AIDSRelief implements a comprehensive HIV care and treatment program in South Africa that is funded

with Track 1 central funding, as well as South Africa COP funding. The activities do not differ across the

funding mechanisms, and this entry is thus a repeat of the South Africa COP entry.

SUMMARY:

Activities are implemented to support procurement of antiretroviral (ARV) drugs under the comprehensive

ART program carried out by Catholic Relief Services (CRS) in 25 sites. Coverage extends to eight

provinces in South Africa (excluding the Western Cape). The emphasis areas are human capacity

development and local organization capacity building. The target population includes people affected by HIV

and AIDS as well as higher risk populations such as migrant workers and refugees.

BACKGROUND:

AIDSRelief (the Consortium led by Catholic Relief Services) received Track 1 funding in FY 2004 to rapidly

scale-up antiretroviral therapy (ART) in nine countries, including South Africa. Since FY 2005, in-country

funding has supplemented Track 1 funding, and this will continue in FY 2008. The activity is implemented

through two major in-country partners, Southern African Catholic Bishops' Conference (SACBC) and the

Institute for Youth Development South Africa (IYD-SA).

ACTIVITIES AND EXPECTED RESULTS:

With funding provided in FY 2008, AIDSRelief will continue implementing the activities in support of the

South African Government (SAG) national ART rollout. In the interest of maximizing available funds the

focus will be placed on strengthening the existing sites' provision of services rather than on assessing and

activating new sites. Utilizing technical assistance from AIDSRelief staff members and South African

experts, ongoing support and guidance will be provided to sites in the form of appropriate refresher medical

training courses, patient tracking and reporting, monitoring and evaluation mechanisms and other

necessary support.

ARV drugs are provided to all qualifying HIV patients who present at the sites, irrespective of their age,

gender, nationality, religious or political beliefs. The access to non-South Africans is particularly significant,

as the public sector rollout program is restricted to South African and legal refugees and asylum seekers.

However, South Africa has a large displaced population, including economic migrants who do not have

South African identity documentation. Historically, about 90% of adults and 10% of children with HIV have

been receiving ARV drugs through the 25 partner sites.

ARV drugs purchased will be used by the 25 sites to treat ARV patients through clinic-based and home-

based activities aimed at optimizing quality of life for HIV-infected clients and their families. For most of the

25 sites, ARV drugs are currently being purchased centrally through a Johannesburg-based pharmaceutical

company, and delivered via courier to the field sites monthly on a patient-named basis. CRS is billed once a

month for all site deliveries after verification of drugs delivered to each site. The opportunity of accessing

preferential cost drugs is being utilized through cooperation with GlaxoSmithKline where available. Although

the AIDSRelief sites have not experienced stock-outs in significant volume, they have been experienced on

a limited number of occasions. Efforts to address or prevent such occurrences in the future include

substitution by a more expensive drug on stock (all approved by the appropriate regulatory authorities of the

host country and the donor).

Generic medications purchased comply with the USG PEPFAR Task Force requirement of FDA approval as

well as approval from the Medicines Control Council of South Africa.

All activities will continue to be implemented in close collaboration with the South African Government's HIV

and AIDS Unit and the respective provincial authorities to ensure coordination and information sharing,

directly contributing to the success of the South African Government's own rollout and the goals of the

President's Emergency Plan. These activities are also aimed at successful integration of AIDSRelief

activities into those implemented by the South African Government, thus ensuring long-term sustainability.

All sites operate in terms of a Memorandum of Understanding (MOU) with the provincial Department of

Health in which they operate, observing the national and provincial treatment protocols. There is a

concerted effort at each site to ensure sustainability by either having the SAG provide antiretroviral drugs, or

by down referring stable patients in to the public primary healthcare clinics after providing training for the

SAG clinic staff. St. Mary's Hospital, which accounts for more than a third of patient numbers, has already

been accredited as a SAG rollout site. Sinosizo is receiving drugs from Department of Health due to its

status as a down-referral clinic for Stanger Hospital. At Centocow and Bethal, all patients are already

receiving drugs through the SAG rollout.

In terms of the actual drug procurement, AIDSRelief in South Africa has a centralized procurement system

of ARV drugs, which already provides the economies of scale in terms of drug pricing to the extent possible

(outside of the SAG-mandated single exit price). This centralized procurement system buys drugs in

volume, and keeps sufficient stock levels to supply the AIDSRelief sites with drugs and ensure no stock-

outs occur. The centralized procurement system also manages losses due to expiry of the drugs, and

ensures compliance with FDA and MCC (Medicines Control Council of South Africa) requirements. Each

patient has their 6-month repeat prescription originally assigned by the doctor and then dispensed by the

pharmaceutical supplier, which is revised where necessary (in line with SAG guidelines).

In terms of monitoring of the program, the majority of the AIDSRelief sites are utilizing the centrally-based

laboratory services provider Toga (a PEPFAR prime partner) that conducts blood tests (CD4, viral load etc.)

for the sits, using the courier service available in country to deliver the blood samples, and reporting back to

the sites on the results through either e-mail or an online electronic reporting system setup by the

Laboratory services provider.

Due to good existing infrastructure in South Africa, AIDSRelief sites are able to perform viral load and CD4

tests once every 6 weeks, to monitor the treatment progress and possible failure on the individual patient

level. These analyses are conducted by each of the AIDSRelief sites, using the data provided by the

Activity Narrative: Laboratory services provider, as part of the clinical management of the patients. The majority of the

AIDSRelief sites also use hand-held lactate meters (provided for free by the Laboratory services provider) to

screen for hyperlactatemia, which is the most common severe side effect of patients who have been on

treatment for prolonged periods of time.

Feedback on program level of the progress and viral suppression is regularly provided by a clinical expert at

the Desmond Tutu HIV Foundation, using the laboratory data provided by Toga Labs on patients whose

blood was tested through their facilities.

FY 2008 COP activities will be expanded to include increased collaboration with the SAG to ensure long-

term sustainability of the program, through different arrangements which vary from one Province to another.

These include the transfer of "stable" patients (on ART for 6 months or longer) to public sector health

facilities, and then enrolling additional patients at the AIDSRelief partner site. Other options include

provision of free ARV and OI drugs and laboratory tests for SAG-accredited facilities run by AIDSRelief, or

those that are physically located on SAG-owned premises, thus allowing them to receive free drugs or

services. As in the case above, this allows the AIDSRelief sites to enroll additional patients on ART. Other

examples include provision of ARV drugs by the SAG, and home-based care and support and adherence

follow-up by the AIDSRelief-run partner site. All the different models of collaboration are individually

discussed with the provinces where the partner sites operate, and largely depend on specific needs and

operating environment of each treatment site and SAG authorities, but are designed to ultimately allow long-

term sustainability and success of the program.

This activity will directly contribute to the goal of 2 million individuals on treatment of the PEPFAR 2-7-10

goals.

AIDSRelief implements a comprehensive HIV care and treatment program in South Africa that is funded

with Track 1 central funding, as well as South Africa COP funding. The activities do not differ across the

funding mechanisms, and this entry is thus a repeat of the South Africa COP entry. All targets are reflected

in the South Africa COP entry.

SUMMARY:

Activities are implemented to support provision of quality ARV services under the comprehensive

antiretroviral treatment (ART) program carried out by Catholic Relief Services (CRS) in 25 sites in 8

provinces in South Africa. Major emphasis will be on human capacity development and local organization

capacity building. The target population includes people affected by HIV and AIDS as well as higher risk

populations such as migrant workers and refugees.

BACKGROUND:

AIDSRelief (the Consortium led by Catholic Relief Services) has received Track 1 funding since FY 2004 to

rapidly scale up antiretroviral therapy (ART) in 9 countries, including South Africa. Since FY 2005, South

Africa in-country funding was received to supplement central funding. The activity is implemented through

two major in-country partners, Southern African Catholic Bishops' Conference (SACBC) and Institute for

Youth Development South Africa (IYD-SA).

ACTIVITIES AND EXPECTED RESULTS:

With funding provided in FY 2008 AIDSRelief will continue implementing the activities in support of the

South African Government (SAG) national ARV rollout. In the interest of maximizing available funds the

focus will be on strengthening the existing sites providing services rather than on assessing and activating

new sites. Utilizing technical assistance from AIDSRelief staff members and South African experts, ongoing

support and guidance will be provided to sites in form of appropriate refresher medical training courses,

patient tracking and reporting, monitoring and evaluation mechanisms and other necessary support.

ARV services will be provided through the 25 sites to ARV patients through clinic-based and home-based

activities to optimize quality of life for HIV-infected clients and their families. All the relevant healthcare

providers and administrative support staff at the sites will be trained to implement the ART program, using

government-approved training curricula. Staff who have already received initial training will undergo

refresher courses (either in-house or external), coupled with exchange of training courses and materials

between sites with active support from the local training provider, Kimera training center. Treatment

adherence training is provided to all patients who are enrolled on the ART program.

In most sites home-based care networks will follow up and support patients. This follow-up is conducted

through direct visits to patients through the extensive home-based care outreach at the SACBC sites, while

IYD-SA sites follow up through means of telephonic contact in most cases. In case the patient cannot be

reached, a "treatment buddy" is contacted to inquire the whereabouts of the patients who did not come back

for the monthly drug package. Inevitably, some patients become lost-to-follow-up in spite of all the efforts to

locate them, due to migrating populations and illegal immigrants served by the program. This number

currently stands at less than 4% of the patients ever enrolled on the program.

Each site ensures that HIV-infected patients are screened for tuberculosis (TB) prior to placing them on

antiretroviral treatment, and are referred to TB treatment if they tested positive. Screening and testing for TB

is conducted in a number of different ways, and these testing methods are specific to each site. While

screening is conducted by a medical professional at each of the sites, in most cases patients are referred to

the nearby SAG medical facility for TB testing and are only enrolled in antiretroviral treatment once they

have completed two months of TB treatment, or have been found not to have active TB.

PEPFAR funding will also be used to support laboratory services, which are outsourced to a private

provider, Toga Laboratories (a new PEPFAR partner since FY 2007). A courier service collects blood that is

drawn at each site, and delivers these samples to the laboratories. Results are e-mailed or faxed back to

the site within 48 hours of the laboratory receiving the blood samples.

The program is designed to improve each site's capacity to implement the national ART program in the long

-term, and to strengthen clinical, administrative, financial and strategic information systems. Sites will be

assisted in developing appropriate policies and protocols and in setting up sound financial and strategic

information systems. Each site will also develop a unique community mobilization plan for the ART program

and implement it in collaboration with relevant community organizations and leaders. Many of the sites are

already involved in HIV and AIDS community mobilization activities and these will be linked to ART

services. These lessons learned will be of value to other partners working in the non-governmental

organization (NGO) sector.

All activities will continue to be implemented in close collaboration with the Department of Health HIV and

AIDS Unit and the respective provincial authorities to ensure coordination and information sharing, and this

will directly contribute to the success of the SAG's own rollout and the goals of PEPFAR. These activities

are also aimed at successful integration of AIDSRelief activities with those implemented by the South

African Government, thus ensuring long-term sustainability.

All sites operate under the terms of a Memorandum of Understanding (MOU) with the provincial Department

of Health in which they operate, observing the national and provincial treatment protocols. There is a

concerted effort at each site to ensure sustainability by having the SAG provide antiretroviral drugs, or by

down referring stable patients into the SAG's primary healthcare clinics after providing training for the SAG

clinic staff. St. Mary's Hospital, which accounts for more than a third of patient numbers, has already been

accredited as a SAG rollout site. Sinosizo receives drugs from the National Department of Health due to its

status as a down referral clinic for Stanger Hospital, and at a further two sites, Centocow and Bethal, all

patients already receive drugs via the SAG rollout. Monthly statistics are shared with the South African

National Department of Health, as well as with relevant provincial health departments in provinces where

AIDSRelief implements the program.

Activity Narrative: There is a concerted effort to include men and children in the program, and all sites have specific plans to

increase enrolment, including couple counseling and using a family-based approach. Although there is no

specific PMTCT program, eligible pregnant women are provided with triple therapy to ensure maximum viral

suppression to prevent the transmission to the baby. Newborn babies are provided with monotherapy after

birth. AIDSRelief sites are encouraged to provide babies with cotrimoxazole after 4-6 weeks of life, and

PCR testing is conducted when relevant. Mothers are encouraged to use safe feeding practices as

appropriate to individual circumstances. Most sites have clinic-based gardens to assist with nutrition

programs, and several sites provide nutrition supplements, as per South African treatment guidelines. All

sites provide ART access to non-South Africans, including refugees. Some of the AIDSRelief sites also

receive PEPFAR and other funding through different sources for the provision of OVC care. The

overlapping of these services provides OVC with access to both care and treatment services provided

under the program.

In terms of the continuous qualitative review of the program, the annual clinical evaluation is done on

available patient data by two South African ART experts, who not only evaluate the data within the program

but also compare it to other large resource-limited programs, such as the program in Khayelitsha.

Even though prevention is not a specific program activity of the overall program, it is promoted through

provision of information to patients regarding HIV and prevention of spreading the virus (prevention for

positives). Secondly, skills training is provided to vulnerable populations, empowering them to make safer

choices about their lives. Additionally, AB messages are shared with the target population, as well as

accurate information regarding condoms is provided.

The CRS treatment program supports the PEPFAR goal of treating 2 million people with antiretroviral drugs.