SUMMARY:

The Africa Centre for Health and Population Studies, in partnership with the Hlabisa Department of Health

(DOH), based in Hlabisa Health District in rural KwaZulu-Natal, operates the Hlabisa antiretroviral treatment

(ART) program and aims to deliver safe, effective, efficient, equitable and sustainable ART to all who need it

in Hlabisa district. The program emphasizes integration of the government Prevention of Mother-to-Child

Transmission (PMTCT) Program and Antiretroviral Treatment (ART) Program. The target population for the

integrated PMTCT and ART Program are people living with HIV and AIDS (of all ages), HIV-infected

pregnant women and HIV-infected infants (0 to 5 years). The major emphasis area of this program is

development of network/linkages/referral systems, and minor emphasis areas include information,

education and communication, local organization development and training.

BACKGROUND:

The Africa Centre, a population research department of the University of KwaZulu-Natal, implements a

PMTCT program in partnership with the KwaZulu-Natal Department of Health (DOH). The program is based

in Hlabisa sub-District, a rural health district in northern KwaZulu-Natal that provides healthcare to 220,000

people through one government district hospital and 15 peripheral clinics. The ART Program is embedded

in the DOH ART rollout whereby the Africa Centre and KwaZulu-Natal DOH work to complement each

others abilities and resources in providing ART. The Africa Centre has expertise in infectious diseases and

management that is not available at the district DOH. In addition to clinical staff, and infrastructure, the

district DOH provides the necessary drugs and laboratory testing for effective ART rollout.

With FY 2008 funds, the Africa Centre will continue partnering with the district DOH to improve and expand

PMTCT services by providing additional human resources and training. In addition, Africa Centre will

integrate PMTCT services with its tuberculosis (TB)/HIV, palliative care, counseling and testing, and

treatment programs. Increased attention will be given to addressing gender inequality (including increasing

male involvement in PMTCT) and promoting HIV service delivery among men and children.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Partnership with South African Government (SAG)

All government clinics within Hlabisa District offer PMTCT services. However, many of these clinics are

under-resourced and require additional human capacity to ensure that HIV-infected women are enrolled in

the PMTCT program. Africa Centre provides training, supervision, mentoring, and systems strengthening in

support of PMTCT services in Hlabisa district. The PMTCT program is the main referral base for assisting

HIV-infected women with ART. Africa Centre aims to address the lack of human resources with the district

DOH to recruit and place nurses and treatment counselors at government facilities to assist with pre and

post-test counseling and appropriate infant feeding counseling. During pregnancy, if criteria are met, or

during post delivery when women become eligible, nurses will provide HIV rapid testing, CD4 counts and

referrals to trained ART counselors. Counselors will offer pre and post-test counseling and further facilitate

enrollment into the ART program. In addition, counselors will offer pregnant women continued follow-up and

support and facilitate testing of all exposed infants at 6 weeks of age, with referral to the ARV program if

they are HIV-infected.

Africa Centre conducts workshops and meetings with DOH promoting linkages between PMTCT and ART

programs and educates clinic staff about available services. Africa Centre will develop and distribute

informational materials for wider circulation in the hospital and clinics and will target pregnant women.

ACTIVITY 2: PMTCT and Treatment

Africa Centre will provide clinics with clinical services (via the provision of doctors and other health workers)

to initiate HIV pregnant women enrolled in the PMTCT program on ART. Africa Centre's assistance provides

the full package of PMTCT services in line with the National Department of Health's PMTCT standards.

Doctors will be present in clinics at appointed times, on a weekly or fortnightly basis, as appropriate, and will

provide treatment management including work-up (complete medical history and medical examination),

consultation, screening, symptom and pain management, and patient counseling (including maternal

nutrition and family planning). PMTCT clients will be referred to Africa Centre-supported ART services.

These services will also provide patients who experience adverse side effects or treatment failure with

additional monitoring and support. Africa Centre-supported home-based care organizations will provide

ongoing care and monitoring support to ensure treatment adherence. All patients transferred into the ART

program from the PMTCT program will be tested for TB and receive TB treatment if necessary.

ACTIVITY 3: Counseling and Support

To reduce vertical transmission of HIV from mother-to-child, treatment counselors will provide counseling on

appropriate infant feeding and support into routine PMTCT in line with the newly published WHO guidelines

on infant feeding. The selection of counseling content and material will be informed by the results from a

large local vertical transmission study conducted by the Africa Centre. All HIV-uninfected women will be

counseled on exclusive breastfeeding from birth to six months, with continued breastfeeding to at least 2

years of age, and on safe sex. HIV-infected women will receive individual counseling and it is anticipated

that most women will choose to breastfeed given the results of previous work in this area and the lack of

resources to fulfill the AFASS criteria for replacement feeding (AFASS: acceptable, feasible, affordable,

sustainable and safe). Women who do not wish to test and who, therefore, do not know their status will be

counseled on infant feeding practices as per HIV-uninfected women (i.e. exclusive breastfeeding to six

months) in line with WHO policy. Opportunities to counsel women and their partners on infant feeding will

be taken at every visit, both antenatally and postnatally. HIV-infected women who choose to exclusively

breastfeed, whatever their CD4 counts, will receive a monthly food parcel from the government, as do

mothers who do not breastfeed. In addition, counseling on family planning will be offered. The program will

address gender by attempting to increase gender equity by promoting the involvement of male partners in

the PMTCT and family planning sessions. The PMTCT counselors will ask pregnant women and mothers to

come with their male partners during follow-up visits. During road shows (a form of "edutainment," which

successfully disseminates information through entertainment since 2004) a special focus will be the

Activity Narrative: involvement of men. Men are still underrepresented in the clinics not only for being tested, but especially for

getting treatment. The main objective will be to make men aware of their responsibility concerning the

response to HIV. Male involvement will be strengthened using existing materials when appropriate. The

possibility of family testing in the home will be investigated.

Finally, counselors will refer eligible patients to the government services that are available (for instance, for

food aid or to a social worker if domestic violence is suspected).

ACTIVITY 4: Human Capacity Development

The South African DOH and Africa Centre counselors and nurses will be trained in the full PMTCT package

according to government guidelines and standards. Refresher and on-the-job training will be provided as

needed, keeping healthcare providers up to date in the delivery of PMTCT services. All healthcare providers

will receive training on HIV and ART. A baseline course is based on the DOH curriculum and comprises four

sessions of three hours each. The four sessions cover basics of HIV and ART, follow-up of patients,

assimilation of follow-up and practical work with a patient (including blood taking for CD4 counts and viral

loads).This training will be enhanced with clinic visits from training officers, during which the officers will

monitor counseling and provide individual mentoring. In addition, nurses and treatment counselors will be

offered the opportunity to participate in short courses covering the management of ART side effects,

opportunistic infections, and pediatric ART. When necessary additional space may be renovated or park

homes provided to increase facility capacity.

Due to the shortage of staff and to the increasing number of patients and increasing workload, additional

staffing will be provided in close cooperation with the facility and wherever possible SAG positions will be

created. It is estimated that one position for each of the 14 sites is necessary and all of these will be staffed

by SAG employees as soon as they can be recruited.

ACTIVITY 5: Monitoring and Evaluation

Africa Centre's Vertical Transmission Study published in the Lancet in 2007 (369: 1107-16) had major

impact on the guidelines of the WHO. It showed that exclusive breastfeeding reduces the risk of Mother-to-

Child transmission compared to mixed feeding. With dedicated Health Workers in the clinics and a strong

M&E system, PEPFAR funding will be used to continue monitoring and evaluation activities.

Africa Centre's integrated PMTCT and ART program contributes to PEPFAR's 2-7-10 goals for South Africa

by improving capacity, access and demand for PMTCT and ART for pregnant women and mothers. These

activities ensure that new infant infections are averted and the HIV-infected treatment-eligible women are

referred and initiated on treatment in a timely matter.

SUMMARY:

The Hlabisa ART program aims to deliver safe, comprehensive, effective, efficient, equitable and

sustainable ART to all who need it in Hlabisa District, in rural KwaZulu-Natal province. Hlabisa District is

characterized by a high HIV prevalence (about 22%), high HIV incidence, unemployment and poverty. Basic

care and support services are part of the overarching HIV Care and Treatment program that is jointly run by

the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, and the Habisa District

Department of Health (DOH). In FY 2008, the program will for the first time provide mobile palliative care

teams that bring HIV care to people's homes and support the families of HIV-infected people. Major

emphasis is on development of linkages and referral systems. This will be done through support to the

SAG, clinical and physical care, home-based care and human capacity development.

BACKGROUND:

The Africa Centre is a department within the University of KwaZulu-Natal, fully funded by grants from mostly

overseas institutions. The Program is based in Hlabisa sub-District, a rural health district in northern

KwaZulu-Natal which provides healthcare to 220,000 people at one district hospital and 14 peripheral

clinics. In September 2004 the program started delivery of ART in Hlabisa and has since expanded ART

services to 14 clinics in the sub-district. The Africa Centre and KwaZulu-Natal DOH work to complement

each other's abilities and resources in providing care and treatment. The Africa Centre has expertise in

infectious diseases and management that are not available at the district DOH. The district DOH has clinical

staff and infrastructure on which to build a care and treatment program. The Africa Centre contributes

nurses, treatment counselors and physicians to the DOH staff, organizes trainings, supports the

management of the supply chain and conducts monitoring and evaluation in cooperation with the DOH. The

Africa Centre's basic care interventions are largely focused on care support, the period from when a patient

tests positive until such time as s/he requires ART. The basic preventive care package is part of the

program, as is symptom and pain management.

With FY 2008 funds the Africa Centre will support the functions mentioned above and expand its support for

the DOH. Specifically, Africa Centre involvement will strengthen the palliative care, TB/HIV Program,

PMTCT, provision of ART and counseling and testing. Increased attention will be given to address gender

issues and to promote the care and treatment services among men and children.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Support to SAG in Hlabisa District through home-based care

FY 2008 funding will be used to provide support to five existing home-based care organizations which are

located in the least served areas within the sub-district. These HBC organizations are operating on an ad-

hoc basis. They are made up of committed caregivers who are passionate about serving their community,

but do not have access to resources or training opportunities. Africa Centre will ensure that the HBC

organizations will not only take care of the patients, but assess the situations in the households and take

care of other family members if necessary. The identified HBC organizations will also be located near DOH

clinics where ART initiations are taking place in order that Africa Centre staff at the clinic can serve as a

point of contact. The Africa Centre will facilitate the distribution of HBC kits and food parcels, supplied by

DOH to the home-based care organizations.

Capacity building will play a major role in the support of the HBC organizations. Africa Centre will ensure

ongoing supportive supervision and mentoring. Training will include DOH-approved HBC, ART literacy,

social grants (process for referral of HIV patients who qualify for disability grants) and HIV Counseling,

Funding will help to support volunteer stipends and equipment (i.e. computers and bicycles) to further

enable these organizations to better manage and support their volunteers.

Funding will also go towards financing additional professional staff, including nurses and social workers who

will constitute the core of a mobile team to provide home-based palliative care. In addition, funds will be

used to finance a car, pharmaceuticals and other necessary supplies. The nurses in the mobile team will

provide basic HIV-related care including prevention messages and symptom and pain screening and

management, and the social worker will refer families for psychosocial services provided by the government

(government food aid, government grants and the services of social workers). A partially financed physician

will visit patients who need more specialized care. The target population for home-based care via the mobile

team is non-ambulatory patients who cannot access treatment in clinics and ambulatory patients who

request a home visit.

Africa Centre's involvement in the existing HBC structure within the sub-district will facilitate a more

cohesive referral system between the DOH, AC and HBC organizations. It will ensure that more home-

based caregivers are provided with essential training and resources to better serve the needs of PLHIV in

their communities.

ACTIVITY 2: Clinical and physical care

HIV-infected people who are not yet eligible for ART will receive palliative care consisting of screening and

treatment of TB, screening for pain and symptoms and elements of the preventive care package such as

prophylactic treatment with cotrimoxazole, INH and fluconazole. Africa Centre supported HBC organizations

will provide ongoing care and monitoring support, including counseling. Patients will be advised to return to

the clinic every six months for a CD4 test and clinical assessment. DOH funds are used for laboratory

services (CD4 counts, viral loads, and routine and routine blood and urine tests) and drugs (ARV

medication, drugs to treat and prevent opportunistic infections (OIs), and drugs to treat non-HIV-related

diseases in HIV-infected patients). Patients on ART and those who are monitored for ART eligibility will be

referred to a physician for further care if required. A pharmacy assistant will be trained to assist the DOH

pharmacist to facilitate faster treatment of OIs and pain.

ACTIVITY 3: Nutrition

All participants will be referred for nutritional assessment and monitoring for food aid (Philani porridge,

sugar beans) from the DOH. In order to ensure nutrition and food security, PEPFAR funding will be used to

employ a dietician to teach families the basics of good nutrition. Volunteers will be recruited to train the

community in nutrition and food preparation. Africa Centre will seek to establish public-private partnerships

(PPPs) with other organizations (e.g. Kellogg Foundation, Garden Africa, Seeds for Africa) for sustainability

of these activities.

ACTIVITY 4: Income generating programs for PLHIV

Activity Narrative: Poverty, unemployment and unpleasant socioeconomic status are prevalent to PLHIV in the area. Some are

receiving disability grant which is still limited to meet their daily basic needs. In order to uplift their economic

status and their nutrition there is a need for those able to be engaged in poverty relief projects/ income

generating projects such as beadwork, woodwork, sewing, food gardens, poultry farming and sleep mats.

Africa Centre has a Community Development Department, which has, over the past several years,

successfully developed income generating programs in the rural area of Hlabisa Sub-district. PEPFAR

funding will be used to strengthen the department through additional staff. These staff members will then

develop business plans for the PLHIV groups and supervise their activities.

ACTIVITY 5: Referrals and linkages

In order to ensure delivery of holistic palliative care, counselors will be trained on available government

support structures to link PLHIV and their families to other government programs, like screening for TB/HIV,

PMTCT clinics, food aid, legal assistance and social workers, who can assist the families with applying for

government grants.

ACTIVITY 6: Caring for Carers

ART Lay Counselors and Nurses are tasked with counseling and caring for patients affected and infected by

HIV and AIDS. On a daily basis, during counseling sessions where they must disclose the patient's HIV

status, they must deal with the trauma of the varied reactions of patients who are hearing for the first time

that they are HIV-infected. To keep staff dedicated and motivated towards achieving their daily demands

there is a need to minimize burnout and work-related stress. The Caring for Carers program aims to protect,

support and care for employees tasked with caring responsibilities. The program started in FY 2007 and will

have a focus on the new staff joining Africa Centre in FY 2008. The program will develop appropriate team

building activities and staff retention strategies.

ACTIVITY 7: Human Capacity Development

The South African DOH and Africa Centre counselors and nurses in the hospital and clinics will be trained in

all aspects of care according to government guidelines and standards. Refresher and on-the-job training will

be provided as needed, keeping healthcare providers up to date in the delivery of care.

Due to the shortage of staff in the clinics and due to the increasing number of patients and increasing

workload, additional staffing in clinics and the hospital will be provided.

ACTIVITY 8: Care Support Program

Services for the persons who have newly tested positive for HIV but are not yet eligible for treatment must

be improved. A care support program will be established including: screening for TB, screening for STIs,

PAP smears, treatment and prophylaxis of opportunistic infections, immunizations, nutritional information,

counseling on family planning and help with grant applications.

SUMMARY:

The Hlabisa antiretroviral treatment (ART) program aims to deliver safe, effective, efficient, equitable and

sustainable ART to all who need it in Hlabisa district in rural KwaZulu-Natal. The program emphasizes the

integration of the government PMTCT and Care and Treatment Programs. An important part of the Care

and Treatment Program is the diagnosis and management of TB. Co-infection rates are high and the

Medical Research Council estimates that 58% of people with TB also have HIV. The target population is

people affected by HIV and AIDS. The major emphasis area is development of linkages and referral

systems.

BACKGROUND:

The Africa Centre for Health and Population Studies (Hlabisa ART Programme) is a partnership between

the KwaZulu-Natal (KZN) Department of Health (DOH) and the Africa Centre, a population research

department of the University of KwaZulu-Natal. The DOH program is based in Hlabisa sub-District, a rural

health district in northern KZN, and provides healthcare to 220,000 people at one government district

hospital and 14 fixed peripheral clinics. The comprehensive ART Program, which includes TB services, is

embedded in the DOH antiretroviral therapy roll-out. TB/HIV services are considered part of the

comprehensive ART roll-out. The Africa Centre and KZN DOH work to complement each others' abilities

and resources in providing TB/HIV and related services. The Africa Centre has expertise in infectious

diseases and management that is not available at the district DOH. In addition to clinical staff and

infrastructure, the district DOH provides the necessary TB/HIV drugs and laboratory testing for effective roll-

out.

With FY 2008 funds, the Africa Centre will continue to partner with the district DOH to improve and expand

TB/HIV services by providing additional human resources and training. In addition, Africa Centre will

continue to provide comprehensive and integrated services for TB/HIV, palliative care, PMTCT, CT and

ART.

With FY 2008 funding the Africa Centre will improve TB and HIV screening and diagnosis for patients and

their families. Specifically, Africa Centre involvement will strengthen the TB/HIV Program, palliative care,

provision of ART and CT. Increased attention will be given to address gender issues through a greater

involvement of men and to promote TB and ART services among men and children.

ACTIVITIES AND EXPECTED RESULTS:

Africa Centre 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. Africa Centre 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. Africa Centre 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. Africa Centre will

continue to integrate TB/HIV interventions with existing agreement programs as Africa Centre works

seamlessly and side by side with government employees at government facilities.

ACTIVITY 1: Partnership with South African Government

Africa Centre will expand TB/HIV screening and diagnosis services in collaboration with the DOH TB

program and will explore other options for TB screening (including CT and PMTCT). Services will be

expanded at all 14 facilities. The Africa Centre will work closely with the DOH to ensure that all patients who

enter the ART program are screened for TB and treated, if necessary. In addition, Africa Centre will provide

training and mentorship to medical staff in order to strengthen the referral of people who receive DOTS for

HIV testing.

ACTIVITY 2: Screening and Diagnosis

As part of general patient work-up for the ART program, Africa Centre-placed staff in close collaboration

with DOH physicians and nurses will ensure that all patients in the ART program receive TB screening and

diagnosis. For those individuals who are unable to produce sputum for TB diagnosis, Africa Centre and

DOH staff in line with current SAG standard practice will refer patients for chest x-rays. Currently, patients

either incur large transportation costs or pay for the chest x-rays out of their own pockets at private

providers. In FY 2006 the ART program contracted a private physician in Mtubatuba sub-District to provide

chest x-rays for free for patients in the ART program. This has substantially reduced the expenses and time

costs of a large proportion of ART patients in having chest x-rays. Contracting the services of more

accessible service providers ensures increased access to the service for patients who need it.

ACTIVITY 3: Treatment

All individuals in the ART program who are diagnosed with TB are treated through the DOT support

program in close collaboration with the existing DOH TB program. Africa Centre, in addition to initiating TB

screening in all individuals who are enrolled in the ART program, monitors the completion of TB treatment

both in individuals in the monitoring cohort and before ART initiation.

In accordance with the South African national HIV and AIDS treatment guidelines, all HIV-infected patients

who are coinfected with TB will receive a full course of TB treatment independent of their HIV stage. In

addition, before TB patients can receive ART, they will have been treated for TB (for two months if CD4

count >50, at least for two weeks if CD4 count <50). All patients who receive treatment for TB will also

receive cotrimoxazole prophylaxis. A family centered approach will be adopted. Given the contagious nature

of TB, patients with TB will be encouraged to bring their families in to be screened. Africa Centre will use

this approach to increase male participation.

ACTIVITY 4: Human Capacity Development

Activity Narrative: The mobile team initiative started in FY 2006 with the goal to provide ART in all 15 DOH clinics, instead of

only in 3 DOH clinics as in FY 2005. In FY 2008, this concept will be extended to provide home-based

palliative care, with a team consisting of nurses, counselors, social worker and the assistance of a physician

when required. Home-based palliative care will include educating patients about the need to screen for TB

and to treat TB, if necessary.

The target population for home-based care is non-ambulatory patients who cannot access treatment in

clinics and ambulatory patients who request a home visit, for instance to involve their partners and other

family members in their care. The team will be able to provide ART and symptom relief, including

symptomatic management of pain. The social worker will provide social counseling and information to the

household on how to access available government psychosocial services (food aid, social workers, and

government grants).

The nurses and the social workers who form the palliative care mobile team will receive intensive training. A

baseline course is based on the DOH curriculum and is comprised of four sessions of three hours each;

covering the basics of HIV and ART and TB, follow up of patients, and practical issues (including blood

taking for CD4 counts and viral loads). In addition, the mobile care team will be specifically trained in

administering and managing palliative care in the family setting.

This training will be further supported with clinic visits from training officers, during which the officers will

monitor counseling and provide individual mentoring. In addition, nurses and treatment counselors will be

encouraged to participate in short courses covering, the management of ART side effects, TB and HIV, and

pediatric ART and TB. Counselors and nurses will be trained to provide TB care with a focus on the family.

ACTIVITY 5: Referrals and linkages

Counselors will be trained on available government support structures to link PLHIV and their families to

other government programs, like ART services, PMTCT clinics, food aid and social workers, who can assist

the families with applying for government grants. All patients who have TB will be tested for HIV and

referred to the ART clinic if tested positive.

Individuals presenting to the DOH TB program independently from the ART program, will be routinely

referred to CT. In order to start this activity, TB staff will be systematically and repeatedly informed where to

access CT and how to talk to patients about HIV.

These activities will contribute to the PEPFAR goals of 2-7-10 by contributing to the goal of 10 million

people receiving care through PEPFAR assistance.

SUMMARY:

The Hlabisa antiretroviral treatment (ART) program aims to deliver comprehensive, integrated, safe,

effective, efficient, equitable and sustainable ART and related services to all who need it in the community.

Counseling and testing (CT) is part of this program in the Hlabisa District set in rural KwaZulu-Natal, South

Africa. The target population for the program is adults and people affected by HIV and their families. The

major emphasis area of this program is community mobilization/participation. Minor emphasis areas include

information, education and communication (IEC), local organization capacity development, and quality

assurance and supportive supervision.

BACKGROUND:

The Africa Centre for Health and Population Studies' Hlabisa ART program is a partnership between the

KwaZulu-Natal Department of Health (KZNDOH) and the Africa Centre, a population research department

of the University of KwaZulu-Natal. The Hlabisa ART program is comprehensive and integrated. CT-related

activities fall within this program. The program is based in Hlabisa District, a rural health district in northern

KwaZulu-Natal, and provides health care to 220,000 people at one government district hospital and 13 fixed

peripheral clinics. The ART program is embedded in the Department of Health's antiretroviral therapy rollout

where the Africa Centre and KZNDOH work to complement each other's abilities and resources in providing

ART. The Africa Centre has expertise in infectious diseases and management that are not available at the

district Department of Health (DOH). In addition to clinical staff and infrastructure, the district DOH provides

the necessary drugs, laboratory tests, and rapid test kits for effective rollout.

With FY 2008 funds, the Africa Centre will continue to improve and expand CT services by providing

additional human resources and training. Africa Centre will link CT services to prevention of mother-to-child

transmission (PMTCT) services, TB/HIV, palliative care, and treatment programs. Increased attention will be

given to addressing gender inequality (including increasing male involvement in CT and care) and to

promoting ART services among men and children.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Partnership with South African Government

Africa Centre will expand CT and provider-initiated testing and counseling (PITC) in collaboration with DOH.

The Africa Centre will work closely with the DOH to ensure that all patients who enter the 14 clinics will be

offered an HIV test.

ACTIVITY 2: Counseling

Counseling centers were established in partnership with another of Africa Centre's donors, the Wellcome

Trust-UK. PEPFAR funds will be used to expand and promote the center at Mtubatuba. Another testing

center will be established at Hlabisa. A mobile testing center will be used during road shows and other

public events. The traditional leaders will be approached for testing in their Isigodi. (Isigodi is the

geographical area where a traditional Zulu authority called the Induna is in charge.)

The Africa Centre covers a research area of approximately 90,000 people in 11,000 households. Funded by

the Wellcome Trust UK, all inhabitants older than 15 years are offered an HIV test annually. Approximately

10,000 people are participating in that study each year. This study is one of the most reliable sources for

incidence data in Africa. The method used for HIV testing is a dried blood sample on filter paper analyzed in

the Africa Centre Virology Lab in Durban. The Africa Centre will return the test result within three weeks of

testing; clients will be provided with post-test counseling together with their test results at one of the Africa

Centre centers. PEPFAR funds will be used to fund HIV counselors accompanying the study team.

Counselors will offer rapid tests for HIV. A small study suggested that 20% of the participants of the study

are interested in a rapid test.

Moving away from clinics and offering the CT in a broader range of settings (e.g. close to a supermarket, in

town), Africa Centre hopes to attract hard-to-reach people to CT. Further, it is hoped that CT centers in non-

clinical settings will help to minimize the stigma attached to taking up HIV testing and counseling. The

counseling centers will offer rapid testing with pre- and post-test counseling. CT services will follow South

African government protocols. CT counselors will refer clients to appropriate further services, including the

ART programs, TB programs and government support services (disability grant, food help). CT counselors

will encourage clients to disclose their status to partners. Prevention counseling will be specifically aimed at

people who are at increased risk for HIV and will be tailored to the individual needs of the patient. Clients

will be counseled on personal risk reduction including messages about partner reduction and behavioral

changes to achieve healthy life styles. Counseling and testing takes place in separate closed rooms in order

to ensure confidentiality. All clients will receive their test results during the post-test counseling session.

New PHEs OGAC money has been reprogrammed to CT services to assist this program towards universal

testing in their assigned district. Monitoring and Evaluation and measurement for this activity will be a BPE.

ACTIVITY 3: Community Mobilization

For several years, the Africa Centre has been conducting road shows to provide information, education and

communication (IEC) services to rural Zulu communities. These road shows and other community events

will be used to promote CT. Specifically, the community will be informed that rapid testing will be offered at

the CT sites. The road shows will also be a forum to reduce the stigma around visiting a CT center.

Appropriate materials will be developed for informing the community about CT and other services offered

through the Africa Centre. All possible efforts will be made to encourage couples and youth to receive

counseling and testing. PLHIV have to play a major role in the community mobilization. Africa Centre will

involve PLHIV in educating the community about HIV, sharing their experiences with the people, and

through that getting more people tested. A behavior change communication specialist will be employed to

develop an appropriate strategy (such as the Stepping Stones strategy).

ACTIVITY 4: Referral and Linkages

Activity Narrative: Africa Centre will strengthen the referral system from the Department of Health's TB program to CT by

providing training to direct observation treatment supporters (DOTS) on the need for HIV testing for patients

who receive TB treatment. HIV-infected people will be referred for CD4 testing and treatment where

applicable. The counselors will inform clients on where to enroll in the ART program and on how to access

government support programs, such as disability grants and food aid.

ACTIVITY 5: Human Capacity Development

PEPFAR funding will be used to provide CT centers with additional CT counselors. As part of capacity

building, counselors are recruited from the local area, and trained and provided with mentoring and

supervision on a regular basis by Africa Centre. In addition, Africa Centre will conduct counselor-debriefing

sessions to discuss their work with their peers and support staff. Counselors will participate in short courses

to refresh their counseling skills. These courses will incorporate education on new initiatives that had not

been a part of their initial training. In addition, Africa Centre will provide training and mentorship to medical

staff in order to strengthen their knowledge about CT and to introduce provider-initiated testing and

counseling into the clinics.

Funding will also be used for additional staffing in clinics and hospital.

These activities will contribute to the PEPFAR goals of 2-7-10 by contributing to the 10 million people who

will receive care through PEPFAR assistance by providing counseling and testing to many individuals in

Hlabisa district.

SUMMARY:

The Africa Centre Hlabisa antiretroviral treatment (ACHART) program aims to deliver safe, efficient,

equitable and sustainable ART to all who need it in the Hlabisa district through the district health

department, rural KwaZulu-Natal. The target population for the treatment program is people living with HIV

(PLHIV), HIV-infected pregnant women and HIV-infected infants and children. The emphasis area of this

program is human capacity development, renovation, and local organization capacity building.

BACKGROUND:

The ACHART Program is a partnership between the KwaZulu-Natal (KZN) Department of Health (DOH) and

the Africa Centre, a population research department of the University of KwaZulu-Natal. The DOH program

is based in Hlabisa sub-district, and provides health care to 220,000 people at a government hospital and

14 fixed peripheral clinics. The ACHART Program is embedded in the DOH antiretroviral therapy rollout

where the Africa Centre and KZNDOH work to complement each other's abilities and resources in providing

ART. The Africa Centre has expertise in infectious diseases and management that are not available at the

district DOH. In addition to clinical staff and infrastructure, the district DOH provides the necessary drugs

and laboratory testing for effective rollout.

With FY 2008 funds the Africa Centre will continue to support the provision of ART and expand its support

for the KZNDOH. Increased attention will be given to address gender issues (especially reaching men) and

to promote the ART services among men and children.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Support to South African Government (SAG)

The ART program is jointly run by the KZNDOH and Africa Centre. The Africa Centre contributes human

resources and co-finances facility needs and supplies. The Africa Centre supports the KZNDOH with

strategic planning and the implementation of the SAG National Strategic Plan 2007-2011 for HIV & AIDS

and STI. This includes the establishment of an up and down referral system that ensures that HIV-infected

people are treated at the optimal level of care at each stage of the disease. The Africa Centre support

further extends to operating the supply chain of drugs from the central pharmacy to the peripheral clinics

and the transport of blood samples from the peripheral clinics to the central laboratories. In addition to this,

Africa Centre also supports the monitoring and evaluation of the ART program and the development of

management and treatment algorithms.

With FY 2008 funding, additional support will include park-homes (inexpensive portable prefab long-lasting

structures) which will be set up in peripheral clinics where patient load exceeds facility capacity.

Operational assistance will be in the form of funding to support training of staff, transport, logistics, IT

support and administrative assistance to smaller peripheral clinics.

ACTIVITY 2: ARV Treatment

The Africa Centre will continue to support the expansion of the ART program at Hlabisa hospital and the 14

KZNDOH clinics. ARV treatment is following the DOH guidelines. Patients with stage IV disease or CD4

count <200 are eligible for treatment. After the necessary baseline investigations (blood tests, screening for

TB) have been performed, the patients are initiated for treatment in 14 government clinics and the hospital.

Through CT, TB and the mobile ART and palliative care programs, the Africa Centre will work to increase

uptake of ART among targeted communities. Africa Centre's goal is to test babies at 6 weeks after delivery

and get them on treatment if required. Mobile teams of nurses and counselors will provide ART in the

clinics, and community mobilization activities will be used to enhance community awareness and uptake of

services. The Africa Centre will investigate the best possible way to roll out ART in the mobile clinics, which

are serving the population. The mobile team will twin with the DOH mobile clinic team, and visit the service

points together.

In FY 2008, additional mobile teams will visit clinics bi-weekly to provide onsite training, assess complicated

patients, and do quality assurance checks. This process will institute a continuous process of quality

improvement. Data capturers, supervised by the M&E officer, will move with these teams to capture data

from the clinics. A doctor will join the mobile team to initiate patients on ART at smaller clinics and assist

with treatment of side-effects and adverse events. All patients will be trained in prevention of HIV

transmission and the importance of treatment adherence. Prophylaxis against common opportunistic

infections includes cotrimoxazole prophylaxis in all patients with CD4 count under 200. Data from these

activities will be monitored to ensure that clients receive comprehensive services and that all eligible

individuals are put on prophylaxis at the earliest opportunity.

Two mobile teams of the DOH are tracking TB patients who don't pick up their treatment. Africa Centre will

integrate the tracking of TB patients by forming two more teams. With that support all four teams are then

able to track TB and HIV patients, thus preventing duplication of tracking and expanding the coverage of

both groups of patients.

ACTIVITY 3: Human Capacity Development

KZNDOH and Africa Centre counselors and nurses who work on the program will receive training on HIV

and ART. The baseline course is based on the KZNDOH curriculum and comprises four sessions of three

hours each, covering basics of HIV and ART; follow-up of patients, assimilation of a follow-up, and practical

work with a patient (including blood taking for CD4 counts and viral loads). Counselors, nurses and

physicians will receive additional training, emphasizing side-effects and second-line treatment to treat

patients with therapeutic failure of first-line therapy. The program will finance a diploma course for a

pharmacy assistant to assist with a satellite dispensing service at the clinics to support the KZNDOH

pharmacist at Hlabisa Hospital. This trainee was recruited locally in June 2007. Doctors and nurses

working on the ART program will attend the AIDS Certification Course, run by another PEPFAR partner, the

Foundation for Professional Development. Due to the shortage of staff in the clinics and due to the

Activity Narrative: increasing number of patients and increasing workload, additional staffing in clinics and hospital will be

provided.

ACTIVITY 4: Human Resources

Africa Centre staff provides clinical care alongside KZNDOH staff in the clinics in order to support the

ongoing ART program and to facilitate skills transfer to build sustainability. The sustainability of the

program largely depends on availability of skilled staff, which is difficult to attract to this rural area. The

Africa Centre is continuously working on recruiting physicians and pharmacists. In FY 2008, Africa Centre

staff in the ART program will be increased including nurses, HIV trainers, HIV counselors, doctors, social

workers, 1 pharmacist, 1 dietician, M&E officers and data capturers. All staff are mentored and supervised

by Africa Centre staff.

ACTIVITY 5: Surveillance Systems

The Africa Centre will establish clinic-based ART drug resistance surveillance. In order to choose the best

second-line therapy, information about the drug resistance in the case of first-line therapy is needed.

Routine ARV drug resistance testing is not part of the South African treatment plan. Including drug

resistance testing in the ACHART program will directly benefit the patients. The findings may benefit other

sites in resource-limited settings. If the Africa Centre finds that most treatment failures are due to

resistance against stavudine (and not lamivudine or nevirapine), the overall quality of choice of second-line

drugs may be improved without genetic drug resistance testing. PEPFAR funding will finance laboratory

equipment and transport costs to set up ART drug resistance surveillance.

ACTIVITY 6: Quality Improvement

In June 2007 a team for Quality Management was introduced in all the clinics. This group provides

leadership and support centrally and to the clinics. In FY 2008 this group will increase capacity to identify,

develop and implement quality improvement interventions internal to the program as well as for identified

problems at the sites being supported.

ACTIVITY 7: Systems Development

With increased funding the Monitoring Evaluation and Reporting systems will be further strengthened to

support the internal and external data needs of the program. The existing databases will be reviewed and,

if appropriate, adapted, and staff will be trained. Additional staff will be needed to cope with the increased

number of data to be collected and used for improvement of the program.

ACTIVITY 8: HIV Awareness

Health education has to be prioritized in the sub-district. The knowledge about ART and other health issues

must be improved. Initial analyses of Africa Centre data shows that a huge number of people don't know

about ART and a large number of those who know about ART don't know where to get treatment. In July

2007 Africa Centre approached the Amakhosi (the highest traditional leaders in the area after the king) to

involve them in the response to HIV. In this area traditional leaders are playing a major role. Billboards at

different places will be placed with messages from the Amakhosi concerning testing and treatment. The

improvement of this knowledge regarding testing and treatment will contribute to PEPFAR'S goals to

increase the community access to ART services.

Africa Centre contributes to PEPFAR's 2-7-10 goals for South Africa by increasing community access to

ART services by facilitating scale up of the SA Government efforts.