SUMMARY:

Ingwavuma Orphan Care will continue to strengthen and, in some cases, formalize new prevention work,

training its staff and volunteers to effectively advocate for and promote prevention, abstinence and

faithfulness among all its beneficiaries. The emphasis areas include gender and human capacity building.

The church congregations and families of clients in our programs for home-based care will be the entry

point to access the target populations which are adolescents, adults, religious leaders and orphans and

vulnerable children.

BACKGROUND:

This project is part of the work of two organizations, Ingwavuma Orphan Care (IOC) and their partner

Lulisandla Kumntwana (LK), which began their work in 2000 and 2002, respectively. The organizations work

in adjacent districts in Northern KwaZulu-Natal, covering an area of around 4,000 square kilometers

between them. The organizations have been networking with each other since 2002 and benefit from this

partnership through sharing ideas, information and resources, and occasionally loaning each other staff with

particular expertise. Both organizations were new to PEPFAR in FY 2007, and are registered as welfare

organizations with the South African Department of Social Development (DOSD). IOC and LK work closely

with the Department of Health, which refers orphans and vulnerable children (OVC) to LK and helps

facilitate psychosocial workshops that train boys and girls in life skills, gender issues, and sexual education.

LK also has an Memorandum of Understanding with the local Department of Welfare to ensure that there is

no duplication of services and to facilitate sharing of information, skills, and resources. These projects

address gender by reducing the burden on girls and women of caring for OVC and reducing the need for

teenage girls and young women to use sex to get food. The youth clubs and psychosocial workshops

described below provide a forum for young people to discuss gender issues and for young girls to boost self

-esteem and build self-confidence. These youth clubs will be actively involved with prevention messaging

and counseling as well as all the other programs of IOC and LK. Prevention has always been a part of the

activities of IOC and LK and the need has been identified to further ensure its quality and scope through

direct project management, support and monitoring; and also through new specific prevention programs.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Behavior Change Outreach

Family Support Teams, comprised of volunteers recruited from local churches, provide intensive care to

OVC living in their immediate vicinity. The teams are supervised by Orphan Care Coordinators and both

conduct regular home visits to OVC. Home-based carers visit the homes of people living with HIV and

nurses, chaplains, youth pastors, social workers, and paralegals, facilitators of youth clubs and support

groups for HIV-infected people all have a strong opportunity to educate on behavior change which includes

encouraging youth aged 10-14 to abstain or delay sexual debut whenever they visit. For older youth aged

15-24, secondary abstinence is encouraged while information on correct and consistent condom use is

provided for youth at risk and those who are sexually active. Education and counseling is done with both

HIV negative and positive people, through support groups for HIVinfected people and counseling home-

based care patients. IOC and LK will ensure all staff and volunteers are trained to do this effectively through

their normal process of line-management supervision and will document and monitor the interventions using

an innovative intervention monitoring database, described below.

ACTIVITY 2: Mobilizing Pastors to Counsel for HIV prevention:

In FY 2007 Ingwavuma Orphan Care meticulously built up relationships with many of the 800 pastors in the

area, and a group of pastors, of all denominations, requested that Ingwavuma Orphan Care provide them

with training on HIV and AIDS and prevention. IOC leadership training for pastors will be conducted in FY

2007/8, using Zulu source material from Dr. John C. Maxwell. Training will be conducted over 5 months in

20 sessions and will be followed up by the training of pastors to give prevention messages to their

congregations along traditionally faith-based lines, including fidelity and mutual monogamy. This messaging

will encourage reduction of the number of sexual partners and discouraging cross generational and multiple

concurrent partnerships. Pastors, as trusted members of the community, will also conduct abstinence

workshops for youth. The pastors have built a good relationship with the community members. They will first

participate in HIV awareness workshops and then prevention and abstinence workshops. Pastors will then

in turn conduct these workshops; targeting youth aged 10-14 before they initiate sexual activity. The

workshops will be held at churches, and will include health presentations from the IOC nurse. Using FY

2008 funding, this activity will be scaled up significantly beyond the scope of the small pilot project that was

implemented in FY 2007.

ACTIVITY 3: Family Counseling:

Ingwavuma Orphan Care holds workshops for couples once a month for a period of six months, rotating

around the different IOC areas, to strengthen marriages and families. A program of oral and video

presentations is given by locally-respected men and pastors, followed up by individual family counseling

initially with the parents and then with the whole family. Counselors will receive additional training in

marriage counseling and counseling in general by an external training provider. The training includes a

series on "How to Have a Successful Marriage" and opportunities will be sought to reach mobile

populations, specifically when husbands are home from the mines. Because its ethos is like a traditional

community meeting profile, with respected elders sharing the secrets of having strong marriages and

individual counseling to individual circumstances, this program has been highly popular since May 2007.

Using FY 2008 funding, IOC will expand the couple's workshops throughout the municipal district, reaching

larger numbers of people with a very high quality and personalized intervention. The workshops and

counseling promote reduction of number of sexual partners and HIV testing with referrals to IOC's testing

program. The expected behavioral changes are strong and monogamous marriages; giving children the

family security they need to be successful and abstinent. The workshops specifically address male norms

and behaviors and address discrimination, abuse and coercion amongst women and girl children.

ACTIVITY 4: Training of Staff and Volunteers:

Activity Narrative: An inter-disciplinary team of nurses, social workers, chaplains, and orphan care coordinators, as well as a

consultant with proven motivational skills will train Family Support Teams. Training of IOC staff to provide

prevention messages will occur every month at one of the three staff team days. Training for pastors,

including prevention messages for AB and methods of disseminating this information to the community will

occur once per month over three months.

ACTIVITY 5: Monitoring and Evaluation:

IOC's sophisticated M&E system operates on a MySQL/ PHP/ Javascript platform covering both home-

based care and orphan care beneficiaries and field workers. Every contact with a beneficiary by a field

worker and every intervention are recorded by timesheet. Each intervention is categorized according to the

PEPFAR SASI indicators so that reporting is extremely simple. A Data Quality Officer audits the data and

verifies the interventions with home-visits on a rolling three-month audit program. The Quality Improvement

Manager and staff undertake regular client satisfaction interviews on visits to the clients' homes after three

or four months subsequent to the intervention and establish what IOC staff and volunteers have done in

practice and whether the client feels their behavior has changed.

This activity will enable IOC to reach hundreds of youth and adults with the abstinence and faithfulness

messages. This activity will contribute to the PEPFAR 2-7-10 goals of averting seven million infections by

helping adults and youth reduce risky sexual behaviors.

SUMMARY:

Ingwavuma Orphan Care (IOC) activities are carried out to expand the current home-based care project

through recruiting and training of lay caregivers and to provide medical support in the way of hiring and

training nurses and provision of medical supplies.

BACKGROUND:

This project started in 2002 and was expanded in 2003 to include additional patients and caregivers. IOC is

a member of the Hospice and Palliative Care Association (HPCA) and has benefited indirectly from

PEPFAR through mentoring and support of the HPCA medical director and professional nurse. IOC became

a PEPFAR partner in FY 2007. The project works closely with Mosvold Hospital and its clinics in KwaZulu-

Natal, with referrals in both directions. The hospital supplies the project with drugs, food and nursing

supplies. The project is also partially funded by the provincial Department of Health/European Union

Partnership. Most of the caregivers are women and the project provides them with education and a regular

income. Male caregivers provide good role models to show that men can also be caring and look after the

sick.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Improving/Expanding Health Services

IOC will use PEPFAR funding to continue to improve and expand its health services. IOC employs three

nurses, a chaplain to offer spiritual support and 25 paid caregivers. All staff are paid adequately and care is

taken to provide good working conditions in order to retain staff in this remote rural area This project offers

pre-employment and in service training and employment for volunteers, all of whom are affected by HIV, as

home-based caregivers. The home-based caregivers live in their own communities spread across 2,100

square kilometers of the health district. They work in teams of 1-4 caregivers plus several local untrained

volunteers. They visit people who are ill, providing basic nursing care and ensuring delivery of the elements

of the preventive care package that includes: psychological, social and spiritual care. Family members are

taught basic nursing techniques and about hygiene and nutrition. The caregivers distribute items such as

gloves to promote infection control. If they suspect that a patient is HIV-infected, they will counsel them

about the need for testing and encourage disclosure and testing of the whole family. Clients who test

positive are then referred to the nearby local Department of Health (DOH) clinics and hospital for

administration of ARVs. Caregivers follow up on referrals to ensure that patients have received the

necessary care and understand medication instructions. Effort will be made to ensure equitable access to

care services for both men and women. The teams of caregivers are visited by the nurses and chaplain 1-4

times a month ensuring the delivery of elements of the basic care package. The nurses and chaplain,

together with the caregivers, then visit the clients needing specialized care. The nurse carries a basic

supply of drugs, including cotrimoxazole, pain medication and treatment for opportunistic infections. Nurses

collect sputum samples if TB is suspected and deliver the samples to the nearest clinic for analysis. If the

results are positive, the clients are referred to the DOH clinic for DOTS. The chaplain visits clients who

request spiritual support. The project also advocates to government sources for HIV-affected families who

do not have enough food. The open and caring attitude of the caregivers helps to reduce discrimination and

stigma against those who are HIV-infected. The caregivers counsel relatives and neighbors who exhibit

discriminatory behavior against the clients. Vulnerable children in the families are identified and referred to

the OVC branch of the project. Bereavement support is provided, if necessary. PEPFAR funding will allow

the project to employ nearly twice as many trained home-based caregivers, which will result in nearly twice

as many patients receiving care. It will also contribute to the support of the clients through medical

personnel and medical supplies. This funding enhances the support already given to the project through the

DOH, which contributes to some of the existing caregivers' salaries and project running costs. The project

will aim to recruit volunteer nurses from the United States to assist with ongoing supervision and in-service

training of the lay caregivers. FY 2008 activities will be expanded to ensure that the entire catchment area

of Mosvold Hospital is provided with palliative care. Quality of care will be further improved to provide the

basic care package to encompass clients who are HIV-infected but asymptomatic.

ACTIVITY 2: Caregiver Training

The main objective of the training is to increase skills in delivery of quality palliative care services including

elements of the preventive care package. Lay caregivers are trained by a former home-based caregiver,

who is assisted by the nursing staff, paralegals, a social worker, and other staff. Subjects covered in the

training include HIV counseling, basic nursing, TB and ARV support, screening for pain and symptoms and

methods of encouraging clients to start and continue taking ARVs or TB medication properly. Volunteer

caregivers will be trained at IOC's training center, doing their practical training at Mosvold Hospital. This 56-

day training is in line with the South African DOH guidelines for home-based caregivers. At the end of the

training these caregivers could be employed by the project to further extend the reach of home-based care

support, funds permitting. FY 2008 activities will be expanded to include training of all staff in the basic care

package. New caregivers will be recruited and trained to provide services in areas which are currently

uncovered. PLHIV will be trained to implement the basic care package.

ACTIVITY 3: Renovation of training center and expanded office facility

The purpose of this activity is to renovate buildings at a new office complex which will allow the integration

of all the activities of Ingwavuma Orphan Care at the geographical center of the area in which it works. A

run down building requires extensive renovation to convert it into some offices and storage area for

PEPFAR-funded staff. Current offices were built to accommodate 7 staff while by 2008 there will be around

30. The current offices will be converted to a full time training center, providing much needed infrastructure

and services in the area. The training center will be used by the organization to train staff, volunteers and

community members for many of the PEPFAR-related activities. Changes to the building will include

landscaping the grounds and purchasing appropriate furniture. Funding for renovation is expected to cost

no more than 10% of funding for this program area.

ACITVITY 4: Support Groups

Activity Narrative: Support groups will be formed to better provide the basic care package. Support groups will be

strengthened throughout the health district. Support groups are aimed at mixed groups of men and women

who are HIV-infected. There are separate groups which target children and their caregivers. Groups meet

once a month. Groups are led by caregivers, especially those who are HIV-infected themselves, but

members of the groups are encouraged to take the lead over time. This will be a place where the basic care

package is implemented as well as integrated prevention strategies. Addressing prevention with HIV-

infected individuals is an important part of a comprehensive care strategy. Through healthy living and

reduction of risk behaviors, these prevention with positives interventions can substantially improve quality of

life and reduce rates of HIV transmission. The goal of these interventions is to prevent the spread of HIV to

sex partners and infants born to HIV-infected mothers and protect the health of infected individuals.

In the above activities, PLHIV will receive at least one clinical and one other category of palliative care

service. Palliative care to family members of PLHIV or OVC will be provided in at least two or the five

categories of palliative care services.

These results contribute to the overall PEPFAR objectives of 2-7-10 by increasing the number of people

trained as home-based caregivers, increasing the number of people receiving palliative care, and increasing

the quality of palliative care services.

SUMMARY:

Ingwavuma Orphan Care (IOC), in partnership with Lulisandla Kumntwana (LK), provides psychosocial,

educational and nutritional support to OVC and facilitates access to government social grants and other

social services. Activities aim to extend the reach of OVC projects in Ingwavuma and Mseleni areas of

Northern KwaZulu-Natal. FY 2008 funding will be used to double the numbers of OVC reached. The primary

emphasis area for this project is human capacity development with additional emphasis on local

organization capacity development, development of network/linkages/referral systems and training. The

primary target populations are OVC, HIV-infected children, and caregivers of OVC.

BACKGROUND:

This project is part of the work of two organizations, Ingwavuma Orphan Care (IOC) and their partner

Lulisandla Kumntwana (LK), which began their work in 2000 and 2002, respectively. The organizations work

in adjacent districts in Northern KwaZulu-Natal, covering an area of around 4,000 square kilometers

between them. There are thought to be about 10,000 orphans (both parents deceased) in this area. Most of

the other 100,000 children under 18 in the region could be said to be vulnerable due to poverty and the

severe impact of HIV and AIDS in the community. The organizations have been networking with each other

since 2002 and benefit from this partnership through sharing ideas, information and resources, and

occasionally loaning each other staff with particular expertise. Both organizations were new to PEPFAR in

2007, and are registered as Welfare Organizations with the South African Department of Social

Development (DOSD). Three of their social workers are funded by the DOSD. IOC also has strong links

with the Department of Home Affairs and its paralegal officers assist clients with getting their applications in

order to secure birth certificates, death certificates and identity documents from this department. IOC's OVC

services are closely linked to its palliative care services, ensuring that children of terminally ill clients are

referred early for support. LK works closely with the Department of Health, which refers OVC to LK and

helps facilitate psychosocial workshops that train boys and girls in life skills, gender issues, and sexual

education. LK also has an MOU with the KwaZulu-Natal Department of Welfare to ensure that there is no

duplication of services and to facilitate sharing of information, skills, and resources.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Service Delivery Improvement and Expansion

In FY 2008 with PEPFAR support, IOC and its partner LK will continue to expand their current OVC services

by establishing more staff and family support teams in areas that are currently not being served.

Infrastructure will be improved with the establishment of further satellite resource centers and upgrading the

central offices and care center. The orphan coordinators will continue to mobilize, train and support teams

of people from local churches who will regularly visit OVC and their caregivers and assist them practically,

spiritually, emotionally and socially. This will lessen the burden of OVC care on women and girls, as many

of the caregivers for OVC are elderly grandmothers and female OVC. Training of the team members

includes child abuse awareness, how to refer children to other services, and addresses the area of reducing

violence and coercion. The coordinators will continue to distribute food and clothes to those in need from

the resource centers, refer families to the social worker to access foster care grants and deal with cases of

child abuse, and refer children in need of health care to the home-based care teams, HIV support groups or

local clinics. The paralegal officers will assist families in getting the documents they need to apply for the

grants. School support officers, memory box workers and a youth pastor, who are funded by other grants,

provide psychosocial, bereavement and spiritual support to the children. The team will ensure that OVC are

attending school and will provide uniforms if needed. A housing project is also ongoing, funded by other

grants such as Greater Good South Africa and school groups, which rebuilds houses for some orphan

families whose houses have collapsed.

ACTIVITY 2: Capacity Building

The organizational capacity of both IOC and LK will continue to be enhanced. This will include in-service

training of existing staff and employing and training new staff to improve sustainability. Training provided to

the IOC and LK staff includes driving lessons, computer literacy, project management skills and advocacy

skills. Another key feature is the implementation of a database to provide clear information on the work

done by the field staff and volunteers and show how many children are receiving at least three of the nine

key OVC interventions. This will allow managers to monitor activities and develop quality improvement

plans.

ACTIVITY 3: Foster Care Facilitation

With FY 2008 PEPFAR funding, LK will continue to run a fostering agency to identify children in need of

care and place them with qualified community families. LK employs two social workers to facilitate this

process. LK recruits foster parents, who attend parenting workshops run by the organizations. IOC will

duplicate this service. The social workers investigate home circumstances, screen the foster parent, and

assist the children in accessing birth and death certificates. The social workers take the family to the

Children's Court at Ubombo and Ingwavuma where the children are officially placed in foster care. The

family is then able to apply for the government foster care grant. The social workers continue to supervise

the placement to ensure quality of care and timely application for foster care renewal. IOC and LK address

gender by reducing the burden on girls and women of caring for OVC and reducing the need for teenage

girls and young women to use sex to get food.

ACTIVITY 4: Memory Boxes

IOC and LK will continue to help HIV-affected families create Memory Boxes for OVC. Memory boxes are

created by the family, and consist of a collection of important documents, photos, meaningful items, and

stories about themselves. This then serves as a memento for the children once the parent has died and the

documents make it easier to sort out a government foster care grant for the children. This is a valuable

psychosocial intervention which helps the OVC to cope with what is happening in their lives. IOC and LK

each employ a Memory Box worker. Community team members are also trained in Memory Box work.

Support groups for HIV-affected and infected children are established which will provide psychosocial

Activity Narrative: support and information for the caregivers and the children.

ACTIVITY 5: Youth Clubs

FY 2008 PEPFAR funding will support 25 after-school youth clubs in 25 primary schools, in addition to

youth clubs that both IOC and LK will establish and run at their centers. These youth clubs will develop the

life skills and spiritual growth of youth in general (aged 5 to 24 years), and orphans and vulnerable children

in particular. The life skills program in the youth clubs and the psychosocial support workshops will include

training for youth on male norms and behaviors and violence avoidance. The support offered to OVC

through these clubs also enables young girls, who are especially vulnerable to abuse, teenage pregnancy,

and HIV infection, to develop self-respect and self-esteem and to develop strategies to protect themselves.

Training for both girls and boys will include discussion on the challenges of early sexual activity, the benefits

of abstinence, and the importance of faithfulness for life with one partner. Youth clubs and workshops

encourage OVC to remain in school and offer help with homework supervision and support. The youth clubs

and psychosocial workshops described below provide a forum for young people to discuss gender issues

and for young girls to boost self-esteem and build self-confidence.

ACTIVITY 6: Renovation of Training Center and Expanded Office Facility

IOC will renovate a building at a new office complex which will allow for the integration of all IOC activities at

the geographical center of the area in which it works. A run-down building requires extensive renovation to

convert it into some offices and storage area for PEPFAR-funded staff. Current offices were built to

accommodate 7 staff while by 2008 there will be around 30. The current offices will be converted to a full

time training center, providing much needed infrastructure and services in the area. The training center will

be used by the organization to train staff, volunteers and community members for many of the PEPFAR

related activities. PEPFAR funding will be used to do the landscaping of the grounds and equipment and

furniture purchases.

These IOC activities contribute to the overall PEPFAR 2-7-10 goals by contributing to the 10 million people

provided with care, including OVC so that OVC are able to grow up in their own communities with their

basic needs and rights fulfilled.

SUMMARY:

Expansion of Ingwavuma Orphan Care's current counseling and testing (CT) project consists of recruiting

and training a dedicated mobile team to provide counseling and testing, specifically targeting youth. The

home-based care staff will continue to provide CT to their clients and clients' families, with task shifting from

nursing staff to lay counselors.

BACKGROUND:

Ingwavuma Orphan Care (IOC) started to offer counseling and testing to its palliative care clients and their

families in April 2007. The National Department of Health and nursing staff train lay caregivers to provide

pre- and post-test counseling to their clients in their homes, while the nurses and doctors carry out the test

at the clients' homes when they next visit. The project has found that many male clients are reluctant to go

to local clinics or the hospital for HIV testing, but are willing to be tested in their own home, so this program

helps to address gender equality in HIV programs. Home testing also increases the uptake of couple testing

and testing children of HIV-infected clients.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Home-based Counseling and Testing Services for Home-Based Care Clients

Counseling and testing services will be integrated with the home-based care project. The lay caregivers will

counsel clients and their families and recommend testing for anyone who has not yet been tested. They will

then offer testing and post-test counseling at the clients' homes. The IOC will train caregivers to administer

the HIV tests as part of a task-shifting strategy. Nurses will supervise and monitor their activities. HIV-

infected clients can immediately be referred into IOC's home care service and support groups that are run

by the organization. The nurses can then take blood to check CD4 counts, which will be transported to the

local hospital. The nurses will undertake quality assurance monitoring. High-risk negative clients will be

referred to existing programs such as loveLife. This activity also works to increase the local organization

capacity through training of staff and employment of skilled personnel.

ACTIVITY 2: Mobile Counseling and Testing Unit Targeting Youth

IOC will set up a CT mobile team consisting of two trained HIV counselors and an assistant. The team will

work from a vehicle with a trailer. The counselors will provide CT, and the IOC medical staff will monitor

their work. These services will be publicized through the extensive existing community links IOC has with

high schools and areas where youth congregate, such as near water points and outside informal drinking

dens. Many of the targeted girls are involved in transactional sex for food or other favors. The emphasis is

on targeting adolescents in a youth-friendly way. However, anyone who wishes to be tested will be welcome

to use the service.

The team will set up three tents with chairs and tables at a selected site such as a high school. The team is

equipped with a music system and DVD projector with which to play music and show DVDs relating to HIV

and abstinence. One tent will house leaflets, information about HIV and other youth-relevant material. The

HIV counselors will work in the other two tents.

Once a group has gathered, people will be encouraged to go for free testing to know their status. In the

tents the counselors will perform confidential pre-test counseling, testing and post-test counseling. Finger

prick tests are used. As per government protocol, the serial testing algorithm should be used, as opposed to

parallel testing. Those who test positive are encouraged to go to the clinic or hospital for CD4 counts. Those

who test negative are provided post-test counseling and referred to youth programs such as loveLife.