SUMMARY:

TB Care Association's activities will be carried out to increase TB and HIV case finding and case holding

through community peer supporters as well as to support facility-based integration of prevention of mother-

to-child transmission (PMTCT) with TB/HIV and antiretroviral treatment (ART) services. The TB CARE

Association PMTCT project emphasizes gender issues by increasing access to PMTCT, TB/HIV and ART

services for women and their partners. A second emphasis area is in-service training. The target

populations for this activity include children under the age of five years, pregnant women, discordant

couples, people living with HIV and AIDS, families. The emphasis area for this program include gender, by

addressing gender equity in HIV and AIDS programs, human capacity development by providing in-service

training and local organization capacity building.

BACKGROUND

Although TB CARE Association is a new FY 2008 PMTCT partner, this is an ongoing activity. TB Care

Association was founded in March 1929 as a social support group for TB sufferers in Cape Town. The core

role of TB Care has remained largely unchanged in the intervening 70+ years. TB Care provides a

comprehensive, developmental social support service to TB sufferers and their families in the City of Cape

Town. TB care operates from the community health centres which patients to take their daily treatment on

the street where they live under the supervision of specially trained community treatment supporters. In

FY07, TB CARE Association partnered with the Medical Research Council in FY 2007 and was a sub-

partner implementing these PMTCT activities. In FY 2008 PEPFAR funding will be coordinated by TB Care

Association and the Medical Research Council will be a sub-partner. The activity will be coordinated with

the provincial and district Departments of Health. TB CARE Association partnered with the Medical

Research Council in FY 2007 and was a sub-partner implementing this activity. FY 2008 PEPFAR funding

will be coordinated by TB Care Association and the Medical Research Council will be a sub-partner. The

activity will be coordinated with the provincial and district Departments of Health.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Community TB/HIV Case Finding and Case Holding Among Women Participating in PMTCT

The Good Start Community Intervention Project (PEPFAR-funded since FY 2005) has trained and

employed community peer supporters to provide household-level support to improve postnatal care of

mothers served by PMTCT programs. In the TB/HIV component of the Community Intervention Project,

community peer supporters will identify suspected TB cases in the households of pregnant mothers and

refer them to the health services for TB diagnosis. They will encourage pregnant women, their partners and

HIV-exposed infants to be tested for HIV and to access health services for appropriate prophylaxis and

antiretroviral therapy (ART). They will also provide adherence support for household members on

prophylaxis or treatment related to TB or HIV.

ACTIVITY 2: Integration of PMTCT with TB/HIV and ART Services

This project will support a comprehensive best-practice approach to integrate PMTCT into TB/HIV care in

Sisonke District in KwaZulu-Natal. The project will improve screening of pregnant women for TB and HIV as

part of antenatal care. HIV-infected pregnant women will routinely have CD4 counts assessed and be

screened for full antiretroviral treatment. HIV-infected mothers will also be screened for prophylaxis

(isoniazid preventive therapy and cotrimoxazole prophylaxis). HIV-exposed infants will receive

cotrimoxazole prophylaxis and will have a PCR test at their six week immunization visit. PCR-positive

infants will have a CD4% test to determine their eligibility for ART. The project will establish a best practice

approach to integrated TB/HIV prevention and care in PMTCT services and will provide training to PMTCT

health care providers on integrated TB/HIV care. Project results and lessons learned will be shared with the

national and provincial Departments of Health to inform existing policies and guidelines on TB/HIV care. TB

patients and PLHIV are the principal target populations and include pregnant women (referred to PMTCT

services) and children (receiving ARVs if indicated).

These activities will contribute to PEPFAR's 2-7-10 prevention goals by reducing mother-to-child HIV

transmission. The prevention outcomes are also in line with the USG goal of integrating TB and HIV

services within primary care systems in South Africa.

SUMMARY:

Activities will be carried out to screen people for TB in non-clinical counseling and testing (CT) and in

clinical sites and to ensure referral for care. The project will support care and treatment services at three

hospital-based clinics and eight primary health clinics (PHC). Clinical training and mentorship will be

provided to screen HIV-infected people for TB, provide appropriate TB treatment, and to screen for isoniazid

preventive therapy (IPT) to prevent TB. Community health workers (CHWs) will educate community

members about the symptoms of TB and the importance of seeking care and completing TB treatment.

They will screen community members for TB symptoms of TB and STIs and refer symptomatic people to

health services. Community adherence support will be provided by CHWs for TB treatment, for prophylaxis

(IPT and cotrimoxazole) and for antiretroviral therapy (ART). The adherence support model used for ART

will be piloted with TB patients.

BACKGROUND:

TB Care Association (TBCA) will implement this activity in collaboration with provincial and district

departments of health. TBCA has been providing community-based counseling, emergency material relief

and TB treatment support in the Western Cape since 1992. The Western Cape province has requested

support from TBCA for the West Coast Winelands district because the burden of TB with HIV coinfection is

high. TBCA is exploring the possibility of expanding activities to the Northern Cape province as well.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: TB and STI Case Finding Linked to VCT

VCT will be provided in non-clinical sites including workplaces. During CT, counselors will routinely screen

for TB and STIs, utilizing a questionnaire. Clients who have TB symptoms will be given 2 sputum containers

by the nurse counselor and a referral letter to go immediately to their nearest health facility. Clients with STI

symptoms will also be given a referral letter to their nearest health facility. The CT register will have

additional columns to indicate if clients have TB or STI symptoms as well as a column to determine if the

patient presents at the health facility to which they are referred.

PEPFAR funds will be used to employ one data capturer for each supported health facility to assist with

recording laboratory results and to trace people with positive TB smears to ensure that they are initiated on

treatment. The data capturer will also be responsible for informing the CT teams and community health

workers (CHWs) if referred patients attend the facilities to which they have been referred.

ACTIVITY 2: Improve the Quality of TB/HIV Care and Treatment

TB/HIV clinical training & mentoring will be provided for all relevant health care workers, in accordance with

the South African National TB Control Program guidelines and national guidelines for HIV care, utilizing

materials adopted by the Western Cape Department of Health (i.e. PALSA plus). Training will focus on the

co-management of TB, HIV and STIs. Health care providers will also be trained to routinely counsel TB

patients about the benefits of knowing their HIV status and to give patients the opportunity to test or to opt

out of testing. HIV-infected TB patients will be offered cotrimoxazole prophylaxis and will have a CD4 count

done as part of screening for antiretroviral therapy (ART). The new NTCP TB register will be introduced to

register all TB patients, to document their HIV status, and to record which TB patients are started on

cotrimoxazole and screened for ART. Health workers who provide care for TB patients will be trained on the

prevention and management of opportunistic infections, on ART and on the new TB register.

Health workers, who provide HIV care, including pediatric services, will be trained to screen all HIV-infected

clients for TB and to screen asymptomatic patients for IPT. HIV-infected individuals with symptoms of TB

will be provided with diagnostic services at the level of care where screened (i.e. ART clinic), including TB

culture. Recording and reporting of TB status will occur at the closest TB treatment clinic. TBCA will work

closely with DOH to integrate services, to allow co-infected patients to seek care at one point of service.

Under the guidance of the clinical coordinator, two nurse mentors will visit health facilities on a regular basis

to provide supervisory support to ensure optimal co-management of HIV, TB and STIs. These visits will

reinforce didactic training and will assist health staff in facilities to solve clinical problems they encounter

through case studies. Nurse mentors will also liaise with the community team leader in each facility to assist

with monitoring referrals to ensure a continuum of care between communities, clinics and hospitals. Training

and mentoring initiatives will address clinical issues identified through quality assurance reviews.

ACTIVITY 3: Improve TB and ART Case Holding through Community-based Adherence Support

The policy of the Western Cape Department of Health is to provide funding for multi-skilled community

health workers (CHWs) rather than community workers that focus on vertical program. CHWs will be trained

on priority health issues to provide integrated community care. They will be responsible for the following

activities:

-HIV prevention and condom distribution

-Education on STI symptoms and the importance of seeking treatment for STIs

-Promotion of HIV voluntary counseling and testing, particularly for pregnant women

-Infant feeding counseling

-Education on TB symptoms and the importance of seeking treatment for TB

-Screening community members for TB and STI symptoms and referring suspects to health facilities

-Education on the importance of adhering to prophylaxis (isoniazid and cotrimoxazole), antiretroviral

treatment and TB treatment

-Monitoring and providing adherence support to TB patients and HIV-infected clients taking prophylaxis or

ARVs with modified directly observed treatment (DOT)

-Home-based care

-Identification of malnourished children and referral to health facilities

-Assistance in obtaining social support grants

-Referral to support services to address substance abuse and domestic violence

Activity Narrative: -Stigma and discrimination towards people living with HIV will be addressed through the efforts of

community mobilizers and CHWs who will increase awareness of HIV in their communities utilizing IEC

strategies.

The TB Alliance DOTS Support Association (TADSA) will be a partner in the formative assessment of

adherence support services. The first step will be to identify existing organizations that are providing home-

based care services in the area. Where possible, existing home-based carers will be recruited and trained

to provide more comprehensive care as CHWs. Carers who are already engaged in home-based care and

who receive a stipend from the provincial government will integrate the new activities into their existing

functions. In areas where there are no home-based care organizations, CHWs will be recruited from the

communities in the catchment areas of the facilities. Stipends for CHWs will be funded from the PEPFAR

budget, at a similar rate to what the Provincial Government pays. This will ensure sustainability for when the

program is taken over by the government. TBCA has a well developed system of financial controls for

managing the payment of stipends. Approximately ten CHWs and one community team leader will be

employed per health facility, depending on the estimated burden of TB & HIV in the community (see Activity

4).

Health facilities will inform TBCA community team leaders of all patients who are initiated on prophylaxis,

ART or TB treatment. Community team leaders will identify a CHW who lives close to the patient and

arrange for the CHW to meet the patient. Patients on treatment will be visited by a CHW daily for the first

two weeks of treatment, then weekly up to eight weeks of treatment, then every two weeks (modified DOT).

CHWs will identify any potential adherence problems, try to address them with the patient and inform the

health professionals of issues that need to be addressed (e.g., side effects).

ACTIVITY 4: Assessment of Quality of Services

The University of the Western Cape, School of Public Health, will be sub-contracted to evaluate the quality

of TB/HIV/STI services. This will be done by conducting facility audits using an integrated TB/HIV/STI

evaluation tool at the beginning of the project, at one year and at the end of the project.

The quality of services will also be assessed through routine TB and HIV monitoring and evaluation.

Existing forms and registers will be reviewed and, if necessary, be revised, piloted and implemented to

collect information for key indicators. District and facility managers will be assisted in monitoring progress in

achieving agreed upon targets.

A baseline survey will be done to assess demographics, TB and HIV education and stigma as well as health

seeking behaviors and uptake of VCT. This survey will be repeated at the end of the project to assess the

impact of the services provided.

ACTIVITY 5: Improving HIV and TB treatment Adherence and Outcomes

Drawing on ART adherence promotion models this project evaluates a pilot program using lay health

workers to support adherence to TB treatment in Cape Town. The pilot replicates what are seen as the key

elements of the ART adherence model: intensive treatment counseling and preparation sessions by trained

lay adherence counselors; the use of a 'buddy' to support patients; and frequent lay treatment supporters

visits to help patients manage problems that arise during treatment. A qualitative assessment will be done

of the feasibility and acceptability of the adherence model. TB treatment outcomes using the adherence

model will be compared with treatment outcomes with the standard of care (directly observed treatment).

SUMMARY:

This project will increase access to HIV voluntary counseling and testing (CT) in non-clinical sites and in

facilities with a large number of TB cases. Two mobile services and fixed non-clinical sites in easily

accessible areas such as taxi ranks and shopping areas will provide CT services. TBCA will also assist the

district in training and supervising counselors in clinical sites. Target populations include the general

population, at risk populations, the business community, discordant couples, pregnant women and orphans

and vulnerable children.

BACKGROUND:

TB Care Association (TBCA) has been providing community-based counseling, emergency material relief,

and support, and TB treatment support in the Western Cape since 1992. Provision of non-clinical CT and

counseling mentorship are new initiatives that will be conducted in collaboration with the Department of

Health. Women are at higher risk for HIV infection. The provision of CT will therefore benefit women who

test HIV positive and will access care and support. Men utilize health services less than women and will

therefore benefit from the provision of CT in non-clinical CT sites. TBCA is exploring the possibility of

expanding activities to the Northern Cape province.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Non-clinical Counseling and Testing

TBCA will hold consultations will be held with key stakeholders from government, non-governmental

organizations, community-based organizations and the private sector, to identify sites in which to establish

new services or strengthen existing services for HIV counseling and testing. The West Coast Winelands

District has suggested that non-clinical CT sites should be established in the taxi ranks in Malmesbury,

Saldanha and Vredenburg. Additionally, two mobile CT teams will provide services in underserved rural and

peri-urban areas and in private sector workplaces such as farms and factories. In small towns, mobile CT

teams will conduct door-to-door community-based CT. A "100% cover" campaign will be piloted. This

campaign aims to counsel and test all the population over 14 years and to promote 100% condom use.

