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
SUMMARY:
The success of Right to Care's (RTC) delivery of the antiretroviral treatment (ART) program activities and
particularly with down referral has led the Department of Health to request support for implementation of
prevention of mother-to-child transmission (PMTCT) activities at all RTC-supported sites. These sites
include government, non-governmental and private sector ART programs that operate in partnership with
primary care providers and workplace programs. RTC will use FY 2009 funds to accelerate the
implementation of the South African government's national Comprehensive Care Management and
Treatment (CCMT) program at government sites in partnership with the provincial Departments of Health
(DOH). This includes the scale up of prevention and PMTCT services at 16 sites in 5 provinces, namely
Gauteng, Mpumalanga, Northern Cape, Limpopo and Free State. PMTCT activity at these sites will be
integrated into existing prevention education, counseling and testing, and ART activities. Emphasis will be
placed on child survival, increasing gender equity, family planning and TB screening. Target populations
will include women, infants, family planning clients, and people living with HIV.
BACKGROUND:
RTC has not been funded for PMTCT programs prior to FY 2008. It subsequently applied for funding
because the organization upholds the importance that successful ART programs be integrated with
prevention, and especially PMTCT programs. A recent change in the National Department of Health
PMTCT guidelines, including the guidelines on dual therapy, has necessitated additional support to sites at
which these guidelines must be implemented.
RTC will focus on expanding PMTCT services using family-centered models developed in FY 2008 at all
supported sites. Since this is a new area of focus for RTC, a lot of training and implementation advice will
be sought from other PEPFAR partners who are already providing this service (e.g., Perinatal HIV Research
Unit, Mothers to Mothers and South to South). The major areas of focus as requested by the provincial HIV
& AIDS and STI and TB directorates are human resources and training.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: PMTCT Coordinator and National PMTCT Guidelines
RTC is appointing a PMTCT Coordinator in COP 2008 to support a family-centered model of PMTCT
according to the national guidelines. The Coordinator would provide technical assistance, coordinating
infrastructure support in the form of renovations to buildings (may be necessary for the pharmacies to store
AZT), training and quality assurance. This post will be filled by an experienced senior registered nurse, with
expertise and experience to conduct site evaluations and to identify training and technical support needs for
PMTCT. During FY 2008 and extending into FY 2009, the Coordinator will be responsible for the
implementation of national PMTCT guidelines and policy-specific training program for PMTCT. Currently a
one-day training program aimed at the development and enhancement of effective and successful
implementation of the current South African national PMTCT policy and guidelines is being conducted and
will be expanded in FY 2008 and FY 2009. RTC will establish a provincial team in each province to conduct
site assessment, monitoring evaluation and continuous quality assurance, particularly as the program
grows. Technical assistance will be provided to sites to address any limitations that hamper scale up of the
program. In some sites, the lack of qualified personnel may be addressed through the hiring and
secondment of personnel, particularly for rural underserved sites and populations.
ACTIVITY 2: Quality Assessment
The aim of the PMTCT program in FY 2009 is to consolidate the work done in FY 2008. The PMTCT
Coordinator will continue to implement the PMTCT training program; this will be done together with training
coordinators for the districts as well as in partnership with the regional training centers. Continuous quality
assurance is a priority in order to assess the standards of PMTCT at each RTC-supported site and to
provide continuous quality improvements where necessary. Program quality assurance will focus on the
provision of dual therapy, supply chain management, implementation of the guidelines, quality of
counseling, proportion of pregnant women taking up PMTCT (target >80%) and incidence of new pediatric
infection (reduced to <5%). Additional staff may be deployed to provide expert on-site training and
mentoring. Community education, mobilization and improved access to health-care will be supported.
Community organizations may be supported to provide lay counseling, in an adapted model, similar to
Mothers to Mothers.
ACTIVITY 3: PMTCT Program
Essential activities using FY 2009 funds to scale up of the PMTCT program at all levels of care, especially
primary health care, include:
a. Integration of the PMTCT program with on-site provider-initiated HIV testing and counseling, aimed at
providing all pregnant women with HIV testing at their first antenatal care (ANC) appointment. As RTC only
operates in high prevalence sites (15-33% ANC HIV prevalence) in the public sector, repeat testing will be
provided in the third trimester and at the time of delivery. Women presenting in labor who have not been
tested during the ANC period will be tested at time of labor and will receive single dose nevirapine and post-
partum AZT. All women will be encouraged to know her status prior to delivery but she will have the right to
refuse the test. Women attending ANC will be encouraged to come with their partners and couple
counseling will be available. Postpartum voluntary counseling and testing will also be available in the post
delivery wards.
b. All counseling and testing activities will be linked to prevention in the context of pregnancy through
ongoing risk reduction sexual behavior education, the provision of condoms and referral to family planning
clinics. Partners of pregnant women will be invited to test. There will also be a strong focus on tracking and
tracing for transition to care to minimize missed opportunities for prophylaxis and treatment.
c. Early and fast track referral of all pregnant women either for PMTCT with dual therapy or if the CD4 <200
Activity Narrative: for the initiation of highly active antiretroviral therapy (HAART), in accordance with the national guidelines
will be provided. As the program grows, HAART initiations may be conducted as part of the ANC service.
d. Patients will be screening for TB, with health-care workers using with symptom questionnaires. This may
result in increased case detection, and the provision of prophylaxis for opportunistic infections and TB to
HIV-infected pregnant women. Women will be linked to nutritional support services that will improve
maternal health.
e. Infant diagnosis using polymerase chain reaction testing will be used to ensure early ART of infants born
HIV positive. RTC will encourage exclusive breast-feeding for infants who are confirmed HIV positive, and
will continue to provide prophylaxis for infants found to be HIV positive. A major focus of the 2009 COP will
on the support of sustained infant feeding choices.
f. Linkages to family planning programs will be established at each of the sites.
g. Through the support of RTC an overall strengthening of the Maternal and Child Health services is
anticipated, this will encourage women to bring children from previous pregnancies for testing. These
services will also provide advice on safe disclosures, which help to reduce gender-based violence.
h. Community Engagement in PMTCT will be promoted.
i. RTC's PMTCT program will address maternal nutritional support, to reduce the maternal death rate during
breast-feeding by approximately 10%, and the provision of information to enable informed choice support
for either exclusive breast-feeding or infant formula feeding. Emphasis will be placed on lactating women
and those with a BMI <16.5.
j. RTC will establish the required monitoring and evaluation (M&E) and quality assurance program to enable
reporting of PEPFAR and South African Department of Health targets, as well as to provide continuous
assessment and technical assistance to sites. The M&E system will be implemented in FY 2009.
RTC is responsible for supporting more than 20 government treatment district and referral hospitals sites in
three provinces. Initially, PMTCT activities will be supported at 8 of these sites in FY 2008 and this number
will increase to 16 in FY 2009. At each of these 16 sites, targets will be set at 80% uptake of counseling and
testing, and for HIV-infected women, an 80% uptake of PMTCT to reduce the infant infection rate to less
than 5%. Improved maternal and child health service quality and better integration of PMTCT into existing
HIV services will be an outcome of FY 2009 RTC activities.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Construction/Renovation
Gender
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Safe Motherhood
* TB
Workplace Programs
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $250,970
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $130,624
and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $50,234
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
Following the National Strategic Plan (NSP), Right to Care (RTC) will use FY 2009 funds to accelerate the
scale up of family-centered approaches to adult and pediatric treatment, care and support. The specific aim
is to increase the access to care support to 80% of individuals infected with HIV, in accordance with the
NSP and the technical considerations for the FY 2009 COP. Focus for the adult care and support program
will be to scale up TB and antiretroviral (ARV) activity at all Department of Health, Comprehensive HIV and
AIDS Care, Management and Treatment (CCMT) sites, supported by RTC. At the request of the provincial
DOH and implemented according to the memorandums of understanding (MOUs) with each province, RTC
will continue to support the activity and budget for family centered treatment, care and support.
RTC provides mentorship and technical assistance to over 18 sub-recipients. These are ongoing programs
expanded with NDOH coordination and private sector support. By providing training and support to these
sites, RTC leverages NDOH resources to reach an increasing number of patients. RTC supports these sites
with infrastructure, staff, training, equipment and data management. In addition, the NDOH has recognized
the successes of RTC supported NGO/FBO sites and has been accrediting these sites and taking over the
provision of ARV drugs, laboratory monitoring and some staff salaries, thus enabling RTC to shift funds to
other sites in need of support.
ACTIVITIES AND EXPECTED RESULTS
FY 2009 funds will be used for human capacity development and salaries at all care and support (C&S)
providers; (1) non-governmental (NGO) and faith-based (FBO) clinics/organizations receive sub-awards
earmarked for doctors, nurses, counselors and other healthcare workers; (2) RTC will provide support to
South African Government (SAG) staff through the salaries of health care providers seconded to DOH
facilities; and (3) a capitation fee-for-service arrangement exists with a network of private sector service
providers for the Thusong program with wellness support to indigent HIV-infected individuals.
ONGOING ACTIVITIES
PEPFAR funds will also be used to maintain RTC's mobile clinics. NGO and FBO clinics also use PEPFAR
funds for laboratory monitoring of HIV patients and for the procurement of health commodities such as
medical equipment, ARVs, drugs for opportunistic infections, counseling and testing kits, and home-based
care kits. RTC supports all the C&S providers by disseminating policies and guidelines and providing quality
assurance through sharing best practices. With FY 2009 funding RTC will provide ongoing training and
continued medical education to assure that staff is aware of the latest treatment norms.
Public-private partnerships (PPPs) have also been formed. These include those with the provincial DOH,
where value is seen by the government in accrediting specific NGO clinics in order to provide ARVs and
pathology monitoring thereby reducing the overall cost on one donor. RTC will continue to work hand in
hand with the SAG to ensure sustainability of the service delivery though a human resource development
plan where value has also been seen when the government takes over certain positions initially paid for by
PEPFAR.
Down referral of stable patients from hospitals to community health centers and local clinics will be
strengthened further with FY 2009 funding, which will ensure that people receive comprehensive care closer
to their homes and thus improve patient retention. The major areas of focus for the down referral process
are human resources, training, infrastructure, data management and support with drug distribution even
though the drugs are not funded by PEPFAR. Up-referral mechanisms linking primary sites to tertiary sites
for complicated patients have been integrated into the RTC network of sites.
HIV-infected women, with or without antiretroviral therapy, are at high risk for the development of cervical
cancer. Cervical cancer screening in HIV-infected individuals has been initiated as an integrated wellness
service for all women attending the Helen Joseph Hospital, Themba Lethu Clinic. Results of the initial period
under review demonstrate that approx. 55% of HIV-infected individuals have abnormal pap smears with
over 30% of those demonstrating high grade pre-cancerous lesions (Ref: Firnhaber et al submitted July
2008). HPV testing conducted in a sub-set of these patients (funding source NIH CFAR) demonstrate that
all samples with abnormality have multiple oncogenic HPV types. Campaigns to increase the uptake of
cervical screening at all treatment and wellness sites supported by RTC will be undertaken.
RTC will continue strengthen links between counseling and testing and care within and between facilities.
For those testing positive a tracer system will reduce loss to treatment initiation. Those who test positive will
be tracked so that they benefit from wellness services and are tested every six months for their CD4 counts
to ensure that they commence ART as soon as they become eligible.
AREAS OF EMPHASIS
RTC will emphasize an increase in activities to meet the objectives of the technical considerations in the
following areas:
a. Cotrimoxazole prophylaxis - RTC sites report a high utilization of cotrimoxazole for patients with a CD4
<200. An increase in training and implementation is required for the discontinuation of cotrimoxazole in
patients with a CD4 count greater than 200 at two sequential time points. This is in line with the
comprehensive care guidelines for South Africa.
b. Palliative care - RTC will continue to emphasize the training for palliative care, with training courses
provided to all counselors, nurses and doctors. Home-based care will continue in remote districts. Palliative
education and training will be undertaken for family members.
Activity Narrative: c.Transition to care and retention in care will be emphasized using call center support for all patients
undergoing HIV testing, inclusion of CD4 testing for staging for all who are tested HIV-positive, site specified
referral to care at the time of CT, and follow-up of patients who do not reach the referral point. RTC uses the
TherapyEdge-VCT module which enables tracking of all these processes.
d. Enhancement of the basic care package for all wellness, pre-HAART patients will include access to
Isoniazid Prevention Treatment (IPT);
e. Positive prevention will continue to be emphasized including provider \-initiated counseling and testing for
family and household members; engagement of disclosure of HIV status for sexual partners; condom
distribution; assessment and diagnosis of both symptomatic and asymptomatic sexually transmitted
infections.
f. All women will be provided with access to cervical dysplasia screening. Treatment will follow the South
African guidelines for cervical cancer screening.
------------------------
Right to Care's PEPFAR program was recompeted through an Annual Program Statement (APS) in 2007
and was a successful applicant. RTC will continue to use PEPFAR funds to strengthen the capacity of
healthcare providers to deliver Care and Support (C&S) services to HIV-infected individuals, and to improve
the overall quality of clinical and community-based health care services in five provinces.
RTC's C&S services will expand from the current levels achieved using PEPFAR funds. The integrated
program of education, counseling and testing, care and ARV treatment has been implemented in five focus
areas: (1) The employed sector, where RTC is currently providing HIV services to >130,000 employees in
>32 companies; (2) FBO/NGO clinics which target underserved populations in rural areas, industrial areas,
and informal housing sectors as well as targeted gender-specific support groups and family-centered
approaches; (3) Thusong, a private practitioner program for indigent patients; (4) Small, Medium, and Micro-
Enterprise, including farm employees, with mobile treatment units; and (5) In partnership with the National
Department of Health (NDOH), capacity support for national comprehensive HIV and AIDS care,
management and treatment sites. RTC provides mentorship and technical assistance to over 15 sub-
recipients and manages their sub-agreements. These are ongoing programs expanded with NDOH
coordination and private sector support. By providing training and support to these sites RTC leverages
NDOH resources to reach an increasing number of patients. RTC has supported these sites with
infrastructure, staff, training, equipment and data management. In addition, the NDOH has recognized the
successes of RTC NGO/FBO sites and has been accrediting these sites to enable the provision of ARV
drugs and laboratory monitoring.
RTC will build on past successes by consolidating and expanding its support for government sites, NGO
and FBO clinics/organizations and private sector programs. FY 2008 PEPFAR funds will be used for human
capacity development and salaries at all C&S providers; (1) NGO and FBO clinics/organizations receive sub
-awards earmarked for doctors, nurses, counselors and other healthcare workers; (2) RTC will not provide
salary support to SAG staff, but rather the salaries of health care providers seconded to DOH facilities
including support for doctors, nurses, data managers, and counselors; and (3) a capitation fee-for-service
arrangement exists with a network of private sector service providers for the Thusong and Direct AIDS
Intervention (DAI) programs.
medical equipment, ARVs, drugs for opportunistic infections including cotrimoxazole, counseling and testing
kits, and home-based care kits.
RTC supports all the C&S providers by disseminating policies and guidelines and providing quality
assurance through sharing best practices. With FY 2008 funding RTC will provide ongoing training and
RTC will ensure that each HIV patient at RTC-supported facilities receives a comprehensive minimum
package of C&S services and preventive care, including clinic, community and home-based services. This
minimum package includes clinical and pathology monitoring, management and treatment of opportunistic
infections, psychosocial counseling, healthy living education, prevention with positives services, nutritional
counseling, assessment, monitoring and referral, home-based care, advice and assistance on welfare
issues and applications for welfare grants, and hospice and end-of-life care for terminally-ill patients.
Emphasis will be placed on increasing the number of HIV-infected children and pregnant women in care. A
number of NGO sites are doing nutritional counseling at community level and refer for nutritional
assessment and monitoring. Examples of non USG-funded community activities include food gardens and
income generating programs in order to support patients that are on ART. In addition, sites supported by the
NDOH have dieticians for ARV-treated patients.
PEPFAR funds facilitate partner linkages and a referral system between treatment sites-based care, and
other non-medical C&S services. At each site RTC will identify a community-based care organization to add
to the counseling capacity of the site. Peer counselors complement the NDOH appointed clinic staff. The
Thusong program is linked with a national network of care organizations. The expansion of the strategic mix
of clinic, home and community-based C&S will bring more C&S services to the doorstep of impoverished
populations such as farm workers, rural communities and residents of informal settlements.
Activity Narrative: Public-private partnerships (PPPs) have also been formed to ensure longer term sustainability. These
include, for example, those with the provincial DOH, where value is seen by the government in accrediting
specific clinics in order to provide ARVs and pathology monitoring thereby reducing the overall cost on one
donor. In addition PPPs are being explored with a number of organizations to provide holistic and
comprehensive care and treatment services to HIV-infected patients.
NGO clinics also receive cooperative funding from donors and patient fees. Knowledge sharing between
treatment sites and networks is being facilitated by Value-based. Referral mechanisms linking primary sites
to tertiary sites for complicated patients have been integrated into the RTC network of sites.
A number of NGO clinics also have gender-specific C&S programs. For example, the ACTS (AIDS Care
Training and Support) clinic has a series of comprehensive monthly support groups aimed at young men or
young women who are HIV-infected. Support group members meet to discuss challenges and problems and
provide each other with support and guidance. These programs include family-centered approaches.
Expansion of gender-specific activities with FY 2008 PEPFAR funding is planned.
Right to Care will continue to use PEPFAR funds to strengthen capacity of healthcare providers to deliver
C&S services to HIV-infected individuals and to improve quality of clinical and community-based health care
services in five provinces. RTC will strengthen links between counseling and testing and care. For those
testing positive a tracer system will reduce loss to treatment registration. Those who test positive will be
tracked so that they benefit from wellness services and are tested every six months for their CD4 counts to
ensure that they commence ART as soon as they become eligible.
By reaching patients with care and support services at various outlets, RTC will contribute to the PEPFAR
goal of providing services to 10 million HIV-infected and affected individuals. In addition, RTC activities will
support the USG Five-Year Strategy for South Africa by training health care workers in care and support
services, significantly expanding access to and quality of palliative care services.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13793
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13793 2975.08 U.S. Agency for Right To Care, 6612 271.08 $1,022,000
International South Africa
Development
7547 2975.07 U.S. Agency for Right To Care, 4460 271.07 $0
2975 2975.06 U.S. Agency for Right To Care, 2652 271.06 $2,200,000
* Addressing male norms and behaviors
Estimated amount of funding that is planned for Human Capacity Development $3,130,397
Table 3.3.08:
This is a new PHE for FY09 that has been approved for $430,307.
PHE tracking number: ZA.09.0265
Title: Validation of HPV, cytology and visual inspection for cervical cancer screening in HIV-positive women.
Estimated amount of funding that is planned for Public Health Evaluation $430,307
ART treatment sites receive the following package of support from Right to Care (RTC):
-RTC conducts an initial needs assessment at all treatment sites, including the epidemiology of HIV and
AIDS in the target population served by the treatment site. During this period, RTC also establishes the
priorities of the district and provincial department of health (DOH) for the health care facility.
-Technical assistance is provided to establish the policies and procedures at the site. This includes
supporting the health care facility to ensure the most efficient workflow processes, task shifting, interaction
with local non-governmental organizations (NGOs), pharmacy supply chain management for facilities, data
system strengthening and quality assurance assessments.
-Training is provided to all health care workers. This provides both on-site mentorship programs, as well as
didactic training courses. Retention of staff and career development are emphasized.
-RTC is focused on the recruitment and retention of staff for treatment sites, particularly in rural and under-
served or hard-to-reach populations. Where possible RTC will fill existing DOH positions, or alternatively if a
position needs to be supported until the DOH can establish new positions, RTC will employ and second
staff to sites. RTC has supported down referral from the overloaded and successful Comprehensive Care
Management and Treatment (CCMT) sites of patients stable on ART. Such down referral is conducted with
an emphasis on transfer not only of the patient, but also the data record. In addition to internal HAART
treatment reviews, quality assurance activities will include the following: (1) review of all counselors at site
to ensure consistent treatment adherence education and counseling (2) review of the use of treatment
protocols at site including pharmacy and laboratory resource utilization (3) review of management of toxicity
e.g. Nevirapine dose escalation and rash or hepatotoxicity, (4) individual clinician level performance review
to ensure management is according to training, policies and guidelines, (5) monitoring the quality of care
provided by down referral sites and maintenance of down referral guidelines, (6) monitoring prescription,
dispensing and supply management of pharmaceutical supplies, (7) provision of cotromoxazole and
isoniazid prophylaxis, (8) management of opportunistic infections.
RTC will use PEPFAR funds to accelerate the implementation of the National Strategic Plan (NSP) CCMT
program at DOH sites. Through memorandums of understanding (MOUs) in the five provinces, RTC plans
to enhance the ART services by developing network coverage of the CCMT and primary health care
facilities in each district. This may include additional CCMT treatment sites as requested by the DOH. More
emphasis is however placed on the improved efficiency of each of the sites, and the integration of CCMT
sites into the primary health care facilities through down referral. FY 2009 funds will be used to expand
access to treatment with a special focus on the following target areas:
-Improved management of patients according to the treatment guidelines focused on safe, effective ART
treatment to reduce HIV and AIDS associated morbidity and mortality.
