SUMMARY

The African Medical and Research Foundation (AMREF) aims to address the need to strengthen voluntary

counseling and testing (VCT) services in partnership with the Eastern Cape Department of Health. The

project is comprised of a series of coordinated interventions that aim to achieve two main outcomes: (1)

assess and build the capacity of the selected CT sites in the Eastern Cape Province (Amatole, Chris Hani

and Ukhahlamba districts) and, (2) strengthen the integration and coordination of HIV and TB services in

selected facilities in the same areas. The target population includes health professionals working in CT and

TB services, lay councilors, DOTS supporters, traditional leaders and local communities. AMREF will

emphasize the strengthening of CT services and co-ordination of CT and TB services to enable increased

access to and quality of CT services.

BACKGROUND:

AMREF will strengthen the current TBCT initiative. Working in partnership with key government and non-

governmental- and community-based organizations at the provincial, district and municipality levels,

AMREF will use PEPFAR funds to strengthen and improve the quality HIV counseling, testing, support and

care services and will ensure that effective referral is taking place. The project also aims to improve

community communication and reduce stigma surrounding TB and HIV co-infection through developing

communication materials and strategies with the full participation of community members and relevant

partners.

ACTIVITIES AND EXPECTED RESULTS

AMREF SA has collaborated with the Eastern Cape Department of Health in developing this proposal in

response to the urgent need for strengthening the current CT program. This activity includes developing

comprehensive training programs; continual mentoring of trainees by local partners; developing and

strengthening sustainable systems for quality CT services; strengthening referral systems; improving CT

and TB co-ordination; and increasing demand for CT services. In the third year of the project, AMREF will

expand the program area and focus its activities to assessment of CT services, capacity building through

training and mentoring support, and monitoring of the referral system. FY 2008 activities will focus on

selected training for service providers in expansion areas, social mobilization, reduction of stigma and

discrimination, social marketing for CT, mentoring, and technical support to retained FY 2006 and FY 2007

facilities. AMREF will continue with mentoring and monitoring referral systems and skills application in

delivering quality services.

ACTIVITY 1: Operations Research

AMREF will expand its program from 70 to 176 facilities, where 106 additional facilities will fall under the

Buffalo City local service area (LSA), based on discussions with the Eastern Cape Department of Health. In

line with FY 2006 approach, AMREF will further test and disseminate "best practice" models through

operations research aimed at assessing the capacity of health workers and quality of CT services and

integration with TB services in expansion area. AMREF will document lessons learned and generate

evidence on approaches and strategies that have the greatest positive impact on CT services in terms of

improving access to appropriate and quality services and cross referrals between CT and TB services.

PEPFAR funds will be used to roll out a monitoring system for tracking and analysis of CT services and to

build capacity of health workers to increase coordination between CT and TB services which can be used to

inform policy makers at all levels.

ACTIVITY 2: Capacity Building

The expansion will include expanded coverage into Buffalo City (based on preliminary discussions with

ECDOH) where only 11 facilities are supported with FY 2006 and FY 2007 funds. An additional 106 facilities

will be supported (showing a 251% increase from 70 facilities supported with FY 2006 and FY 2007 funds to

the proposed 176 sites). AMREF will facilitate effective planning and coordination, through workshops,

mentoring, on-site support and training programs to improve the overall quality of service provision for CT in

the expansion LSAs. Capacity building will focus on the critical weaknesses that have been identified by the

provincial and district DOH of the Eastern Cape and NGO partners at the local level. This activity includes

improving the knowledge and skills of CT and TB service providers and NGO partners. Capacity building

activities will focus on developing skills to refer and support CT services effectively; and use of a functional

recording system to follow-up and monitor delivery of and demand for CT services at local service areas

(i.e. facility levels). Health professionals from 106 additional facilities will be trained in counseling and

testing according to national and international standards. Capacity building assistance to strengthen data

collection, management and organizational systems will be included in the AMREF agreement with Centers

for Disease Control and Prevention (CDC). In line with South African National Strategic Plan (2007 to 2011),

AMREF will strengthen the capacity of facilities to implement provider-initiated testing and counseling,

especially among TB patients. AMREF will retain current districts (Chris Hani, Amatole, and Ukhahlamba) in

FY2008. Under the retained facilities, AMREF will use the FY 2008 funds to (a) support facilities in

establishing a Counselors Support System/Forum aimed at reducing burn out of counselors and helping

improve the quality of counseling services offered to clients; and (b) strengthen district HAST Committees

through capacity building (training) and mentoring using supported LSAs as mentor sites for a district model

of CT-TB integration.

ACTIVITY 3 - Referral Systems

AMREF will institutionalize the use of systems and tools for cross referrals from CT and TB services.

AMREF will work in collaboration with service providers in establishing referral systems to promote

screening of TB patients for HIV and screening of CT clients for TB. This will enable accurate data and

monitoring of the number of HIV infected clients that are undergoing screening for TB. AMREF will also

expand referral systems to include expansion sites. Through local partnerships and networks, AMREF will

advocate for CT policy change through engagement of policy makers with the aim of strengthening of CT-

TB integration and provision of facilitating provider-initiated TC.

ACTIVITY 4: Community Mobilization

Activity Narrative:

AMREF will facilitate community mobilization for testing through further support of social marketing

campaigns using mass media messages and inter-personal communication. Information, Education and

Communication (IEC) materials developed with FY 200820082008 funds will be disseminated through

community members and service providers. Youth advocates will be engaged to discuss issues around

testing with their peers. Messages will also inform people of service provision and assist in facilitating

linkages between prevention, testing, treatment, care and support services. Social marketing will focus on

Community-led information education communication (IEC) material development and dissemination. Youth

advocate training and support for peer education and mobilization for prevention and testing.Strengthening

of existing attempts to promote couples counseling and Behavior Change Communication (BCC) through

mass media messages (radio, community talks) and inter-personal communication. Training for NGOs,

CBOs, FBOs and traditional healers, leaders and other community stakeholders (HBC, CCW, CHWs etc) in

community mobilization, BCC, IEC material development, and support to assist them facilitate access to

testing for community members. It is estimated that 310,104 people are infected with HIV in the four

targeted LSAs and approximately 2.9% access CT (NDOH, 2006).

AMREF will assist PEPFAR in reaching the vision outlined in the South African Five Year Strategy by

increasing access to care and treatment through the improvement of health services to deliver quality CT for

local communities and improved CT/TB coordination and by strengthening and improving the quality of CT

programs through implementation, evaluation and replication of best practices in the area of CT

programming. AMREF activities will contribute to the PEPFAR 2-7-10 goals by ensuring community

involvement and increased capacity and referral for CT programs.

SUMMARY:

African Medical Research Foundation (AMREF) will employ three key strategies: 1) Implement social

marketing and stigma reduction strategies; 2) Health system strengthening (training and mentoring including

sub-granting and support); and 3) Community partnerships. The project will tap into previously developed

and tested AMREF training curricula, partnerships with government and community counseling and testing

(CT) providers. The project will expand CT coverage by both improving and ensuring quality, accessibility,

appropriateness and convenience of services and developing targeted social marketing campaigns to

improve CT uptake.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: NGO VCT Assessment

AMREF will map NGO VCT sites surrounding selected facilities; assess the service in terms of

confidentiality practices, compliance with quality assurance methods for rapid testing, accessibility, quality,

utilization of VCT services, data management; and client awareness/perceptions of local communities of

VCT services and facilities. AMREF will assess clients' referral sources, perceptions, opening hours of and

waiting times at the VCT service; application of existing policies and guidelines on VCT related services;

and audit the structural conditions of VCT facilities. AMREF will assess the extent to which TB staff from

health facilities are testing TB patients for HIV and monitoring the CD4 count of TB patients. With the aim of

expanding access to VCT services, AMREF will review the relationship between NGOs offering (or seeking

to offer) VCT and the Department of Health, specifically to understand the role that NGOs can play in

expansion of VCT services.

ACTIVITY 2: Social Marketing and Stigma Reduction

Key activities include: 1) Desktop review of VCT social marketing activities (Government, CBOs, etc);

consultation at all levels (national to district); assessment of knowledge, attitudes and perceptions (KAP)

about HIV/AIDS and VCT within local targeted communities; 2) Design and develop information, education,

and communication materials; (3) Build capacity of local stakeholders in order to fight stigma; 4) Social

marketing campaign and facilitation of access to wider sources of care and support for people living with

HIV; and 5) Conduct monitoring and evaluation (M&E) and documentation of best practices.

ACTIVITY 3. Health Systems Strengthening

Activities will focus on building the capacity of VCT services through training and mentoring to improve

quality, confidentially, equity, access and demand for services and strengthen coordination between VCT

and TB services. The program will also strengthen the capacity of health service staff at VCT and TB clinics

to monitor and evaluate and keep accurate records of patients and services.

AMREF will train and mentor 30 VCT staff at selected VCT centers in HIV counseling and testing according

to national and/or international standards; support TB and HIV linkages, TB symptoms and referral to TB

testing; improve VCT service management and mentoring for clinic staff. To strengthen quality assurance

AMREF will train 60 mentors in mentoring and coaching VCT staff and will develop a mentoring system to

ensure that VCT testing staff are mobilising and referring. AMREF will strengthen the district health

information systems (DHIS) and improve providers' ability to collect and analyze data, document results,

and use data effectively in health service planning and management. AMREF will train 60 government

HIV/AIDS STI and TB (HAST) committee members in M&E for comprehensive care.

AMREF will train 30 CBO carers, managers and nurses in ARV literacy; strengthen and support HAST

committees to encourage networking and collaborative service provision between TB and HIV/AIDS

services; mobilise and motivate TB patients for HIV testing and vice versa. AMREF will develop a referral

system, tools and guidelines for health professionals, local NGOs/CBOS, primary health care and

community service providers, in collaboration with VCT and TB nurses; and will monitor the implementation

of the referral system.