PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
SUMMARY:
These activities have previously been implemented by the Medical Research Council (MRC). However, this
year these activities will be recompeted and a partner yet to be determined will be implementing them to
continue the work started by the MRC.
The partner will carry out activities to support a comprehensive best-practice approach to integrated TB/HIV
care at existing sites and new sites in KwaZulu-Natal, North West, Eastern Cape, Western Cape and
Mpumalanga. The project aims to improve access to HIV care and treatment for TB patients by
strengthening the role of TB services as an entry point for delivery of HIV and AIDS care, and by expanding
TB screening to people living with HIV (PLHIV). Project results and lessons learnt 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 key target populations and include pregnant women (referred to prevention of
mother-to-child transmission (PMTCT) services) and children (receiving antiretroviral treatment (ART) if
indicated).
Activities in FY 2009 will continue in applying a best-practice model to integrated TB/HIV care with TB
services as the entry point to comprehensive HIV care. Activities in the currently supported sites will be
continued; in addition sites in the Northern Cape will be added as well as additional sites in the supported
districts to expand the services to patients and the community. Additional activities will focus on continued
TB/HIV training for professional staff and lay counselors and will include infection control training. It will also
focus on awareness campaigns in the community to decrease stigma, outreach to communities to ensure
counseling and testing access, patient tracing to ensure adherence as well as streamlining of monitoring
and evaluation activities and the implementation of standardized clinical forms to ensure quality of care and
reliable data collection systems.
BACKGROUND:
The MRC initiated a best-practice approach to integrated TB/HIV care with FY 2004 PEPFAR funding. Early
activities included a systematic description of barriers faced by TB patients co-infected with HIV in an
accredited ART site, and in FY 2005, activities were focused on the development and implementation of a
best-practice model. Preliminary results from the model site confirmed the benefits of an integrated TB/HIV
approach, reflected in a drastic reduction in patient mortality, improved quality of life for TB patients living
with HIV and prolonged survival rates. Results also confirm the safety and efficacy of dual regimens,
showing that ART can safely be instituted within the first month of TB treatment. Activities in the established
sites will continue in FY 2009. The best-practice approach will be expanded to additional sites in FY 2009
(i.e. one site in Mpumalanga, two sites in the Western Cape, one site in the Eastern Cape and one in the
North West). The best-practices model drew from lessons learn in the start-up sites, such as the need for
essential human resources, the importance of negotiated partnerships with health departments, and the
challenges posed by dual stigmatization and discrimination. The new sites are characterized by extreme
poverty, poor health infrastructure, cross border migration and limited health care access. Meeting the
challenges of an integrated TB/HIV approach in such settings will be specifically addressed, as will
strengthening down-referral capacity in existing sites.
ACTIVITIES AND EXPECTED RESULTS:
Activities include provider-initiated HIV CT; TB screening by symptoms and sputum investigations; referral
to appropriate services such as PMTCT, sexually transmitted infection (STI) and partner counseling
programs; and enrollment of patients in relevant HIV care and treatment programs. Two activities will be
implemented:
ACTIVITY 1: Best-Practice Model
The partner will support implementation of a best-practice model of integrated TB/HIV care in sites providing
TB and HIV services. This approach involves: (1) clinical management (counseling and testing (CT), ART,
management of adverse drug effects, STI management, preventive therapy); (2) nursing care (TB
screening, patient education, treatment adherence, HIV prevention); (3) integrated TB/HIV information,
education and communication; (4) nutrition intervention; and (5) palliative care and support. Activities
include site renovation to meet South African accreditation requirements for ARV roll out, site and
supervisory staff training, hiring key personnel, development of patient educational materials, commodities
procurement, and establishment of appropriate referral links, including those with governmental ARV sites
to ensure continuity of care. The partner will monitor CT practices, strengths and weaknesses of TB/HIV
referral systems, human resources and conventional TB treatment outcomes. The partner will implement
ongoing quality assessments through onside supervision and external quality assurance mechanisms such
as checklists. Regular feedback meetings will be held with project staff and Provincial representatives in the
relevant programs to identify potential problems and to facilitate corrective action. Stigma around HIV, AIDS
and TB is specifically addressed through patient education and targeted interventions such as peer group
counseling and advocacy campaigns. Results from the project will facilitate evidence-based policy
formulation on expansion of integrated TB/HIV care, improve access to HIV care by co-infected TB patients,
and increase TB case finding among PLHIV. Implementation of lessons learnt in the best-practice approach
will facilitate rapid identification of systems and operational needs, and allow for corrective action. Results of
this expanded approach to integrated TB/HIV management will facilitate national scale-up of comprehensive
programs for dually-infected patients. This activity will strengthen TB services as a point of delivery of ART,
by ensuring that human, financial and infrastructure needs for integrated TB/HIV programs are met through
equitable allocation of scarce resources and through analyzes of cost effectiveness and cost benefit.
Increased TB case finding in HIV settings is a crucial component of disease control; yet largely lacking in
routine health services. In FY 2008 the project will continue to evaluate strategies for active TB case finding
in vulnerable populations and assess implications for TB and HIV control programs. PEPFAR funding will
also be used to implement an integrated electronic patient information system at the sites to support routine
data collection, facilitate patient referral and allow data transfer to the national routine TB recording and
Activity Narrative: reporting system, which is now integrating HIV testing and service data.
ACTIVITY 2: Community TB/HIV Case Finding and Holding Among Women in PMTCT
This activity will identify pregnant women in the 34 project clusters and provide peer support to each of
these households until the infants reach 6 months of age. Community peer supporters will educate
households on symptoms of TB, cure rates, and adherence to TB treatment. They will refer household
members with TB symptoms to health services for diagnosis. Children under 5 years who are TB contacts
will be referred for TB preventive therapy, and HIV-infected mothers will be encouraged to take HIV-
exposed infants for CPT, PCR testing and screening for ART. In addition, adherence support for all
household members on TB treatment, to pregnant women/mothers taking ART and infants on CPT or ART
will be provided. PEPFAR funds will provide stipends to peer supporters and allow for
supervision/mentoring of peer supporters and transport to visit mothers in the clusters. Expected results
include: recruitment of HIV-infected women, provision of community peer support and referral of TB
suspects.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Construction/Renovation
Gender
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.12:
The HIV Counseling and Testing (CT) activities had previously been implemented by the Medical Research
Council (MRC). However, this year these activities will be re-competed and a partner yet to be determined
(TBD) will be implementing them to continue the work started by the MRC.
MRC's That's It project began three years ago with the aim of integrating tuberculosis (TB) and HIV
programs in public health facilities. This project was started as a pilot project but now has expanded to
about 30 sites across South Africa and has become more of a service delivery project. Therefore, these
activities are going to be moved from being implemented by the MRC, which is more of a research-oriented
partner.
This TBD partner will carry out two separate activities in this program area.
ACTIVITY 1: Expand CT for TB patients
The partner will seek to improve CT uptake for TB patients in order to increase their access to HIV care and
treatment. Efforts will be made to work with public health care workers to routinely offer HIV testing and
document their HIV status in TB registers.
ACTIVITY 2: Community Outreach
The partner will also implement community outreach to improve uptake of couple-counseling and testing
and follow-up on referral. This is achieved by the utilization of a mobile clinic vehicle that attends to farm
communities, businesses, factory workers and mothers and children at home in informal settlements and
local townships. Health education is given on methods of TB and HIV prevention (group and individually).
* Increasing women's legal rights
* Reducing violence and coercion
Table 3.3.14:
These activities had previously been implemented by the Medical Research Council (MRC). However, this
year these activities will be re-competed and a partner yet to be determined will be implementing them to
continue the work started by the MRC. The overall aim of this project is to improve integration of TB and
HIV programs and public sites.
The partner will support a comprehensive best-practice approach to integrated TB/HIV care that will
improve access to HIV care (counseling and testing, care and treatment, screening, referral,
pharmaceuticals) for TB patients. This activity will also promote TB screening (and eventual TB treatment
as required) among patients attending HIV clinics, with particular reference to provision of antiretroviral
drugs (ARVs) to TB patients meeting eligibility criteria according to the South Africa HIV treatment
guidelines. Activities are focused in five provinces of South Africa. Specific objectives of the project in the
supported sites will be to fast-track down referral systems (to ensure a one-stop service) and prepare all
supported TB hospitals in the Eastern Cape for accreditation according to the requirements of the
Department of Health in South Africa. In this way bottlenecks in service delivery will be minimized and
service delivery improved.
A best-practice approach to integrated TB/HIV care was initiated by the MRC with FY 2004 PEPFAR
funding. Early activities included a systematic description of barriers faced by TB patients co-infected with
HIV in an accredited ARV site, and the development and implementation of a best-practice model in FY
2005. Preliminary results from the model site confirmed the benefits of an integrated TB/HIV approach,
reflected in a drastic reduction in patient mortality, improved quality of life of TB patients with HIV and
prolonged survival. Results also confirm the safety and efficacy of dual regimens, showing that antiretroviral
therapy (ART) can safely be instituted within the first month of TB treatment.
Expansion of the best-practice approach to two additional sites in different geographical settings was
started in FY 2006 based on lessons learned in the start-up sites, including essential human resource
needs, the importance of negotiated partnerships with departments of health (DOH), and the challenges
posed by dual stigma. Activities in the existing sites will continue in FY 2009, with expansion to additional
sites in remote rural settings where active TB screening among people living with HIV (PLHIV) will be
implemented. These sites are characterized by extreme poverty, poor health infrastructure, cross border
migration and limited health care access for patients. The challenges of novel solutions for treatment
delivery in such settings will be specifically addressed, as will strengthening of systems for treatment
adherence.
Activities include commodity procurement, logistics, distribution, pharmaceutical management, and cost of
ARV drugs to confirmed TB patients meeting South African government (SAG) ARV enrollment criteria.
Routine offer HIV counseling and testing will be offered to all patients and those qualifying for ART identified
as quickly as possible. Initiation of ART will be based on CD4 counts and on SAG policies. Patients
(including children) with a CD4 count < 200 will be eligible for ARV initiation after one month of conventional
TB treatment, while those with a CD4 count < 50 will be fast-tracked for immediate ART initiation based on
clinical status.
ARV drugs will be procured according to projected estimates based on HIV prevalence and the estimated
proportion of patients eligible for ART. As per the USG PEPFAR Task Team requirement, only generic
drugs approved by the SA Medicines Control Council (MCC) and the US Food and Drug Administration
(FDA) will be used. This project will support the cost of ART for initiation in sites not yet accredited or
waiting to be accredited by government.
Referral links to an accredited ART site will be established for each TB patient initiated on ART in the
participating sites in order to allow seamless transition and ART access upon discharge. Sites that are not
yet accredited for ART roll out will be assisted to acquire DOH accreditation, which will ensure the
necessary continuity of care. Activities will be directed towards eliminating bottlenecks in ART provision
(particularly human resource capacity), addressing weaknesses and limitations in down referral systems,
documenting and managing drug adverse effects, and monitoring of treatment adherence.
Integration of TB and HIV services will facilitate quick and seamless patient access to ARV drugs, thereby
decreasing patient morbidity and mortality. Review of HIV counseling and testing practices, strengths and
weaknesses of TB/HIV referral systems, human resource analyzes, treatment adherence, drug adverse
effects and conventional TB treatment outcomes in patients on dual therapy will be recorded. TB patients
and PLHIV constitute the principal target populations and include pregnant women (referred to PMTCT
services) and children (receiving ART if indicated).
Ongoing quality assessment and quality improvement will be implemented through on-site supervision and
external quality assurance mechanisms such as checklists. Regular feedback meetings will be held with
project staff to identify potential problems and rapidly facilitate corrective action. Results from the project will
facilitate evidence-based policy formulation on expansion of integrated TB/HIV care while increasing and
improving access to ART for eligible TB patients. TB services in South Africa will in future form a vital link to
accredited government ARV sites. This project will contribute to strengthening of the role of TB services as
point of delivery of ARVs, by ensuring that human, financial and infrastructure needs for comprehensive
TB/HIV programs are met through equitable allocation of scarce resources and through analyzes of cost-
effectiveness and cost-benefit.
Funding will be used to support sites to implement the pharmaceutical elements of the best-practice
approach to integrated TB/HIV care, including drug distribution and supply chain logistics to meet SA
Activity Narrative: accreditation requirements for ARV roll out, site staff training, and pharmaceutical management to maintain
MCC and FDA quality standards, and the cost of ARVs. Where applicable, sites will be prepared to comply
with the requirements of accreditation for ART in order to ensure continuity of care.
Table 3.3.15:
