical for instilling effective HIV prevention awareness among young

people, especially awareness of a balanced AB approach to preventative sexual behavior.

The particular programmatic importance of this PHE builds on the work done in the previous year by

adapting the AB life skills curriculum for use in 8th and 9th grade (13-14 year old learners) classrooms. As

the Life Orientation Learning Outcomes and Assessment Standards vary by grade, the curriculum that has

been developed for the 6th and 7th grades must adapt to reflect the requirements for the 8th and 9th grade

DOE Life Orientation program. The PHE will measure the success of this adaptation process through

rigorous process evaluation of actual classroom implementation and through the panel study that follows

the learners over time with multiple observations of sexual prevention outcomes.

Overall this PHE will contribute to the PEPFAR global 2-7-10 goals by providing an important set of data

needed to assess the effectiveness of school-based AB prevention curricula.

TIMELINE AND FUNDING: The total project timeframe is two years. This entry describes activities during

the second year of the project, which mainly include development of protocols; training of study team;

implementation of process evaluation; adaptation of the curricula; collection of panel data on sexual

prevention outcomes; analysis of data; and dissemination of findings. The budget requested for the second

year of study is $400,000.

METHODS:

Training: A total of 80 Life Skills educators and 10 Peer Educators from the 30 selected schools will be

trained using the "Dare to be Different AB Life Skills Curriculum." (The total number of individuals trained in

AB prevention for this PHE is 90.) This training component enhances the capacity of both peer educators

and teachers to promote AB messages among learners in schools and the community level. Through parent

-teacher meetings, parents will also be exposed to the Life Skills program so that they can assist in creating

an enabling environment for their children to participate in this program.

Process Evaluation: Population Council will monitor and evaluate implementation of the adapted curriculum

in the 8th and 9th grade classrooms to ensure that (a) the material is age appropriate, (b) material meets

the DOE Learning Outcomes and Assessment Standards, and (c) teachers adhere to the curriculum in

terms dosage and fidelity. This component will reach more than 1,500 learners in two districts in

Mpumalanga province.

Panel Study: The study team will follow an additional 1,562 learners (9 schools) who received the AB

curriculum as part of their schools' Life Orientation Program in the 6th and 7th grades in 2007. The panel

study will focus on sexual behavior outcomes but will also examine knowledge and attitudinal outcomes

around abstinence and faithfulness. As the Life Orientation Learning Outcomes and Assessment Standards

vary by grade, the curriculum that has been developed for the 6th and 7th grades will be adapted to reflect

the requirements for the 8th and 9th grade DOE Life Orientation Program. In total, 3,062 (1,500 + 1,562)

learners will be reached. A subset of this total (approximately 1,000) will receive AB prevention messages

that are predominately abstinence-only.

POPULATION OF INTEREST/GEOGRAPHIC AREA: The population of interest is grades 6 to 9 learners in

South African schools. The geographical area covered in South Africa is Mpumalanga Province.

INFORMATION DISSEMINATION PLAN: The results of this PHE will be disseminated as widely as possible

in South Africa and other resource-constrained African countries, most of which are struggling with the

Activity Narrative: problem of identifying a rigorously tested and successfully implemented school-based AB prevention

program for young learners. Results will be presented to local, provincial, and national government officials

and made available online through the Population Council and other websites. Findings will be presented to

USAID/South Africa at the appropriate time, as well as at national and international conferences.

BUDGET JUSTIFICATION FOR YEAR 2 (USD):

Salaries/ fringe benefits: $320,000

Equipment:$15,000

Supplies: $5,000

Travel: $20,000

Participant Incentives: $ -

Laboratory Testing: $ -

Other: (communications): $ 40,000

Total: $400,000

The majority of funds (80% of the total) will be used for salaries and benefits for study staff, including the

principal investigators/lead behavioral scientists, field directors, data managers, statistical analyst, trainers,

and data collectors. Approximately seven laptop computers and related support (IT) equipment will be

purchased for field data entry and analysis (equipment, 4%). Supplies will include general office supplies,

computer supplies, and photocopying of data collection instruments (1%). Travel (5% of the total) will

include local transport for the study team and limited international travel for Pop Council New

York/Washington based technical expertise visits to South Africa. Finally, communications, office space,

and other expenses will account for 10% of the total.

SUMMARY:

Prevention efforts are key to reducing sexual transmission of HIV. In South Africa, the Population Council

(PC) has implemented several prevention programs targeting young people, learners, as well as men and

couples to delay sexual debut, promote faithfulness and mutual monogamy, and to reduce risk behaviors.

With PEPFAR FY 2008 funds, PC intends to strengthen and expand these activities. The proposed

activities are in response to requests from various government departments (provincial and national), and

will draw upon exiting partnerships with South African institutions and organizations such as the

Departments of Health and Education and the South African Council of Churches.

BACKGROUND:

Over the past few years, the PC has developed an expertise in developing strategies and interventions that

more specifically focus on the role of men in HIV prevention. The first activity has been to work with the

Department of Education, South African Council of Churches and local FBO piloting interventions on AB in

primary schools and mutual monogamy in churches in Mpumalanga Province and the Eastern Cape

Province, respectively. These community interventions have reached couples, church members, youths,

teachers, learners, parents/guardians and other stakeholders. However, reaching an adequate number of

men through churches is a major challenge because fewer men than women participate in church activities.

This year's activities will continue to increase male involvement through specific strategies such as

strengthening couples interventions and educating learners. The emphasis area include: human capacity

development public health evaluations / targeted evaluations. Interventions will target program managers,

program implementers, NGOs and other stakeholders.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: AB Life Skills

AB Life Skills: Adapting a comprehensive school-based AB Life Skills Curriculum for 8th and 9th grade

learners. The AB Life Skills curriculum, Dare to be Different (D2BD) is a Horizons developed

comprehensive ABC prevention curriculum specifically designed for South African schools. D2BD is unique

to the life skills curricula currently being implemented in South African schools as it is an outcomes-based

curriculum that utilizes a learner-centered approach that promotes a balanced ABC prevention strategy by

emphasizing abstinence (A) and faithfulness (B) and building upon the existing condom knowledge of in

school learners. D2BD has been designed to meet all the learning outcomes and assessment standards set

forth by the South African DOE and the National Curriculum Statement for the national Life Orientation/life

skills program in schools. D2BD promotes a balanced ABC strategy through a comprehensive curriculum

that addresses/promotes goal setting, character building, messages and activities that promote the

advantages of abstinence and the consequences of sexual engagements, activities around risk

assessment, and skills building, including: decision making, critical thinking, problem solving, resisting peer

pressure and communication skills. D2BD features two additional components: (1) Hometalk: homework

activities fostering parent/child communication, and (2) Peer Support: supplemental activities to be

implemented by trained learners. The current Life Orientation curricula being implemented in South African

schools do not address any of the above mentioned messaging or skills building and this is what makes the

D2BD curriculum unique.

D2BD has been piloted in nine primary schools in Mpumalanga District among 1,562 learners and 25

teachers. Data from the pilot suggests that the curriculum differs from what is currently being implemented,

provides more comprehensive information on HIV prevention, encourages parent-child communication

around HIV prevention and pregnancy and is well received by learners and teachers.

In FY 2008, Population Council will build on the findings of the pilot and implementation of the curriculum in

6th and 7th grades in 2006 and 2007 and adapt the AB life skills curriculum D2BD for use in 8th and 9th

grade (13-14 year old learners) classrooms in South African schools in Mpumalanga Province. The D2BD

curriculum that has been developed for the 6th and 7th grades, and as the Life Orientation learning

outcomes and assessment standards vary by grade, D2BD will need to be adapted to reflect the

requirements for the 8th and 9th grade DOE Life Orientation Program.

Population Council will monitor and evaluate the implementation of the adapted curriculum in the 8th and

9th grade classrooms. Some formative research, and a pre-test and pilot will need to be conducted to be

sure that the material is age appropriate, that it meets the DOE Learning Outcomes and Assessment

Standards and that teacher's are comfortable with the curriculum. For this evaluation Population Council is

interested in following the same cohort of students who participated in the program in 2007. As this study

will be a cohort study Population Council will also need to continue monitoring and evaluating the

implementation of the AB life skills curriculum in the 7th grade classrooms. The 2008 cohort study will follow

the 1,562 learners who received the AB curriculum as part of their schools Life Orientation Program in the

6th and 7th grades in 2007. The cohort study evaluation will focus on sexual behavior outcomes but will

also examine knowledge and attitudinal outcomes around abstinence and faithfulness.

ACTIVITY 2: Strengthening FBO Prevention Activities

Kindly note that the program area for the FBO Mutual Monogamy Study has been changed to Counseling

and Testing. For FY 2008, this program focuses on promoting Couple's HIV Testing and Counseling

through faith-based organizations

The program will continue to focus on couples in churches with the goal of mutual monogamy among these

couples. Couples will continue to receive messages and skills to enable them to establish and/or maintain

mutual monogamy in their partnerships. Indeed, mutual monogamy messages are still important for this

population as baseline data collected April 2007 among church members in Butterworth and Alice indicated

that approximately one-third of church-goers in stable relationships suspected their primary partner to be

having sex with someone else, and 17 percent of those in stable relationships indicated they had sex with

someone else outside of their primary relationship. Given the potential for exposure to HIV through non-

monogamous relationships, HIV testing among couples becomes crucial, particularly in light of the high

level of HIV serodiscordance among couples that have been reported in Sub-Saharan Africa.

Activity Narrative:

An integral part of the FBO program on mutual monogamy has been the promotion of HIV counseling and

testing, particularly as a couple, so that they can know their HIV status and plan accordingly as a couple. In

the current program, individuals and couples have been referred for HIV counseling and testing, however,

the quality of the service of couples counseling and testing is likely to be poor. Therefore, by adding on the

couple counseling and testing component to this program, the program becomes more comprehensive.

This activity contributes to the PEPFAR goal of averting seven million infections.

BACKGROUND:

There has been growing alarm regarding the high levels of rape reported in South Africa. Sexual violence

and violence against women have become one of considerable political importance and the Department of

Justice (DOJ) has launched a major initiative to address the needs of rape victims in a comprehensive

manner. Meeting the immediate healthcare needs of rape survivors (including HIV, sexually transmitted

infections, treatment of injuries, and counseling) is a priority. Guidelines exist for the provision of PEP, along

with these other key services; however, evidence shows that these are not often followed. In addition, there

is a poor link between medical post-rape services and the necessary legal and police procedures.

SUMMARY:

Population Council (PC) and Rural Aids and Development Action Research (RADAR) have been working in

Limpopo to implement and evaluate a rural, multi-sectoral model for post-rape care. A number of obstacles

in providing comprehensive post-rape care at the project site were identified, including uptake of service by

community, institutional and provider capacity, quality of service delivery, and inter-sectoral linkages. An

intervention strategy was developed to address these key challenges. A Project Advisory Committee (PAC)

was formed and a hospital rape management policy was developed.

Healthcare workers and other providers were trained on multi-sectoral approaches to rape management,

centralization and co-ordination of post rape care, strengthening of inter-sectoral linkages with local police

and community awareness. Following the interventions, a repeat evaluation at the hospital and police

station indicated that the flow of patient care has been streamlined, necessitating fewer providers, fewer

steps, and fewer delays in treatment. Nurses are taking a more active role in management of rape cases,

using formal protocols and policies, and referral rates to other providers appears to be increasing. With

support from hospital management, the hospital pharmacist has begun to dispense a full 28-day regiment of

PEP on the initial visit. Community awareness campaigns have reached over 14,000 individuals in the

hospital catchment area, with information about post-rape services, including PEP. Whether due to

increased awareness and/or other factors, there has been an observed increase in the uptake of services at

the hospital. The project is also working with national and provincial (Limpopo and Mpumalanga)

Departments of Health to train healthcare workers and health managers regarding management of sexual

assault, and to share policies and management tools. Although these activities have strengthened the

health sector response to violence, they have also revealed weaknesses in addressing the legal needs of

rape survivors. Nurses and doctors have been trained in collecting forensic evidence, but few cases are

actually brought to court, and even fewer successfully prosecuted. Lack of confidence in legal proceedings

discourages survivors from seeking medical care or reporting to police.

In FY 2008 the activity outlined above will be replicated and scaled-up in collaboration with the

Tshwaranang Legal Advocacy Centre (TLAC) in Limpopo and Mpumalanga. The aim of the activity is to add

a strengthened legal and mental health component to an existing model for post-rape care and HIV post-

exposure prophylaxis in rural South Africa, and to begin to explore questions concerning the uptake and

feasibility of the model. Emphasis areas of this activity will be: increasing women's legal rights, reducing

violence and coercion, human capacity development, local organization capacity building and strategic

information.

ACTIVITIES AND EXPECTED RESULTS:

PC will implement continued monitoring of VCT and PEP services at the hospital and strengthening the

referral system between the health sector and the criminal justice sector.

ACTIVITY 1: Ongoing Monitoring of VCT/PEP Services at the Hospital

During the first phase of the project called Refentse Project, a number of monitoring and evaluation tools

were developed and introduced at the hospital to follow uptake and provision of VCT and PEP. This

included establishing a confidential hospital rape register completed by outpatient nurses, and an interview

with clients to determine PEP adherence at 4-weeks following the incident. During the second project

phase, the use of these tools will continue to be supported and adapted as needed, with the aim of

monitoring the provision of VCT and PEP, as well as adherence to the 28-day ARV regimen among clients.

FY 2008 additional funds will be used to expand existing TA to provincial DOH to expand services and job

aids on comprehensive post-rape care and HIV PEP

ACTIVITY 2: Project Advisory Committee Meetings

The previously established multi-sectoral Project Advisory Committee (PAC) will continue to meet at regular

intervals. The PAC will continue to play an important role during this phase of the project, bringing together

key stakeholders to share information and experiences, identify systemic problems and strengthen the

linkages between the health system and the criminal justice system.

ACTIVITY 3: Strengthening the Referral System between Health and Justice Sectors

A system will be developed for referring all domestic violence and rape survivors for further legal and

psychosocial support. This will entail training outpatient nurses, and developing a communication and

monitoring system between the hospital's outpatient department (where such cases present) and the

service providers responsible for ongoing paralegal and psychosocial support.

ACTIVITY 4: Introducing direct legal services and psychosocial counseling

A trained, community-based paralegal officer will provide day to day legal advice to clients at the project

site. To facilitate access to the service, the paralegal will operate from the Victim Empowerment Unit,

situated behind the local police station and will also conduct a weekly legal clinic at Tintswalo Hospital. It is

envisaged that by physically locating the service at these premises, it will ensure greater access for women,

as it will be immediately available to women who seek medical treatment and care and those that seek the

intervention of the criminal justice system.

Activity Narrative: ACTIVITY 5: Case Management and Data Collection

The paralegal will be managed as part of TLAC's legal services unit and TLAC's current case management

system will be used to track progress of and manage cases. Cases will be entered into a database and

TLAC's attorney will have remote access to the database. TLAC's attorney will hold regular supervision

meetings with the paralegal and will provide ongoing feedback on casework. A set of indicators has been

developed to monitor both the progress and the impact of individual cases. The cases will be routinely

tracked to identify systemic problems faced by women and these will be fed into various fora, including the

already established Project Advisory Committee.

ACTIVITY 6: Paralegal Training

This activity is described in the Explanation of Training Activities text box below.

Expected Results: these are embedded in the descriptions of each activity, above, and are further quantified

in the targets section of this COP.

This activity (and the sub-activities described above) will contribute to PEPFAR's overall project goals by

increasing the legal and other institutional support systems available for rape victims in South Africa and

specifically strengthening the HIV-related health care available to rape victims.

SUMMARY:

In collaboration with the South African Government (SAG), FY 2008 PEPFAR funds will be used to support

a service availability mapping exercise that will allow organizations to be able to locate all necessary HIV

and AIDS related services they may need in order to strengthen their own care and treatment service

delivery. This service availability mapping exercise of districts and sub-districts will assist home-based

caregivers, volunteers, community-based organizations, faith-based organizations and public health

facilities to provide referrals efficiently in order for clients to access services closest to their household.

USAID/South Africa recognizes the need to be aware of available services and resources in order to identify

gaps, avoid duplication and to maximize collaboration and linkages with other stakeholders and partners.

This activity will include mapping of the essential services available from the South African Government, for

example Home Affairs for birth certificates and identification documents, legal-aid centers for land disputes

and inheritance issues, Social Development for access to grants, Rape Centers for access to post exposure

prophylaxis (PEP), and ART treatment sites for access to pediatric and adult treatment, etc. Mapping

provides a means of organizing local knowledge through the common language of geography and visual

representation. Through a participatory process, local knowledge can be gathered, integrated, represented,

and shared. Maps can then act as a basis for community discussion, empowerment, and decision-making.

A service provider to implement this activity will be selected in October 2007.

Primary emphasis will be on local capacity building and the development of network referrals and

Information, Education and Communication. The final product, a directory of services, will be used widely

both by PEPFAR supported partners as well as the SAG and other organizations that provide HIV and AIDS

services in South Africa. This booklet will be shared widely through the HIV and AIDS networks and forums

in South Africa.

The primary target populations for the intervention include OVC, people living with HIV and AIDS and the

general population aged over 25 years.

BACKGROUND:

The South Africa PEPFAR program embarked on a geographical information systems (GIS) mapping

activity in FY 2005. These maps have proven a valuable tool for planning and coordinating activities within

and across partners. However, to date, these maps only show PEPFAR supported services, as well as SAG

ART services. The USG Team would like to take this mapping down to a community level to improve

service delivery on the ground. This activity will strengthen referrals and linkages between government

departments, NGOs, civil society groups and HIV and AIDS service providers through sharing and

dissemination of information on the availability and location of essential services in South Africa.

ACTIVITIES AND EXPECTED RESULTS:

A directory of organizations providing HIV and AIDS related services in South Africa will provide a useful

guide to the many agencies and organizations working to address the critical challenges faced by HIV and

AIDS in South Africa. There is a need for a comprehensive database of organizations working with and for

HIV-infected and affected individuals in South Africa. In 2001 a directory of Child HIV and AIDS services

was published by the Department of Social Development in collaboration with Save UK and UNICEF. In

addition, service availability mapping was completed in the Eastern Cape province during the former USAID

equity project. These directories are now out of date, however they will be used as the starting point to

establish a district map of the services and key service providers will be added. The availability mapping

exercise will inform all those concerned about HIV and AIDS, especially the partners funded by PEPFAR, of

the various services and initiatives available to assist them and to strengthen their efforts to support HIV-

infected individuals and their families. This directory will be user-friendly and will facilitate smooth referrals

and encourage linkages. The service directory will also enable organizations to better utilize services that

are available, facilitate new partnerships to address the gaps in service delivery and encourage a multi-

agency approach to assisting individual infected by HIV, their families and their communities. This activity

would begin in three of the provinces and will then be replicated in all nine provinces of South Africa. In

addition, this directory will be linked to GIS data points for more interactive usage of the directory and to

produce various maps.

This activity will contribute to the PEPFAR goal of providing care and support to 10 million HIV-affected and

infected individuals, including OVC. In addition it will contribute to the success of the following objectives of

the SAG’s National Strategic Plan; to develop and implement mechanisms to identify, track and link

OVC and child-headed households to grants, benefits and social services at local levels and to increase the

proportion of vulnerable children accessing social grants, benefits and services.

SUMMARY:

Prevention efforts are key to reducing sexual transmission of HIV. In South Africa, the Population Council

(PC) has implemented several prevention programs targeting men and women of reproductive age

including young people, learners, as well as couples to delay sexual debut, promote faithfulness and mutual

monogamy, promote voluntary counseling and testing and to reduce risk behaviors. With PEPFAR FY 2008

funds, PC intends to strengthen and expand these activities. The proposed activities are in response to

requests from various government departments (provincial and national), and will draw upon exiting

partnerships with South African institutions and organizations such as the Departments of Health and

Education and the South African Council of Churches.

BACKGROUND:

Over the past years, the PC has developed expertise in developing strategies and interventions focused on

preventing HIV transmission including promotion of counseling and testing. The first activity, which is co-

funded by the Department of Health (DOH) seeks to operationalize the South African government policy

and the national contraceptive guidelines by increasing counseling and testing (CT) uptake by family

planning (FP) clients. These models have been implemented in three South African districts in 30 clinics in

the North West province and will be introduced to all seven regions in the North West, Gauteng and the

Eastern Cape provinces. The second activity builds on ongoing work with faith-based organizations (FBO)

in the Eastern Cape. To date, earlier work examined ways of promoting mutual monogamy and promoting

partner reduction among members of churches affiliated to the Eastern Cape Council of Churches. Most

HIV transmission in sub-Saharan Africa occurs among people in stable sexual partnerships, and rates of

HIV serodiscordance are as high as 20-30%. However, uptake of HIV testing has been extremely low,

particularly couples' HIV testing. In this second activity, Population Council has been working with the

Department of Education, the South African Council of Churches and local FBOs piloting interventions on

AB in primary schools and mutual monogamy in churches in Mpumalanga and the Eastern Cape provinces,

respectively. These community interventions have reached couples, church members, youths, teachers,

learners, parents/guardians and other stakeholders. However, reaching an adequate number of men

through churches is a major challenge because fewer men than women participate in church activities. The

target population for this activity is men and women of reproductive age, program managers, program

implementers, church leaders, NGOs and other stakeholders. The emphasize areas are gender, human

capacity development (training), public health evaluations / targeted evaluations and strategic information.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training, Ongoing Quality Assurance and Supportive Supervision

PC will provide continued technical assistance (TA) for capacity building and support training on HIV and FP

integration to DOH as they train providers in the three provinces. Developed training material and

information, education and communication (IEC) will be shared with the national and provincial departments

of health for adoption in various provinces. TA will be provided to adapt materials to provincial contexts for

example addressing language. A register will be developed to keep track of the number of trained staff, staff

turnover and to ensure completion of training for each provider in intervention clinics. Support to relevant

DOH staff will be provided to strengthen and clarify supervisory roles and responsibilities. In addition, PC

will plan and host, in collaboration with the NDOH, the review of the National Contraceptive Policy and

Management guidelines with a view to integrating relevant HIV issues.

ACTIVITY 2: Development of Network/Linkages/Referral Systems

PC will facilitate the establishment of provincial fora to address challenges and solutions to the

implementation of tested models of integrating HIV into FP. In order to ensure sustainability, PEPFAR funds

will be used to support NDOH-to-province and province-to-province collaboration on the Maternal, Child,

Women's Health and Genetics, Voluntary Counseling and Testing, Comprehensive HIV and AIDS, Care,

Management and Treatment Plan programs. Strengthening referral systems for HIV-infected clients post CT

will be one of the major foci in order to improve continuity of care. This activity involves raising awareness

on the importance of creating links among treatment, care and support with FP services, so that HIV-

infected clients can benefit from an effective referral system. Treatment sites as well as sites that provide

care and support will be identified. Training will be provided to FP providers and lay counselors on

appropriate referral and available sites for referral in the location. The target group for this activity includes

healthcare providers, DOH program managers as well as community-based organizations and non-

governmental organizations.

ACTIVITY 3: Continued Partnership with the National and Provincial Government

As part of aligning PC's work with government policy, PEPFAR funding will be used to enable the activity to

work more closely with the NDOH national voluntary counseling and testing program and to continue

working with the WHG program. PC will support the NDOH by providing TA to the department in terms of

planning for scale-up of effective components and assisting in identifying key policy barriers in implementing

integrated HIV and reproductive health services. Target groups for this activity include national and

provincial CT program staff as well as other NDOH staff under the HIV prevention, treatment, care and

support program. This activity will assist the South Africa PEPFAR program to reach its goal in both care

and treatment by strengthening the continuum of care with the particular Population Council emphasis on

designing sustainable programs and service improvements.

ACTIVITY 4: Creating Conditions for Scale-up and Capacity Building

An evaluation of the effectiveness of integrating HIV into FP services will be completed. Funds will be used

to develop and modify evaluation tools, train field workers, and to collect and analyze data. In addition,

seminars will be conducted with relevant stakeholders to encourage information dissemination and use. At

these seminars, innovative interventions on how to increase CT uptake will be discussed, as well as how to

continue strengthening the continuum of care and support for HIV-infected individuals. This activity will

assist the South Africa PEPFAR program to reach its goal in both care and treatment by strengthening the

continuum of care.

Activity Narrative:

ACTIVITY 5: Promoting couples' HIV counseling and testing through FBOs and churches

FY 2008 funds will be used to continue to work with couples with expansion to include faith-based

interventions emphasizing couple CT. The emphasis will be on increasing uptake of couples for HIV

voluntary counseling and testing (CHCT). Through CHCT, couples can learn their HIV status together as a

unit. When partners test separately as individuals, disclosure rates are low, and there is no planning for risk

reduction. CHCT is an effective prevention intervention; it facilitates disclosure and allows the couple to

jointly plan for risk reduction. However, CHCT is underutilized. Demand for CHCT is low for a number of

reasons including high stigma, belief that monogamy is safe, gender inequalities between husband and

wife, and lack of knowledge about the benefits of CT or where it can be obtained. Additionally, few

counseling and testing sites provide appropriate CHCT or provide support for discordant couples, and few

healthcare providers are trained in CHCT. In other words, health centers tend not to be very couple-friendly

for HIV testing. Therefore, a faith-based CHCT may have to take advantage of being able to provide a more

couple-friendly environment that facilitates couples testing. Church leaders and counselors have been

unofficially involved with facilitating disclosure among couples in their congregation. Therefore, church

leaders can be used to promote CHCT.

The proposed evaluation will be designed to determine the effectiveness of a faith-based intervention in

increasing uptake of couples HIV counseling and testing and document how it can be implemented by

FBOs and churches.

Appropriate influential church member couples will be used to promote and encourage CHCT through

church interventions. This will be supplemented with congregation-wide messages on couple testing. This

will be implemented in 10 churches in Alice (Eastern Cape), where CT is available at the existing FBO-run

hospice. Five churches will be selected as non-intervention churches and data will be collected and

compared with the intervention churches.

In-depth interviews with male and female church members who are married or cohabiting will be conducted

in order to understand the facilitators of and barriers to couples counseling and testing. The findings about

their relationships and their perceptions and attitudes about CHCT will guide the intervention and couples'

counseling sessions to appeal to couples to attend CHCT. To support CHCT, a faith-based intervention will

be appropriately designed to meet the needs of HIV discordant couples. This intervention will focus on

assisting couples develop a long-term plan to help reduce the chances of HIV transmission to the negative

partner and help the HIV-positive partner live positively. This study will accomplish all this in a period of two

years.

SUMMARY:

ARV services are being rolled out in a phased approach in South Africa, however, barriers to accessing

treatment remain at the community and health facility level, particularly for children and OVC. Data from

public sector sites also reveal that counseling and testing (CT) is not acting as an effective entry point for

treatment, care and support services due to poor linkages and referral systems. The Population Council

(PC) will address issues concerning accessing treatment through 3 key activities with an emphasis on

linkage and referral networks. The emphasis areas are human capacity development, local organization

capacity building and wraparound (health).

BACKGROUND:

Over the past two years, the PC has worked closely with projects that specifically seek to increase access

to antiretroviral treatment (ART) through different entry points at health facilities. Data from three separate

projects show that major barriers still exist. A recent study showed that HIV-infected children in communities

do not have access to ART for several reasons, including limited availability of PMTCT interventions, the

limited number of facilities offering treatment, caregivers' ignorance of the HIV status of children, and a lack

of programs addressing access to ART. Group discussions with caregivers and OVC service providers, as

part of an elderly caregivers intervention, showed that the caregivers had very little knowledge and

information on ART for children as well as relevant prevention issues. Data from public sector sites in North

West province reveal that once tested for HIV, few clients are referred for assessment, treatment, wellness,

or care and support services. Thus CT is not acting as an effective entry point for these services. This

activity area addresses the strengthening of three key entry points to ART delivery. The following

interventions are ongoing and will be expanded.

ACTIVITY 1: Access to Integrated Family Planning (FP) and ARV Services

The integrated FP and ART service provision will be consolidated at both FP services as well as in ART and

other HIV related services in three sub-districts in North West Province. Training and technical assistance

will be provided to ARV and FP providers, district program management staff, lay counselors and health

informatics personnel. Training content will include the rationale for integration, proficiency in using various

integration job aides, referral and linkages, documentation, recordkeeping and loss-to-follow-up. Where

feasible support will be provided to strengthen the health facility based intervention to include the

establishment of support groups for HIV positive clients on ART. The National Department of Health

(NDOH) will be provided with technical assistance to inform the development of a strategy and inform

guidelines for the integration of ART and FP. Particular attention will be given to ART and FP services for

youth. Target groups for this activity include NDOH program managers and other implementing agencies.

The third strategy in this activity will focus on addressing stress and burnout amongst providers of ART and

CT, including providers of post-rape services in North West Province. The PC will work with providers and

a psychologist to structure and initiate mechanisms to introduce peer education and support for ART, CT

and sexual assault services providers. This activity will inform the development of materials for debriefing

providers working in HIV related services.

ACTIVITY 2: Expanding Access to ARV Services through the Family-Centered Approach (FCA)

The family-centered approach is currently being tested at three centers; Tapologo group of health facilities,

Royal Bafokeng (both in North West province) and Cecilia Makiwane in East London (Eastern Cape

province). The FCA involves recruiting family members, specifically children, to access CT and

subsequently, treatment services at health facilities. Identification and contact with primary patients will be

made at CT and PMTCT sites and through immunization and child health programs. Support to improve CT

as an entry point to care and treatment services is the focus of this activity.

ACTIVITY 3: Expanding OVC Treatment Access

Based on earlier work conducted on the elderly and caregivers in the Eastern Cape, and work by NGOs

focusing on orphans and vulnerable children (OVCs), FY 2008 funds will be used to conduct the following

interventions: (a) develop the capacity of OVC service providers to engage in relevant ART related services

(e.g. referral to HIV testing, ART and TB services); (b) Develop and implement training for caregivers that

combines information on obtaining HIV treatment (e.g., treatment literacy, side-effects, nutrition, adherence,

how to access ART facilities) and provide care and support with HIV prevention and life skills for OVC. The

HIV prevention and life skills components will focus on the ABC prevention strategy. The caregiver training

will be designed to provide regular support to the caregivers and to address the psychosocial needs of the

caregivers; (c) Develop referral networks and linkages between caregivers and service providers in the

community to increase HIV testing, ART services and HIV related care for OVC. Concerns around

disclosure of HIV status of children and counter stigma faced by infected children and affected caregivers

and families will be addressed.

These activities support the PEPFAR 2-7-10 goals.