SUMMARY:

St. Mary's Hospital in Durban, KwaZulu-Natal will aggressively address the need to prevent the

transmission of HIV from mother-to-child. St. Mary's is ideally situated and offers a wide range of services to

'capture' the target group to ensure success. This will be achieved through the integration of maternal

services at the primary health care facility. The activities will encompass human resources, laboratory tests

and medical supplies. The emphasis area of this activity is to provide counseling and testing to the family

unit and in particular there will be a focus on couple counseling. The ultimate aim is to reduce the number of

new infections from mother-to-child and to refer the mother into treatment programs when required. The

target groups for this activity are people living with HIV, pregnant women, and their infants.

BACKGROUND:

This is a new program activity funded in FY 2008, although St. Mary's has received previous PEPFAR

funding as a sub-partner to Catholic Relief Services (CRS). This activity is linked in with the counseling and

testing activity program. The program is supported by the South African Government as St. Mary's Hospital

has a service level agreement with the KwaZulu-Natal Provincial Department of Health and the Hospital is

in partnership with the District Office of the Department of Health to provide HIV and AIDS training to all

clinical staff over the next two years.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Routine HIV testing and counseling

The PMTCT program is based in the primary health care (PHC) facility that has an antenatal clinic. This is

the first point of entry for a pregnant mother (not in labor) to the hospital. It is at this point that the pregnant

mother will be counseled and tested using same-day rapid test results to establish her status. Provider-

initiated Testing and Counseling is currently the standard practice for testing in the entire facility. Women

who initially test negative will be offered a repeat HIV test during the last trimester in the pregnancy, and if

the mother is not tested at the PHC facility then the mother will be tested at the hospital when the mother is

in labor. Linkages and referral to the PMTCT program will occur at the primary health care facility as well as

from the midwifery and obstetrics unit in hospital. The overall objective of this activity is to routinely counsel

and test as many pregnant mothers as possible so preventative prophylaxis will be offered to the women

and their infants. Counseling and testing in hospital at labor and delivery will also be a focus as some

mothers are referred from community clinics and have not attended the antenatal clinics sessions on site.

Partner counseling and testing will also occur at the primary health care facility as well as in the hospital. In

addition attention on TB screening will occur at all levels of health care for the mother. A group of six

PMTCT counselors based at the PHC facility and in the hospital will be trained extensively in PMTCT and

pediatric ART to ensure that the goals of this activity are achieved. Government counseling and testing

protocols will be adhered to. The expected results of this activity are to: (a) create a culture in which all

people regularly seek counseling and testing for HIV; (b) provide preventative treatment to mothers for their

unborn child; and (c) the subsequent follow up and support for the family unit post-delivery.

ACTIVITY 2: The provision of ARV prophylaxis and post-delivery support

The provision of ARV prophylaxis dependent on the CD4 count of the mother will be in line with the South

African Guidelines, which currently include single-dose nevirapine (SDNVP). However, when the guidelines

change to include dual therapy, St. Mary's will change its protocols. Single-dose nevirapine will be provided

to pregnant mothers that have a CD4 count of 200 and above and HAART to pregnant mothers that have a

CD4 count of below 200. ARV prophylaxis will be provided to pregnant mothers who test positive during

labor and who have not previously entered the PMTCT program at the PHC facility. PCR testing is

conducted at 6 weeks post-delivery and if these infants are born positive to mothers who entered the

PMTCT program, the children will be referred to the pediatric ARV program. This is an extension of the

PMTCT program. Similarly, the mother and partner will be referred post-delivery if necessary. Subsequent

PCR testing is conducted 6 weeks after cessation of exclusively breastfed babies, and formula fed infants

will be re-tested at 18 months to determine HIV status. Home-based visits will occur through the counseling

and testing activity program. St. Mary's Hospital is accredited as a baby-friendly hospital and the hospital

promotes exclusive breast feeding; however, other feeding options are discussed in the extensive infant

feeding counseling that is provided. A PMTCT therapeutic counselor will provide nutritional support and

counseling to the mother, mother-in-law and father of the baby. Infant formula is available through the PHC

facility on site as well as at the community clinic level. This is a service from the Department of Health. In

addition, one of the treatment activity plans is for the dietician/nutritional expert to provide ongoing

education to communities at clinic level. This educational support will be expanded to include pregnant

mothers and mothers post-delivery. In addition, the therapeutic counselors will visit mothers in the home

setting which is addressed as a counseling and testing activity program. Extensive counseling on feeding

options will be provided in the home setting.

The expected results of this activity are: (1) Prevent the transmission of HIV from mother to child; (2)

Effective referral and access to treatment programs if the child is born positive; (3) The referral and access

to treatment programs for HIV or TB for the mother and partner if necessary; (4) Additional home-based

support if required to the family unit to limit loss to follow-up, especially to those mothers that did not enter

the PMTCT program at the PHC facility; (5) Address referral links for care and treatment to St. Mary's

Hospital or other treatment centers.

ACTIVITY 3: Provision of support and guidance to referral clinics

The PMTCT program based at St. Mary's Hospital will work extensively with referral clinics in the area to

ensure that pregnant mothers from referral clinics will be afforded the same service as if they had attended

the PMTCT program at St. Mary's. The PMTCT training that will be afforded to the staff at St. Mary's

Hospital will be extended to the referral clinics to the PHC facility on site. This will be included in the

treatment activity plan.

These activities contribute directly to the overall PEPFAR 2-7-10 goals as HIV-infected pregnant mothers

will be identified, appropriately treated, cared for and supported. Family members affected will benefit

Activity Narrative: directly from counseling and support within the hospital environment as well as within the community setting

during home visits.

SUMMARY:

St. Mary's Hospital in Durban, KwaZulu-Natal will implement palliative care activities that encompass human

resources, training and consumables. A dedicated palliative care team will identify and provide clinical,

spiritual, psychosocial, social and preventive support to the HIV-infected client and family. A hospital-wide

education program will be initiated to enhance knowledge of palliative care practice. In addition a number of

consumable items will be purchased to assist in managing pain and symptoms related to HIV and AIDS and

ensuring comfort of people living with HIV (PLHIV). The emphasis areas of the project are related in

particular to human resource support for the palliative care team, training, commodity procurement and the

development of networks/linkages/referral systems. The primary target population is pregnant mothers,

children, adults infected with HIV and AIDS; family members affected by HIV and AIDS and healthcare

workers.

BACKGROUND:

This is a new program funded since FY 2007, although St. Mary's has received previous PEPFAR funding

as a sub-partner to another PEPFAR partner, Catholic Relief Services. The project is an expansion of the

current palliative care program that functions at St. Mary's Hospital. The hospital, established in 1927,

serves a peri-urban/rural community of 750,000 people, a third of which are HIV-infected. The community

has a high unemployment rate of around 60% and an estimated 25,000 people in the community require

ART. On an annual basis approximately 3,000 of St. Mary's inpatients require palliative care support,

35,000 require palliative care, and over 2,500 patients are currently in HIV care at the hospital, who by

definition fall into the category of people requiring palliative care including ART adherence support.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Dedicated Palliative Care Team and Trained personnel to Ensure Delivery of Quality Services

The overall objective of this activity is to ensure that patients who require palliative care and their affected

families are adequately supported in the hospital and in their surrounding communities; including clinical,

spiritual, psychological, social, and prevention support. Patients and families requiring palliative care will be

identified in the inpatient, maternity section, outpatient and ART clinic and hospice care settings. The need

to expand to the wards dedicated to pregnant mothers is due to a high maternal death rate as a result of

HIV and AIDS. The Hospital's caesarian rate is increasing due to HIV and averages around 29%. It is

estimated that around 68% of the births at St. Mary's Hospital are from HIV-infected mothers. Activities to

address this are described elsewhere in the COP. The HIV-related services offered by the hospital and its

hospice service is based on the belief that the palliative care activity is central and automatically provides a

network of services, from counseling and testing, stigma reduction, integrated preventions services,

including prevention with positives, ART and adherence, counseling and support to the individual and

family, end of life care, referral to other organizations and continuous education and support thereafter to all

concerned. The palliative care team will work with other facility-based health providers to ensure that HIV-

infected adults and children in all facility settings are either provided or referred (with follow-up) for evidence

-based preventive care interventions which include the following: OI screening and prophylaxis (including

cotrimoxazole, TB screening/management), counseling and testing for clients and family members, safe

water and personal hygiene strategies to reduce diarrheal disease, HIV prevention counseling, including

prevention with positives, provision of condoms, referral for family planning services for HIV-infected

women, appropriate child survival interventions for HIV-infected children and nutrition counseling, clinical

measurement, nutrition monitoring and targeted support based on WHO criteria for severely malnourished

PLHIV. The package of services also includes basic pain and symptom management and facility-based

support for adherence to OI medications (including cotrimoxazole prophylaxis and TB treatment) and

antiretroviral therapy (ART). Community and home-based psychological support, stigma reduction

strategies and adherence support for OI medications and ART will be provided by therapeutic counselors

who are trained PLHIV, employed by the hospital that visit the patients and their families in the community.

Attention will be given to increasing the gender equity in the HIV and AIDS programs, increasing male

involvement in the program, addressing stigma and discrimination, and partnerships with local NGOs, FBOs

and CBOs. In addition to care for PLHIV, therapeutic counselors and hospital staff will also expand their

provision of psychological, spiritual and social support of affected family members. A complex referral

network to a number of organizations, inter alia the KwaZulu-Natal Department of Health, the Ethekwini

Metropolitan (Durban), other NGOs, the Highway Hospice, and the Dream Centre exists and is used on a

proactive basis. A dedicated palliative care professional nurse and pastoral care worker will manage this

activity, with additional involvement of other members of the palliative care multi-disciplinary team including

hospital doctors and nurses, a social worker and the community outreach coordinator. The palliative care

program is managed and administered via the organizational arrangements pertaining to the hospital itself

and relies on a multi-disciplinary team approach for service delivery.

Training & Volunteer Engagement: The program relies on both volunteer and fulltime qualified and

registered healthcare professionals who require technical support and training. St. Mary's hospice care

program is a member of the PEPFAR-funded Hospice Palliative Care Association (HPCA) who is supporting

St. Mary's with critical areas including staff training and clinical protocols so St. Mary's may meet the HPCA

accreditation requirements essential to providing holistic quality health care to patients. In FY 2007, St.

Mary's will scale up its palliative care training for all health professionals, volunteers and PLHIV therapeutic

counselors involved in palliative care service delivery with training materials from HPCA and from the World

Health Organization's (WHO) Integrated Management of Adolescent Illnesses (IMAI) program. All modules

of IMAI will be utilized, however, the IMAI module on palliative care which will be made available to all the

nursing students and staff at St. Mary's who will be directly involved in palliative care. Clinical protocols

designed and approved by the HPCA are used for support and clinical services for opportunistic infections

and pain assessment and management. St. Mary's has a number of partnerships with US universities and

interest and support from US-based volunteers. On average, four to six U.S. volunteers will be

accommodated by St. Mary's on a monthly basis (supported with non-PEPFAR funds). A relationship is

currently being explored to link in with an active OVC program in the area that cares for children at drop-in

centers in and around the community. St. Mary's will offer testing; counseling and treatment services; and

the OVC program will provide the ongoing adherence support for the children. All palliative care support

services will be offered by St. Mary's Hospital to children in care at the relevant drop-in centers

Activity Narrative: ACTIVITY 2: Commodity Procurement

Provision has been made for palliative care medications and commodities which directly improve the

comfort of PLHIV, including medications for appropriate pain and symptom control (additional morphine for

pain control, syringe drivers, anti-nausea medications, cotrimoxazole and other drugs for symptom control).

Provision for such palliative medications and supplies are included in this activity and are vital to the overall

success of the program. In addition there is a need to address some of the theatre requirements and

consumables associated with caesarian section births at the Hospital. Almost 30% of all the births (150

births per month) in hospital are non elective caesarian sectional births. The primary reason for this high

rate is due to the impact of HIV and AIDS in pregnant mothers. There is a steady increase in the number of

maternal deaths due to HIV and very sick mothers are too weak to deliver naturally. The affect of this is the

long stay of many mothers and their premature babies in the high care nurseries and palliative care medical

wards, post delivery.

These activities contribute directly to the overall PEPFAR objectives of 2-7-10 as HIV-infected people will be

identified, appropriately treated, cared for and supported. Family members affected will benefit directly from

counseling and support within the hospital environment as well as within the community setting during home

visits.

SUMMARY:

St. Mary's Hospital in Durban, KwaZulu-Natal will implement extensive counseling and testing services in

the hospital as well as in the community to encourage patients' referral to the hospital for antiretroviral

treatment (ART). The activities will encompass human resources, consumables and asset procurement.

The emphasis area of this activity is to provide counseling and testing to the family unit and communities

and in particular, there will be a focus on couple counseling at the prevention of mother-to-child

transmission (PMTCT) program. This is in line with the goals of the HIV & AIDS and STI Strategic Plan for

South Africa, 2007-2011 to reduce the impact of HIV and AIDS on individuals, families, communities and

society and with the ultimate aim to reduce the number of new infections. The target group for this activity is

the general population and pregnant mothers; partners of pregnant mothers, children from prior pregnancies

and extended families of HIV infected individuals. There is also a focus on men in the workplace as

counseling and testing and referral to St. Mary's Hospital for treatment has been offered to industries

surrounding St. Mary's Hospital.

BACKGROUND:

This is a new program activity funded in FY 2008, although St. Mary's has received previous PEPFAR

funding as a sub-partner to another PEPFAR partner, Catholic Relief Services. This activity will enhance the

PMTCT, palliative, treatment and care programs that were funded by PEPFAR in FY 2007. The program is

supported by the South African government as St. Mary's Hospital has a service level agreement with the

provincial Department of Health and the Hospital is in partnership with the District Office of the Department

of Health to provide HIV and AIDS training to all clinical staff over the next two years.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Dedicated Counselors in the Hospital Setting Providing HIV Testing and Counseling

The overall objective of this activity is to routinely counsel and test as many patients as possible in the

hospital setting. Patients and extended family members will be encouraged to be tested and continuously

be re-tested in order to refer to the care and treatment programs if appropriate. The goal will be to counsel

and test all patients attending the facility whether or not the patient has symptoms of HIV and regardless of

the patient's reason for attending the facility. In addition, the focus will also be on encouraging those that are

negative to remain negative. This will be addressed through extensive counseling and the need for a

change in behavior if necessary. All areas of the hospital will be targeted both inpatient and outpatient

areas. In particular, the PMTCT program will encourage the counseling and testing of couples and members

of the family unit. A provider-initiated testing and counseling (PITC) approach has been adopted as the

preferred method of counseling and testing throughout the facility.

There is an integrated approach to the treatment of TB and HIV at the facility. This will ensure that all TB

patients will be routinely tested for HIV, and all newly diagnosed HIV-infected clients at the facility will be

screened for TB (via the Catholic Relief Service funding).

A group of thirteen counselors will be in the wards, outpatient section and the primary healthcare clinic,

which is an integrated clinic setting that addresses TB, hypertension, diabetes, antenatal services, primary

health services and PMTCT. Approximately 2 000 patients make use of this facility on a monthly basis. In

order to maximize the goals of this activity it is important to have counselors spread throughout the facility.

The counselors will be trained and continuously updated through the treatment program activity area to

ensure that patients will make informed decisions. Government counseling and testing protocols will be

adhered to. The expected results of this activity is to (a) create a culture in which all people regularly seek

counseling and testing and re-counseling and testing on an ongoing basis for HIV; (b) provide HIV and

AIDS care and treatment to those who require this treatment, and particularly addressing the referral and

access to treatment programs; and (c) provide accurate clinical information to health care workers when

treating patients.

ACTIVITY 2: Community Mobilization/Outreach

A vehicle will be purchased and a team of two counselors and a nurse will be tasked to work with the 19

referral clinics to St. Mary's Hospital and the primary healthcare clinic to provide mobile HIV counseling and

testing. The primary goal of the activity is to encourage regular counseling and testing in the clinics; and

counseling and testing for family members in a home setting. This activity will be an extension of the

PMTCT program. The community mobilization of testing and counseling will extend to a large industrial

community that surrounds St. Mary's Hospital. A team of counselors will primarily target men in the

workplace and offer testing and counseling to all, and treatment to those who require treatment.

Currently a local radio media campaign exists (not a St. Mary's Hospital funded activity) that encourages

industry to establish a culture of ongoing testing and counseling in the workplace; and support and referral

to treatment sites for those that require treatment. St. Mary's activities will support this initiative. The

outreach counseling team will also address loss to follow-up and counseling and testing of partners of

pregnant mothers and extended family members of the pregnant mother. The expected results of this

activity is to (a) address couple counseling and testing but in a home-based program which has shown to

reduce HIV transmission in sero-discordant couples; (b) address referral links for care and treatment to St.

Mary's Hospital from referral clinics and home-based settings; and (c) address the culture of counseling and

testing in the community.

These activities contribute directly to the overall PEPFAR objectives of 2-7-10 as HIV-infected people will be

identified, appropriately treated, cared for and supported. Family members affected will benefit directly from

counseling and support within the hospital environment as well as within the community setting during home

visits.

SUMMARY:

The proposed St. Mary's Hospital project addresses comprehensive and holistic HIV care and treatment,

including antiretroviral treatment (ART) within a hospital setting, with a large focus on training at a

community clinic level to ensure that stable patients, once down-referred from the hospital can be treated on

a continuous basis at a community level. The major emphasis area for this project is human capacity and

the development thereof both in the community as well as in the hospital. The expansion plans for FY 2008

is to provide holistic treatment and care to patients that are experiencing side-effects of ART as well as

babies born to mothers that are HIV infected (described elsewhere in the COP). The care and treatment is

extended to the rehabilitation department for adults and children. Some focus will be on community

participation, national media campaigns addressing preventative educational messages in partnership with

other donors (also described elsewhere in the COP), linkages with other sectors, and the capacity

development of local organizations. The primary target populations will be the general population, people

affected by HIV and AIDS, discordant couples in special populations, the community, the South African

Government (SAG), healthcare providers and other groups, pregnant women and children, partners of

pregnant women and people infected with HIV and on treatment as well as children with rehabilitation needs

that were born to HIV infected mothers.

BACKGROUND:

Since 2003 St. Mary's hospital has successfully implemented an ART program based on holistic and

comprehensive treatment of HIV and AIDS patients. This program was funded through another PEPFAR

partner, Catholic Relief Services (CRS) as part of their Track 1 program. Since FY 2005, the USG has

added additional funding to St. Mary's Hospital to focus on pregnant women.

Successful treatment of HIV and AIDS requires that patients maintain adherence to medication,

incorporating overall wellbeing, including nutrition. The early stages of the treatment program allowed St.

Mary's to maintain an average adherence rate of around 90%, which was largely due to a patient-centered

model of care. However as the patient numbers have increased St. Mary's has realized that there is a

greater need to provide patient support both in the community and to the community clinics. St. Mary's will

aggressively address loss-to-follow-up, and ensure a more efficient down referral process of patients from

the hospital setting to the community clinics. In the district that St. Mary's serves, it is estimated that 25,000

patients require immediate treatment. Just over 2,500 patients are currently in HIV care and just over 2,200

patients are on antiretroviral treatment at the hospital.

It has been noted that many patients on treatment are experiencing neurological side-effects to treatment

that require services associated with rehabilitation both on an inpatient and outpatient basis. In addition

there is a need to provide rehabilitation support to HIV infected patients that are experiencing complications

due to opportunistic infections. It is estimated that 60% of the patients attended to by the rehabilitation

department are HIV infected and require extensive rehabilitation support. The hospital delivers

approximately 500 babies per month and many of these babies are to HIV infected mothers resulting in the

need for rehabilitation services to mother and infant at a ward and outpatients level. Follow-up is provided to

the mother and child upon discharge from the hospital at weekly support clinics held at the PHC facility.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: Human Resource Capacity Training.

As an accredited SAG antiretroviral (ARV) rollout site and as an extension of the service level agreement

the Hospital has with the Department of Health, St. Mary's will contribute to the success of the SAG ARV

rollout plan through this project. The funding allows St. Mary's to continue to initiate patients on ART, and

once stable, down refer them to the community clinics in the area. St. Mary's will assist with the training of

health workers at clinic level to facilitate this. St. Mary's has identified local partners as well as the World

Health Organization's Integrated Management of Adult Illnesses (IMAI) training toolkit as a vehicle for

training. The toolkit makes use of people living with HIV (PLHIV) as expert trainers which are directly

aligned to the success of St. Mary's ART program. All three sites within St. Mary's Hospital strongly

emphasize human capacity development. Within the entire Hospital setting (including the three ART sites)

patients who have tested HIV positive but whose CD4 counts and staging preclude them from treatment

form part of a wellness program. Opportunistic infections are treated at every point of care, and service and

nutrition interventions are made, as per SAG protocols and guidelines. Social support services, which may

take the form of social grants in accordance with the SAG guidelines, are also initiated as appropriate,

providing patients with access to financial resources.

The community clinics surrounding St. Mary's are linked into St. Mary's via the referral patterns already

established. The implementing organization will be St. Mary's Hospital and local partners will be recruited to

assist with the WHO ART training modules. Gender issues will be addressed throughout the project as well

as stigma and discrimination, twinning, the use of US-based volunteers from a training perspective, as

stated in the palliative care section. Gender equity will become an increased focus as women are provided

with resources (grants, nutrition) and capacitated to become self-sufficient. Through a partnership with the

Treatment Action Campaign (TAC) male norms and behaviors will be addressed directly through patient

education, encouraging prevention, 'know your status', and promoting family values. A comprehensive

nutrition program will be implemented to boost immunity with the patient cohort which will be the

responsibility of the dietician employed at St. Mary's Hospital, and is supported via a partnership with the

KwaZulu-Natal Department of Health (DOH). As an accredited ARV rollout site this is a vital component to

the success of the treatment program. A patient follow-up program, funded as part of the CRS activity

treatment program, makes use of therapeutic counselors (TCs) in the community to support patients from

St. Mary's Hospital. As the patient numbers have increased, St. Mary's acknowledges that additional

human resources are required for patient follow-up and support activities. The current treatment activity

program addresses the need to make use of TCs based in the community referral clinics, to help capacitate

the clinics to offer support to all patients in the community. This will be part of the clinic strengthening

activity plan. It is envisioned that the TCs will mentor community health care workers to ensure the long-

term sustainability of ARV treatment in communities.

Activity 2: Pediatric Treatment.

Activity Narrative:

As stated previously, St. Mary's is a DOH accredited ARV rollout site and the partnership will be enhanced

and expanded through the additional PEPFAR funding. Within the antenatal clinic, patients who have

received PMTCT are followed up post-delivery and if clinically appropriate, placed on antiretroviral

treatment. This is a seamless program which also places the children of HIV-infected mothers on ART if

clinically appropriate. The program also provides education and nutrition support in partnership with the

KwaZulu-Natal DOH. Pediatric HIV care is strengthened through early testing and diagnosis. The hospital

has secured the services of a volunteer pediatrician from Harvard Medical School twice a week. The

pediatrician will treat HIV infected children in-hospital and manage children as outpatients from the PHC

facility. The pediatrician will also mentor clinical staff in the facility. The main challenge is polymerase chain

reaction (PCR) testing and follow-up in this area, given that 19 clinics are being supported in the process.

St. Mary's currently has a relationship with Toga Laboratories (a PEPFAR partner) and it is envisioned that

counselors visiting clinics will refer patients requiring PCRs to the hospital's PMTCT program so that tests

can be conducted through Toga Laboratories.

Activity 3: Rehabilitation Services.

The rehabilitation department consists of a physiotherapy department (inclusive of a speech therapist) and

an occupational therapy department with a small community outreach service. Care and treatment will be

provided to those in and outpatients experiencing ARV side-effects, primarily related to neurological

conditions; and care and treatment to HIV infected inpatients that are severely disabled, who have had

strokes or heart attacks. Rehabilitation support is also required to babies experiencing developmental

delays born to HIV infected mothers. The areas of care will be at an inpatient hospital level and primary

health care (PHC) level as an outpatient service. Many babies born in hospital are referred to the PHC

facility for follow-up, and a clinic treatment day is held for babies experiencing developmental delays.

Weekly outreach treatment, education and support clinics are offered to one of the larger referral clinics in

the district as well as to children in an orphans and vulnerable children partner program.

By strengthening the down-referral system, providing technical assistance to the public sector, and

providing supportive treatment for patients on ARVs and affected by HIV and AIDS; St. Mary's hospital is

contributing to the PEPFAR 2-7-10 goals.