PEPFAR funds will be used to purchase two vehicles for the mobile CT teams.

Counseling and testing teams will be recruited, hired and trained in collaboration with NGOs that are

already providing CT services in the area. Each team will include two lay counselors, one nurse counselor

(who will also do the HIV testing) and a community mobilizer funded by PEPFAR. Five CT teams will be

hired and trained in the first year of the project.

Gender equity in HIV and AIDS programs will be addressed through the provision of non-clinical CT that will

increase access to men. The education provided by the community mobilizer and the risk reduction

counseling will help to change male norms and behaviors and reduce violence and coercion. As more

people access CT, it is hoped that there will be more discussion of HIV in communities and that stigma and

discrimination towards people living with HIV will decrease.

The community mobilizer will provide education on HIV prevention (abstinence, being faithful, using

condoms), the benefits of knowing your HIV status, TB and STI symptoms and the importance of being

treated for TB and STIs. Couples will be encouraged to go for counseling together. The community

mobilizer will also distribute condoms.

Counseling and testing will be provided according to national and international standards. Counseling will

focus on personalized risk assessment and risk reduction. Correct condom use will be demonstrated and

condoms, procured by the Department of Health will be dispensed. HIV testing will be informed, voluntary

and consented. Rapid test kits will be provided by the National Department of Health (NDOH).

Any individual who agrees to HIV counseling and testing will also be screened for tuberculosis and sexually

transmitted infections (see TB/HIV Program Area). If symptoms are present, they will be referred to the

nearest clinic/hospital where further investigations and/or treatment will be available. All HIV-positive clients

will be referred for HIV clinical care and support services and will be counselled on preventing transmission

with a specific focus on discordant couples. The CT register will have additional columns to indicate if

clients have TB or STI symptoms as well as a column to determine if the patient presents at the health

facility to which they are referred.

PEPFAR funds will be used to employ one data capturer for each supported health facility to assist with

recording laboratory results and to trace people with positive TB smears to ensure that they are initiated on

treatment. The data capturer will also be responsible for informing the CT teams and community health

workers if referred patients attend the facilities to which they have been referred.

ACTIVITY 2: Training and Supervision of Counselors

PEPFAR funds will be used to hire a CT Coordinator to train, mentor and supervise the CT teams. Training

will comply with national guidelines and will be conducted in collaboration with National Department of

Health and the AIDS Training Information and Counseling Centre (ATICC). Additional training will be

provided on couple counseling for concordant and discordant couples, counseling for youth, and counseling

to address substance abuse and domestic violence. The CT Coordinator will also visit clinical CT sites to

provide mentorship and technical support, focusing on TB treatment facilities. The five CT teams, consisting

of five nurse counselors, ten lay counselors and five community mobilizers, will be trained. Additionally, one

counselor in each of the 11 facilities will be trained, mentored and supervized. In health facilities, routine

counseling and testing will be offered to pregnant women and patients with TB or sexually transmitted

infections.

ACTIVITY 3: Measuring Costs and Assessing Cost-effectiveness of Non-Clinical HIV Counseling and

Testing

Activity Narrative: To assess the affordability of the interventions, a cost-effectiveness analysis will be done through a sub-

contract with the Health Economics Unit of the University of Cape Town. The cost per person post-test

counseled will be measured and the cost per HIV infection averted will be estimated for non-clinical HIV

counseling and testing compared to standard HIV counseling and testing. The opportunity costs of adding

TB and STI screening during pre-test counseling will be measured.

The project aims to counsel and test 10,000 people the first year. These results contribute to the PEPFAR 2

-7-10 goals by improving access to and quality of CT services in order to identify HIV-infected persons and

increase the number of persons receiving ARV services.

This is a new activity in FY 2008.

SUMMARY:

TB Care Association (TBCA) will support care and treatment services at three hospital-based clinics and

eight primary health clinics (PHC). Training and mentoring on topics to ensure provision of quality care will

be provided: clinical care, social support, monitoring & evaluation, and health system support. Referral

systems, including community adherence support and coordination of services between hospital and PHC,

will be strengthened through human resource, capacity development and programmatic support. People

infected and affected by HIV, including healthcare providers will be the beneficiaries of this PEPFAR-

supported program.

BACKGROUND:

TBCA has been providing community-based counseling, emergency material relief, and support, and TB

treatment support in the Western Cape since 1992. Support for HIV care and treatment services in the West

Coast Winelands is a new initiative. Training and mentoring activities will be done in collaboration with the

Department of Health (DOH). Support has been requested by the Western Cape province and all program

activities will occur within public health facilities. Essential drugs and ARVs will be procured through DOH,

and the National Health Laboratory Service (NHLS), through the DOH, will provide laboratory services. The

Western Cape has identified the West Coast Winelands as a district that would benefit from technical

assistance because the burden of TB with HIV co-infection is high. In Malmesbury, clinical support will be

provided at Swartland Hospital (ART site) and Dorp and West Bank clinics. In Saldanha, clinical support will

be provided in Dorp and Diaz Ville clinics. In Vredenburg, clinical support will be provided in Vredenburg

Hospital (ART site) and Dorp and Hannah Coetzee clinics. In Atlantis, clinical support will be provided in

Wesfleur Hospital (ART site) and Saxon Sea and Protea Park clinics. In summary, three hospitals and eight

clinics will be supported in the Western Cape province. TBCA is exploring the possibility of expanding

activities to the Northern Cape province.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Integration of Services and Quality Assurance

The first activity is human capacity development, focusing on integration of the HIV program into primary

healthcare services, including pediatrics. Under the guidance of the clinical coordinator, two TBCA-

employed nurse mentors with extensive experience in HIV care and treatment will work closely with the

DOH to identify training/mentoring needs. DOH clinicians will be trained through didactic and mentoring

sessions, on topics including identification and counseling of victims of abuse, reducing stigma, clinical

management of patients, integration of services, and clinical management of TB and HIV. HIV testing, care

and treatment will be strengthened by ensuring all clinicians involved in patient care (doctors, nurses,

pharmacists) in all areas of patient care services (outpatient services, pediatrics, TB, family planning,

antenatal services) are clinically competent in managing HIV-infected clients. A quality assurance program

will be implemented through support of the DOH multi-disciplinary team meetings, provision of clinical

updates and in-service mentoring, and introduction of a formal routine chart review, in collaboration with

clinic managers. National and provincial standards of care and guidelines will be followed. TBCA will work

closely with DOH to facilitate coordination of services among the three hospitals and their affiliated clinics,

anticipating provision of ART at clinic level by end of FY 2008. Systems support will be provided as needs

are identified (e.g., down-referral of drugs, strengthening of patient referrals). Ten percent of the budget will

be spent on promoting pediatric services.

ACTIVITY 2: Community Mobilization Related to Care and Treatment

The second activity is to strengthen community involvement in HIV care and treatment services through

outreach services provided by community health workers (CHW). In consultation with the DOH, TBCA will

employ one community team leader and ten CHWs for each clinical site supported. The Western Cape

province has plans to expand CHW programs, therefore sustainability will be addressed. TBCA will train the

CHWs on priority health issues so that they are multi-skilled to provide integrated community care. The role

of the CHWs will be to promote information, education, communication (IEC) in the communities they serve.

IEC activities aim to increase awareness of the availability of comprehensive HIV services; tp promote HIV

prevention, including prevention with positives; to ensure family-centered care through referrals of family

members affected by HIV; and to ensure community-level follow-up of patients who have not returned for

routine care (in collaboration with M&E). Existing community groups will be encouraged to participate, and

through collaboration with existing home-based care programs, community-based wellness programs will

encourage patients to seek routine care. Peer counseling and education provided by the CHWs will target

male behaviors. The team leaders and TBCA-employed nurse mentors who supervise them will facilitate

links with social development programs, nutritional support programs, and other governmental and non-

governmental services.

ACTIVITY 3: Strengthening Clinical Services through Monitoring and Evaluation (M&E) Support

The final activity is to assist with monitoring and evaluation of the national comprehensive HIV care and

treatment program at supported sites. TBCA will employ a data capturer at each site to assist with TB/HIV

reporting. Coordination of M&E with clinical services will ensure prompt follow-up of patients enrolled in care

who do not return to clinic. Data collection will be facilitated through provision of computers to each clinic.

Training needs related to capturing quality data will be identified and addressed. Gender equity in the HIV

program will be revealed through collection of data showing breakdown of women and men receiving

prevention, care and treatment services. The data capturers will liaise with community team leaders to

follow up patients referred from TBCA-supported voluntary counseling and testing sites that tested HIV

positive as well as those who have TB or STI symptoms.

These results contribute to the PEPFAR 2-7-10 goals by improving access to care and treatment services,

thereby increasing the number of persons receiving ARV services.