-Integration of ART with prevention of mother-to-child (PMTCT) activities with Highly Active ART (HAART)
provided to all eligible pregnant women.
-Improved follow-up of patients in pre-HAART wellness clinics through the provision of care and support
activities at these clinics, strengthening the scope of non-ART services including but not limited to, HIV
counseling and testing (CT), HIV primary care, opportunistic infection management, family planning,
nutritional counseling, linkages to in-patient care, home-based care, and secondary prevention, and OVC
and social services.
-Increased CT for ART access, and transition to care by linking CT activities to referral treatment sites. CT
is provided to couples, to reach the partners and family members of individuals already in care.
-Focused activities to the current gender imbalance focused on reaching more men (approx. 65% of ART
patients are women).
-Inclusion of pediatric patients in family-focused clinics
-Expansion of the successful down referral model to 18 sites in four provinces Mpumlanga, Free State,
Gauteng and Northern Cape as requested by those provincial DOH. By the end of FY 2009 RTC will have
over 20,000 patients will be treated at down referral sites.
- RTC will support the early diagnosis of TB, improved TB treatment, access to TB culture and polymerase
chain reaction (PCR) testing for drug resistance, HIV testing in TB, and provision of ART to TB patients.
Linkage between ART treatment sites and TB hospitals will facilitate care for patients diagnosed with
multi/extensively drug resistant TB. Isoniazid prophylaxis will be introduced and expanded in all RTC-
supported CCMT sites, in accordance with the national and provincial treatment guidelines.
-RTC will continue to support capacity development for pharmacy services, in particular the training of
pharmacy assistants, integration of pharmacy supply chain IT systems chosen in each province with HIV
data systems, and overall reporting of outcomes according to SAG and PEPFAR requirements.
-RTC will increase the access to data management systems enabling clinics to monitor quality assurance
including CD4 percentage increases, viral load, disease stage, side-effects, adverse events and outcomes
at annual intervals.
In order to complement clinic-based ARV services, support is provided to at least one community-based
care organization to partner with each treatment site. This team is tasked with monitoring patients'
adherence, providing support such as nutrition, wellness and welfare services, encouraging patients to
remain on treatment, tracking patients that are lost to follow up and providing home-based care services for
those that are terminally ill. The Clinical Mentorship Program will continue to enhance the provision of HIV
care by transferring skills, using local and international clinical mentors. Implemented in rural sites and hard
to reach populations, with human capacity development and skills transfer, increased numbers of people in
hard to reach populations will receive quality care and treatment services. To address gender imbalances,
RTC anticipates opening a male-only clinic in partnership with the Clinical HIV Research Unit (CHRU) at
Wits University. This clinic will focus on recruiting adult males from local industries dominated by males in
the private sector as well as males from indigent populations.
-------------------------------
Right to Care (RTC) will use FY 2008 PEPFAR funds to strengthen the capacity of healthcare providers to
deliver ARV treatment (ART) services to eligible HIV-infected individuals in five provinces. Emphasis will be
placed on increasing the number of HIV-infected children and pregnant women on ART. The emphasis
areas are renovation, gender, human capacity development, and local organization capacity building. The
Activity Narrative: primary target populations are people living with HIV (PLHIV), public and private healthcare providers.
RTC's ARV Treatment (ART) services are a continuation of activities, which have been USG-funded since
2002. Originally initiated as a holistic education, testing, care and treatment program for the employed
sector (called the Direct AIDS Intervention (DAI) program), RTC's ART activities have expanded their reach
through a range of partnerships with government sites, private sector providers and NGO and FBO clinics
and organizations. RTC is now reaching substantial numbers of people from predominantly vulnerable
populations in five provinces. RTC's ART activities consists largely of support for the ART services of all of
RTC's treatment partners, including its Thusong network of private practitioners, many government sites
and NGO and FBO clinics and organizations. In addition, RTC itself implements the ART components of the
DAI and other partnership workplace programs. ART training is conducted by RTC's Training Unit as well as
by several sub-partners. With FY 2008 funding, RTC will expand its pediatric treatment, expand into a male-
only clinic and increase its focus on reducing stigma and encouraging disclosure. RTC will consolidate and
expand its support for government sites, NGO and FBO clinics and organizations and private sector
programs, and build on past successes (over 22,500 people reached with ART by the third quarter of FY
2007).
RTC will use PEPFAR funds to accelerate the implementation of the national rollout plan at government
sites in partnership with the National Department of Health (NDOH). As the procurement of ARV drugs and
lab services is undertaken by government in these sites, PEPFAR funds will be used to expand access to
treatment. RTC has successfully negotiated for the NDOH to supply certain NGO and FBO sites with ARVs
and laboratory services, freeing PEPFAR funds to support new treatment sites.
PEPFAR funds will be used for: (1) human capacity development and salaries (consultant and part-time
healthcare workers) at all ART facilities: NGO and FBO clinics and organizations receive sub-awards for
doctors, nurses, pharmacists and counselors, and a fee-for-service arrangement exists with the network of
private sector service providers for the Thusong and private programs; (2) developing a training program for
pharmacy assistants as human capacity development for the distribution of ARVs and HIV services; (3)
addressing minor infrastructure needs where necessary at NGO, FBO and government sites, and to
maintain RTC's mobile clinics; (4) NGO and FBO clinics use PEPFAR funds for the laboratory monitoring of
HIV patients, as well as for the procurement of health commodities; and (5) covering the costs of labs for
the new mobile clinic treatment program servicing remote communities in Mpumalanga, in collaboration with
another PEPFAR-funded partner, FHI.
Down referral sites will be established with the Department of Health in Gauteng and Mpumalanga in FY
2007 for stable patients. Human capacity, minor infrastructure and training will be provided to these sites. A
'smart card' system is being developed with Therapy Edge and Supply Chain Management Service to track
transfer of patient data.
RTC supports its ART providers by disseminating policies and guidelines and sharing best practices.
Ongoing quality assurance and supportive supervision is undertaken by centralized treatment experts. RTC
and several of its sub-partners will also provide training in ART services for health workers. In the delivery of
medical ART services, doctors are given ongoing support in clinical decision-making, prescribing and case
management by RTC's team of medical HIV experts, through RTC's Expert Treatment Program (ETP). The
ETP management model enables primary healthcare providers to communicate directly with HIV experts.
ETP uses a sophisticated web-based IT tool in the form of TherapyEdge, licensed to RTC, which enables
the effective management of patients and includes a secure patient database. The Clinical Mentorship and
Preceptorship Program (CMPP) will continue to enhance the provision of HIV care and clinical expertise
across the intermediate levels of health care within the overburdened public healthcare system. Through
human capacity development, increased numbers of people will receive care, support and treatment. The
anticipated benefit of the mentorship program is the dissemination of training and knowledge gained by
healthcare personnel in the urban academic site to rural and smaller sites around the country.
A new PPP, the AIDS Treatment Institute (ATI), is proposed with Vodacom and the DOH. Vodacom will
provide all infrastructure requirements for a HIV care and treatment centre for indigent patients, with the
DOH supplying all ARV and covering lab costs. PEPFAR funds will be used for training, human capacity
development of necessary health care workers, and ongoing technical assistance. This clinic is targeted to
provide treatment for 10,000 patients, care and support to 15,000 patients, CT to 40,000 individuals and
prevention education to 100,000 in FY 2008. Vodacom, other private sector organizations and DOH will
provide over 90% of support for this program, and PEPFAR funds will provide less than 10% of the PPP
budget.
RTC will ensure that each ART patient at RTC-supported facilities receives a minimum package of ART
services, including clinical and pathology monitoring, adherence counseling and support, and follow-up of
defaulting ART patients. Adherence activities will include a focus on reducing stigma and encouraging
disclosure in order to enhance drug compliance and to improve patient retention. Emphasis will be placed
on increasing the number of HIV-infected children and pregnant women on ARVs according to the national
treatment guidelines. Mobile clinics are used to bring ART services to farm workers and other vulnerable
populations in rural areas of the Northern Cape and Mpumalanga.
To support the implementation of ART, adherence counseling and support is implemented through
individual counseling, support groups and direct observed therapy, either clinic-based or community-based.
In order to complement clinic staff, support is provided to at least one community-based care organization to
partner with each treatment site. This team is tasked with monitoring patients' adherence, providing support
such as nutrition, wellness and welfare services, and providing home-based care services for those that are
terminally ill. The team also provides referral services to clinics and in some cases, arranges transport or
hospice services. RTC anticipates opening a male-only clinic in partnership with the Clinical HIV Research
Activity Narrative: Unit (CHRU) at Wits University. This clinic will focus on recruiting adult males from local industries
dominated by males in the private sector as well as males from indigent populations. Patients in this clinic
will receive ART services, clinical and pathology monitoring, with specific adherence and other support
designed to meet the needs of men. Best practices on adherence and support as well as clinical care from
this clinic will be shared with other RTC partners. In FY 2008, RTC will contribute to increased patients on
ART at various sites towards the PEPFAR treatment target of 2 million patients, and will train healthcare
workers in ART services. RTC will support the PEPFAR vision outlined in the Five-Year Strategy for South
Africa by expanding access to ART services for adults and children, building capacity for ART service
delivery, and increasing the demand for and acceptance of ARV treatment.
Continuing Activity: 13797
13797 9453.08 U.S. Agency for Right To Care, 6612 271.08 $29,554,000
9453 9453.07 U.S. Agency for Right To Care, 4460 271.07 $0
Estimated amount of funding that is planned for Human Capacity Development $17,367,031
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $493,661
Estimated amount of funding that is planned for Food and Nutrition: Commodities $194,470
Table 3.3.09:
FY 2008 COP activities will be expanded to include:
-PEPFAR funds will also be used to structurally improve and maintain all RTC supported clinics;
-PEPFAR funds will be used for human capacity development and salaries at all pediatric care and support
providers; and
-Using FY 2009 funds RTC will consolidate provincial centers of pediatric ART expertise established in FY
2008.
Following the emphasis in the National Strategic Plan 2007-2011, RTC will use FY 2009 PEPFAR funds to
accelerate the scale-up of family-centered approaches to pediatric treatment, care and support. The specific
aim is to increase the access to antiretroviral therapy for pediatrics from the current 7% of patients treated
to 15%, in accordance with the National Strategic Plan (NSP) and the technical considerations for the FY
2009. Focus for the Pediatric treatment program will be to integrate into the adult treatment at all
Department of Health, Comprehensive HIV/AIDS Care, Management and Treatment (CCMT) sites,
supported by Right to Care. At the request of the provincial Department of Health (DOH) and implemented
according to the memorandums of understanding (MOUs) with each province, RTC has increased the
activity and budget emphasis towards pediatric treatment, care and support. The implementation is
conducted in collaboration with the Hospital, District, Provincial and National Departments of Health (DOH).
The guidelines that are available for the care and support of HIV exposed and HIV-infected children will be
followed at all RTC supported sites.
The Right to Care Pediatric Program was established in March 2008. Prior to this date, pediatric treatment
was supported at all sites, with training and preceptorship received from ECHO. It became apparent that the
scale of Right to Care program required a dedicated training and mentorship program within the
organization. Dr. Leon Levin was recruited from private practice to join the organization as a full-time
employee. Dr. Levin is one of only eight Pediatricians in South Africa who are experts in HIV treatment,
antiretroviral therapy and infectious Diseases. Dr. Levin has been involved in HIV treatment with
antiretroviral therapy for over 10 years; has established the largest cohort of patients on treatment in private
practice; and established a specialized referral clinic for complex pediatric HIV cases on the East Rand of
Johannesburg. PEPFAR funds are used to support access to this referral site for indigent public sector
pediatric patients.
The major initial aim of this program was to increase the number of pediatric patients on antiretroviral
therapy (ART) at all Right to Care assisted ART sites. According to December 2007 statistics, children
under 14 years only represent about 7-8% of all patients on ART at Right to Care. The National Department
of Health has called on all HIV and AIDS/STI/TB (HAST) directorates to ensure that at least 15% of all
patients receiving ART are children.
The integrated program of pediatric and adolescent education, counseling and testing, care & support and
ARV treatment will continue to be implemented using RTCs existing models of care:
1) In partnership with the National Department of Health (NDOH), capacity support for pediatric care and
support at CCMT sites in five provinces i.e. Gauteng, Mpumalanga, Northern Cape, Limpopo, and Free
State;
2) Strengthening the pediatric care component of FBO/NGO clinics, which target underserved populations
in rural areas, industrial areas, and informal housing sectors;
3) Thusong, a private practitioner program for indigent patients where pediatric care is emphasized is the
treatment model used in areas where there are no government systems in place. The Thusong pediatric
program is not planned for expansion, patients have started to be transitioned into the government program
and this will continue in FY 2008 and FY 2009. However, this program will remain operational to allow RTC
to treat under this program where necessary; and
4) The employed sector, where RTC is providing HIV disease management services to >130,000
employees in >30 companies and pediatric dependents who are HIV exposed or infected are encouraged to
enroll onto the workplace care and support program.
Since March 2008, the pediatric team has conducted needs assessments for pediatrics at 10 sites
throughout the provinces. Training programs have been finalized for implementation and have been
conducted on 3 occasions with 120 health care workers (HCWs) attending. The training provided includes
the following broad areas of emphasis:
conducted on 3 occasions with 120 HCW attending. The training provided includes the following broad
areas of emphasis:
a. Diagnosis of HIV in infants and children
b. Diagnosis and treatment of TB and other common opportunistic infections
c. Laboratory monitoring of HIV disease in children
d. Treatment initiation in children
e. Pharmacology, dosing, formulation of ARVs in children
f. Treatment adherence in children
g. Adolescent counseling and adherence to treatment
h. Family centered approach to ARVs including linkages to nutritional support program
Activity Narrative: Dr. Levin, Dr MacDonald and others have established mentoring support of treatment sites, with on-site
management of patients supported by pediatric experience clinicians. Mentoring pediatricians are sent to
sites throughout the network at regular intervals, providing both didactic continuing medical education, and
practical bedside teaching. Ongoing support is provided with access to a mobile call-line for clinicians to
receive specific advice from the treatment experts. This line is now available to all clinicians in RTC sites,
with utilization increasing to 6 calls per day. In FY 2008 linkage will be established to the FPD supported
HCW call center.
The pediatric program is linked to an increase in the activities under RTCs PMTCT program at sites
throughout the five supported provinces. Particular emphasis is placed on the provision of infant PCR
diagnosis to all infants exposed to HIV, and early treatment initiation for all children, to reduce early infant
mortality. As the effectiveness of the PMTCT program is enhanced, with transmission of HIV reduced to
less than 5%, children requiring treatment will decrease.
Through the development of treatment sites emphasis is placed on the family centered approach, with
improved pre and post-natal care and mothers, their partners and children treated in the same clinic, this is
in line with safe motherhood. Clinician training is focused on medical officer and primary health care nurse
prescribed HIV treatment.
By providing pediatric training and implementation support to these sites RTC leverages NDOH resources
to reach an increasing number of children. RTC supports these sites with infrastructure especially focus on
renovating the facilities and making them child and adolescent friendly as well as support with staff, training,
equipment and data management.
Through the provision of technical assistance, RTC has established a number of pediatric specific IT
solutions, which will be ready for beta testing within RTC sites in October 2008. Particular emphasis in
TherapyEdge-Pediatrics (TE-Peds) is the provision of treatment guidelines specific to children, yet
accessible as part of the real-time integration of the data system at all sites, to all clinicians. TherapyEdge-
Pediatrics improves disease management through guideline directed, expert systems and pediatric specific
therapeutic intervention. The system provides enhanced clinic management, with the development of
workflow processes that define roles and responsibilities enabling shifting, yet ensuring quality assurance.
Through interfacing with the NHLS, Toga Laboratories, Lancet Laboratories and others, direct provision of
laboratory results into the data system will enable real-time laboratory alerting. The data system provides
overall health system strengthening with integration of guidelines and data collection according to IMCI
WHO standard. RTC has already demonstrated that the use of TherapyEdge-HIV (TE-HIV) in adult patients
has led to: (1) enhanced efficiencies in clinics with reduced waiting periods to <2hours in the largest HIV
clinic in South Africa, Helen Joseph Hospital; (2) improvements in patient retention with a reduction in LTFU
from 21% to 4%; (3) improvement in clinical quality with response to toxicity, virologic failure, dosing errors,
drug interactions and TB diagnosis demonstrated (4) overall mortality, morbidity and viral load suppression
rates have improved; (5) staffing: patient ratios required by Helen Joseph Hospital are approx. 25% of the
ratios recommended by the DOH, due to the ability to shift and efficiencies of the clinic. Through enhanced
guideline driven decision support, RTC will demonstrate the benefits of TE-Peds, in particular the more
accurate prescription of drugs according rapidly changing weight, body surface area, and BMI in children
growing with antiretroviral therapy. RTC continues to support the pharmacovigilance program of the
Medicine Control Council for antiviral therapy in pediatric patients, through the provision of data from all of
our sites.
RTC will use COP 09 funds to build on consolidating and expanding its support for pediatric care at
government sites, NGO and FBO clinics/organizations and private sector programs. NGO and FBO clinics
also use PEPFAR funds for laboratory monitoring of HIV pediatric and adolescent patients and for the
procurement of health commodities such as medical equipment, ARVs, drugs for opportunistic infections,
counseling and testing kits, and home-based care kits. RTC supports all pediatric care and support (C&S)
providers by disseminating policies and guidelines and providing quality assurance through sharing best
practices.
FY 2009 PEPFAR funds will be used for human capacity development and salaries at all C&S providers; (1)
NGO and FBO clinics/organizations receive sub-awards earmarked for doctors, nurses, counselors and
other healthcare workers; (2) RTC will not provide salary support to SAG staff, but rather the salaries of
health care providers seconded to DOH facilities including support for doctors, nurses, data managers ,
counselors; and (3) a capitation fee-for-service arrangement exists with a network of private sector service
providers for the Thusong program.
The program of pediatric care will have strong emphasis on diagnosing infants and children with HIV early
and national guidelines on PCR testing will be followed. Family members, usually female caregivers, who
require care will also be identified during this process and pregnant caregivers will be referred into PMTCT
services. Couples counseling will be offered to parents who bring children to the clinics together and this will
help to promote the testing of men. RTC will continue getting the children into care as soon as possible and
starting them on ART early, especially young infants who are at high risk of dying. RTC support at the sites
will ensure that a comprehensive package of preventive care is available to all HIV exposed infants and
infected children and ensure that they receive CTX prophylaxis in a timely manner and that they are
appropriately referred for immunizations according to the national guidelines. The staff who will be hired for
the pediatric program will conduct nutritional assessments, nutritional counseling and refer appropriately for
support, an important area of focus will also be TB screening, TB treatment and IPT for those under 5 who
do not have active disease. This will include the clinical management of common opportunistic infections
and other conditions affecting children with HIV and their management. Emphasis will be placed on quality
assurance and assessing and improving the programs already in place.
PEPFAR funds will also be used to structurally improve and maintain all RTC supported clinics and these
Activity Narrative: will offer clinical and psychological and services to HIV-infected and affected children and their families with
strong links to available social and spiritual services. PEPFAR funds will be used to facilitate partner
linkages and a referral system between treatment sites-based care, and other non-medical C&S services.
At each site RTC will identify a community-based care organization to add value to the counseling and
testing program by tracking and tracing pregnant moms who are lost to initiation and PMTCT and by finding
the babies of these mothers to assess them and ensure that they benefit from care. The care and support
NGOs will also help to minimize the pediatric loss to follow up rate.
Using FY 2009 funds RTC will consolidate provincial centers of pediatric ART expertise established in FY
2008 in each province in order to allow staff from other sites to rotate through the centre of excellence and
learn to treat and care for pediatric patients under supervision. In so doing staff from other clinics will
acquire expertise in pediatric care and support and then take that expertise back to their own clinics where
service delivery will be sustainable.
We would expect the number of pediatric patients on ART to increase at all RTC sites and reach the
required15% pediatric patients on ART to be achieved by the end of the FY 2009. In addition, the quality of
pediatric care would continue to improve in FY 2009.By reaching patients with care and support services at
various outlets, RTC will contribute to the PEPFAR goal of providing services to 10 million HIV-affected
individuals.
Estimated amount of funding that is planned for Human Capacity Development $801,489
Table 3.3.10:
Following the emphasis in the National Strategic Plan 2007-2011 (NSP), Right to Care (RTC) will use FY
2009 COP PEPFAR funds to accelerate the scale up of family-centered approaches to pediatric treatment,
care and support. The specific aim is to increase the access to antiretroviral therapy for pediatrics from the
current 7% of patients treated to 15%, in accordance with the NSP and the technical considerations for the
FY 2009 COP. Focus for the pediatric treatment program will be to integrate into the adult treatment at all
Department of Health (DOH), Comprehensive HIV and AIDS Care, Management and Treatment (CCMT)
sites, supported by Right to Care. At the request of the provincial DOH and implemented according to the
Memoranda of Understanding (MOU) with each province, RTC has increased the activity and budget
emphasis towards pediatric treatment, care and support. The implementation is conducted in collaboration
with the hospital, district, provincial and national Departments of Health. The guidelines that are available
for the care and support of HIV-exposed and HIV-infected children will be followed at all RTC supported
sites.
The Right to Care Pediatric Programme was established in March 2008. Prior to this date, pediatric
treatment was supported at all sites, with training and preceptorship received from Enhancing Children's
HIV Outcomes (ECHO). It became apparent that the scale of the Right to Care program required a
dedicated training and mentorship program within the organization. Dr Leon Levin was recruited from
private practice to join the organization as a full-time employee. Dr Levin is one of only eight pediatricians
in South Africa who are experts in HIV treatment, antiretroviral therapy and infectious diseases. Dr Levin
has been involved in HIV treatment with antiretroviral therapy for over 10 years, has established the largest
cohort of patients on treatment in private practice, and established a specialized referral clinic for complex
pediatric HIV cases on the East Rand of Johannesburg. PEPFAR funds are used to support access to this
referral site for indigent public sector pediatric patients.
therapy (ART) at all Right to Care-assisted ART sites. According to December 2007 statistics, children
of Health has called on all HAST directorates to ensure that at least 15% of all patients receiving ART are
children.
The integrated program of pediatric and adolescent education, counseling and testing, care and support
and ARV treatment will continue to be implemented using RTC's existing models of care:
(1) In partnership with the National Department of Health (NDOH), capacity support for pediatric care and
support at CCMT sites in five provinces i.e. Gauteng, Mpumalanga, Northern Cape and Free State.
(2) Strengthening the pediatric care component of Faith-Based Organization (FBO) and Non-governmental
organization (NGO) clinics which target underserved populations in rural areas, industrial areas, and
informal housing sectors.
(3) Thusong, a private practitioner program for indigent patients where pediatric care is emphasized is the
to treat under this program where necessary.
(4) The employed sector, where RTC is providing HIV disease management services to >130,000
employees in >30 companies and pediatric dependents who are HIV-exposed or infected are encouraged to
enroll onto the care program.
Since March 2008, the pediatric team has conducted needs assessments for children at 10 sites throughout
the provinces. Training programs have been finalized for implementation and have been conducted on
three occasions with 120 HCW attending. The training provided includes the following broad areas of
emphasis:
b. Diagnosis and treatment of common opportunistic infections
h. Family-centered approach to ARVs
Dr Levin, Dr MacDonald and others have established mentoring support of treatment sites, with on-site
with utilization increasing to six calls per day. In FY 2008, linkages will be established to the FPD supported
The pediatric program is linked to an increase in the activities under RTC's Prevention of Mother-to-Child
(PMTCT) program at sites throughout the five supported provinces. Particular emphasis is placed on the
provision of infant Polymerase Chain Reaction (PCR) testing to all infants exposed to HIV, and early
treatment initiation for all children, to reduce early infant mortality. As the effectiveness of the PMTCT
program is enhanced, with transmission of HIV reduced to less than 5%, children requiring treatment will
decrease.
Activity Narrative: Through the development of treatment sites emphasis is placed on the family-centered approach, with
mothers, their partners, and children treated in the same clinic. Clinician training is focused on medical
officer and primary health care nurse prescribed HIV treatment.
to reach an increasing number of children. RTC supports these sites with infrastructure, including staff,
training, equipment, data management, and making the facilities child- and adolescent-friendly.
Through the provision of technical assistance, RTC has established a number of pediatric-specific IT
TherapyEdge-Paediatrics (TE-Paeds) is the provision of treatment guidelines specific to children, yet
accessible as part of the live real-time integration of the data system at all sites, to all clinicians.
TherapyEdge-Paediatrics improves disease management through guideline-directed, expert systems and
pediatric-specific therapeutic intervention. The system provides enhanced clinic management, with the
development of workflow processes that define roles and responsibilities enabling task shifting yet ensuring
quality assurance. Through interfacing with the NHLS, Toga Laboratories, Lancet Laboratories and others,
direct provision of laboratory results into the data system will enable real-time laboratory alerting. The data
system provides overall health system strengthening with integration of guidelines and data collection
according to IMCI WHO standard. RTC has already demonstrated that the use of TE-HIV in adult patients
has led to: (1) enhanced efficiencies in clinics with reduced waiting periods to less than two hours in the
largest HIV clinic in South Africa, Helen Joseph Hospital; (2) improvements in patient retention with a
reduction in loss-to-follow-up (LTFU) from 21% to 4%; (3) improvement in clinical quality with response to
toxicity, virologic failure, dosing errors, drug interactions and TB diagnosis demonstrated (4) overall
mortality, morbidity and viral load suppression rates have improved; (5) staff-to-patient ratios required by
Helen Joseph Hospital are approximately 25% of the ratios recommended by the DOH, due to the ability to
task shift and efficiencies of the clinic. Through enhanced guideline-driven decision support, RTC will
demonstrate the benefits of TE-Paeds. In particular, the more accurate prescription of drugs according
rapidly changing weight, body surface area, and BMI in children growing with antiretroviral therapy. RTC
continues to support the pharmaco-vigilance program of the Medicine Control Council for antiviral therapy in
pediatric patients, through the provision of data from all of our sites.
ACTIVITY 1: Increasing Access to Pediatric Support, Care and Treatment
RTC will use FY 2009 COP funds to build on consolidating and expanding its support for pediatric care at
government sites, NGO and FBO clinics/organizations and private sector programs. RTC currently supports
five provinces. At the request of the DOH in the provinces Gauteng, Mpumalanga, Northern Cape, Free
State, and Limpopo, both funding and activity emphasis will be placed on increasing access to pediatric
support, care and treatment at each of these sites.
NGO and FBO clinics also use PEPFAR funds for laboratory monitoring of HIV pediatric and adolescent
patients and for the procurement of health commodities such as medical equipment, ARVs, drugs for
opportunistic infections, counseling and testing kits, and home-based care kits. RTC supports all the Care
and Support (C&S) providers by disseminating policies and guidelines and providing quality assurance
through sharing best practices.
The program of pediatric care and treatment, through linkages with the PMTCT program, will have strong
emphasis on diagnosing infants and children with HIV early and national guidelines on PCR testing will be
followed. Family members who require care, including fathers, will also be identified during this process and
pregnant caregivers will be referred into PMTCT and care services resulting in the promotion safe
motherhood. RTC will continue getting the children into care as soon as possible and starting on ART early,
especially in young infants who are at high risk of dying. RTC supports the roll-out of the Children with HIV
Early Antiretroviral Therapy (CHER) study results demonstrating a reduction in early mortality in children
initiated on ART at or after six weeks of age. RTC support at the sites will ensure that a comprehensive
package of preventive care is available to all HIV-exposed infants and infected children and ensure that
they receive cotrimoxazole prophylaxis and that they are appropriately referred for immunizations according
to the national guidelines thereby increasing child survival. The staff who are hired for the pediatric program
will conduct nutritional assessments, nutritional counseling and refer appropriately for support, an important
area of focus will also be TB screening, treatment and prophylaxis for those under five who do not have
active disease. This will include the clinical management of common opportunistic infections and other
conditions affecting children with HIV and their management. Emphasis will be placed on quality assurance
and assessing and program monitoring in order to improve the programs already in place.
ACTIVITY 2: Infrastructure and Human Capacity Development
FY 2009 PEPFAR funds will be used for infrastructure, human capacity development and salaries at all
C&S providers; (1) NGO and FBO clinics/organizations receive sub-awards earmarked for doctors, nurses,
counselors and other health-care workers; (2) RTC will not provide salary support to SAG staff, but rather
the salaries of health care providers seconded to DOH facilities including support for doctors, nurses, data
managers, counselors; and (3) a capitation fee-for-service arrangement exists with a network of private
sector service providers for the Thusong program.
Using FY 2009 COP funds, RTC will consolidate already-established provincial centers of pediatric ART
expertise, maintained within family clinics, in order to allow staff from other sites to rotate through the centre
of excellence and learn to treat and care for pediatric patients under supervision. In so doing staff from other
clinics will acquire expertise in pediatric care and support and then take that expertise back to their own
clinics where service delivery will be sustainable.
PEPFAR funds will also be used to maintain the infrastructure of all RTC-supported clinics, which will offer
clinical and psychological and services to HIV-infected and affected children and their families with strong
links to available social and spiritual services. NGO and FBO clinics also use PEPFAR funds for laboratory
Activity Narrative: monitoring of HIV-infected and exposed pediatric patients and for the procurement of health commodities
such as medical equipment, ARVs, drugs for opportunistic infections.
ACTIVITY 3: Linkages and Referrals
PEPFAR funds will be used to facilitate partner linkages and a referral system between treatment sites-
based care, and other non-medical C&S services. At each site, RTC will identify a community-based care
organization to add value to the counseling and testing program by tracking and tracing pregnant moms
who are lost to initiation and PMTCT and by finding the babies of these mothers to assess them and ensure
that they benefit from care. The care and support NGOs will also help to minimize the pediatric loss to follow
up rate.
required 15% pediatric patients on ART to be achieved by the end of FY 2010. In addition, the quality of
pediatric care would continue to improve in FY 2010. By reaching patients with care and support services
at various outlets, RTC will contribute to the PEPFAR goal of providing services to 10 million HIV-affected
Estimated amount of funding that is planned for Human Capacity Development $2,659,301
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $160,570
Estimated amount of funding that is planned for Food and Nutrition: Commodities $90,241
Table 3.3.11:
Right to Care (RTC), in support of the South African government's TB program and the World Health
Organization's policy on collaborative TB/HIV activities, has developed and implemented a model of TB/HIV
integration through TB focal point activities at provincial and district hospitals, and at local primary care
clinics. At the request of the Department of Health (DOH) RTC will help the government to expand the
TB/HIV integration model in FY 2009.
In FY 2009, RTC will scale up the TB/HIV integrated package to all sites in the six provinces. This will
include: (a) enhanced uptake of Isoniazid Preventative Therapy; (b) evaluating and implementing improved
infection control practices at all antiretroviral and TB facilities to prevent nosocomial transmission of TB; (c)
support the development of drug-resistant TB treatment at Sizwe Hospital; (d) improve data collection and
system linkages between treatment points and the laboratory; and (e) strengthen laboratory services to
implement the TB/HIV program.
TB Focal Point Scale-up: The DOH has asked RTC to expand TB Focal Point in sites in six provinces.
Scaled up activities will include (1) increased access to HIV counseling and testing for patients with TB; (2)
intensified case finding through TB symptom screening at all points of contact with patients; (3) improved
access to induced sputum for TB diagnosis in HIV-infected individuals through specialized sputum induction
rooms that comply with occupational and environment safety standards, thus enhancing infection control
and increasing the sensitivity of sputum testing; (4) improved linkages between the HIV and TB programs at
each of the sites through referral, notification and follow-up; (5) infrastructure support to develop TB sputum
induction rooms with appropriate infection control procedures to prevent the transmission of TB; and (6)
targeting faith-based and non-governmental clinics focusing on underserved populations in rural areas,
industrial areas and informal housing sectors. The programs will promote sustainability through training of
health care-workers and partnerships with the National Department of Health (NDOH) to fund the ongoing
running cost and staff components. PEPFAR funds will enable long-term sustainability through training,
human capacity development and infrastructure support at all RTC-supported TB/HIV clinics.
