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.
Years of mechanism: 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
The Perinatal HIV Research Unit (PHRU) strives to continually improve the quality of prevention of mother-
to-child transmission (PMTCT) services and has attained very high uptake in Soweto. One challenge, which
is being worked on, is to strengthen links from these services to HIV care and treatment services. Male
participation remains a concern. Quality improvement and linkages is a focus going forward.
The PHRU will continue to work in the government PMTCT program as described in COP 08, and will
expand and enhance these services in the following ways:
Scale-up
The PHRU has received funding from Orange Babies (Netherlands) to enhance PMTCT services in rural
Limpopo province, one of the poorest in South Africa. This complements PHRU's current PEPFAR-funded
work in the district, which is vast and distances between clinics are extensive, making travel time and cost
of public transportation to clinics difficult.
Routine Testing and Re-testing
Most sites routinely test women for HIV at their first antenatal visit. The PHRU will put this in place at all
supported sites where permission is obtained from the Department of Health (DOH). Re-testing women, in
accordance with South African Government (SAG) guidelines, will be scaled up. The re-testing of HIV-
negative women helps reinforce counseling and testing (CT) and will help identify those women where
primary infection occurs during pregnancy. Recent statistics show a five percent rate of infection.
Dual Therapy / Antiretroviral Treatment
Optimal antiretroviral treatment (ART) for pregnant women is critical to reduce transmission to infants. The
PHRU works with the provincial DOH to implement dual therapy, which has been successfully implemented
in PHRU sites in Western Cape and Gauteng. PHRU will support the switch from nevirapine to dual therapy
at the other sites in partnership with DOH. Referral for ART is required because the services are not
integrated, resulting results in mothers not getting onto triple therapy. The PHRU will strengthen these
linkages so that more than 50% of eligible women get ART. Tracking women and following them through
their pregnancy will be stepped up.
Opportunistic Infection Prevention and Treatment, TB Screening and Family Planning
Opportunistic Infection (OI) prevention and treatment is provided at antenatal care (ANC). Routine TB
screening for all pregnant women is being introduced. Women suspected of having TB will be referred to
the nearest TB treatment site since this is not provided at all clinics. Family planning and preventing HIV
transmission to partners needs to be addressed at ANC, as seroconversion during pregnancy remains an
issue. These HIV prevention and care issues will be enhanced and referral networks strengthened.
Early Infant Diagnosis, Treatment and Care
In 2007, PHRU participated in the National Institute of Allergy and Infectious Diseases' ground-breaking
research, the Children with HIV Early Antiretroviral Therapy (CHER) study, regarding early treatment of
children. The results of this study have now been incorporated into World Health Organization and U.S.
guidelines. The PHRU will continue to test and follow HIV-exposed infants. Re-testing infants at one year
will be scaled up. Tracking these children will be stepped up. Safe infant feeding methods and weaning will
be emphasized to mothers opting to breastfeed.
Male Involvement
There are very few PMTCT programs that have successfully involved men at ANC, primarily because the
atmosphere at ANC is not conducive for male involvement. Other services that are male friendly will be
developed so that men and their partners will feel free to test, to participate in couple counseling, to discuss
prevention, family planning and secondary transmission, and to develop strategies on issues of fatherhood.
Through what is learned in through our sexual prevention work, PHRU will develop innovative ways to
increase male involvement in issues related to child rearing and family responsibility.
Training
PHRU will expand training efforts on PMTCT to other provinces as needed through workshops and on-site
training and mentoring. PHRU will develop and distribute appropriate materials to health-care workers and
parents in an effort to improve the program.
PHRU has conducted three very successful "Priorities in AIDS Care and Treatment" (PACT) conferences
which are targeted at public sector health-care workers (doctors, nurses and pharmacists) and program and
facility managers. These conferences have had different themes and were very practical in nature. They
were well received by participants who claimed that they were able to take away useful information and
knowledge to improve the quality of care and treatment access at their facilities. PHRU has also used these
conferences to disseminate its research findings and HIV prevention, care and treatment experiences, and,
in addition, has invited other PEPFAR partners to share their experiences, knowledge and best practices.
More than 800 people have attended these conferences.
------------------------
SUMMARY:
The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high quality care
Activity Narrative: and support for people living with HIV and AIDS (PLHIV). The PHRU will use PEPFAR funds to provide high
quality coverage of prevention of mother-to-child transmission of HIV (PMTCT) in Soweto (Gauteng
province) and Mpumalanga provinces. This will include support to pregnant women for pre- and post- test
counseling and testing (CT), information on safe infant feeding choices, referral of women to appropriate
HIV and AIDS treatment programs and support for early testing of infants exposed to HIV. The major
emphasis area addressed is human resources; minor areas are information, education and communication,
local organization capacity development and training. The target populations are adults, pregnant women,
HIV-infected infants (0-5 years), PLHIV and their families.
BACKGROUND:
In partnership with the Gauteng Provincial Department of Health (DOH) the PHRU has been running the
Soweto (Gauteng) PMTCT program since 2000. All pregnant women accessing public health antenatal
clinics are reached, resulting in very high uptake rates. The PHRU offers post-partum counseling and
testing (PPCT) in the maternity wards at the tertiary hospital (Chris Hani Baragwanath Hospital (Bara))
where most deliveries in Soweto take place, and provides post-exposure prophylaxis (PEP) to infants
exposed to HIV. The PHRU has supported the Mpumalanga Provincial DOH by providing PMTCT service in
the Bushbuckridge district since 2003. The PMTCT service is integrated into maternal and child health
services. All activities are ongoing and are funded by PEPFAR. The close partnership with the DOH and
emphasis on capacity building and training ensures sustainability of the programs. All PMTCT sites use
rapid HIV tests with results given on the same day. Each day a group health talk is given, followed by
individual pre-test counseling. After a pregnant woman voluntarily consents to testing, the test is conducted
and the results given during individual post-test counseling session. Women testing HIV-infected are then
provided with ARV prophylaxis following the South African Government (SAG) guidelines. The PMTCT
program is an important entry point for HIV-infected women to access palliative care and antiretroviral
treatment (ART) for themselves and their families. All women who test positive are referred for CD4 count
tests, those with CD4 counts<200 cells/mm3 are referred for ART. Infants born to positive women are given
nevirapine syrup in the labor wards and a PCR test is conducted at 4 to 6 weeks. Infants are given
cotrimoxazole prophylaxis and other basic preventive care. Psychosocial support is provided through
ongoing counseling and support groups. Information is provided on issues such as safe infant feeding
practices, formula, nutrition, general healthcare, family planning, prevention for positives and disclosure.
Negative women are provided with information on how to stay negative. Safe disclosure is encouraged to
reduce stigma and violence. All women are encouraged to bring their partners for testing to increase male
involvement in HIV and AIDS care and treatment programs and to improve male involvement in PMTCT and
reduce stigma. Health workers and lay counselors are mentored, provided with debriefing and continuous in
-service training on PMTCT and developments in the field.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: PMTCT, Gauteng (urban township)
The PMTCT program in Soweto is considered a best practice model for PMTCT in South Africa with greater
than 96% uptake at each stage of the cascade. The program is ongoing and will continue operating in all
Soweto public antenatal clinics with funding from PEPFAR and Gauteng DOH. Staff employed with
PEPFAR funding offer PMTCT to around 30,000 pregnant women annually. Around 30% are HIV-infected
and about 27,500 receive their results. Following SAG guidelines for PMTCT, positive women and their
babies are provided with ARV prophylaxis. Support groups run at all clinics with emphasis on HIV
information, prevention for positives, informed infant feeding choices, nutrition, safe disclosure to partners,
etc. Partners are encouraged to come for testing and be involved in PMTCT. All HIV-infected women are
referred for CD4 count tests and those with CD4<200 cells/mm3 are referred for ART. Currently over 60%
of women accept the CD4 count test with half receiving their results. The introduction of PCR testing for
infants by DOH provides the opportunity for early infant diagnosis of HIV and referral for appropriate
treatment and care, currently more than 50% of babies are tested. During FY 2008, the program will
become more closely integrated with ARV treatment and will improve gender equity in treatment programs.
ACTIVITY 2: Post-Partum Counseling and Testing (PPCT), Gauteng (urban township)
Each year, two thirds of births (around 20,000) in Soweto occur at Bara Hospital. Around 3,000 women at
the time of delivery present with an unknown HIV status. In this ongoing activity, staff funded by PEPFAR
work with DOH staff to provide PPCT. A PEP dose of nevirapine syrup is provided for HIV-infected mothers'
infants to reduce the risk of transmission. It has been shown that a post-exposure prophylactic dose of
nevirapine is effective if given to infants within 72 hours of birth. Approximately 2,500 women are offered
PPCT, about 2,000 accept and receive their results. Around 30% of these test HIV-infected. Over 98%
accept nevirapine for their infant. The uptake of the program is high and operates seven days a week to
ensure access for all women giving birth. Women who tested negative early in pregnancy will be offered a
follow-up test. Positive women identified at the time of delivery are provided with psychosocial support
through counseling and groups, referred for CD4 count tests and early infant diagnosis.
ACTIVITY 3: PMTCT, Mpumalanga (rural facilities)
PMTCT in the Bushbuckridge District is run by the provincial DOH. The PHRU and HIVSA, support PMTCT
at Tintswalo hospital with PEPFAR funding. Activities include mentoring the counselors, assisting with
referrals and providing education and support to pregnant women. Each year, around 4,000 women deliver
at the hospital; about 25% are HIV-infected. PHRU will liaise with the PMTCT service providers to ensure
increased uptake of HIV counseling and testing. Following SAG guidelines, ARV prophylaxis is given to the
mother and infant. Women testing positive are referred for CD4 count tests and to ART if
CD4<200cells/mm3. All women are encouraged to bring their infants for testing at 6 weeks. Support groups
and counseling are available with emphasis on informed safe infant feeding practices, nutrition, disclosure
to partners, early infant testing, HIV information, etc. HIVSA provides support groups in the district primary
care clinics assisted by a US-based volunteer.
Activity Narrative: These activities directly contribute to the PEPFAR 2-7-10 goals by improving access to and quality of
PMTCT services, testing pregnant women, identifying HIV-infected persons, reducing transmission to
infants and improving access to care and ARV treatment.
New/Continuing Activity: Continuing Activity
Continuing Activity: 14262
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
14262 3103.08 U.S. Agency for Wits Health 6758 1066.08 PHRU $1,837,180
International Consortium,
Development Perinatal HIV
Research Unit
7599 3103.07 U.S. Agency for Perinatal HIV 4482 1066.07 PHRU $1,450,000
International Research Unit,
Development South Africa
3103 3103.06 U.S. Agency for Wits Health 2710 1066.06 PMTCT and $1,035,000
International Consortium, ART Project
Emphasis Areas
Gender
* Addressing male norms and behaviors
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Safe Motherhood
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $1,380,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $40,000
and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
Male circumcision, which was in Other Prevention in FY 2008, has been moved into the male circumcision
program area. The description below outlines activities falling into this program area.
and support for people living with HIV/AIDS (PLHIV) and prevention for both HIV-infected and HIV-negative
people. Prevention forms a part of all the PHRU's programs and through these efforts PHRU has
recognized that a one size fits all approach to prevention does not work for all populations. Under this
program area PHRU is targeting high risk populations, in particular men, adolescents and pregnant women,
in order to have the greatest impact.
Prevention is the cornerstone to curbing the spread of HIV. All PHRU's activities include prevention as a
fundamental component of the activity. In FY 2009 the PHRU will focus on particular communities that are
at higher risk for HIV infection and whose needs have not been addressed in mainstream prevention,
including single men, men who have sex with men, people engaging in multiple and concurrent
partnerships, adolescents and pregnant women. This aligns with the HIV & AIDS and STI Strategic Plan for
South Africa, 2007-2011 strategy to target prevention programs to higher risk groups. PHRU already has
programs for these high risk groups and through this targeted funding, PHRU will increase their participation
in PHRU programs.
All people identified through these programs will be encouraged to be tested for HIV and enter into
appropriate HIV services, or to stay negative. All the programs described below will have major input from
the PHRU communities. The programs will be monitored using both qualitative and quantitative methods to
establish their effect in the different communities.
ACTIVITY 1: Men who have sex with men (MSM)
The issue of MSM has not been widely addressed in HIV-related services. The fact that the South African
epidemic is largely in the heterosexual community has focused HIV-prevention on this population. However,
the recognition that there is a gap in services for MSM has prompted PHRU to develop expertise and
programs to address this issue. Through collaborative research with the University of California San
Francisco PHRU has learned that the prevalence amongst MSM in Soweto is around 25%. In a recent
paper at the AIDS 2008 conference in Mexico, HIV prevalence among this population in the Western Cape
is 31%. These men are clearly at risk of HIV infection and need urgent attention.
The Western Cape provincial Department of Health (DOH) has requested PHRU to assist them to expand
HIV services in the primary care clinics to MSM. This will include training health care workers on the special
needs of this population including risk reduction counseling, STI screening and treatment, and alcohol and
drug abuse counseling. There have been few programs addressing the needs of this vulnerable population
and even less addressing HIV. This activity will address this gap. PHRU will develop and expand programs
in Soweto (Gauteng) and Cape Town (Western Cape) and will train other organizations as needed. PHRU
will link with other organizations that do outreach to the MSM community such as Triangle and Desmond
Tutu HIV Foundation in Cape Town, Soweto HIV/AIDS Counselors Association (SAHACO) and Gay and
Lesbian Memory in Action (GALA) in Johannesburg, and the Human Sciences Research Council (HSRC)
and OUT in Pretoria. People referred from these groups will be able to receive a comprehensive prevention,
care and treatment program. This program will include risk reduction counseling, advising consistent
condom use with lubricants, provision of condoms, voluntary counseling and testing (VCT), sexually
transmitted infection (STI) treatment, tuberculosis (TB) screening and HIV care and treatment. The MSM
community will be consulted and involved in the development of this initiative. PHRU has actively engaged
with other organizations working with MSM.
ACTIVITY 2: Multiple and concurrent partnerships
The risk of HIV transmission increases considerably when either partner engages in sexual activity with
other partners. In a poster presented at the 2008 AIDS conference in Mexico it was shown that although, in
a period of a year, men are more likely to engage in multiple concurrent partnerships (MCP), women are
more likely to engage in multiple serial partnerships. These partnerships include cross-generational sex
which is often accompanied by gifts which sustain the relationship. Alcohol and drug abuse increases these
sorts of interactions. PHRU will intensify efforts to understand the nature of these relationships in our
communities, many of which are poorly resourced, have high unemployment rates and where there may be
a culture of concurrent relationships. Concurrent relationships are seen as culturally acceptable and the
norm through peer pressure and the notion of masculinity in South Africa. Being mobile and abusing alcohol
and drugs can increase risky behavior and infidelity. PHRU will draw on knowledge from their programs
that have engaged with couples and men to develop strategies to address this issue in our communities.
Prevention with HIV-infected and HIV-uninfected people as well as concordant and discordant couples will
be addressed. Risk reduction counseling, advising consistent condom use and partner reduction, reducing
concurrent partners and increasing time between partners will be encouraged. PHRU's and the University of
the Witwatersrand School of Journalism's AIDS and the Media project was established in 2003 with funding
from USAID and is now funded by PEPFAR through Johns Hopkins University. This project engages and
trains journalists and media practitioners on various aspects of HIV/AIDS. The focus going forward is on
MCP and male norms and will be able to draw on and publicize these findings.
ACTIVITY 3: Men
Activity Narrative: Men and single men have been underserved in HIV prevention efforts. The majority of prevention has been
targeted towards empowering women to negotiate safer sex and to PMTCT, with men being left out. In
addition, when prevention has been targeted to men it has been assumed that they are a homogenous
group. Media often portrays men in a negative fashion as the perpetrators of violence, of spreading HIV and
of being irresponsible. PHRU will include family planning in the prevention package as it is generally seen
as a women's issue and is seldom discussed. Moreover, high unemployment rates in South Africa
disadvantages the men in engaging in traditional cultural practices such as lobola (giving a gift to the bride's
parents). PHRU will develop programs together with men such that messages will have greater impact. It is
expected that more men will be tested and engage in HIV services.
ACTIVITY 4: Adolescents
The particular issues involving adolescents are addressed in the counseling and testing (CT) and pediatric
care and treatment program areas. Abstinence and delaying sexual debut is the central focus of this
initiative. PHRU has outreach activities in schools in Soweto, including providing CT. Through this and
HIVSA's camp project for adolescents and walk-ins to the Kganya Motsha adolescent clinic, adolescents
are identified through these outreach activities. Under this program area PHRU will investigate and address
the issue of delaying sexual debut and cross-generational relationships in the communities in which PHRU
works. PHRU will capacitate adolescents to make informed decisions and to empower them to not engage
in sexual activity until they are older. KidzPositive is providing similar services in Cape Town.
ACTIVITY 5: Pregnant women
Women have been shown to be more susceptible to HIV infection while pregnant. Pregnant women access
many programs including PMTCT. PHRU will use risk reduction counseling and encourage women to have
open dialogue with their partners around pregnancy and HIV infection, to bring their partners in for testing
and to engage with them around fatherhood. In addition, PHRU will encourage repeat testing at 32 weeks or
in labor as per South African government guidelines.
The above activities will link with local NGOs and CBOs in the communities where PHRU works. PHRU will
train these organizations on prevention for vulnerable groups. PHRU will support these activities through
developing strategies, providing the means and identifying venues for outreach activities. PHRU will provide
outreach material, set up referral networks, ensure HIV services are accessible, monitor and evaluate the
interventions. PHRU will also train the health care providers on the special needs of these communities to
ensure that clients get appropriate care. Once they have been shown to work, PHRU will expand these
programs.
PHRU has run three very successful Priorities in AIDS Care and Treatment conferences which are targeted
to public sector health care workers (doctors, nurses and pharmacists) and program and facility managers.
These practical conferences have been well received by participants who find that they are able to take
away useful information and knowledge to improve the quality of care and treatment access at their
facilities. Through these conferences PHRU been able to disseminate its research findings and HIV
prevention, care and treatment experiences and has invited other PEPFAR partners to share their
experiences, knowledge and best practices. Over 800 people have attended these conferences.
The approach taken by the PHRU is one of comprehensive, high quality care and support for PLHIV.
Building on their 2006 workshop on the feasibility of scaling-up doctor-based male circumcision, the PHRU
are using FY 2007 funds to organize and facilitate a stakeholders workshop on the feasibility, acceptability,
and resource requirements of alternative models of delivering circumcision as a part of a comprehensive
HIV prevention program. The workshop compares three models of male circumcision: the use of traditional
healers (where they are culturally appropriate) as circumcisers; use of trained doctors; and a nurse-based
approach to circumcision. The workshop draws upon the work of Human Sciences Research Council
(HSRC) and PHRU's non-PEPFAR funded study of the feasibility and acceptability of nurse-based male
circumcision. This activity will be used by the Health Policy Initiative in their policy analysis of the impact of
pending South African legislation restricting male circumcision to doctor-based programs and will be
coordinated with JHPIEGO and the NDOH TBD support to the NDOH. FY 2008 funds will be used to
conduct an additional symposium, similar to that held with FY 2007 funds, which will continue to involve
major stakeholders in the policy analysis, brainstorming, and other major issues surrounding male
circumcision. The major emphasis area addressed in this activity is human capacity development.
Healthcare workers, program managers, and local health officials are the target group for this activity.
Although not widespread, prevalence rates for male circumcision in South Africa ranges from about 30%
national average to nearly universal among some ethnic groups. Male circumcision is a procedure that is
usually done for cultural or religious reasons rather than for health benefits. This is seen among certain
ethnic groups such as the Xhosa who routinely practice male circumcision as part of boys' initiation to the
transition to manhood. In such cases the circumcision is done by traditional healers rather than by medically
trained staff in a health facility. A recent study conducted in South Africa showed that male circumcision
reduces the risk of becoming HIV-infected. UNAIDS and WHO have stated that these results should be
confirmed prior to recommendations being issued regarding policy and program development. Two further
large scale studies of circumcision for HIV prevention are in progress in Uganda and Kenya, with results
anticipated later in 2007. Scaling-up male circumcision in South Africa may soon become a priority, as a
component of comprehensive HIV prevention programs. In anticipation of this development, the PHRU held
workshops in 2006 and 2007 on issues related to the feasibility of scaling-up male circumcision.
Contributions to this workshop were made by researchers who conducted the South African trial,
Activity Narrative: academics, surgeons, and included input on diverse aspects of possible interventions including training
requirements, legal and ethical concerns, traditional methods, anesthesia, cultural concerns, and potential
target groups. An important conclusion from this preliminary consultation was that there is little circumcision
being carried out by trained surgeons. A medical model with circumcision delivered by trained nurses could
also be considered. PHRU is currently conducting research, with non-PEPFAR funding, on the feasibility
and acceptability of a nurse-based approach to circumcision. Through non-PEPFAR funding, male
circumcision would be performed by trained nurses under the supervision of a surgeon in sterile operating
rooms at primary and tertiary health facilities. It is expected that this activity would impact male norms and
increasing equity in treatment programs.
ACTIVITIES AND EXPECTED RESULTS
ACTIVITY 1: Male Circumcision Using Nursing Staff
No male circumcision training or service delivery will take place without the express consent of the National
Department of Health. In the absence of such approval and based on discussions with the PEPFAR South
Africa team, funds could fully or partially be reprogrammed. Should the approval for safe clinical male
circumcision activities be given, PHRU is proposing the following male activities:
This activity assumes that the South African Government will change legislation to allow male circumcision
to take place on a large scale in South Africa. Recognizing that specialized surgical and other staff are in
short supply, this activity will look at alternative models to scale-up male circumcision. This will include
training nurses to do male circumcision, paying staff to perform circumcisions and paying for materials
required to perform male circumcision. Training, mentoring and implementation will be the main areas of
emphasis and developed in consultation with NDOH and JHPIEGO. It is likely that this activity will take
place initially in Gauteng, but may be expanded to other provinces on request of the National Department of
Health.
These activities will contribute to the PEPFAR goal of preventing 7 million new infections by exploring
innovative prevention possibilities, which will result in a lower transmission rate.
Continuing Activity: 14263
14263 7881.08 U.S. Agency for Wits Health 6758 1066.08 PHRU $369,570
7881 7881.07 U.S. Agency for Perinatal HIV 4482 1066.07 PHRU $160,000
* Increasing gender equity in HIV/AIDS programs
Estimated amount of funding that is planned for Human Capacity Development $100,000
Table 3.3.03:
See Other Sexual Prevention for the FY 2008 Male Circumcision COP.
The Perinatal HIV Research Unit (PHRU) will continue to investigate the feasibility of safe and scalable
methods of male circumcision (MC).
Three separate randomized controlled trials of male circumcision have confirmed multiple observational
studies and shown adult male circumcision to be very effective in preventing acquisition of HIV in high risk
male populations; reducing the risk of HIV acquisition by 50% in all three trials. Furthermore, all three trials
confirmed that surgical circumcision was a safe procedure and overall, there were not significant increases
in sexual risk behavior in those men who were circumcised.
The challenge to health policy is to scale up circumcision services in high burden countries - such as South
Africa. Policy makers will have to ensure that sufficient numbers of young men have access to information
to be able to make a choice about whether they want to be circumcised or not and generate demand for the
procedure. Very importantly, health services must be able to provide safe surgical circumcision effectively
and efficiently; in Soweto alone, it is estimated that about 8,000 men would have to be circumcised per
annum to get 60% coverage of male circumcision in a single year's birth cohort. However, currently, the
public sector hospital in Soweto supplies just over one circumcision per day.
In the absence of a South African Government decision to implement services, the PHRU will continue to
investigate supply and demand side factors that could be critical to the successful rollout of this public
health intervention. In conjunction with Dr. Dino Rech, who is the medical manager of a large circumcision
program in Orange Farm, an informal settlement near Johannesburg, and who has an interest in
circumcision in Africa, the PHRU will perform valuable work that will inform the rollout of circumcision in
South Africa.
ACTIVITY 1: MC instrumentation
PHRU will assess the most appropriate instrumentation for circumcision in resource-poor settings. This will
include assessing the packaging and preparation thereof. Design and sourcing and manufacture of novel
devices to assist with a circumcision and estimating the costs of a most appropriate kit. PHRU will work with
PEPFAR partners in the development of a kit.
ACTIVITY 2: Training
PHRU will assess training requirements for nurses and draw up a detailed curriculum for training of nurses
for circumcision both theoretical and practical/experiential.
ACTIVITY 3: Method comparison
PHRU will compare in detail the most appropriate circumcision methods that are currently being used
(sleeve, dorsal-and-ventral slits and forceps guided). This design of the comparison will be key informant
interviews, post circumcision satisfaction surveys and will include cosmetic outcome, ease of operation,
safety and duration of the operation. Travel to countries where each procedure is used widely will be
required in order to carry out key informant interviews and post circumcision surveys. The outcome of this
will be a publishable report.
ACTIVITY 4: Gender
Recent results from the study in Orange Farm (South Africa) and elsewhere show that male circumcision
has a protective effect on High-Risk Human Papilloma virus and on Trichomonas Vaginalis which may in
turn have beneficial effect for women. Women need to be included in the issue of male circumcision, they
need to get good information on the protective effect and also understand that condoms still need to be
used. The PHRU will engage with women to determine the effects of male circumcision on their lives and if
there is a tendency to riskier sexual intercourse if their partner is circumcised as has been reported
elsewhere. The PHRU will develop strategies to ensure that condoms are still used after circumcision.
Engaging men and women on issues around male circumcision including HIV-testing, family planning, STI
treatment and condom use will be integrated into to the PHRU prevention, care and treatment programs.
Men who are already circumcised will be encouraged to engage in safe sex practices, to test regularly for
HIV, and to enter care and treatment programs if required.
ACTIVITY 5: PACT Conference
PHRU has run three very successful Priorities in AIDS Care and Treatment (PACT) conferences which are
targeted to public sector health care workers (doctors, nurses and pharmacists) and program and facility
managers. These conferences have different themes and are very practical in nature. They have been well
received by participants who find that they are able to take away useful information and knowledge to
improve the quality of care and treatment access at their facilities. Through these conferences PHRU been
able to disseminate its research findings and HIV prevention, care and treatment experiences and has
invited other PEPFAR partners to share their experiences, knowledge and best practices. Over 800 people
have attended these conferences.
Activity Narrative: -----------
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.07:
The activities involving children will now be described under Pediatric Care and Support.
The Perinatal HIV Research Unit (PHRU) will continue improving on the care and support package
described in the above activities. There is considerable drop-out from HIV-care programs and PHRU will
explore innovative ways to improve retention. The greater numbers attending care programs and the
relatively longer time between appointments makes this task more difficult. People are extremely mobile
and tend to move around seeking opportunities for employment. PHRU will attempt to increase retention
rates in care through outreach, counseling and health promotion programs.
PHRU has started investigating HIV-related mental health issues and how to include mental health
screening and appropriate referral into the HIV-care and treatment services. Working with psychiatrists and
psychologists we are developing a screening tool, assessments and referral to appropriate services. PHRU
will strengthen mental health screening and referral to mental health services as issues such as depression
and stress are impacting on adherence and quality of life. In addition, we will increase our efforts on pain
and symptom screening and provide relief where necessary.
Women are still the main group of people accessing HIV-care and treatment services. Trying to address this
imbalance in innovative ways to make the services more attractive to men remains a challenge, and will be
addressed in all PHRU's activities. PHRU has specific activities targeting men and expect that overtime
more men will access the HIV-care and treatment services.
Prevention for HIV-infected people is an important component of PHRU's work and will be strengthened to
ensure that the risk of transmission is reduced. Clients will be encouraged to bring partners and family
members to the service for counseling and HIV-testing. Risk reduction counseling will be provided to help
the client understand the risks of transmission, condoms will be promoted and distributed, and disclosure
encouraged.
Alcohol and drug abuse remains prevalent in many communities that the PHRU works in. Domestic and
gender violence, unemployment and other social issues increase risk of HIV transmission. PHRU will
explore innovative ways to work with people, especially men, to explore these risk factors and to reduce
alcohol consumption. Both community and individual approaches will be explored.
Renovation and refurbishing will be needed at some of the sites we support to increase the capacity and
efficiency of the site to provide HIV-care and treatment services.
able to disseminate it's research findings and HIV-prevention, care and treatment experiences and has
-----------------------------
The Perinatal HIV Research Unit (PHRU) will use PEPFAR funds to continue to provide quality holistic care
for PLHIV comprising of elements in the preventive care package, medical care and psychosocial support
categories in Gauteng, rural Limpopo, Mpumalanga and Western Cape provinces. Clients are monitored,
prepared and referred for antiretroviral treatment (ART). Linkages to counseling and testing (CT), the
prevention of mother-to-child transmission (PMTCT) and referral to ARV services will be strengthened. The
major emphasis area is human resources, minor emphasis areas are development of networks, local
organization capacity development and training. A family-centered approach targets HIV-infected adults,
children and infants.
Since 2002, PHRU has established palliative care programs in Gauteng, rural Limpopo and Mpumalanga
provinces for people identified as HIV-infected through PMTCT and CT (also funded by PEPFAR). Primary
health care nurses are the main providers of care under physician supervision. The Department of Health
(NDOH) guidelines for HIV care and laboratory testing are used to ensure compatibility with South African
Government (SAG) treatment sites. In South Africa, a care program covers the period from testing positive
through end of life care. A holistic approach is taken comprising elements of the preventive care package
for adults and children, clinical services, psychosocial support, healthy lifestyle promotion and preparation
and transition of clients onto ART when required. These programs are predominately accessed by women;
however PHRU is attempting to redress this imbalance. Men are encouraged to participate through CT
programs which specifically target men. Clients are encouraged to bring partners, children and other family
members. A focus of the program is to identify HIV-infected infants and children and to provide family-
centered care and support. Quality assurance, client retention, monitoring and evaluation are integral parts
of the program. The aim of the programs is to delay progression of HIV to AIDS by providing palliative care
and support to HIV-infected clients who do not yet qualify for ART. Care includes: screening for active TB,
preventative treatment for latent TB infection, cotrimoxazole prophylaxis for OIs, syphilis screening,
symptomatic screening for syndromic STIs, screening for cervical cancer, provision of family planning and
regular CD4 counts. Opportunistic illnesses are treated using a formulary based on the South African
Essential Drug List. Support for clients, their families and community members is provided through support
groups and education sessions at all sites covering issues such as basic HIV and AIDS information, HIV
Activity Narrative: services, PMTCT, ART, opportunistic infections, TB, prevention, disclosure, prevention, nutrition, stigma,
positive living and adherence.
ACTIVITY 1: Soweto, Gauteng
The Soweto care program was initiated in 2002 serving over 4,500 adults with around 700 people being
transferred onto ART and others who have been referred to SAG rollout sites. Support groups and
education sessions are run by an NGO partner, HIVSA. Since 2004, a focus has been to identify children
requiring care, ART and psychosocial support through linkages to PMTCT and infant testing. Over 630
children are currently receiving care and referred for growth monitoring and routine immunizations. Support
programs are in development to assist caregivers and children, in particular around issues of bereavement,
disclosure, dealing with stigma and discrimination, positive living and life skills.
ACTIVITY 2: Bushbuckridge, Rural Mpumalanga/Limpopo
The Bushbuckridge District in Limpopo/Mpumalanga province is one of the poorest in South Africa. Access
to information and HIV healthcare and support is a basic need. The PHRU in partnership with Rural AIDS
Development Action Research Program (RADAR) and HIVSA established a wellness clinic at Tintswalo
hospital and a district wide support network for people living with HIV and AIDS. Since 2003, over 2,000
people have accessed the wellness clinic and 2,500 have accessed support groups running in the district
clinics. A training program has been implemented to train nurses, lay facilitators, counselors and local
NGOs to provide effective support to people living with HIV and AIDS and the preventive care package,
pain and symptom management, basic education on HIV, CT, HIV treatment services and related issues to
the broader community. Disclosure is encouraged to reduce stigma, discrimination, improve male norms
and attitudes and reduce violence. US-based volunteers have worked in these programs. Expansion of
medical care to the district primary health care clinics and to prepare for down referral from tertiary facilities
is planned.
ACTIVITY 3: Tzaneen, Rural Limpopo
Since 2003, the University of Limpopo (UL) has been supporting the DOH to develop a district-wide
wellness program based in the primary health care clinics in the Letaba sub-district of the Mopani District in
Limpopo province. PHRU partnered with UL to formalize and expand the program. With PEPFAR funding
health workers have been trained in HIV care of adults and children and infrastructural support provided.
HIVSA has provided training to support group members to enable them to run more effective support
groups and provide better information to people in the district. The Mopani District (population 1 million) is
extremely poor. The program operates in the primary care clinics with support by a medical doctor and aims
expand to the whole district. Over 600 people have enrolled and more than 100 are now on treatment and
supported at the clinics. On going in-service training and mentoring occurs at the clinics. US-based
volunteers support the program. These activities will be continued and expanded to additional groups with
FY 2008 funding.
ACTIVITY 4: Western Cape
In 2006, PHRU partnered with a number of organizations in the Western Cape including the University of
Stellenbosch, Red Cross Hospital and the Desmond Tutu HIV/AIDS Foundation that support a number of
DOH ART sites. PEPFAR funds support these programs to improve linkages to primary care clinics for
down referral, and to provide holistic care and support to people on ART and their families. Training staff to
assist with scale-up and sustainability are focus areas. These activities will be continued and strengthened
and will reach additional people with FY 2007 funds. With FY 2008 funds PHRU will continue to support one
of its sub-partners, HIVSA, to expand palliative care services in rural areas in Mpumalanga, Western Cape,
and Limpopo and in urban areas in Gauteng province. HIVSA utilizes male involvement, door to door, home
-based care, and youth friendly models. HIVSA will implement systems to ensure that all PHRU assisted
ART sites will reduce loss to ART initiation from the time tested positive until eligible for ART and will
improve uptake of ART as soon as a patient is eligible. Support group models will also be expanded. HIVSA
will also assist PHRU treatment programs to better monitor care provided to family members. Retention in
care after HIV diagnosis will be a focus for FY 2008.
In all of the above activities, PLHIV will receive at least one clinical and one other category of palliative care
service. Palliative care to family members of PLHIV or OVC will be provided in at least two of the five
categories of palliative care services.
These activities directly contribute to the PEPFAR 2-7-10 goals by improving access to and quality of
palliative care for HIV-infected individuals and their families.
Continuing Activity: 14264
14264 3102.08 U.S. Agency for Wits Health 6758 1066.08 PHRU $1,619,000
7598 3102.07 U.S. Agency for Perinatal HIV 4482 1066.07 PHRU $1,700,000
3102 3102.06 U.S. Agency for Wits Health 2710 1066.06 PMTCT and $1,350,000
Construction/Renovation
Estimated amount of funding that is planned for Human Capacity Development $200,000
Table 3.3.08:
All activities align with the South African Government's (SAG) policies and programs outlined in the National
Strategic Plan (NSP). Pediatric ARV treatment is described separately. The current activities will continue,
and emphasis will be placed on the following areas:
Family approach:
Since children are retained in the system better than adults, we will continue to encourage the whole family
to be treated in the same facility. Mothers identified through prevention of mother-to-child transmission
(PMTCT) as being infected with HIV are referred to antiretroviral (ARV) treatment and care programs and
encouraged to bring their partners with for counseling and testing (CT), care and treatment providing a safe
space for mothers. Family planning and ongoing counseling are important components to ARV treatment
programs and are provided at these ARV sites. The promotion of strong family networks to and support of
the family institution form part of the program. Including men in these programs encourages them to be
more responsible in their sexual behavior and child-rearing and allows safer disclosure of status and
ongoing counseling reduces violence towards women and constructive engagement in health care.
Gender equity:
Most ARV treatment sites have more women than men attending the clinics. The Perinatal HIV Research
Unit (PHRU) has a number of programs targeting men that aim to increase the number of men knowing
their HIV-status and attending care and treatment programs. PHRU supports adolescent-friendly services
that are designed to attend to the special needs of girls and boys in a confidential and appropriate manner.
Workplace program:
The PHRU has over 500 staff and has an active HIV-workplace program. The program comprises HIV-
prevention, care and treatment as well as general health care and family planning. Being an HIV research
organization, many of the staff are HIV-infected. PHRU also encourages their sub-partners to develop
workplace programs.
Lay staff:
Lay staff are the backbone of the ARV program in South Africa. PHRU will continue training and developing
these staff to enable them to grow in their careers. In addition, these staff will be used to assist nurses in
their duties to enable task shifting to take place.
Strengthen down referral systems:
PHRU has been instrumental in setting up down referral systems in Gauteng. PHRU will continue to
disseminate this information through training and mentoring to support increase numbers of ART sites.
Number of sites:
Expanding access by increasing the number of sites that can initiate and maintain people on ARV treatment
is important for equity in health care (an NSP goal). Many of these sites require refurbishing or renovation
such that these clinics can be accredited and patient flow can be improved resulting in more people
accessing ARV treatment. The focus of this expansion is in the rural and less resourced areas of the
provinces in which we work.
At the same time, the PHRU will endeavor to pull out of sites that have the capacity of working on their own
and only to provide technical support and assistance on an as needed basis.
Expand access to treatment for marginalized and most at-risk populations (MARPs)
A focus of PHRU's ARV treatment and care programs is to increase access to treatment for all people
infected with HIV including marginalized and MARPs. PHRU will continue to work by mainstreaming this
focus into public sector health facilities.
Training:
Training is becoming an increasingly important component in all our programs and PHRU will continue to
expand this aspect. PHRU will continue running workshops, providing in-service training and mentoring,
updating staff on latest developments and continue running the larger practically oriented AIDS priorities
symposiums, conferences and workshops.
Rural Mpumalanga:
In rural Mpumalanga province, the focus will be on the ARV sites. There are many non-governmental
organizations (NGO) now offering HIV-services in the district and rather than duplicating efforts the PHRU is
focusing on supporting and increasing the number of ARV treatment sites in the district. PHRU liaises with
the other NGOs that provide the support networks in the district.
Adolescents:
The activities have been described under Pediatric Treatment. Young women, in particular, are vulnerable
to violence and coercion to engage in sexual activities. While the PHRU focuses on prevention of HIV-
infection in adolescents it is recognized that some will require ARV treatment. The sites PHRU supports are
trained to be able to provide services that take into account the special requirements of adolescents.
TB:
In South Africa, the TB program is generally run separately from the ARV treatment program. In all
programs, TB prevention, screening, testing, referral and follow-up for TB treatment is encouraged.
------------------------------
The Perinatal HIV Research Unit (PHRU) provides comprehensive care and support for people living with
HIV (PLHIV). PHRU will use PEPFAR funds to provide high quality, holistic ARV treatment and
Activity Narrative: psychosocial support in Soweto (Gauteng), rural Limpopo and Mpumalanga, and the Western Cape. PHRU
will also use PEPFAR funds to provide personnel and ARV drugs for these services. Clients are provided
with ART, pre-treatment literacy, adherence counseling and access to adherence support groups. Linkages
from CT, PMTCT, and palliative care will be strengthened. The emphasis areas for ARV services are
renovation, gender, human capacity development, local organization capacity building, and TB. A family-
centered approach targets HIV-infected adults and children.
Since 1998 PHRU has provided comprehensive treatment, care and support to PLHIV. Since 2004,
PEPFAR funding has supported ARV treatment and South African Government (SAG) ART sites in
Gauteng, rural Limpopo and Mpumalanga provinces, and the Western Cape. PHRU purchases ARVs and
provides treatment for adults and children. PHRU's family-centered approach encourages clients to bring
partners and other family members for testing and treatment. PHRU is expanding activities to scale up
government ART sites and to investigate down referral systems. With FY 2008 funds, PHRU will work with
provincial health departments to ensure safe transfer of participants to ongoing care within the SAG rollout
program. PHRU will support, train and mentor healthcare workers involved in the management, care and
treatment of HIV-infected individuals. All programs follow national guidelines for ART. PHRU provides
regular training on ART issues such as adherence, medical treatment, and appropriate regimens. A NGO
partner, HIVSA, provides all sites with psychosocial support programs providing community-based support,
support groups and education. They cover issues such as basic HIV and AIDS information, HIV services
and treatment, treatment literacy, adherence, TB, positive living, nutrition, prevention, opportunistic
infections and TB. The comprehensive care approach leads to stigma reduction, increased disclosure, and
improved adherence to ART. Throughout the comprehensive program, PHRU has established a continuous
set of assessment functions to improve the quality of care at ART service sites.
All of the activities described in this section will be continued and expanded with FY 2008 funds.
ACTIVITY 1: Adults, Soweto
Funding from PEPFAR supports women on treatment in the family-centered PMTCT program. The program
is ongoing and provides treatment, monitoring and support for adults who meet SAG guidelines for
treatment. HIVSA provides treatment literacy and adherence support.
ACTIVITY 2: Pregnant Women, Soweto
This program has been initiated in the maternity section at Bara in July 2005 by PHRU in partnership with
the Department of Obstetrics and Gynecology. In Soweto 8,000 pregnant women are identified annually as
HIV-infected, with around 1,600 needing treatment. Following SAG guidelines, pregnant women eligible for
treatment are offered HAART. In order to fast-track women onto treatment, PHRU is training and mentoring
doctors and nurses. The program is being expanded to other ART sites in the area through FY 2008 funds.
HIVSA provides treatment literacy and adherence support.
ACTIVITY 3: Children, Soweto
The PHRU identifies HIV-infected children who need treatment through PMTCT and children of adults who
are already on treatment. As part of a comprehensive family-centered approach, these children are put onto
treatment following SAG treatment guidelines with ARVs purchased by PHRU according to USG and SAG
guidelines. Staff is trained on an ongoing basis in pediatric ART.
ACTIVITY 4: Rural Mpumalanga and Limpopo
At Tintswalo Hospital, Limpopo, in partnership with Rural AIDS Development Action Research Program
(RADAR), adults and children are identified as needing treatment in the palliative care and PMTCT
programs. RADAR supports the ART site at this hospital, as well as Mapulaneng hospital, and is assisting
other sites for ART accreditation. Human capacity building is fundamental to sustainability of the program
and PHRU provides staff, training and mentoring existing treatment staff. HIVSA offers district-wide support
in the primary care clinics that includes treatment literacy, adherence counseling and group support for
these clients.
ACTIVITY 5: Tzaneen, Limpopo
PHRU in partnership with the University of Limpopo is supporting the Limpopo Department of Health
wellness program operating in the district's primary healthcare clinics. Currently clients are referred to the
ART sites including Letaba hospital and CN Phatudi hospital. Through Choice, a local NGO, clients are
provided with a treatment readiness program, referred to rollout sites when they become eligible for
treatment and given adherence support. Due to vast distances to the hospitals, clients on ART are
supported in local primary care clinics.
ACTIVITY 6: Franchise, Gauteng
This program targets uninsured workers in densely populated areas in Johannesburg. ARVs are made
available and affordable through a franchising scheme, and supplied free of charge or at significantly
discounted rates to patients unable to purchase their own medication. ARV drugs are procured and supplied
within the service by trained providers. This program provides a stand-alone ART full service clinic in
Johannesburg and provides lessons learned about demand for ART outside the public sector, willingness
and ability to pay for services, and the cost-effectiveness of this model of delivery.
ACTIVITY 7: Western Cape
Activity Narrative: A number of partners and SAG ART sites have been identified in the Western Cape that need support to
scale up their activities. These include the Desmond Tutu HIV/AIDS Foundation, the University of Cape
Town and Stellenbosch University. These partners are supporting SAG ART sites and provide training,
mentoring and support. Many ART sites in tertiary hospitals are reaching capacity and the PHRU is
establishing innovative down referral mechanisms.
In FY 2008, all activities will expand. Additional partners are likely to be identified in order to increase
access to treatment. A specific emphasis will be placed on pediatric treatment. In addition, tracing and
tracking programs will be implemented to ensure retention in care. Renovations will be made as necessary
per facility. Training for all categories of health workers and task shifting strategies will be implemented in
FY 2008. Task shifting focuses on the effective utilization of existing staffing skills.
These activities will contribute substantially to the PEPFAR 2-7-10 goal of providing ARV treatment to two
million people by supporting SAG treatment sites.
Continuing Activity: 14268
14268 3101.08 U.S. Agency for Wits Health 6758 1066.08 PHRU $11,185,000
7597 3101.07 U.S. Agency for Perinatal HIV 4482 1066.07 PHRU $7,900,000
3101 3101.06 U.S. Agency for Wits Health 2710 1066.06 PMTCT and $3,407,000
* Reducing violence and coercion
Estimated amount of funding that is planned for Human Capacity Development $4,600,000
Table 3.3.09:
FY 2008 COP activities will be expanded to include:
-Establish and staff a Perinatal HIV Research Unit (PHRU) adolescent clinic; and
-Scale up treatment for HIV-infected and HIV-exposed children.
The PHRU will use PEPFAR funds to continue to provide quality holistic care for HIV-infected and HIV-
exposed children (0 - 14 years) comprising elements in the preventive care package, medical care and
psychosocial support categories in Gauteng, rural Limpopo, rural Mpumalanga and Western Cape
provinces. Children are identified through the prevention of mother to child transmission (PMTCT) and
counseling and testing (CT) programs. Early infant diagnosis at 4-6 weeks. Children are monitored,
prepared and referred for antiretroviral (ARV) treatment. Linkages to CT, the PMTCT and referral to ARV
services will be strengthened. A family-centered approach targets HIV-infected adults, children and infants.
Since 2002, PHRU has established and supported palliative care programs in Gauteng, rural Limpopo and
Mpumalanga, and the Western Cape provinces for children identified as HIV-infected through PMTCT and
CT (also funded by PEPFAR). Very young infants are referred to specialized services care. Primary health
care nurses are the main providers of care under physician supervision. The Department of Health (DOH)
guidelines for HIV care and laboratory testing are used to ensure compatibility with South African
through end of life care. A holistic family centered approach is taken comprising elements of the preventive
care package for adults and children, clinical services, psychosocial support, healthy lifestyle promotion and
preparation and transition of clients onto ARV treatment when required. These programs are predominately
accessed by women; however PHRU is attempting to redress this imbalance. Men are encouraged to
participate through CT programs which specifically target men. Clients are encouraged to bring partners,
children and other family members. A focus of the program is to identify HIV-infected infants and children
and to provide family-centered care and support. Quality assurance, client retention, monitoring and
evaluation are integral parts of the program. The aim of the programs is to delay progression of HIV to AIDS
by providing palliative care and support to HIV-infected clients who do not yet qualify for ARV treatment.
Care includes: screening for active TB, preventative treatment for latent TB infection, cotrimoxazole
prophylaxis for opportunistic infections (OIs), syphilis screening, symptomatic screening for syndromic STIs,
screening for cervical cancer, provision of family planning and regular CD4 counts. Opportunistic illnesses
are treated using a formulary based on the South African Essential Drug List. Support for clients, their
families and community members is provided through support groups and education sessions at all sites
covering issues such as basic HIV and AIDS information, HIV services, PMTCT, ARV treatment,
opportunistic infections, TB, prevention, disclosure, prevention, nutrition, stigma, positive living and
adherence. At the end June 2008, with PEPFAR funding PHRU supports 4696 children (0-14) out of a total
of 27238 people in care, 17.8%. This exceeds the target set by PEPFAR and the National Strategic Plan
(NSP).
ACTIVITY 1: PHRU clinic Soweto, Gauteng
The Pediatric Wellness Program has been supported by funding through PEPFAR since 2002. Currently
1062 children (0-14) are enrolled in the program. Since 2004, a focus has been to identify children requiring
care, ARV treatment and psychosocial support through linkages to PMTCT and infant testing at 4-6 weeks
using PCR (as per SAG guidelines). Children receive care, growth monitoring and routine immunizations.
Support programs assist caregivers and children, in particular around issues of bereavement, disclosure,
dealing with stigma and discrimination, positive living and life skills.
ACTIVITY 2: Adolescents
This activity is cross-cutting since the primary focus is on prevention of adolescents getting infected with
HIV in the first place (see CT program area) but inevitably some adolescents will be identified as HIV-
infected through CT activities, and these adolescents will be referred to appropriate care and treatment
programs. Depending on the age of the adolescent, and the major activity at the site they are included
under Pediatric or Adult care, treatment and support.
Adolescents have special healthcare needs which they are often reluctant to address; some of these are
sexuality, pregnancy, drug and alcohol abuse, sexually transmitted infections (STI), gender and mental
health issues, coercion, violence, transgenerational sex and abuse. They are at high risk of contacting HIV
and other STIs. PHRU has established a specialized adolescent clinic PHRU to address these needs with
PEPFAR funding by offering comprehensive counseling and care services that are youth-friendly,
confidential and empowering to clients so that they are able to make informed and responsible healthcare
choices, including being empowered to abstain and delay sexual debut. Through CT, education and
counseling, PHRU increases awareness of HIV. The clinic in Soweto is based close to places to where
adolescents congregate. Pregnancy in adolescents is a concern and the program will ensure that these
young mothers receive a continuum of care during and after their pregnancy. Services comprise CT and
confidential and free care; information, education and counseling on sexual and reproductive health; health
information; counseling and appropriate referral for violence abuse and mental health issues; contraceptive
information and counseling on individual choices; STI information, including information on effective
prevention; and syndromic management of STIs. PEPFAR funds will be used to establish and staff this
project.
Activity Narrative: ACTIVITY 3: Support government facilities, Gauteng, Rural Mpumalanga/Limpopo, Western Cape.
In partnership with provincial Departments of Health the PHRU supports government facilities to scale up
treatment for HIV-infected and HIV-exposed children. The special needs of children are taken into account
and the package described above is implemented either by the PHRU or their sub-partners in the various
sites that PHRU supports.
PEPFAR funds support these programs to improve linkages to primary care clinics for down referral, and to
provide holistic care and support to people on ART and their families. Training, mentoring and support to
staff in these facilities is a focus area.
In all of the above activities, people living with HIV (PLHIV) will receive at least one clinical and one other
category of palliative care service. Palliative care to family members of PLHIV or orphans and vulnerable
children (OVC) will be provided in at least two of the five categories of palliative care services.
Estimated amount of funding that is planned for Human Capacity Development $250,000
Table 3.3.10:
The Perinatal HIV Research Unit (PHRU) has been involved in Pediatric Care since 1996. The PHRU
provides comprehensive care and support for children (0-14) living with HIV. PHRU will use PEPFAR funds
to provide high quality, holistic ARV treatment and psychosocial support in Soweto (Gauteng), rural
Limpopo and Mpumalanga, and the Western Cape. PHRU will also use PEPFAR funds to provide
personnel, infrastructure, training and ARV drugs for these services. Clients are provided with TB screening,
ARV treatment, pre-treatment literacy, adherence counseling and access to adherence support groups.
Immunization, growth monitoring, nutrition and assessments for other illnesses form part of the package.
Linkages from counseling and testing (CT), prevention of mother-to-child transmission (PMTCT), and
palliative care services will be strengthened. Linkages to child and maternal health, immunization and TB
services are supported to ensure holistic care and sustainability. A family-centered approach targets HIV-
infected adults and children. Men are actively encouraged to take part in their children's well-being and
treatment.
Since 1998 PHRU has provided comprehensive treatment, care and support to people living with HIV
(PLHIV). Since 2004, PEPFAR funding has supported ARV treatment and South African Government (SAG)
ARV treatment sites in Gauteng, rural Limpopo and Mpumalanga, and Western Cape provinces. PHRU
purchases ARV drugs and provides treatment for adults and children infected with HIV. PHRU's family-
centered approach encourages clients to bring partners and other family members for testing and treatment.
PHRU is expanding activities to scale up government ARV treatment sites and to investigate down referral
systems. With PEPFAR funds, PHRU will work with provincial health departments to ensure safe transfer of
participants to ongoing care within the SAG roll-out program. PHRU will support, train and mentor health-
care workers involved in the management, care and treatment of HIV-infected individuals. All programs
follow national guidelines for ARV treatment. PHRU provides regular training on HIV-treatment issues such
as adherence, medical treatment, and appropriate regimens. A non-governmental organization (NGO)
partner, HIVSA, provides all sites in Soweto and Mpumalanga with psychosocial support programs
providing community-based support, support groups and education. They cover issues such as basic HIV
and AIDS information, HIV services and treatment, treatment literacy, adherence, positive living, nutrition,
prevention, opportunistic infections and TB. The comprehensive care approach leads to stigma reduction,
increased disclosure, and improved adherence to ART. Throughout the comprehensive program, PHRU
has established a continuous set of assessment functions to improve the quality of care at ART service
sites.
All of the activities described in this section are on-going and will be expanded with FY 2009 funds.
ACTIVITY 1: Children, PHRU Clinic and Soweto
The PHRU identifies HIV-infected children who need treatment through PMTCT, CT, Pediatric Care and
Support services and children of adults who are already on treatment. PHRU has been actively involved in
expanding testing of infants using PCR at 4-6 weeks (see Pediatric Care and Support) and rapidly putting
young infants onto treatment. As part of a comprehensive family-entered approach, these children are put
onto treatment following SAG treatment guidelines with ARVs purchased by PHRU according to United
States Government (USG) and SAG guidelines. Men are actively encouraged to take part in their children's
well-being and treatment. PHRU and Department of Health (DOH) staff are trained on an ongoing basis in
pediatric ARV treatment. PHRU was instrumental in changing pediatric treatment policy through the NIH-
funded Comprehensive International Program of Research on AIDS (CIPRA) Children with HIV Early
Antiretroviral Therapy (CHER) study which showed that HIV-infected infants under one year should be
started on treatment as soon as they are identified as being HIV-infected. Refurbishing and renovation may
be required as the program expands.
HIV in the first place (see CT program area) but inevitably adolescents will test HIV-positive through CT
activities, and these adolescents will be referred to appropriate care and treatment programs. Depending on
the age of the adolescent, and the major activity at the site, they are included under Pediatric or Adult care,
treatment and support.
and other STIs. Through a specialized adolescent clinic PHRU will continue to address these needs with
confidential and empowering to clients so that they may make informed and responsible healthcare choices,
including being empowered to abstain and delay sexual debut. Through CT, education and on-going
counseling, PHRU increases adolescent's awareness of HIV. The clinic called Kganya Motsha (Shine
Young One) in Soweto is based close to places to where adolescents congregate. Services comprise CT
and confidential and free care; HIV care, support and treatment; TB screening and referral for TB treatment;
information, education and counseling on sexual and reproductive health; health information; counseling
and appropriate referral for violence abuse and mental health issues; contraceptive information and
counseling on individual choices; STI information, including information on effective prevention; and
syndromic management of STIs. In addition, the clinic staff go to schools and NGOs in the area providing
CT, education and training for adolescent HIV-prevention and care. PEPFAR funds will be used to continue
with this work.
ACTIVITY 3: Support government facilities in Gauteng, Rural Mpumalanga and Limpopo and Western
Activity Narrative: Cape.
sites that we are supporting. Refurbishing and renovation may be required as the program expands.
Supporting sites in less well resourced and rural areas forms part of PHRU's pediatric strategy.
provide holistic care and support to people on ART and their families. Children are identified in the National
Strategic Plan to be targeted for treatment. Training, mentoring and support to staff in these facilities are
focus areas.
ACTIVITY 4: Human Capacity Development for Task Shifting
The PHRU activities supports human capacity development (HCD). Most of the activities focus on building
the public health service to increase access and to improve HIV services in partnership with the relevant
DOH, and is integral in the planning of workshops, in-service training and mentoring, task shifting strategies,
retention and performance assessment.
South Africa has a deficit of skilled health and managerial personnel. This has necessarily meant that lower
level staff takes on tasks that were originally done by higher level staff. An example is that many lay
counselors now are expected to take clients vitals, and take care of all their counseling needs. Task-shifting
is therefore an essential component to scaling up HIV-services. The PHRU assists in the training and
mentoring of this process. PHRU has trained pharmacy assistants to dispense ARV drugs under the
supervision of a pharmacist which has increased the capacity of clinic pharmacies to provide treatment
services in the primary care clinics.
Lay counselors form the backbone of HIV services in South Africa. These counselors generally have a high
school certificate and have undergone a lay counseling course. As the need for HIV services increases so
does the reliance on these health care workers. Increasingly they are expected to take on more
responsibilities in the clinics. Many of these counselors work on a voluntary basis receiving only a stipend.
Until now there has been no career path for these counselors, with the result that many leave the profession
once they find a higher paying job. PHRU together with its sub-partner HIVSA has developed a training
course such that these counselors can now become accredited at different levels. This is a big step forward
as HIV-services become increasingly dependent on this level of staff.
Estimated amount of funding that is planned for Human Capacity Development $2,000,000
Table 3.3.11:
Perinatal HIV Research Unit (PHRU) integrated TB/HIV issues into all PEPFAR-funded program areas.
With the emergence of multi- and extensively drug-resistant (MDR/XDR-TB) health-care workers and HIV-
infected people are at increased risk of contracting these resistant strains. PHRU will intensify TB/HIV
training for health workers, particularly focusing on the prevention, detection, and management of MDR-
and XDR-TB, and will ensure that workplaces implement and adhere to TB infection control procedures.
Active case finding is being done in a number of facilities.
PHRU will work with the Department of Health (DOH) to encourage HIV counseling and testing of TB-
infected clients in accordance with guidelines. PHRU will continue to support TB facilities to test for and
treat HIV infection at TB treatment sites such as Charles Hurwitz in Soweto and Brooklyn Chest.
TB screening will be expanded in all PHRU programs, including adult and pediatric, with emphasis on
isoniazid preventive therapy for TB-negative HIV-infected clients and appropriate referral for TB-infected
clients. Clients diagnosed with active TB will be encouraged to bring in family members and close contacts
to screen for TB infection. PHRU will emphasize TB screening for pregnant women and pediatric clients.
TB-positive clients will be tracked to ensure that they start TB-treatment and will be followed to completion.
PHRU follows international and national research on best practices, and diligently implements new
developments into policy. PHRU includes these best practices in all training and workshops.
----------------------------------
and support for PLHIV. PHRU will use PEPFAR funds to continue its TB services to patients accessing care
in Soweto (Gauteng), rural Limpopo/Mpumalanga Provinces and in the Western Cape. The TB/HIV program
is integrated into all programs by providing screening, referring people with active TB to National TB
treatment sites and providing preventative treatment for latent TB. The program is also linked to National TB
treatment sites providing HIV care and treatment. The major emphasis areas are human capacity
development and local organization capacity building. The primary target populations are HIV-infected
adults and children.
PHRU established palliative care programs in Soweto (Gauteng) and in rural Limpopo and Mpumalanga
and have partnered with organizations in the Western Cape to provide care and support to people identified
as HIV-infected through PMTCT and CT. High rates of TB in South Africa continue to be challenging and
MDR-TB is considered to be on the rise. The PHRU will strengthen its emphasis on diagnosis of TB via its
PMTCT program (through screening during CT when possible), and through screening of all patients testing
positive. Once tested positive, all patients enter a wellness program where they will be screened and
treated according to WHO protocols for TB. In South Africa, a wellness program covers the period from
testing positive to needing treatment. The high HIV prevalence in South Africa requires a cost-effective
package of care and support for people with HIV prior to ARV treatment. Primary health care nurses are the
main providers of care under physician supervision in these programs. The programs follow the Department
of Health guidelines for HIV care and laboratory testing to ensure compatibility with South African
Government treatment sites. The programs have been approved by the medical ethical review board of the
University of the Witwatersrand. The aim of the programs is to delay the progression of HIV to AIDS by
providing palliative care and support to HIV-infected clients who do not yet qualify for ARV treatment. Care
includes: elements of the preventive care package, screening for active TB, preventative treatment for latent
TB infection, cotrimoxazole prophylaxis for opportunistic infections, syphilis screening, symptomatic
screening for syndromic STIs, screening for cervical cancer, provision of family planning and regular CD4
counts. Opportunistic illnesses are treated using a formulary based on the South African Essential Drug
List. Support for clients, their families and community members is provided by support groups and
education sessions at all sites covering issues such as basic HIV and AIDS information, HIV services,
PMTCT, ARV treatment, opportunistic infections, TB, prevention, disclosure, nutrition, stigma positive living
and adherence. Training of professional and lay staff takes place on a regular basis.
PHRU will continue to work with the national and provincial departments of health and specifically with the
HAST (HIV, AIDS STI, and TB) managers to prioritize interventions designed to address weaknesses
(identified by the departments of health) in the DOTS and TB/HIV programs. PHRU will focus on improving
policy adherence and patient follow-up. Individuals will be hired for each site as tracers to track patients and
ensure that referrals are completed. PHRU is setting aside funding to develop (with other relevant partners
or agreement counterparts) standardized tools to ensure that policies and guidelines recommended by
NDOH are followed, including guidelines for infection control. PHRU will continue to integrate TB/HIV
interventions with existing agreement programs as they work seamlessly and side by side with government
employees at government facilities.
In 2002 a care program was initiated in Soweto, a large urban area south-west of Johannesburg with very
high HIV prevalence (30% in the ante-natal clinics). A holistic approach is provided to all enrolled in the
wellness program and covers clinical services, psychosocial support, and healthy lifestyle promotion,
including exercise, nutrition, and decreasing the use of alcohol and tobacco. To date over 4,500 adults have
accessed the program with PEPFAR support. Support groups and education sessions, run by HIVSA, are
Activity Narrative: available to all clients. All clients are symptom screened for TB at each visit and are referred for TB
treatment to the government TB treatment clinics. PHRU is supporting the Charles Hurwitz Hospital, a
government TB treatment facility, to integrate TB and HIV care and treatment. Expanding the program with
FY 2008 funds, PHRU proposes to link TB screening into PMTCT service in Soweto and screen all
pregnant women for active TB and refer those with positive results to government TB treatment sites. PHRU
will work with public facilities to ensure that care for both TB and HIV is monitored and coordinated. Training
for health care professionals working at PHRU and its partners (including the provincial Department of
Health) in all aspects of HIV palliative care takes place on an ongoing basis.
Bushbuckridge district in Mpumalanga/Limpopo is one of the poorest in South Africa. Access to information
and HIV healthcare and support is a basic need for all people living with HIV. PHRU in partnership with
Rural AIDS Development Action Research Program (RADAR) and HIVSA established a wellness clinic at
Tintswalo hospital and a district-wide support network for people living with HIV and AIDS. Since 2003, over
2,000 people have accessed the wellness clinic and more than 2,500 have accessed the support groups. A
training program has been implemented to train nurses and lay facilitators, counselors and NGOs to provide
effective support to people living with HIV and AIDS and basic education on HIV, TB, CT, HIV services and
related issues to the broader community and build the capacity of linked local organizations. All clients are
screened for active TB at each visit.
Since 2003, the University of Limpopo has been supporting the Department of Health to develop a wellness
program based in primary healthcare clinics in Tzaneen District. In 2004 PHRU partnered with University of
Limpopo to formalize and expand the program. PHRU has mentored the program, assisted with training
health workers and has provided infrastructural support. In addition, HIVSA has provided training to support
group members to enable them to run more effective support groups, and provide better information to
people in the district. The program takes a district health approach and aims to operate throughout the
district. Over 600 people have enrolled in the program and more than 100 have been referred to ART sites
for ARV treatment. People on treatment are supported at primary care clinics through this program. The
program will be expanded to other sub-districts in the Tzaneen area. All clients attending Wellness services
will be screened for active TB at each visit. US-based volunteers have supported this program.
In 2006 PHRU partnered with a number of organizations in the Western Cape including the University of
Stellenbosch, Red Cross Children's Hospital and the Desmond Tutu HIV/AIDS Foundation. The aim is to
support government ART sites to scale-up and develop down referral systems. PHRU will continue to
screen HIV-infected clients for TB and those who are found to be co-infected will be referred to public sites
for treatment. Expansion of these activities is planned. These activities will contribute to the PEPFAR 2-7-10
goals by providing TB/HIV care and services to HIV-affected people.
Continuing Activity: 14265
14265 3099.08 U.S. Agency for Wits Health 6758 1066.08 PHRU $873,000
7595 3099.07 U.S. Agency for Perinatal HIV 4482 1066.07 PHRU $550,000
3099 3099.06 U.S. Agency for Wits Health 2710 1066.06 PMTCT and $150,000
Table 3.3.12:
IMBIZO: The IMBIZO men's health project will become more integrated with mainstream counseling and
testing (CT) services. Rather than providing a separate and distinct service for men, the project team will
visit CT centres and train staff to provide better services to men. In addition, the team will do outreach
activities at places where men congregate such as shebeens, sports venues and hostels to encourage men
to test, and provide follow-up counseling and services for men.
In all programs, the Perinatal HIV Research Unit (PHRU) will implement a system by which counseling will
link in with prevention for clients who test HIV-negative and with relevant HIV-services for those that test
HIV-infected. A CD4 count test is therefore the next step in the chain and PHRU will ensure that people are
tested and that they receive CD4 count results. PHRU will investigate rapid CD4 count technologies to
determine if this improves retention in care. All clients testing HIV-negative are encouraged to come back
for a further test in six weeks to three months because of the window period which is explained to them, and
then to return every six months to a year for retesting.
Counseling men includes addressing male norms and behaviours such as family responsibility, responsible
sexual behaviour, safe disclosure and domestic violence. The focus on men increases gender equity in the
South African context where more women than men access HIV-services.
PHRU will expand its CT services at the PHRU clinic such that clients will be offered a range of services to
encourage clients to return on a regular basis. These will include tuberculosis (TB) and sexually transmitted
infection (STI) screening, CD4 counts, counseling, treatment readiness and family planning advice. Clients
suspected of having TB after screening will referred to TB treatment sites and followed-up to see if they get
treatment. Clients will be linked with other services such as family planning services as the need arises.
PHRU will provide training around issues such as counseling couples, men and adolescents. As described
under human capacity development, PHRU in collaboration with HIVSA has developed an accredited
training program for counselors. These counselors will now have a career path and will be able to specialise
in some of these aspects of counseling.
All people who are doing rapid HIV-testing will undergo an annual proficiency test and a random sample of
blood taken for rapid testing will be sent for an Enzyme-Linked Immunoadsorbent Assay (ELISA) test to
confirm accuracy of results given in the field.
-------------------------
and support for people living with HIV (PLHIV). PHRU will use PEPFAR funds to promote voluntary
counseling and testing (CT) through HIV prevention workshops and health promotion activities, and to
pregnant women at PMTCT to increase uptake of CT for HIV. In particular, services will be promoted to men
in an effort to increase gender equality in HIV and AIDS programs and make them available to adolescents
as part of a prevention program. The major emphasis area is human resources; minor areas include local
organization capacity development, community mobilization/participation, and information, education, and
communication. The target populations are the general population with a focus on men and adolescents.
This CT program is an ongoing activity operated in partnership with a local non-governmental organization,
HIVSA, and other CT organizations in Soweto (Gauteng). The program will be expanded to rural Limpopo
and Mpumalanga. Women have mainly accessed HIV services in Soweto and this project aims to improve
gender equity in these services. In June 2005, the IMBIZO project, which broadens access to HIV and AIDS
information, was established. This project was designed to enhance male involvement in counseling and
testing and other health services. IMBIZO drop-in centers operate five days a week and are located close to
areas where men congregate and are easily accessible. The concept of the IMBIZO program is one
designed by men for men and evolved from research that indicated that men preferred to be counseled by
men at locations away from the primary healthcare clinics. Within the project, marginalized communities
such as men who have sex with men are encouraged to access CT. A focus of this program is to reduce
stigma associated with HIV, to encourage disclosure, to support partners and family members with HIV and
to promote active engagement with HIV services. A program promoting IMBIZO to partners of pregnant
women is being run in the antenatal clinics, with the aim of increasing male involvement in PMTCT and
fatherhood. Reduction of violence and coercion, also main components of IMBIZO, is a major focus of the
program. Outreach activities take place in prisons, workplaces, hostels, sports matches and other places
where men congregate. PHRU offers a couple counseling service called "Tshwarisanang" through external
foundation funding and all other PHRU CT services can refer to them.
ACTIVITY 1: IMBIZO - Men's Health Centers
Male IMBIZO centers are funded by PEPFAR. The project receives approximately 300 drop-in clients and
performs approximately 140 CT each month. A male registered nurse manages the program. Clients are
referred to local clinics for HIV services and treatment. Stigma decreases men's uptake of CT services and
innovative strategies to increase men using CT are being developed. At-risk male populations such as men
who have sex with men, migrants, and prisoners are focus populations. This program will expand to rural
Mpumalanga provinces. Information on TB, PMTCT, HIV services, prevention, nutrition, etc., is available.
Clients are counseled on prevention and condoms are distributed. Support is given to clients to encourage
disclosure, to decrease stigma, to mitigate domestic violence, and to provide support to partners. To
Activity Narrative: increase male support of PMTCT programs, pamphlets have been designed for male partners of pregnant
women that explain PMTCT, encourage active involvement in fatherhood, and encourage men to access
the IMBIZO centers and to go for CT. Outreach activities take place regularly with community organizations,
workplace programs, and health services. Mobile CT is used to take CT to communities that do not have
easy access to healthcare services. A focus of this program is to reduce stigma, increase male involvement
in all services relating to HIV thus increasing gender equity. U.S.-volunteers will support the rural program.
and other STIs. Through a proposed specialized adolescent clinic PHRU will address these needs with FY
2007 PEPFAR funding by offering comprehensive counseling and care services that are youth-friendly,
including being empowered to abstain and delay sexual debut. Through CT, education and counseling,
PHRU will increase awareness of HIV. The clinic in Soweto will be based close to places to where
adolescents congregate. Services will comprise CT and confidential and free care; information, education
and counseling on sexual and reproductive health; health information; counseling and appropriate referral
for violence abuse and mental health issues; contraceptive information and counseling on individual
choices; STI information, including information on effective prevention; and syndromic management of STIs.
PEPFAR funds will be used to establish and staff this project.
ACTIVITY 3: CT Plus
In the Western Cape a mobile CT program providing counseling and testing, point of care CD4 counts, TB
screening and referral into care and ART services programs will be supported. The Western Cape has very
high TB prevalence. This program will provide CT to underserved populations.
ACTIVITY 4: Couple Counseling
PEPFAR funds will be used to expand an existing couple counseling program operating at the PHRU in
Soweto. Specialized counseling for couples has proven to be effective for preventing further infection
particularly in discordant couples. In many programs lay counselors do not have sufficient expertise to
counsel couples and therefore a referral service is essential.
ACTIVITY 5: Farm Workers
A CT activity linked to care and ART for farm workers in the Westcoast winelands region of the Western
Cape will be expanded to other districts in the region. The male CT program will expand to target all men
including men who have sex with men and other vulnerable male groups in Soweto (Gauteng) and
Bushbuckridge (Mpumalanga).
These activities will contribute to the PEPFAR 2-7-10 goals by increasing access to and improving quality of
CT services, particularly to hard-to-reach populations of men and adolescents in urban and rural districts in
Continuing Activity: 14266
14266 3100.08 U.S. Agency for Wits Health 6758 1066.08 PHRU $773,000
7596 3100.07 U.S. Agency for Perinatal HIV 4482 1066.07 PHRU $400,000
3100 3100.06 U.S. Agency for Wits Health 2710 1066.06 PMTCT and $200,000
Estimated amount of funding that is planned for Human Capacity Development $70,000
Table 3.3.14:
The Perinatal HIV Research Unit (PHRU) will continue with the activities below, but will increase support to
South African government clinics to ensure expanded access to antiretroviral (ARV) treatment. This will be
done through the training of staff, task shifting, implementing pharmacy management systems and assisting
sites to be accredited to dispense ARV drugs. In addition, the importance of client retention and adherence
will be reinforced in all the work. The PHRU will use the pharmacy staff to alert outreach staff when clients
have missed a visit. PHRU will step up training to pharmacy staff to ensure that quality services are
available for everyone including children, adolescents, men and women.
PHRU has assisted many sites to be accredited in Gauteng and rural Mpumalanga and Limpopo provinces
and to be in a position to dispense ARV drugs. This has been achieved through the seconding of staff to the
clinics in a cost efficient way. PHRU has trained pharmacy assistants to dispense ARV drugs, be able to
provide adherence counseling and through drug management systems to manage the pharmacy under the
supervision of a pharmacist who may not be on site. In addition, the PHRU has put in robust pharmacy
management systems to allow the pharmacy assistant to manage the pharmacy. This has increased the
number of sites that are able to be accredited for ARV services and thereby improving equity and the
number of people on ARV treatment. This has been particularly important in the rural districts in which they
work.
Innovative ways will be sought such as the Zuzimpilo (Franchise) clinic and novel down referral systems to
expand access to quality ARV treatment.
----------------------------------------------
The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high-quality care
and support for people living with HIV (PLHIV). The PHRU will use FY 2008 funds to continue to provide
high-quality holistic antiretroviral treatment (ART) and psychosocial support in Gauteng, rural Limpopo and
Mpumalanga, and Western Cape. These funds will contribute towards antiretroviral (ARV) drugs and
services. Clients are provided with ART, pre-treatment literacy, adherence counseling and adherence
support groups. Linkages from CT, PMTCT, basic care and support will be strengthened. The emphasis
areas are human capacity development and local organization capacity building. The family-centered
approach targets HIV-infected adults, children and infants.
Since 1998 the PHRU has provided comprehensive treatment, care and support to people living with HIV
(PLHIV). The PHRU has received funding from PEPFAR since 2004 to support ART services in Gauteng,
rural Limpopo and Mpumalanga, and Western Cape provinces. PHRU directly purchases ARVs with
PEPFAR funds and has demonstrated the ability to rapidly scale up treatment. PHRU has adopted a family-
centered approach and clients are encouraged to bring partners and other family members for testing and
treatment. Of patients supported by the PHRU, about one-third is supported through PEPFAR-funded ARV
drugs. PHRU is expanding activities to directly support scale-up at government ART sites and support down
referral systems. PHRU works with the provincial health departments to ensure safe transfer for the
participants to ongoing care within the South African Government (SAG) rollout program to ensure
sustainability. PHRU works only in government facilities, where government takes the lead in all aspects of
the program. The PHRU together with government counterparts identify gaps that will slow down
implementation according to national and provincial guidelines. Upon request from the facility, PHRU
provides support through a Memorandum of Understanding to fill the gaps and work towards the provincial
financing of related activities. PHRU supports, trains and mentors healthcare workers involved in the
management, care and treatment of HIV-infected individuals. All programs follow national guidelines for
ARV treatment. Training is adequately and broadly proclaimed by provincial government through training
programs that are approved by the province and adhere to all guidelines and standards of the national
government. Quality assurance, client retention, monitoring and evaluation form an integral part of the
program. PHRU provides regular training for professional and lay staff on ART issues such as adherence,
medical treatment, and appropriate regimens.
All sites have psychosocial support programs which provide community-based assistance, support groups
and education covering issues such as basic HIV and AIDS information, HIV services, HIV treatment,
treatment literacy, adherence, TB, positive living, nutrition, prevention, opportunistic infections and TB. The
comprehensive care approach leads to stigma reduction, increased disclosure, and improved adherence to
ART.
Funding from PEPFAR supports adults on treatment in the family-centered PMTCT program. The adult
treatment program is ongoing and drugs are purchased for patients at the PHRU clinic based at Chris Hani
Baragwanath Hospital (Bara). The program provides treatment, monitoring and support for adults who meet
the SAG guidelines for treatment. HIVSA, an NGO partner, provides treatment literacy and adherence
support. This activity will be continued and expanded with FY 2008 funds.
This program was started in the maternity section at Bara in July 2005 by PHRU in partnership with the
Department of Obstetrics and Gynecology. In Soweto 8,000 pregnant women annually are identified as
positive with an estimated 1,600 needing treatment. Following SAG guidelines, pregnant women who are
eligible for treatment are offered HAART. In order to fast-track women onto treatment, PHRU is training and
Activity Narrative: mentoring the doctors and nurses. The program is being expanded to other ART sites in the area with FY
2008 funds. HIVSA, an NGO partner, will continue to provide treatment literacy and adherence support.
The PHRU clinic identifies HIV-infected children who need treatment through PMTCT and children of adults
who are already on treatment. This activity will continue and will be strengthened through additional
counselors with FY 2008 funds. As part of a comprehensive family-centered approach, children are put onto
guidelines. ARV drugs for children are supplied through the PHRU pharmacy system. Staff is trained on an
ongoing basis in pediatric ARV provision.
ACTIVITY 4: Franchise, Gauteng
available and affordable through a franchising scheme, and supplied free of charge or at a significantly
discounted rate to patients unable to purchase their own medication. Those who can afford to pay for all or
a portion of their drugs are expected to do so. ARV drugs are procured and supplied within the service by
trained providers. This program provides a stand-alone ART full service clinic in downtown Johannesburg
and provides lessons learned about demand for ART outside the public sector, willingness and ability to pay
for services, and the cost-effectiveness of this model of delivery.
ACTIVITY 5: Sub-partners
A number of partners in the Western Cape have been identified and are supported to provide ARV
treatment. Most of these partners receive ARV drugs from the Department of Health and PEPFAR funds are
provided to support the services to expand and develop down referral systems. Pediatric treatment is a
priority. It is likely that additional partners will be identified to enable increased access to treatment.
Continuing Activity: 14267
14267 3331.08 U.S. Agency for Wits Health 6758 1066.08 PHRU $6,305,000
7600 3331.07 U.S. Agency for Perinatal HIV 4482 1066.07 PHRU $3,400,000
3331 3331.06 U.S. Agency for Wits Health 2710 1066.06 PMTCT and $958,000
Estimated amount of funding that is planned for Human Capacity Development $500,000
Table 3.3.15:
