SUMMARY:

Absolute Return for Kids' (ARK) focus is to provide a comprehensive care package for PMTCT services to

HIV-infected mothers and their children through partnerships with local government health facilities. ARK's

primary emphasis has been in areas of human capacity development, local organization capacity

development, and construction/renovation at about ten facilities. The target population is HIV-infected

pregnant women and their infants.

BACKGROUND:

ARK is a charity organization whose mission is to facilitate and support delivery of accessible, sustainable

comprehensive treatment, care and support services to children and their caregivers in communities

affected by HIV and poverty. In partnership with the KwaZulu-Natal Department of Health (KZNDOH), ARK,

has established an antiretroviral treatment program in government primary health facilities and hospitals.

Specifically, ARK works with the KZNDOH to identify sites and areas for capacity building, including human

resources, modest infrastructure support, and organizational capacity development. PEPFAR funding has

enabled ARK to successfully enroll over 15,000 patients in ART in KZN with about 12000 remaining in care

at ARK supported sites.

FY 2008 funding will enable ARK to expand its established ARV treatment program to include a

comprehensive range of PMTCT services. These services will be supported by improvements in the

infrastructure of targeted sites, and the provision and training of human resources in partner health facilities

to further strengthen their capacity to deliver quality counseling and testing, treatment, care and support for

HIV-infected mothers and their children.

ACTIVITIES & EXPECTED RESULTS:

ACTIVITY 1: Support to KZNDOH

ARK works with the KZNDOH to develop the necessary processes and systems to manage the PMTCT

program, to ensure that the model implemented is scaleable, sustainable and replicable elsewhere. ARK's

PMTCT program works within KZNDOH selected districts and focuses on strengthening the existing

networks of operating clinics; capacity-building is site specific. Upon identification of a site, ARK conducts

an analysis to identify staffing, clinical equipment, and infrastructure needs. The program works with facility

management to prioritize and promptly address gaps and develop plans for manageable scale-up. ARK

also assesses hospital patient data management systems and will employ and train, where needed, data

capturers. The data capturers support both providers and facility administrators to strengthen the

management and use of patient records systems for improved service delivery.

ACTIVITY 2: Human Capacity Development

ARK will conduct a thorough needs analysis of human resource capacity prior to initiating support to the

PMTCT program at each site and recruit all the necessary medical staff required for the successful rollout of

services. The staff recruited varies from site to site but include doctors, nurses, pharmacists, pharmacy

assistants, medical technologists, facility-based counselors, and patient advocates. For all key staff, ARK

will provide two-week orientation training based on the National PMTCT and Infant Feeding Curriculum and

Methodology. The training and follow-up refresher courses cover all aspects of ARK's PMTCT program

including employee policies and procedures, onsite mentorship from experienced ARK staff, and an

introduction to key performance areas. The specific topics covered include: counseling and testing,

treatment guidelines for pregnant women, management of opportunistic and sexually transmitted infections,

adherence support as well as the value of community access, prevention counseling and patient advocacy.

Staff are invited and encouraged to attend formal training offered by external providers including other

PEPFAR partners such as the Foundation for Professional Development (FPD).

ACTIVITY 3: Counseling and Testing

ARK will focus on provider driven opt-out testing to all pregnant mothers entering the antenatal clinics. To

better ensure sustainability, where possible, ARK will use the counselors available through the District HIV

program and existing trained community care workers to provide counseling. Where needed, ARK will

employ and train additional counselors. Counseling and ongoing training will be in line with the National

Department of Health (NDOH) Guidelines. ARK will provide mentorship and supportive supervision to lay

counselors to ensure high quality standards for CT. In accordance with NDOH standards, all testing will be

conducted by trained medical staff (primarily nurses). Pre-and post-test counseling for all clients will include

information on HIV & AIDS, STIs, prevention education, risk reduction strategies, and partner testing. Post-

test counseling will further include information and support on treatment, care and support services, and

positive living.

Formal and informal training and onsite mentorship will be provided to all lay counselors in the program.

ARK, in partnership with the Centre for Social Science Research at the University of Cape Town, will

continue to develop and improve training modules for lay counselors. The areas covered in training include:

basic and advanced counseling skills, positive living, disease progression, opportunistic infections, risk

reduction for HIV transmission and safer sex.

ACTIVITY 4: Treatment for HIV-infected pregnant women

All pregnant women testing positive for HIV will have an immediate CD4 test and will have a clinical

assessment for the present of opportunistic infections and for staging. Women will receive nutritional

counseling as well as counseling around feeding options for their babies. Exclusive breast feeding will be

encouraged in those women who do not satisfy the AFASS principles for formula feeding. A particular focus

will be on triaging pregnant women who are treatment eligible into treatment programs, and ensuring that

women who are not treatment eligible are provided with the appropriate dual-drug prophylaxis (new DOH

guidelines.) The process and follow up of women on triple therapy will be dependant on the facility. In some

facilities this site will be in the same place as the antenatal service, in others the ARV treatment site will be

separate to the antenatal clinic.

Upon registration into the PMTCT program, a paid trained patient advocate is assigned to the patient. The

patient advocate conducts a pre-treatment home visit and provides ongoing support to the patient and her

family. The patient advocate will accompany the mother to her antenatal visits, provide adherence support

and referrals and follow-up as needed. Should a patient be non-adherent or lost to follow-up, the patient

advocate will investigate the reasons for this, acting as the link between the patient and the clinic. ARK

facilitates the integration process for ART, TB, palliative care and OVC care and support services where

appropriate.

Activity Narrative: ACTIVITY 5: Pediatrics

HIV-infected pregnant women will be educated and encouraged during pregnancy to undertake post

delivery testing for their babies. All children born to HIV-infected mothers will be closely followed up for any

evidence of early deterioration and will receive NVP and AZT as per PMTCT protocol. At the six week visit,

all HIV exposed babies will have a PCR test done, will be given cotrimoxazole prophylaxis and multivitamins

to await the PCR result. Mothers with a CD4>350 or between 250-350 with WHO STG 1&2 will stop HAART

if babies are exclusively formula fed OR after weaning if exclusively breast fed. Formula fed babies that test

negative will be offered an Elisa at 18 months. Breast fed babies if tested negative will be offered a PCR at

12 weeks after weaning and if still negative an Elisa at 18 months. HIV-infected babies will be immediately

referred to ARK's ARV treatment program and will have access to cotrimoxazole prophylaxis, multivitamin

supplements and general nutritional advice, and breastfeeding counseling and support for the mother. The

patient advocates (PA) will ensure that all babies are brought back for their immunization and testing for HIV

will be actively encouraged by the community workers.

ACTIVITY 6: Family-Centered Care and Support Services

In an effort to encourage adherence among mothers and ongoing care for their infants, ARK's program

takes an integrated maternal and child health care approach and extends care and support (including

treatment literacy and prevention education) to all members of a patient's household. Together, facility-

based counselors and patient advocates counsel mothers and their partners on treatment literacy, nutrition,

safe infant feeding practices, and safe sex. They offer services within homes and provide encouragement

and support to male partners to serve as "adherence buddies" in the management of care during pregnancy

and after delivery. Patient advocates are also trained to provide basic psychosocial support and link

mothers to individual counseling services and/or support groups.

ACTIVITY 7: Quality Assurance/Improvement

ARK provides computers and employs data capturers at all sites. Data is captured from patient folders and

transferred to ARK's data center, allowing for ongoing evaluation and outcome analysis. Adherence rates,

death rates and loss to follow-up are closely monitored. Quarterly updates are provided to the KZNDOH and

information is used within the clinics to strengthen service delivery. All ARK staff are provided onsite, on-the

-job training, followed with regular onsite mentorship and evaluation by ARK's national executive and

provincial management teams. Informal training sessions are conducted quarterly. Staff are encouraged to

attend formal external training courses offered by FPD.

These activities contribute to PEPFAR's 2-7-10 goals by increasing the number of South Africans on

treatment and possible new infections averted among infants and children.

SUMMARY:

Absolute Return for Kids' (ARK) focus is to provide a comprehensive palliative care package for services to

HIV-infected mothers and their children through partnerships with local government health facilities. ARK's

primary emphasis areas are human capacity development, local organization capacity development, and

construction/renovation. The target population is people living with HIV and AIDS.

BACKGROUND:

ARK is a charity organization whose mission is to facilitate and support delivery of accessible and

sustainable comprehensive treatment, care and support services to children and their caregivers in

communities affected by HIV and poverty.

ARK's mission is to facilitate and support delivery of accessible and sustainable comprehensive treatment,

care and support services to children and their caregivers in communities affected by HIV and AIDS. In

partnership with the KwaZulu-Natal Department of Health (KZNDOH), ARK, as the implementing partner,

has established an antiretroviral treatment program in government primary health facilities and hospitals.

Specifically, ARK works with the KZNDOH to identify sites and areas for capacity building, including human

resources, modest infrastructure support, and organizational capacity development. PEPFAR funding has

enabled ARK to successfully enroll over 15,000 patients in ART in KZN with about 12000 remaining in care

at ARK supported sites.

FY 2008 funding will enable ARK to expand its established ARV treatment program to include a

comprehensive range of palliative care services. These services will be supported by improvements in the

infrastructure of targeted sites, and the provision and training of human resources in partner health facilities

to further strengthen their capacity to deliver quality care and support for HIV-infected mothers and their

children. ARK provides palliative care services in accordance with South African national treatment

guidelines.

ACTIVITIES AND EXPECTED RESULTS:

ARK's primary objective is to keep mothers alive to continue caring for their children. The primary

caregiver's continued survival and potential ability to earn a living while receiving ARV treatment will have a

substantial impact on the extended family.

ACTIVITY 1: Support to KZNDOH

ARK works with the KZNDOH to develop the necessary processes and systems to manage the palliative

care program, to ensure that the model created is scaleable, sustainable and replicable elsewhere.

Capacity-building is site specific. Upon identification of a site, an analysis of the needs of each site will be

done with respect to staffing (doctors, nurses, pharmacists and pharmacy assistants), clinical equipment,

management systems, patient advocacy and temporary structures. The most pressing requirements are

met in order to speed up the ability for patients to receive treatment. Where necessary ARK provides

support in the ARV site and pharmacy accreditation process.

ACTIVITY 2: Human Capacity Development

ARK will conduct a thorough needs analysis of human resource capacity prior to initiating support to the

palliative care program at each site and recruits all the necessary medical and support staff required for the

successful rollout of services. The staff recruited varies from site to site but include doctors, nurses,

pharmacists, pharmacy assistants, medical technologists, facility-based counselors, and patient advocates.

For all key staff, ARK will provide training and follow-up refresher courses cover all aspects of ARK's

palliative program including employee and volunteer policies and procedures, onsite mentorship from

experienced ARK staff, and an introduction to key performance areas. The specific topics covered include:

counseling and testing, screening for pain and symptoms, screening for OIs including the provision of

cotrimoxazole prophylaxis, symptom control and management of opportunistic and sexually transmitted

infections, nutritional assessment and counseling, adherence support, as well as the value of community

access, prevention with positives, referral and patient advocacy. Staff are invited and encouraged to attend

formal training offered by external providers including other PEPFAR partners such as the Hospice

Palliative Care Association (HPCA) and Foundation for Professional Development (FPD).

ACTIVITY 3: Clinical Care

ARK's palliative care program focuses on a network of clinics operating within a district, in order to create a

sustainable and efficient system that supports the continuum of care and up and down referral. ARK-

employed doctors and nurses provide comprehensive treatment management including patient uptake,

doctor consultations, counseling and testing, TB screening and management, pain management and

symptom control, treatment of opportunistic and sexually transmitted infections including the provision of

cotrimoxazole, lab testing and patient education. Pharmacists are responsible for the dispensing of

medication.

As part of the palliative care package for HIV-infected individual, individuals accessing ARK's services will

be staged and entered into ARK's ARV treatment program. All patients with a CD4 count of <200 will be

referred to ARK's ART program to confirm their eligibility for treatment. The program's medical and

psychosocial criteria are designed to ensure that the patient is prepared and ready to adhere to ART. All

patients being assessed undergo a treatment literacy program and are educated about positive living.

Patients are encouraged to motivate their partners/spouses to get tested and, if necessary, enter the

treatment program. HIV-infected patients, not in-need of ARV treatment and not with active TB, will be

offered isoniazid prophylaxis, monitoring, and ongoing counseling support for 6 months. At the end of the 6

months, these patients will be reassessed for further treatment. Although ARK's treatment target population

is predominantly mothers and children, increased attention is being given to encourage and increase male

partner (and men in general) participation.

ACTIVITY 4: Family-Centered Care and Support Services.

Activity Narrative:

In an effort to encourage adherence among mothers and ongoing care for their infants, ARK's program

takes an integrated, family-centered approach to care and extends support (including treatment literacy and

prevention education) to all members of a patient's household. Together, trained facility-based counselors,

patient advocates and community health workers (CHWs) counsel patients and their partners on treatment

literacy, positive living, nutrition, safe infant feeding practices, and safe sex. CHWs conduct pre-treatment

home visits and provide ongoing psychosocial support to patients and their families. They also promote and

support disclosure to partners and family, partner testing and facilitate treatment access. CHWs are

required to facilitate support groups for their clients and ensure that all patients and their families have

access to spiritual care, psychosocial support, prevention messaging including prevention with positives,

nutritional counseling, economic assistance (government grants), and protection services, when required.

ACTIVITY 5: Reporting and Quality Assurance/Improvement

ARK provides computers and employs data capturers at all sites. Data is captured from patient folders and

transferred to ARK's data center, allowing for ongoing evaluation and outcome analysis. Adherence rates,

death rates and loss to follow-up are closely monitored. Quarterly updates are provided to the KZNDOH and

information is used within the clinics to strengthen service delivery. To ensure high standards and quality of

care in line with the national guidelines, all ARK staff are provided onsite, on-the-job training. This is

followed up with regular onsite mentorship and site evaluation by ARK's national executive and provincial

management teams. Informal training sessions are conducted quarterly by national staff. Staff are also

encouraged to attend formal external training courses offered by FPD.

These activities contribute to PEPFAR's 2-7-10 goals by increasing the number of South Africans receiving

palliative care.

SUMMARY:

As part of a comprehensive treatment program, Absolute Return for Kids' (ARK) focus is to improve and

enhance TB screening and treatment services for HIV-infected patients and their families. ARK will train and

place required human resources (medical and counseling staff) and develop performance monitoring

systems to strengthen adherence monitoring. The primary emphasis area is human resources. The target

population is people living with HIV and AIDS (PLHIV) and HIV-affected families.

BACKGROUND:

ARK is a charity organization whose mission is to facilitate and support delivery of accessible and

sustainable comprehensive treatment, care and support services to children and their caregivers in

communities affected by HIV and AIDS and poverty. In partnership with the KwaZulu-Natal (KZN) provincial

government, ARK has established an HIV and AIDS treatment program in government primary health

facilities and hospitals. To date, PEPFAR funding has enabled ARK to successfully put over 15,000 patients

onto ARV treatment in KwaZulu-Natal. Dual infection rates of TB with HIV are very high. The Medical

Research Council reports the national rate at 58%. Many TB/HIV co-infected individuals are unaware of

their dual infection, and CT services for coinfection are limited or non-existent. With COP 08 funding, ARK

will continue its work to enhance and improve its HIV and AIDS treatment program by strengthening TB

screening, care and support services for HIV-infected patients and their families.

ACTIVITIES AND EXPECTED RESULTS:

ARK will continue to work with the national and provincial departments of health and specifically with the

HAST (HIV, AIDS STI, and TB) managers to prioritize interventions designed to address weaknesses

(identified by the Departments of Health) in the DOTS and TB/HIV programs. ARK will focus on improving

policy adherence and patient follow-up. Individuals will be hired for each site as tracers to track patients and

ensure that referrals are completed. ARK is setting aside funding to develop (with other relevant partners or

agreement counterparts) standardized tools to ensure that policies and guidelines recommended by NDOH

are followed, including guidelines for infection control. ARK will continue to integrate TB/HIV interventions

with existing agreement programs as they work seamlessly and side by side with government employees at

government facilities.

ACTIVITY 1: Support to Provincial Government

ARK works with provincial government in developing the necessary processes and systems to manage the

HIV care and treatment program and to ensure that the model created is scaleable, sustainable and

replicable elsewhere. Specifically ARK has a mandate with provincial government to recruit and place

human resources (doctors, nurses and pharmacists) in public clinics for a maximum of three years. ARK

fully funds these positions, which will be taken over by provincial governments at the end of the period. The

clinicians provide screening for TB, CT for HIV, and treatment management including patient consultations

and treatment of opportunistic and sexually transmitted infections if necessary. ARK also provides training

and mentorship to government community health workers (CHWs) to improve and enhance TB/HIV co-

infected patient support. Community health workers provide care and support services including needs

assessment and psychosocial support, and serve as a link, during and after TB treatment, and between the

patient and the clinic to address patient needs. At government clinics, ARK strengthens data information

systems to enable clinics to provide quarterly updates to provincial government to improve ongoing

evaluation, data for outcomes computation and analysis.

ACTIVITY 2: Human Capacity Development

Formal and informal training and on-site mentorship is provided to all CHWs. ARK, together with the Centre

for Social Science Research Unit, University of Cape Town, developed training modules for CHWs on HIV

and AIDS care. The areas covered include: TB/HIV coinfection, TB treatment guidelines for adults and

children, maternal and child care in the context of HIV and AIDS, and adherence to TB and ART treatment.

ARK provides overall supervision of the program, ensuring ongoing mentorship of the trained CHWs.

ACTIVITY 3: Screening for TB with HIV-infected Patients

All HIV-infected individuals entering the program will be assessed for the presence of active TB. An inquiry

about symptoms that would suggest active TB and any history of TB or known/likely exposure will be

ascertained. For patients who report that they have received treatment of active TB or latent TB in the past,

the adequacy of the treatment will be assessed. A physical examination that includes examination of extra-

pulmonary sites of disease, such as lymph nodes, and chest radiography will be performed. ARK clinical

and counseling staff will work with patients with infectious TB to identify their close contacts for screening

and preventative treatment. ARK will also integrate TB screening into established PMTCT programs at ARK

sites. HIV-infected patients who are candidates for, but who do not receive, TB preventive therapy will be

assessed periodically for symptoms of active TB as part of ongoing management of HIV infection.

ACTIVITY 4: CT for DOTS Program

Patients with TB constitute an important "sentinel" population for HIV screening. The benefits of identifying

previously unrecognized HIV infection are substantial in terms of both the opportunities for preventing future

HIV transmission and the large potential benefits to the patient of antiretroviral therapy. Knowledge of the

HIV sero-status of TB patients may also influence the treatment of their TB. ARK will work with established

DOTS programs in its sites to promote the routine offering of CT for TB patients in order to increase the

number of TB patients undergoing HIV CT. ARK will offer training to DOT supporters on HIV and AIDS and

coinfection, and treatment and referral options. ARK will work with healthcare providers, administrators, and

designated TB controllers to promote routine offering of CT and more coordinated care for patients with TB

and HIV in government clinics through strengthening, and in some cases, establishing referral systems

between the TB control programs and HIV and AIDS programs. Referrals and service use will be tracked to

monitor the use of CT services among TB clients. ARK will also facilitate the sharing of information from the

treatment program to the TB program and through the TB register. For TB patients who test positive for HIV,

ARK CHWs will ensure that patients who are awaiting ARV treatment are adequately informed about ART

Activity Narrative: and are prepared to take treatment adherently. All patients who are pre-assessed undergo a treatment

literacy program and are educated about "Positive Living." Patients are encouraged to motivate their

partners/spouses to get tested.

ACTIVITY 5: Treatment, Care and Support

Individuals accessing ARK's services will be staged and entered into ARK's ARV treatment program. The

program provides patient uptake, patient consultation, ongoing assessment and monitoring, CT and drug

provision. HIV-infected patients, without active TB and not in-need of ARV treatment, will be offered

isoniazid prophylaxis, monitoring, and ongoing counseling support for 6 months. At the end of the 6 months,

these patients will be reassessed for further treatment. HIV-infected patients with active TB will be linked

with DOT supporters and ARK's community health workers will provide them with ongoing TB treatment

management and support. Once the patient has been successfully treated for TB, ARK will enroll the patient

onto ART. Adherence support is a critical component, complementing clinical services. ARK utilizes a family

centered approach for care and treatment. ARK-trained CHWs conduct pre-treatment home visits and

provide ongoing psychosocial support to patients and their families. CHWs promote and support disclosure

to partners and family, partner testing and facilitate treatment access. CHWs are required to facilitate

support groups for their clients and ensure that all patients and their families have access to grants, spiritual

support and psychological support and counseling where indicated. ARK will strive to identify children

needing TB treatment and ART through ARK's OVC care and support, and CT programs. This activity will

contribute to PEPFAR goals of 2-7-10 by providing care and treatment to many South Africans through

ARK's TB/HIV program.

SUMMARY:

ARK's activities are aimed at improving the lives of orphans and other children made vulnerable by HIV and

AIDS through strengthening school communities to meet the needs of orphans and vulnerable children

(OVC); identifying OVC and assisting them to access government social grants, community support as well

as appropriate referral to health facilities; and nutritional support through establishing sustainable food

gardens in the schools. The primary emphasis areas for these activities are training and local organization

capacity development. Specific target populations include the general population from children less than 5

years to adults, OVC and their caregivers.

BACKGROUND:

ARK is a charity organization whose mission is to facilitate and support delivery of accessible and

sustainable comprehensive treatment, care and support services to children and their caregivers in

communities affected by HIV and AIDS and poverty.

In partnership with the KwaZulu-Natal (KZN) provincial government, ARK has established a comprehensive

antiretroviral HIV and AIDS treatment program in government primary health centers and hospitals.

Specifically, ARK works with the provincial government to identify sites and areas for capacity building

including human resources, human capacity development, and modest infrastructure. Last year with other

donor funds, the ARK Child Services program piloted its interventions through schools and community care

workers to identify and assist OVC to access government grants; improve access to health facilities; access

counseling; and providing a seven-day school-based feeding and sustainable food gardens. To date 5,000

children from 12 schools in rural KZN are fed daily; 687 children have been assisted to access grants; 461

children referred to health facilities; 1000 received the services of social workers; and 50 destitute families

were provided with monthly food parcels. With FY 2008 PEPFAR funding, ARK will expand its child services

program in KZN communities.

ARK's activities will be implemented in partnership with the provincial government of KZN, specifically with

Departments of Education, Health and Social Development. The KZN Departments of Education and Social

Development support the expansion of this project

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Support to Provincial Government

ARK will work with provincial government to develop the necessary processes and systems to manage the

OVC program and to ensure that the model created is scaleable, sustainable and replicable. ARK will

employ social workers and nursing staff to work with the local government schools in linking sick children to

primary healthcare facilities at which ARK's ARV treatment program is in place.

ACTIVITY 2: Community Mobilization

This activity will mobilize and empower school communities to meet the needs of OVC. Schools will form

clusters (4 - 8 schools per cluster) around primary healthcare facilities at which ARK's ARV program is in

place. These schools will be empowered with knowledge, skills and strategies to plan, execute and monitor

interventions that respond to the needs of orphans and vulnerable children attending their schools. This

activity will provide a strong base in the community by utilizing available resources (schools and educators)

to ensure that vulnerable children are cared for. This activity is in line with one of the key strategies of the

government to mobilize and strengthen community-based responses for the care, support and protection of

orphans and other children made vulnerable by HIV and AIDS. ARK will develop a tool which accurately

and reliably identifies children who fit the profile of the target population including those in need of grants

who have not accessed one.

ACTIVITY 3: Healthcare Support

Each cluster of schools will be allocated at least one registered community health nurse who will visit the

schools to assist with the identification of sick children needing ARV treatment and other health services.

ARK will develop a tool which accurately and reliably identifies children who fit the profile of ARK's target

population; HIV-infected children and those in need of ARV treatment. Each cluster of schools will have a

social worker who will oversee home visits; conduct needs assessments and refers sick siblings in the

household to the relevant healthcare facility.

ACTIVITY 3: Economic and Social Support

Community care workers (CCW) will be recruited to assist orphans and vulnerable children in accessing

suitable social and health facilities. These community workers (3-4 community workers per school) will be

trained to identify OVC, follow-up through home visits, conduct needs assessments, and assist with access

to birth certificates and government grants. Each cluster of schools will have a social worker who will be

responsible for supervising the community workers and following up the more serious cases. The CCW will

co-ordinate the referral system between teachers and community workers and will ensure appropriate case

management. The community workers will also be trained to facilitate support groups for the children

especially groups for child-headed households and will focus on special needs of girls.

ACTIVITY 4: Food Security

ARK will provide nutrition support through the establishment of food gardens in the cluster of schools.

Schools will work with the community workers to initiate food gardens. ARK will partner with KZN provincial

government, specifically the Department of Agriculture's extension officers, and other NGOs that provide

training for the development of food gardens and ongoing agricultural support. ARK will provide the

resources such as gardening equipment, services of an agricultural organization to train and mentor the

schools for the sustainability of the food gardens.

ACTIVITY 5: Capacity development

Activity Narrative:

ARK will provide both formal and informal training per cluster for two social workers, 18 - 24 community care

workers, as well as 80 educators and institutional management teams in the schools. ARK will utilize

existing and will develop specialized training modules where needed, that will address topics such as: the

developmental stages of the child (male and female); grant access; child protection, special needs of the girl

child, and minimizing stigma. Training of community workers will be conducted in collaboration with

accredited service providers such as the National Association of Child Care Workers (NACCW). The Valley

Trust will provide training in establishing food gardens. ARK will provide overall support and supervision to

the project, ensuring ongoing mentorship of the trained groups, as well as liaison with other partners for

knowledge sharing and identifying opportunities for growth. Through home visits, Child Care workers (CCW)

will be able to train and support caregivers to better care for their children.

ACTIVITY 6: Referrals and Linkages

ARK works in partnership with other NGOs, local government and government departments. ARK has had

extensive consultations with the Departments of Education, Health and Social Development to ensure

support of this program. Other local service providers, NGOs, CBOs and FBOs will be identified for referrals

to and from ARK services.

The Department of Social Development has acknowledged the significant contributions from ARK in the

policy development processes for OVC and this will continue. ARK participates in the National Action

Committee for Children Affected by HIV and AIDS (NACCA).

ARK's OVC activities directly contribute to the PEPFAR goal of 2-7-10 by providing care to 10 million

people, including OVC.

SUMMARY:

ARK's focus is to provide antiretroviral treatment (ART) and accompanying support to primary HIV-infected

caregivers with children. This includes the encouragement and support for the voluntary counseling and

testing (CT) of partners and children, to ensure complete family coverage and earlier access to ongoing

treatment, care and support. Although the primary focus of ARK is on the caregivers of children, ARK offers

its services to the entire population in all of its service areas. CT services will be delivered in all of ARK's

supported communities.

The primary emphasis areas for these activities are community mobilization, local organization capacity

development, human resources, and training. Primary target populations include adult women and men and

their families.

BACKGROUND:

ARK is a charity organization whose mission is to facilitate and support delivery of accessible and

sustainable comprehensive treatment, care and support services to children and their caregivers in

communities affected by HIV and AIDS and poverty.

In partnership with the KwaZulu-Natal (KZN) provincial government, ARK has established a comprehensive

ART program in government primary health centers and hospitals. ARK works with the provincial

government to identify sites and areas for capacity building in areas such as human resources, human

capacity development, modest infrastructure improvements and service delivery. ARK's activities enable the

provincial government to increase the number of patients counseled, tested, and provided ART and related

services.

To date, PEPFAR funding has enabled ARK to successfully provide over 15,000 patients onto ART in KZN

through the sustained development of primary care facilities and their down referral sites in five districts, in

primarily peri-urban and rural communities.

With FY 2008 funding, ARK will focus on provider driven opt-out testing to all pregnant mothers entering the

antenatal clinics, and CT services to children and spouses/partners of caregivers and other household

members. This activity will be linked to home visits undertaken by ARK's community adherence workers.

Home visits serve to evaluate the psychosocial situation of patients, the degree of family support, and

issues related to disclosure. Although ARK's treatment target population is predominantly mothers,

caregivers, and their spouses/partners and children, increased attention is given to encourage men, single

women and children to come forward for testing and treatment.

ACTIVITIES AND EXPECTED RESULTS:

ARK's primary objective is to keep mothers alive to continue caring for their children and to reduce the

incidence of orphans and vulnerable children (OVC). Early, widespread testing and access to ART reduces

the likelihood of morbidity and mortality from HIV. This, in turn, increases the likelihood of survival of family

units, which guard income security and ongoing nurturing required by children in these households.

Furthermore, the psychosocial component of counseling and testing forms a vital component for behavior

change.

ACTIVITY 1: Support to Provincial Government for CT Services

ARK works with the KZN provincial government to develop the necessary processes and systems to

manage a comprehensive HIV and AIDS treatment program, and to ensure that the model created is

scaleable, sustainable and replicable elsewhere. ARK, in partnership with KZN provincial government, will

provide training and mentoring for government employed lay counselors and community adherence workers

working at these primary sites where ARK's ART program exists. ARK will ensure that management

systems are in place to support the work of the counselors and the delivery of CT.

ARK will strengthen or initiate CT services at all sites identified by the provincial health department and

assigned to ARK for support. To better ensure sustainability, where possible, ARK will use the counselors

available through the district HIV program. ARK will also employ counselors and train existing employed

community care workers to provide counseling for CT services. Where infrastructure support is required,

ARK will, in consultation with the facility managers and district managers, decide on the most cost-effective

infrastructure support (prefab or modest renovations). ARK's OVC program, through the social workers and

community workers placed at schools, will establish links with clinic services to ensure better and more

efficient referral of children in need of testing and care, including their caregivers and immediate family.

ACTIVITY 2: Human Capacity Development

Formal and informal training and on-site mentorship will be provided to all lay counselors in the program.

ARK, in partnership with the Centre for Social Science Research at the University of Cape Town, will

continue to develop and improve training modules for lay counselors. The areas covered in training include

basic and advanced counseling skills, positive living, disease progression, opportunistic infections, risk

reduction for HIV transmission, and safer sex. Counseling and ongoing training will be in line with the

National Department of Health's (NDOH) guidelines. ARK will provide mentorship and supportive

supervision to lay counselors in the program to ensure high-quality standards for CT. Nurses conduct

testing, in accordance with NDOH standards, at the CT sites. Support in terms of systems management and

coordination of lay counseling will be provided to CT sites.

ACTIVITY 3: Referrals and Linkages

Community care workers and social workers will be recruited to assist OVC and their caregivers in

accessing ARK-assisted primary health facilities for CT. They will coordinate the referral system between

caregivers, children and CT services. ARK will inform and coordinate activities with local NGOs, CBOs, and

FBOs to establish effective referral networks for CT services. Lay counselors will refer HIV-infected

individuals to ARK's ART sites.

Activity Narrative: SUMMARY:

SUMMARY:

ARK's focus is to provide ART and accompanying support to HIV-infected caregivers of children, their

spouses, and children. Primary emphasis areas are renovation, human capacity development, and local

organization capacity building. Target populations include OVC, people living with HIV (PLHIV), HIV-

infected pregnant women, HIV-affected families, and caregivers.

BACKGROUND:

ARK is a charity organization whose mission is to facilitate and support delivery of accessible and

sustainable comprehensive treatment, care and support services to children and their caregivers in

communities affected by HIV and AIDS. In partnership with the KwaZulu-Natal Department of Health

(KZNDOH), ARK, as the implementing partner, has established an antiretroviral treatment program in

government primary health facilities and hospitals. Specifically, ARK works with the KZNDOH to identify

sites and areas for capacity building, including human resources, modest infrastructure support, and

organizational capacity development. PEPFAR funding has enabled ARK to successfully enroll over 15,000

patients in ART in KZN. FY 2008 funding will enable ARK to provide ARV treatment to existing and new

patients, strengthen the infrastructure of the ARV delivery system in targeted sites, provide human

resources, and build local institutional capacity to deliver ARV services. ARK provides treatment in

accordance with national treatment guidelines.

ACTIVITIES & EXPECTED RESULTS:

ARK's primary objective is to keep mothers alive to continue caring for their children. The primary

caregiver's continued survival and potential ability to earn a living while receiving ARV treatment will have a

substantial impact on the extended family.

ACTIVITY 1: Support to KwaZulu-Natal Department of Health

ARK works with the KZNDOH to develop the necessary processes and systems to manage the ARV

program, to ensure that the model created is scaleable, sustainable and replicable elsewhere. Capacity-

building is site specific. Upon identification of a site, an analysis of the needs of each site will be done with

respect to staffing (doctors, nurses, pharmacists and pharmacy assistants), clinical equipment,

management systems, patient advocacy and temporary structures. The most pressing requirements are

met in order to speed up the ability of patients to receive treatment. Where necessary ARK provides

support in the ARV site and pharmacy accreditation process.

ARK's ARV program focuses on a network of clinics operating within a district, in order to create a

sustainable and efficient system that supports the continuum of care and up and down referral. While

patients are being assessed for treatment, a community health worker (CHW) from ARK's palliative care

program is allocated to the patient. This CHW will conduct a pre-treatment home visit and will provide

ongoing support to the patient and his/her family. Should a patient be non-adherent or lost-to-follow-up, the

CHW will investigate the reasons for this, acting as the link between the patient and the clinic. ARK

facilitates the integration process for ART, TB, other palliative care, and maternal HIV services.

ACTIVITY 2: Human Resources

ARK conducts a thorough needs analysis of human resource capacity prior to initiating support to the

treatment program at each site. Once it has been determined that KZNDOH has budgeted for the identified

posts needed within a period of three years, ARK recruits all the necessary medical staff required for the

successful rollout of ART. The staff recruited vary from site to site but include doctors, nurses, pharmacists

and pharmacy assistants. In addition ARK employs data capturers for monitoring and evaluation of the

program.

ACTIVITY 3: Family-Centered Treatment Services

Although ARK's primary goal is to provide ARV service support to primary caregivers with children, ARK

assists in the treatment of all HIV-infected adults and children requiring ART at ARK sites in KZN. All

patients considered for ART need to meet both medical and psychosocial criteria before starting therapy.

The psychosocial criteria are designed to ensure that the patient is prepared and ready to adhere to ART.

All patients being assessed undergo a treatment literacy program and are educated about positive living.

Patients are encouraged to motivate their partners/spouses to get tested and, if necessary, enter the

treatment program. Although ARK's treatment target population is predominantly mothers and children,

increased attention is being given to encourage and increase male partner (and men in general)

participation. ARK-employed doctors and nurses are responsible for treatment management, patient

consultations and the treatment of opportunistic and sexually transmitted infections. Pharmacists are

responsible for the dispensing of medication.

ACTIVITY 4: Pediatrics

HIV-infected parents and caregivers will be encouraged and educated by the medical staff to get their

children tested and to enter the treatment program where indicated. Staff in the local midwifery and

obstetric units will be trained to refer HIV-infected mothers and their babies to the ARK ART program,

ensuring access to full ART services when indicated. All at-risk infected infants with HIV diagnosis

confirmed by PCR will be monitored, and have immediate access to ARVs and related services including

the preventive package of care. Children identified through ARK's OVC program (also PEPFAR-funded) will

be referred to the clinic by community care workers and social workers.

ACTIVITY 5: Human Capacity Development

Key staff are provided with a two week orientation training which covers all aspects of ARK's ARV program

areas including employee policies and procedures, onsite mentorship from experienced ARK staff, and an

introduction to key performance areas. The areas covered in training include: ARV treatment guidelines for

adults and children, adherence, opportunistic and sexually transmitted infections as well as the value of

Activity Narrative: community access, adherence and refresher on prevention, including prevention for HIV-infected people.

Staff are invited and encouraged to attend formal training offered by external providers including other

PEPFAR partners such as the Foundation for Professional Development (FPD).

ACTIVITY 6: Reporting and Quality Assurance/Improvement

ARK provides computers and employs data capturers at all sites. Data is captured from patient folders and

transferred to ARK's data center, allowing for ongoing evaluation and outcome analysis. Adherence rates,

death rates and loss-to-follow-up are closely monitored. Quarterly updates are provided to the KZNDOH

and information is used within the clinics to strengthen service delivery. To ensure high standards and

quality of care in line with the national guidelines, all ARK staff are provided onsite, on-the-job training. This

is followed up with regular onsite mentorship and site evaluation by ARK's national executive and provincial

management teams. Informal training sessions are conducted quarterly by national staff. Staff are also

encouraged to attend formal external training courses offered by FPD.

These activities contribute to PEPFAR's 2-7-10 goals by increasing the number of South Africans on

treatment.