RTC will focus on improving monitoring and evaluation (M&E) methods and data collection tools to
demonstrate the integration outcomes of TB/HIV integration. A successful RTC technical assistance team
has been established to continue to expand the activities from the key sites, to include all sites in the RTC
network.
Pediatric TB/HIV Care: An experienced pediatrician leads the RTC pediatric care and support program.
Training health-care workers (HCW) to enhance the diagnosis and treatment of TB in children will be
focused upon. In addition, training will include skills to improve clinical recognition of TB, specimen
collection and treatment with both TB and antiretroviral treatment.
Implementation of the DOH government policy and guideline for Isoniazid Preventative Therapy: RTC will
provide appropriate training to HCWs and family members, aimed at increasing the delivery of IPT and
treatment adherence. Duration of IPT will follow the NDOH guidelines.
Improved Infection Control: To prevent nosocomial infection of TB in clinical facilities supported by RTC, an
emphasis will be on introducing best practices for infection control. This will focus on urgent referral of TB
suspects out of the clinic to prevent transmission, ventilation, ultra-violet lights, masks and regular staff
screening for TB.
Drug-resistant TB: At the request of the Gauteng DOH, Sizwe, the provincial MDR/XDR-TB referral hospital,
is supported by RTC. RTC will continue activities at Sizwe. The DOH has requested support for a second
MDR/XDR-TB hospital. The planned activities include: (1) continuing to contribute to the overall activities at
Sizwe linked to the development of new treatment options for MDR/XDR-TB. Research is funded by the
pharmaceutical industry, National Institutes of Health and European Union (e.g., TMC207-TiDP13 phase 2
clinical trial currently underway at Sizwe); (2) supporting a prospective trial to evaluate the use of line-probe
assay PCR testing to monitor patients on MDR/XDR-TB treatment with the aim of reducing hospital stay; (3)
improving data collection (using DOH staffed vehicles) and linkages with laboratories to facilitate rapid
referral of MDR/XDR-TB patients; (4) adhering to the TB Strategic Plan for South Africa 2007-2011, where
emphasis will be placed on occupational development and income generation projects for patients admitted
to MDR/XDR-TB facilities; (5) enhancing data collection and linkages to facilitate tracing contacts of
MDR/XDR-TB patients; and (6) examining the feasibility of community-based treatment of MDR-TB with
strong DOT support as was successfully implemented in Lima, Peru. FY 2009 activities will pursue the
development of such a model and a potential demonstration project in one of the townships of South Africa.
Strengthening Laboratory Services: RTC will, in line with recent NDOH guidelines, support the line-probe
assay using PCR methods on all culture positive specimens. This will facilitate the rapid diagnosis of TB
and early diagnosis of M/XDR-TB. As on the South African incidence of drug resistant TB increases, further
expansion of the laboratory infrastructure is required to meet the demand for PCR services. RTC aims to
strengthen access to PCR testing through the central laboratory services of the Department of Molecular
Biology, Contract Laboratory Services, and Wits Health Consortium. Activities will establish the laboratory
infrastructure, provide technical assistance, training of laboratory personnel, and disseminate the DOH and
NHLS guidelines for PCR testing. The sustainability of the laboratory including staffing, pathologist support,
and laboratory consumables will be provided by the NHLS and clinical treatment sites. Linking laboratory
results to patients is critically important. FY 2009 funds will be used to enhance the quality and quantity of
TB diagnosis, including rapid turn-around time for sputum samples to less than three hours, use of LED
microscopy and fluorescent staining methods, and linkage of results to the patient. Throughout the process,
from specimen collection to the final culture result, enhanced attention will be paid to improved infection
control and biosafety standards for TB.
---------------------------------------
Activity Narrative: SUMMARY:
Right to Care (RTC) will use FY 2008 PEPFAR funds in five provinces to strengthen the capacity of
healthcare providers to deliver TB/HIV services, identify TB and HIV co-infected individuals, and improve
the overall quality of clinical and community-based healthcare services. The major areas of emphasis are
human capacity development and local organization capacity building. Target populations include people
infected with TB/HIV, public health care providers and local organizations.
Throughout South Africa, active TB incidence rates are rising, reaching 608 per 100,000 per annum. HIV-
infected patients are at significant risk for developing TB, and 58% of patients attending TB clinics have
been identified as HIV-infected. Of primary importance is the identification of TB in HIV infected individuals,
with over 60 percent of co-infected patients being sputum negative. Improved and early diagnosis of TB in
HIV-infected individuals improves outcomes of morbidity and mortality. Co-infected individuals need to be
initiated on antiretroviral therapy, according to standard treatment guidelines, to ensure improvement in
mortality, morbidity and TB cure rates. RTC will support the South African government's TB program and
the World Health Organization's policy on collaborative TB/HIV activities.
Since FY 2006 RTC has received funding for TB/HIV and plans to integrate the services for TB/HIV for all
co-infected patients at sites throughout the RTC network with the FY 2008 funding. The additional activities
at each of the sites will be: (1) access to HIV counseling and testing for patients with TB, (2) improved
access to induced sputum for TB diagnosis in HIV-infected individuals, (3) improved linkages between the
HIV and TB programs at each of the sites through referral, notification and follow-up; (4) infrastructure
support to develop TB sputum rooms with appropriate infection control procedures to prevent the
transmission of TB. Activities are currently limited by budget to the sites at Themba Lethu Clinic, Sizwe
Hospital, Kimberley Hospital, Shongwe and 4 NGO sites. (5) FBO/NGO clinics focusing on underserved
populations in rural areas, industrial areas and informal housing sectors as well as targeted gender specific
support groups and family centered approaches will be targeted. The programs will promote sustainability
through training of health care workers and partnerships with the National Department of Health (NDOH) to
partially fund the ongoing running cost and staff components, over time.
RTC 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. RTC 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. RTC 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. RTC 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.
With FY 2008 funding, the program will be expanded to all sites in the RTC network. RTC support to
government sites will include infrastructure, human capacity development, salaries and training. Technical
assistance will be provided to improve the integration of TB and HIV services and referral between the sites
treating each of the diseases. In all cases where RTC provides salary support an agreement is made with
the facility where positions will be created and funded by provinces in due course. Oftentimes a government
position has been created, but not filled, and RTC supports a consultant to fill the position until such time as
the province successfully recruits for it.
PEPFAR funds will enable long-term sustainability through support of, salaries, training and human capacity
development at all RTC-supported TB/HIV clinics, in the form of sub-awards for NGO and FBO clinics and
direct salary support for government sites. PEPFAR funds will also be used to adapt existing training
materials to specific TB/HIV issues, and address infrastructure needs, such as HIV counseling rooms in TB
clinics and specialized sputum induction rooms that comply with occupational and environmental safety
standards. This will enhance both safety of obtaining sputum samples and increase sensitivity for positive
sputum test.
At TB/HIV treatment sites, emphasis will be placed on identification of co-infected individuals, through
promoting routine HIV counseling and testing for TB patients and TB screening of HIV patients who present
with risk factors. Co-infected patients will be evaluated for correct application of ARVs and TB medications.
Those on combined ARV and TB treatment will be monitored for the development of Immune Reconstitution
Inflammatory Syndrome. Emphasis is placed on adherence support to address the increased risk of non-
compliance due to high pill burden, and overlapping toxicities, particularly hepatotoxicity. Human capacity
development in the management of anticipated drug interactions and shared adverse effects is an additional
expected result. Family and community support network will be educated and trained in basic TB knowledge
to help support the client with his/her treatment to improve compliance.
In addition to sputum collection, the implementation of low-cost, high through-put, digital, mobile chest x-ray
technology, access to screening x-rays will be improved at rural, distant sites and in underserved
populations. FY 2008 PEPFAR funding will be used to purchase and equip one mobile x-ray facility to assist
the program in rural Northern Cape and Mpumalanga provinces. While x-ray is not a microbiological
diagnosis, it is a simple method to augment diagnosis. TB bactecs and bone marrow procedures are not
planned for the sites at present.
Although the current government policy includes access to INH for primary TB prophylaxis, most clinics do
not have the required capacity or experience to provide this. INH is provided to Helen Joseph by the
provincial government. RTC will evaluate INH prophylaxis at the Helen Joseph Hospital using evidence-
Activity Narrative: based locally relevant data collected within the unit. In collaboration with the local National Health
Laboratory Services ongoing monitoring of the evolution of mycobacterial resistance and effect on incidence
of TB at the hospital will be undertaken. PEPFAR funds will be used for human capacity development,
consultant and sessional salaries and infrastructure, but not for the purchase of INH prophylaxis.
RTC and several of its sub-partners will also continue to incorporate TB/HIV training in ART courses for
doctors, nurses and lay counselors to ensure quality of care.
Through induced sputum and chest x-ray, this program will improve TB case finding, improved sputum
diagnosis and early TB treatment initiation. Through improved adherence to TB treatment, and improved
notification and referral, the aim is to improve TB cure rates. Through improved HIV counseling and testing
and referral to ARV treatment, overall TB cure rates and mortality outcomes are anticipated.
Overall the planned activities include monitoring and evaluating the outcomes of the integration of TB and
HIV services on patients' outcomes, hospital stays, and mycobacterial outcomes of cure and resistance.
By reaching patients with TB/HIV therapy at various outlets, RTC will contribute to the PEPFAR goal of
providing services to 10 million HIV-affected individuals. In addition, the activities support the USG Five-
Year Strategy for South Africa by training health care workers in TB/HIV services, significantly strengthening
these services and their integration into HIV and primary health care services.
Continuing Activity: 13794
13794 3276.08 U.S. Agency for Right To Care, 6612 271.08 $3,395,000
7548 3276.07 U.S. Agency for Right To Care, 4460 271.07 $0
3276 3276.06 U.S. Agency for Right To Care, 2652 271.06 $350,000
Estimated amount of funding that is planned for Human Capacity Development $2,840,296
Table 3.3.12:
SUMMARY: Right to Care (RTC) is one of the most successful counseling and testing (CT) partners of the
South African PEPFAR program, using leveraged funds to provide access to the Proudly Tested program.
In FY 2009, PEPFAR funds will emphasize provider initiated HIV testing at all antiretroviral treatment (ART)
sites, and, through direct community-based access to CT in all nine provinces of South Africa.
BACKGROUND: RTCs CT services are a continuation of ongoing activities. The point of care testing is
conducted using an opt-in policy of the Department of Health (DOH) and is provided with streamlined post-
test counseling for risk reduction. Couples CT and improving the testing of males and home-based HIV
testing have been successfully implemented by RTC. Sexually transmitted infection (STI) assessments and
tuberculosis (TB) symptom screenings are included in CT activities. The CT activities of RTC now exceed
100,000 clients annually from predominantly vulnerable populations.
RTC implements workplace programs and collaborates with employers to extend the HIV testing funded by
the employer to the temporary or contractors workers and/or community. This workplace program is
currently contracted to 130,000 employees of 38 companies. After three years of the program, >80% of
employees volunteer to go for CT. All RTC CT initiatives are coordinated through the Proudly Tested
campaign. This campaign, a registered trademark under RTC, is intended to create a brand that promotes
regular CT for individuals and groups in all social levels. RTC has implemented a unique mobile data
system, encompassing biometric consent, to enable both the collection of data and improved transition to
care through reporting and referral.The data systems have been developed on an open-source code
platform and can be made available to other CT partners.
ACTIVITY 1: Scaling of access to CT through provider initiated CT
FY 2009 funds will support the continuation of assistance to government sites, non-governmental and faith-
based organization (NGO), and faith-based organization (FBO) clinics, as well as to private practitioners to
ensure the widespread availability of CT services. PEPFAR funds will largely be used for human capacity
development including: (a) salaries for consultants and part-time healthcare workers at all CT providers, (b)
sub-grants for NGO and FBO clinics and organizations that are partially earmarked for nurses and lay
counselors, (c) direct salary support for lay counselors and nurses at government sites, (d) providing direct
CT support to all TB sites supported by RTC to ensure that all TB patients are tested for HIV, and (e)
scaling up the PMTCT testing of pregnant women, their partners through the use of rapid testing methods
for point of care diagnosis of HIV, and infant PCR diagnosis for children born of HIV-infected mothers.
PEPFAR funds will also be utilized to address minor infrastructure needs such as for the delivery of CT
services at NGO, FBO and government sites.
ACTIVITY 2: Support for CT Providers
RTC will support all its CT providers by disseminating guidelines on CT, by providing quality assurance
through sharing best practices and supportive supervision, and by offering guidance on monitoring and
reporting of results. RTC and several of its sub-partners will also provide ongoing training in CT services for
lay counselors and nurses (either employed by RTC or its partners, or external health workers) to ensure
strict adherence to CT protocols and high quality counseling. RTC will also support healthcare providers in
public health facilities to implement provider-initiated counseling and testing (PICT) as recommended in the
HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011.
ACTIVITY 3: Community-based CT
The strategic mix of clinic-based and community-based CT will see further expansion of activities which will
bring CT services to the doorstep of impoverished populations and high-risk, male dominated groups such
as truck drivers, farm workers, small and medium enterprise (SME) employees, Direct AIDS Intervention
(DAI) contract/temporary workers, tertiary students, rural communities and residents of informal settlements.
Mobile and rural clinics, home-based CT in partnership with the Home Loan Guarantee Company, and clinic
-linked units will be established in vulnerable communities.
ACTIVITY 4: Prevention and Behavior Change
In FY 2009, RTC will support a partnership with Cell-life to develop a cell phone program focused on the
provision of prevention education messaging using mobile technologies. This program will be a public
private partnership with the Vodacom Foundation (committed to providing 1:1 funding to Cell-life) for the
expansion of the use of mobile platforms for HIV prevention and transition to care. Content for messaging
has already been developed. This same platform will be used to manage all appointments scheduling for
patients who are found to be HIV-infected at the time of CT, and through TxtAlert provide patient reminders
for medical appointments.
ACTIVITY 5: Strengthening Expansion of Referral Networks and Increasing Initiation to Treatment
Linkages with community mobilization and outreach activities will be continued to promote the uptake of CT
services and to normalize CT-seeking behavior using community lay counselors and educators. These
linkages and capacity building with indigenous organizations will affect long-term sustainability. Prior to all
CT activities, referral linkages will be established for direct referral at the time of CT.
ACTIVITY 6: Large Scale Mass Media CT Promotion
In collaboration with other CT providers, RTC is participating in the annual national HIV testing week
promoted through Khomanani and will include enhanced testing at mobile and facility-based sites and other
Activity Narrative: non-traditional testing sites. The entire network of RTC nurses will be available at treatment sites.
------------------------------
INTEGRATED ACTIVITY FLAG:
SUMMARY: Right to Care's PEPFAR program will be recompeted through an Annual Program Statement
(APS) in 2008. Right to Care (RTC) will use FY 2008 PEPFAR funds to identify HIV-infected individuals by
supporting selected antiretroviral treatment (ART) sites and through direct community-based access to
counseling and testing (CT) in seven provinces, namely KwaZulu-Natal, Free State, Eastern Cape,
Limpopo, Mpumalanga, Western Cape and Northern Cape. CT is used as a prevention mechanism to
promote abstinence, be faithful and condoms, as well as an entry-point into care, support and ART. It is also
an essential tool for fighting stigma and discrimination. The major area of emphasis is human resources.
Minor areas of emphasis include community mobilization/participation, training and workplace program.
Specific target populations include university students, adults, pregnant women, HIV-infected infants,
truckers, and public and private sector healthcare providers.
BACKGROUND: RTC's CT services are a continuation of ongoing activities. CT was originally part of RTC's
holistic education, testing, care and treatment program for the employed sector, known as the Direct AIDS
Intervention (DAI) program. RTC's CT activities have since expanded their reach through a range of
partnerships with government sites, private sector providers and non-governmental and faith-based clinics
and organizations, and are now reaching substantial numbers of clients from predominantly vulnerable
populations, through clinic-based and mobile CT services.
RTC is currently implementing a program of CT for vulnerable populations. Testing is conducted by nurse
networks, General Practitioner (GP) networks, mobile CT clinics or by sub-partner non-governmental
organizations (NGOs). RTC implements workplace programs and often collaborates with a private sectorr
partner, Alexander Forbes' Comprehensive Health and Wellness Solutions.
Uptake of on-site CT is reaching high proportions. Almost 90% of employees volunteer to go for CT. RTC
supports the Access CT activities of treatment partners, including the Thusong network of private
practitioners, several government sites, and non-governmental and faith-based organization sites. CT
training is conducted by RTC's Training Unit as well as by several of RTC's sub-partners.
All RTC CT initiatives are coordinated through the Proudly Tested campaign. This campaign, a registered
trade mark under RTC, is intended to create a brand that promotes regular CT for individuals and groups in
all social levels. High-profile leaders within communities will promote this brand and strategy to create
increased social acceptance of CT. The Proudly Tested activities will also include commercial CT, which will
receive technical support through PEPFAR funds.
RTC used FY 2008 funds to consolidate and expand its existing activities; building on past successes. RTC
tested more than 52,000 clients, and trained 180 healthcare workers and lay counselors in the first three
quarters of FY 2007.
ACTIVITY 1: Assistance to South African Government Sites
FY 2008 funds will support the continuation of assistance to government sites, NGO, and FBO clinics as
well as to private practitioners to ensure the widespread availability of CT services. PEPFAR funds will
largely be used for human capacity development including (a) salaries for consultants and part-time
healthcare workers at all CT providers; (b) sub-grants for NGO and FBO clinics and organizations that are
partially earmarked for nurses and lay counselors; (c) direct salary support for lay counselors and nurses at
government sites; and (d) support for a fee-for-service arrangement with private contractors such as the
private and Access CT programs and a network of private practitioners for the Thusong program. PEPFAR
funds will also be utilized to address minor infrastructure needs such as for the delivery of CT services at
NGO, FBO and government sites, for the maintenance of RTC's mobile clinics, and for the procurement and
distribution of HIV test kits for NGO and FBO clinics.
public health facilities to implement provider-initiated testing and counseling (PITC) as recommended in the
HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011. Providers will be trained on PITC as well
as on conducting HIV rapid tests. This activity will include internal and external quality assurance around
rapid testing.
ACTIVITY 3: Prevention and Behavior Change
The success of CT as a prevention activity should include promoting prevention and behavior change
including "abstinence, be faithful and condom use", reducing stigma, encouraging disclosure and couple
counseling. HIV-infected individuals are referred from CT to care services. RTC's counselors are trained to
provide counseling services in all prevention areas. In FY 2007 RTC will maintain models of increasing
transition to care including the use of CD4 count testing at the time of CT to encourage early patient staging
for referral. Access to a 24-hour call center for post-test counseling has also proven to be beneficial.
Activity Narrative: ACTIVITY 4: Strengthening Expansion of Referral Networks and Increasing Initiation to Treatment
The strengthening and expansion of referral networks and linkages with care and treatment services for
clients identified as HIV-infected remains one of the central focus areas of RTC's CT activities. Linkages
with community mobilization and outreach activities will be continued to promote the uptake of CT services
and to normalize CT-seeking behavior using community lay counselors and educators. These linkages and
capacity building with indigenous organizations will affect long-term sustainability. Prior to all CT activities,
referral linkages will be established for direct referral at the time of CT. A CT module through Therapy Edge,
an electronic patient database system, is being developed to track all positive CT clients, for call center
counselors to follow-up and direct referral and regular CD4 test.
ACTIVITY 5: Community-based CT
as truck drivers, farm workers, small and medium enterprise (SME) employees, DAI contract/temporary
workers, tertiary students, rural communities and residents of informal settlements. Mobile and rural clinics,
home-based CT in partnership with the Home Loan Guarantee Company, and clinic-linked units will be
established in vulnerable communities. Through a public-private partnership, RTC will increase CT uptake
in a cost-sharing model with commercial companies. PEPFAR funds will be used for technical support,
training and CT kits, while the commercial partner will cover the substantial direct cost of nurses, facilities
and other direct activities. This cost-sharing model will enable CT of contract workers, employees and
unemployed persons.
Emphasis will be placed on consolidating and expanding CT services for couples, infants and children, and
cross-testing (testing STI and TB patients for HIV and vice versa, and testing of pregnant women).
FY 2008 funds for counseling and testing will be used by Right to Care to expand services in government
sites, NGO and FBO clinics as well as to private practitioners to ensure the widespread availability of CT
services. The organization will assist the National Department of Health and the provincial Departments of
Health in Gauteng, Northern Cape, and Mpumalanga with activities for National Testing Week. The South
African National Testing Week will include enhanced testing at mobile and facility-based sites and other non
-traditional testing sites. Right to Care will also focus on improving provider-initiated testing and counseling.
Continuing Activity: 13795
13795 2972.08 U.S. Agency for Right To Care, 6612 271.08 $1,616,000
7544 2972.07 U.S. Agency for Right To Care, 4460 271.07 $0
2972 2972.06 U.S. Agency for Right To Care, 2652 271.06 $1,100,000
Estimated amount of funding that is planned for Human Capacity Development $1,997,027
Estimated amount of funding that is planned for Education $60,893
Table 3.3.14:
Right to Care (RTC) supports the South African Government in the implementation of the HIV and AIDS
Program. However, in areas where health systems are weak and there are no ARV services, NGO
treatment sites are capacitated by RTC as requested by government to provide comprehensive HIV and
AIDS services. These sites which are earmarked for accreditation as government sites once governments
budget becomes available serve a large number of very poor individuals who are mostly based in rural
settings and cannot afford to access health care services. FY 2009 funding for ARV drugs will be used to
only expand government requested assistance in developing non-governmental (NGO), faith-based
organization (FBO), and community-based organization (CBO) clinics. Thusong, a private practitioner
program for indigent patients is the treatment model used in areas where there are no government systems
in place. The Thusong program is not planned for expansion, patients have started to be transitioned into
the government program and this will continue in FY 2008 and FY 2009. However,, this program will remain
operational to allow RTC to treat patients under this program where necessary. No new NGO treatment
sites will be started without the support and commitment of government. The areas of emphasis where
PEPFAR funds are used include: human resources (direct salary support for government seconded
pharmacists, pharmacist assistants and therapeutic counselors and sub grants for NGOs), human capacity
development, drug and commodity procurement and distribution, quality assurance, supportive supervision,
infrastructure, and training. All of the government sites that RTC supports receive its drugs through internal
government systems and the drugs are not procured using PEPFAR funds.
In FY 2009, pharmaceutical procurement and supply will continue to be managed by RTCs partnership with
Rightmed Pharmacy, this partnership has enabled all RTC supported facilities to have no stock-outs to date
on any drugs despite global shortages of stavudine and lamivudine.
PROCUREMENT AND STORAGE:
The wholesalers deliver medicines to Rightmed and these are signed for by a pharmacist, the medication is
checked against the invoice and stored at Rightmed under temperature-controlled conditions which are
monitored and recorded daily.
PRESCRIPTIONS:
Prescriptions from the NGO treatment sites are either couriered or faxed daily (with follow up originals to be
couriered weekly) to Rightmed and are dispensed as they are received and then batched for courier
collection with the drug arriving at the sites within 48hours depending on the area of the site. All
prescriptions must contain the patient's weight and site identifier as well as all information required by the
South African Pharmacy and Medical Regulations. All prescriptions are checked to ensure all regimens and
dosages conform to SA HIV treatment guidelines.
DISTRIBUTION AND DISPENSING:
A pharmacist or a qualified post basic pharmacist assistant is responsible for retrieving, labeling and
packing the ordered medicine. The medication is individually labeled using labels printed by the
Pharmassist software program. The labels will show the following information: the date the prescription was
processed, drug trade name, drug strength, drug quantity, directions of use, prescription number, patient
initials and surname, dispenser name and telephone number, prescriber name, pharmacy address and
contact details. Patient details and treatment history are stored in an electronic dispensing program, which
assigns prescription numbers to all prescriptions and chronologically stores all the prescription details. A
second pharmacist quality assures the shipment by verifying that the correct drug was dispensed to the
correct patient as well as all other dispensing and shipping details. It is highly unlikely that the patients need
come to the pharmacy but they may, they may also call the pharmacy and speak to the pharmacist at any
time during office hours or call the 24-hour toll-free line for after hours advice. All the pharmacy staff that
work at Rightmed are highly trained and experienced in the field of HIV treatment. The expertise from
Rightmed Pharmacy will continue to be used for training and mentorship for various government and NGO
ACCOUNTABILITY:
A Complete Drug Accountability Record is kept at Rightmed with the following information: drug description
(name and strength), batch number, expiry date, prescription number (which holds all script details), number
of containers dispensed, and dispenser initials. The medication is packed into a carton and shipments are
processed one shipment at a time. A packing list is sent with every shipment. Once the medication arrives
at the site, the site checks the medication, signs the packing list and faxes it back to Rightmed. Drugs are
then securely stored at the site and are issued to the patients on a monthly basis, in remote areas where it
is hard to attract and retain scarce skills like pharmacists; this model removes the requirement to have a
pharmacist on site because the drugs have already been dispensed at Rightmed. As the patient numbers
grow and where the sites are able to harness the capacity of a pharmacist, direct procurement is facilitated.
The medication is issued to patients by the site clinician who counsels the patient and ensures that the
patient understands the directions. All the staff at the RTC supported sites is offered comprehensive HIV,
TB and counseling training courses free of charge. The patients receive their drugs at no cost as this is
funded by Right to care. Any unused medicine is returned to Rightmed for incineration or destroyed at site
level using the services of a medical waste disposal company. At any one time a three-month buffer supply
of stock is held at Rightmed so as to ensure uninterrupted drug supply to the patients. If there are any
transferred or deceased patients, the site managers inform Rightmed so that pharmacy records are
updated.
Activity Narrative: Following DOH accreditation of the NGO and CBO clinics, government takes over the costs of the drugs,
labs and some staff salaries and the funding which was used for that is re-channeled to other areas that still
need strengthening within the site or to other sites that need support. RTC is working with each site to
ensure that there is a plan in place for the government to take over these salaries as soon as feasible and a
RTC hand over to government has already occurred in the Mpumalanga province. In an effort to support the
government to address the chronic shortage of pharmacists, RTC has embarked on a program to train
pharmacist assistants in partnership with government using PEPFAR funding. This crucial training program
will continue to be supported as the learners are earmarked for placement government sites once they are
qualified. With the graduation of NGO sites and the training of pharmacist assistants sustainability is
addressed. RTC will also expand the current pharmacist expertise in pediatric treatment. The provision of
additional staff that are trained and the clinical infrastructural improvements contribute to the improvement
of quality treatment outcomes.
With FY 2009 funding, RTC will continue to use PEPFAR funds for direct salary support for pharmacists and
pharmacy assistants at government treatment sites to enhance the widespread and sustainable availability
of ARV drug services. Subject to government requests, PEPFAR funds may be used to upgrade
infrastructure and equipment needs at government sites and at NGO and FBO clinics. RTC will also expand
the current pharmacist expertise in pediatric care and procurement.
With FY 2009 funding, RTC will procure and supply ARV drugs to RTC-supported treatment programs and
sites, directly contributing to the 2-7-10 goal of two million people treated. RTC will support the PEPFAR
vision outlined in the Five-Year Strategy for South Africa by expanding access to ART services for adults
and children, building capacity for ART service delivery, and increasing the demand for and acceptance of
ARV treatment.
Right to Care (RTC) will use FY 2008 PEPFAR funds to procure and distribute antiretroviral (ARV) drugs to
partner antiretroviral treatment (ART) sites and programs in five provinces to expand ART for eligible HIV-
infected individuals. Funds are used to procure ARV drugs used in non-governmental and faith-based
organizations (NGOs, FBOs), and remote treatment sites. RTC will continue to refer HIV-infected individuals
identified through counseling and testing (CT), care, and support services, when indicated, into ART
services. The emphasis areas are human capacity development, renovation, and local organization capacity
building. Populations to be targeted include people living with HIV (PLHIV) and pharmacists.
Since 2005 PEPFAR funds have been used for human capacity development and for consultant and
sessional salaries for employees that augment NGO clinics and government sites. Pharmacists are
employed at each site as it grows and as numbers of patients on treatment rise above 500. RTC will
continue ARV drug activities, which have been PEPFAR-funded since 2004, when RTC began supporting
the purchase of ARV drugs for patients treated through NGOs, FBOs, and the Clinical HIV Research Unit
(CHRU). Pharmaceutical procurement and supply is managed by Rightmed Pharmacy, an independent
pharmacy established that meet the South African pharmacy regulations.
With FY 2008 funding, RTC will consolidate and expand its existing activities, building on past successes in
procuring and supplying ARV drugs to its treatment sites/programs. RTC sites have had no stock-outs to
date on any drugs despite global shortages in stavudine and lamivudine. All RTC-supported government
sites receive drugs through internal government systems.
PEPFAR funds will continue to be used for the procurement and distribution of ARV drugs via Rightmed
Pharmacy for the current NGO and FBO clinics as well as for the Thusong program. The Thusong program
provides ART to those unable to access care through Department of Health (DOH) sites. ARV scripts are
forwarded to Rightmed, which handles all the procurement, logistical and pharmaceutical management,
dispensing and distribution of ARVs. The drugs are delivered to the treatment sites via an independent
courier company on a weekly basis. Treatment sites receive batches of drugs for multiple patients, with
drugs labeled and dispensed on a patient-named basis. Drugs are then securely stored at the site and
dispensed to the patient on a monthly basis. Where sites are able to harness the capacity of a pharmacist,
direct procurement is facilitated. Sub-awards for clinics will also include funding for pharmacy staff.
Following DOH accreditation of the NGO and FBO clinics, the South African government will take over the
costs of the drugs and labs. RTC will re-channel funds that were allocated to ARVs and labs to supporting
additional staff, human capacity development and minor infrastructure adjustments. Additional staff,
including dieticians and social workers, may be hired to meet the full staff complement for an accredited
ARV clinic as defined by government. RTC is working with each site to ensure that the South African
government takes responsibility for these salaries at accredited sites as soon as feasible. With government
taking over the cost of ARVs, and the increased number of pharmacists receiving training, sustainability is
addressed. The provision of additional staff that are trained and the clinical space adjustments will
contribute to the improvement of quality treatment outcomes.
In FY 2008, RTC will use PEPFAR funds for direct salary support for pharmacists and pharmacy assistants
at government treatment sites to enhance the widespread and sustainable availability of ARV drug services.
Subject to needs assessments, PEPFAR funds may be used to upgrade infrastructure and equipment
needs at government sites and at NGO and FBO clinics. RTC will also expand the current pharmacist
expertise in pediatric care and procurement. Expertise from Rightmed Pharmacy will be used in training and
mentorship at various government and NGO sites.
Activity Narrative: In FY 2008, RTC will procure and supply ARV drugs to RTC-supported treatment programs and sites,
directly contributing to the 2-7-10 goal of two million people treated. RTC will support the PEPFAR vision
outlined in the Five-Year Strategy for South Africa by expanding access to ART services for adults and
children, building capacity for ART service delivery, and increasing the demand for and acceptance of ARV
treatment.
Continuing Activity: 13796
13796 2974.08 U.S. Agency for Right To Care, 6612 271.08 $1,173,000
7546 2974.07 U.S. Agency for Right To Care, 4460 271.07 $0
2974 2974.06 U.S. Agency for Right To Care, 2652 271.06 $5,321,000
Estimated amount of funding that is planned for Human Capacity Development $1,905,277
Table 3.3.15:
