PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
Absolute Return for Kids (ARK) will use PEPFAR FY 2009 funds to co-fund new prevention of mother-to-
child transmission (PMTCT) activities in the Eastern Cape (EC). ARK has been requested by the EC HIV
and AIDS, STI and TB (HAST) directorate and the Nelson Mandela Metro to scale up support in this
province. ARK has been supporting the province since 2006 and is currently working in 11 sites, delivering
care and treatment in 10 sites and PMTCT services in 1 site.
PEPFAR funding for FY 2009 will support the implementation and scale up of the revised national PMTCT
guidelines in the EC. The scale up in ARK-supported sites will ensure that women in the high HIV burden
areas of the EC are reached with PMTCT services.
Modifications to FY 2008 activities are as follows:
ACTIVITY 1: Support to KwaZulu-Natal and Eastern Cape Departments of Health
Referral systems will be strengthened to ensure the easy, quick referral of patients between antiretroviral
ARV, TB, PMTCT and pediatric ARV services to ensure that mothers and infants testing HIV positive will be
referred for early care and treatment. Tracing of lab results for early infant diagnosis will be conducted
proactively to ensure that bottlenecks in the system are addressed with the KwaZulu-Natal and Eastern
Cape Departments of Health and the National Health Laboratory Services. Additional information
management capacity will be added to sites including data capturers and computers. All sites will have
internet connectivity to facilitate information management activities. TB infection control practices are
standard at ARK-supported sites, include well-ventilated waiting areas and consulting rooms, safe sputum
collection, and patient and staff education on safe cough etiquette and hygiene. All HIV-infected pregnant
women and HIV-exposed infants who have a TB contact will receive TB screening, prophylaxis and
treatment if appropriate.
In those clinics where space is a bottleneck to service delivery, ARK will assist the facility with the provision
of space in the form of temporary infrastructure, or renovating existing rooms to ensure efficient patient flow.
ACTIVITY 2: Treatment for HIV-infected Pregnant Women
All HIV-infected pregnant women will be screened for TB and referred for further diagnostics, prophylaxis
and treatment as appropriate. Linkages to on-site family planning services will be established where
available. Linkages will be established with other service providers who are providing prevention-focused
support groups for HIV-infected pregnant women.
ACTIVITY 3: Pediatrics
ARK's program follows current National Department of Health guidelines for PMTCT prophylaxis, therefore
mothers with a CD4>350 or between 250-350 with WHO Stage 1&2 will not be given Highly Active
Antiretroviral Therapy (HAART), as anticipated in the FY 2008 plan. All babies will be tested 12 weeks post-
weaning if breastfeeding, and all negative infants will be re-tested with an Elisa at 18 months.
The PMTCT program will link into the pediatric care component to allow for improved child survival activities
with specific reference to improved diagnosis and treatment of TB, recommended Vitamin A
supplementation, routine immunization and the integrated management of childhood diseases. All HIV-
exposed infants will receive the basic preventative care package including infant feeding and nutrition,
cotrimoxazole prophylaxis, early testing, and TB screening, prophylaxis and treatment.
------------------------------------------
SUMMARY:
Absolute Return for Kids' (ARK) focus is to provide a comprehensive care package for PMTCT services to
HIV-infected mothers and their children through partnerships with local government health facilities. ARK's
primary emphasis has been in areas of human capacity development, local organization capacity
development, and construction/renovation at about ten facilities. The target population is HIV-infected
pregnant women and their infants.
BACKGROUND:
ARK is a charity organization whose mission is to facilitate and support delivery of accessible, sustainable
comprehensive treatment, care and support services to children and their caregivers in communities
affected by HIV and poverty. In partnership with the KwaZulu-Natal Department of Health (KZNDOH), ARK,
has established an antiretroviral treatment program in government primary health facilities and hospitals.
Specifically, ARK works with the KZNDOH to identify sites and areas for capacity building, including human
resources, modest infrastructure support, and organizational capacity development. PEPFAR funding has
enabled ARK to successfully enroll over 15,000 patients in ART in KZN with about 12000 remaining in care
at ARK supported sites.
FY 2008 funding will enable ARK to expand its established ARV treatment program to include a
comprehensive range of PMTCT services. These services will be supported by improvements in the
infrastructure of targeted sites, and the provision and training of human resources in partner health facilities
to further strengthen their capacity to deliver quality counseling and testing, treatment, care and support for
HIV-infected mothers and their children.
ACTIVITIES & EXPECTED RESULTS:
ACTIVITY 1: Support to KZNDOH
Activity Narrative: ARK works with the KZNDOH to develop the necessary processes and systems to manage the PMTCT
program, to ensure that the model implemented is scaleable, sustainable and replicable elsewhere. ARK's
PMTCT program works within KZNDOH selected districts and focuses on strengthening the existing
networks of operating clinics; capacity-building is site specific. Upon identification of a site, ARK conducts
an analysis to identify staffing, clinical equipment, and infrastructure needs. The program works with facility
management to prioritize and promptly address gaps and develop plans for manageable scale-up. ARK
also assesses hospital patient data management systems and will employ and train, where needed, data
capturers. The data capturers support both providers and facility administrators to strengthen the
management and use of patient records systems for improved service delivery.
ACTIVITY 2: Human Capacity Development
ARK will conduct a thorough needs analysis of human resource capacity prior to initiating support to the
PMTCT program at each site and recruit all the necessary medical staff required for the successful rollout of
services. The staff recruited varies from site to site but include doctors, nurses, pharmacists, pharmacy
assistants, medical technologists, facility-based counselors, and patient advocates. For all key staff, ARK
will provide two-week orientation training based on the National PMTCT and Infant Feeding Curriculum and
Methodology. The training and follow-up refresher courses cover all aspects of ARK's PMTCT program
including employee policies and procedures, onsite mentorship from experienced ARK staff, and an
introduction to key performance areas. The specific topics covered include: counseling and testing,
treatment guidelines for pregnant women, management of opportunistic and sexually transmitted infections,
adherence support as well as the value of community access, prevention counseling and patient advocacy.
Staff are invited and encouraged to attend formal training offered by external providers including other
PEPFAR partners such as the Foundation for Professional Development (FPD).
ACTIVITY 3: Counseling and Testing
ARK will focus on provider driven opt-out testing to all pregnant mothers entering the antenatal clinics. To
better ensure sustainability, where possible, ARK will use the counselors available through the District HIV
program and existing trained community care workers to provide counseling. Where needed, ARK will
employ and train additional counselors. Counseling and ongoing training will be in line with the National
Department of Health (NDOH) Guidelines. ARK will provide mentorship and supportive supervision to lay
counselors to ensure high quality standards for CT. In accordance with NDOH standards, all testing will be
conducted by trained medical staff (primarily nurses). Pre-and post-test counseling for all clients will include
information on HIV & AIDS, STIs, prevention education, risk reduction strategies, and partner testing. Post-
test counseling will further include information and support on treatment, care and support services, and
positive living.
Formal and informal training and onsite mentorship will be provided to all lay counselors in the program.
ARK, in partnership with the Centre for Social Science Research at the University of Cape Town, will
continue to develop and improve training modules for lay counselors. The areas covered in training include:
basic and advanced counseling skills, positive living, disease progression, opportunistic infections, risk
reduction for HIV transmission and safer sex.
ACTIVITY 4: Treatment for HIV-infected pregnant women
All pregnant women testing positive for HIV will have an immediate CD4 test and will have a clinical
assessment for the present of opportunistic infections and for staging. Women will receive nutritional
counseling as well as counseling around feeding options for their babies. Exclusive breast feeding will be
encouraged in those women who do not satisfy the AFASS principles for formula feeding. A particular focus
will be on triaging pregnant women who are treatment eligible into treatment programs, and ensuring that
women who are not treatment eligible are provided with the appropriate dual-drug prophylaxis (new DOH
guidelines.) The process and follow up of women on triple therapy will be dependant on the facility. In some
facilities this site will be in the same place as the antenatal service, in others the ARV treatment site will be
separate to the antenatal clinic.
Upon registration into the PMTCT program, a paid trained patient advocate is assigned to the patient. The
patient advocate conducts a pre-treatment home visit and provides ongoing support to the patient and her
family. The patient advocate will accompany the mother to her antenatal visits, provide adherence support
and referrals and follow-up as needed. Should a patient be non-adherent or lost to follow-up, the patient
advocate will investigate the reasons for this, acting as the link between the patient and the clinic. ARK
facilitates the integration process for ART, TB, palliative care and OVC care and support services where
appropriate.
ACTIVITY 5: Pediatrics
HIV-infected pregnant women will be educated and encouraged during pregnancy to undertake post
delivery testing for their babies. All children born to HIV-infected mothers will be closely followed up for any
evidence of early deterioration and will receive NVP and AZT as per PMTCT protocol. At the six week visit,
all HIV exposed babies will have a PCR test done, will be given cotrimoxazole prophylaxis and multivitamins
to await the PCR result. Mothers with a CD4>350 or between 250-350 with WHO STG 1&2 will stop HAART
if babies are exclusively formula fed OR after weaning if exclusively breast fed. Formula fed babies that test
negative will be offered an Elisa at 18 months. Breast fed babies if tested negative will be offered a PCR at
12 weeks after weaning and if still negative an Elisa at 18 months. HIV-infected babies will be immediately
referred to ARK's ARV treatment program and will have access to cotrimoxazole prophylaxis, multivitamin
supplements and general nutritional advice, and breastfeeding counseling and support for the mother. The
patient advocates (PA) will ensure that all babies are brought back for their immunization and testing for HIV
will be actively encouraged by the community workers.
Activity Narrative: ACTIVITY 6: Family-Centered Care and Support Services
In an effort to encourage adherence among mothers and ongoing care for their infants, ARK's program
takes an integrated maternal and child health care approach and extends care and support (including
treatment literacy and prevention education) to all members of a patient's household. Together, facility-
based counselors and patient advocates counsel mothers and their partners on treatment literacy, nutrition,
safe infant feeding practices, and safe sex. They offer services within homes and provide encouragement
and support to male partners to serve as "adherence buddies" in the management of care during pregnancy
and after delivery. Patient advocates are also trained to provide basic psychosocial support and link
mothers to individual counseling services and/or support groups.
ACTIVITY 7: Quality Assurance/Improvement
ARK provides computers and employs data capturers at all sites. Data is captured from patient folders and
transferred to ARK's data center, allowing for ongoing evaluation and outcome analysis. Adherence rates,
death rates and loss to follow-up are closely monitored. Quarterly updates are provided to the KZNDOH and
information is used within the clinics to strengthen service delivery. All ARK staff are provided onsite, on-the
-job training, followed with regular onsite mentorship and evaluation by ARK's national executive and
provincial management teams. Informal training sessions are conducted quarterly. Staff are encouraged to
attend formal external training courses offered by FPD.
These activities contribute to PEPFAR's 2-7-10 goals by increasing the number of South Africans on
treatment and possible new infections averted among infants and children.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13355
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13355 13355.08 U.S. Agency for Absolute Return 6447 2787.08 $727,500
International for Kids
Development
Emphasis Areas
Health-related Wraparound Programs
* Child Survival Activities
* Safe Motherhood
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $62,412
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
SUMMARY
Absolute Return for Kids (ARK) will be using PEPFAR FY 2009 funds to co-fund its Community Access and
Adherence (CAA) activities in the Eastern Cape (EC). ARK has been requested by the EC HIV and AIDS,
STI and TB (HAST) directorate and the Nelson Mandela Metro to further scale up support in this province.
ARK has been supporting the province since 2006 and is currently working in 11 sites, delivering care and
treatment in 10 sites and prevention of mother-to-child (PMTCT) services in one site. The scale up in these
sites will ensure that individuals in needy areas of the EC have adequate access to care and treatment.
ACTIVITY 1: Support to KwaZulu-Natal (KZN) Department of Health (DOH) and EC Department of Health:
All diagnosed HIV-infected patients and family members will receive TB screening, prophylaxis and
treatment if appropriate
(ARV), TB, PMTCT and pediatric ARV services Tracing of lab results for early and ongoing diagnosis will be
conducted proactively to ensure that bottlenecks in the system are addressed with DOH and the National
Health Laboratory Services (NHLS).
TB infection control practices are standard at ARK-supported sites and include well-ventilated waiting areas
and consulting rooms, safe sputum collection, and patient and staff education on safe cough etiquette and
hygiene.
ACTIVITY 5: Reporting and Quality Assurance/Improvement
Scale-up of clinical services includes increasing capacity for data management and reporting. All sites will
have additional data capturing support, and additional monitoring and evaluation management support at
the provincial office. All sites will have internet connectivity to facilitate information management activities.
-------------------------------
Absolute Return for Kids' (ARK) focus is to provide a comprehensive palliative care package for services to
primary emphasis areas are human capacity development, local organization capacity development, and
construction/renovation. The target population is people living with HIV and AIDS.
ARK is a charity organization whose mission is to facilitate and support delivery of accessible and
sustainable comprehensive treatment, care and support services to children and their caregivers in
communities affected by HIV and poverty.
ARK's mission is to facilitate and support delivery of accessible and sustainable comprehensive treatment,
care and support services to children and their caregivers in communities affected by HIV and AIDS. In
partnership with the KwaZulu-Natal Department of Health (KZNDOH), ARK, as the implementing partner,
comprehensive range of palliative care services. These services will be supported by improvements in the
to further strengthen their capacity to deliver quality care and support for HIV-infected mothers and their
children. ARK provides palliative care services in accordance with South African national treatment
guidelines.
ACTIVITIES AND EXPECTED RESULTS:
ARK's primary objective is to keep mothers alive to continue caring for their children. The primary
caregiver's continued survival and potential ability to earn a living while receiving ARV treatment will have a
substantial impact on the extended family.
ARK works with the KZNDOH to develop the necessary processes and systems to manage the palliative
care program, to ensure that the model created is scaleable, sustainable and replicable elsewhere.
Capacity-building is site specific. Upon identification of a site, an analysis of the needs of each site will be
done with respect to staffing (doctors, nurses, pharmacists and pharmacy assistants), clinical equipment,
management systems, patient advocacy and temporary structures. The most pressing requirements are
met in order to speed up the ability for patients to receive treatment. Where necessary ARK provides
support in the ARV site and pharmacy accreditation process.
Activity Narrative: ARK will conduct a thorough needs analysis of human resource capacity prior to initiating support to the
palliative care program at each site and recruits all the necessary medical and support staff required for the
successful rollout of services. The staff recruited varies from site to site but include doctors, nurses,
pharmacists, pharmacy assistants, medical technologists, facility-based counselors, and patient advocates.
For all key staff, ARK will provide training and follow-up refresher courses cover all aspects of ARK's
palliative program including employee and volunteer policies and procedures, onsite mentorship from
experienced ARK staff, and an introduction to key performance areas. The specific topics covered include:
counseling and testing, screening for pain and symptoms, screening for OIs including the provision of
cotrimoxazole prophylaxis, symptom control and management of opportunistic and sexually transmitted
infections, nutritional assessment and counseling, adherence support, as well as the value of community
access, prevention with positives, referral and patient advocacy. Staff are invited and encouraged to attend
formal training offered by external providers including other PEPFAR partners such as the Hospice
Palliative Care Association (HPCA) and Foundation for Professional Development (FPD).
ACTIVITY 3: Clinical Care
ARK's palliative care program focuses on a network of clinics operating within a district, in order to create a
sustainable and efficient system that supports the continuum of care and up and down referral. ARK-
employed doctors and nurses provide comprehensive treatment management including patient uptake,
doctor consultations, counseling and testing, TB screening and management, pain management and
symptom control, treatment of opportunistic and sexually transmitted infections including the provision of
cotrimoxazole, lab testing and patient education. Pharmacists are responsible for the dispensing of
medication.
As part of the palliative care package for HIV-infected individual, individuals accessing ARK's services will
be staged and entered into ARK's ARV treatment program. All patients with a CD4 count of <200 will be
referred to ARK's ART program to confirm their eligibility for treatment. The program's medical and
psychosocial criteria are designed to ensure that the patient is prepared and ready to adhere to ART. All
patients being assessed undergo a treatment literacy program and are educated about positive living.
Patients are encouraged to motivate their partners/spouses to get tested and, if necessary, enter the
treatment program. HIV-infected patients, not in-need of ARV treatment and not with active TB, will be
offered isoniazid prophylaxis, monitoring, and ongoing counseling support for 6 months. At the end of the 6
months, these patients will be reassessed for further treatment. Although ARK's treatment target population
is predominantly mothers and children, increased attention is being given to encourage and increase male
partner (and men in general) participation.
ACTIVITY 4: Family-Centered Care and Support Services.
takes an integrated, family-centered approach to care and extends support (including treatment literacy and
prevention education) to all members of a patient's household. Together, trained facility-based counselors,
patient advocates and community health workers (CHWs) counsel patients and their partners on treatment
literacy, positive living, nutrition, safe infant feeding practices, and safe sex. CHWs conduct pre-treatment
home visits and provide ongoing psychosocial support to patients and their families. They also promote and
support disclosure to partners and family, partner testing and facilitate treatment access. CHWs are
required to facilitate support groups for their clients and ensure that all patients and their families have
access to spiritual care, psychosocial support, prevention messaging including prevention with positives,
nutritional counseling, economic assistance (government grants), and protection services, when required.
information is used within the clinics to strengthen service delivery. To ensure high standards and quality of
care in line with the national guidelines, all ARK staff are provided onsite, on-the-job training. This is
followed up with regular onsite mentorship and site evaluation by ARK's national executive and provincial
management teams. Informal training sessions are conducted quarterly by national staff. Staff are also
encouraged to attend formal external training courses offered by FPD.
These activities contribute to PEPFAR's 2-7-10 goals by increasing the number of South Africans receiving
palliative care.
Continuing Activity: 13344
13344 12351.08 U.S. Agency for Absolute Return 6447 2787.08 $824,500
12351 12351.07 U.S. Agency for Absolute Return 4446 2787.07 $700,000
Gender
* Increasing gender equity in HIV/AIDS programs
Estimated amount of funding that is planned for Human Capacity Development $80,767
Table 3.3.08:
In addition to above work in KwaZulu-Natal (KZN) province, Absolute Return for Kids (ARK) will be using
PEPFAR funds to co-fund its treatment activities in the Eastern Cape (EC). ARK has been requested by
the Eastern Cape HIV and AIDS, STI and TB (HAST) unit and the Nelson Mandela Metro to further scale up
support in this province. ARK has been supporting the Eastern Cape since 2006 and is currently working in
eleven sites delivering care and treatment in ten sites and PMTCT services in one site - Uitenhage
provincial hospital.
FY 2009 funds will be used to support the scale-up of integrated treatment services in the EC. The scale-up
in these sites will ensure that communities in this resource constrained province are reached at the primary
level of care. Nelson Mandela Metro has one of the largest treatment gaps in the province with a large peri-
urban population, thus treatment will reach patients in these high burden areas.
Modifications to FY 2008 Activities are as follows:
ACTIVITY 1: Support to KwaZulu-Natal Department of Health and Eastern Cape Department of Health
Referral systems will be strengthened to provide effective referral of patients between ARV, TB, prevention
of mother-to-child (PMTCT) and pediatric antiretroviral (ARV) services to ensure that mothers and infants
testing positive will be referred for early care and treatment, and people co-infected with HIV and TB receive
early diagnosis and appropriate care. Tracing of lab results for HIV-infected pregnant women and HIV-
exposed infants for early infant diagnosis will be conducted proactively to ensure that bottlenecks in the
system are addressed with DOH partners and the National Health Laboratory Services (NHLS). TB infection
control practices are standard at ARK-supported sites and include well-ventilated waiting areas and
consulting rooms, safe sputum collection, and patient and staff education on safe cough etiquette and
ACTIVITY 3: Family-Centered Treatment Services
ARK supports a family-centered approach that integrates care for the whole family to ensure access to all
appropriate services. ARK's PMTCT program will link into the adult ART and pediatric care component. HIV
-infected pregnant women will receive comprehensive HIV care including TB and other opportunistic
infection (OI) screening and treatment, cotrimoxazole prophylaxis and rapid enrollment for those eligible for
ART. All HIV-infected pregnant women and HIV-exposed infants who have a TB contact will receive TB
screening, prophylaxis and treatment if appropriate. HIV-exposed infants will be monitored closely in the
postnatal period by community-based patient advocates who will ensure referral at any signs of
deterioration prior to immunization, and encourage and support testing at six weeks, and entry into care and
treatment services for HIV-infected infants. ARK patient advocates encourage male partners, other family
members, and exposed children to test and enter care services if needed. Patient advocates provide TB
prevention education and engage family members in assisting with treatment adherence measures as part
of creating a supportive environment that encourages full disclosure and minimizes stigma within the family.
ACTIVITY 4: Pediatrics
Pediatric ART services will focus on improved child survival activities with specific reference to improved
diagnosis and treatment of TB, recommended Vitamin A supplementation, routine immunization and the
integrated management of childhood diseases. All HIV-exposed infants will receive the basic preventative
care package including infant feeding and nutrition, cotrimoxazole prophylaxis, early testing, and TB
screening, prophylaxis and treatment.
ACTIVITY 5: Human Capacity Development
ARK provides training and mentoring of ARK and department of health (DOH) clinical staff (doctors, nurses,
pharmacists and pharmacy assistants) in KwaZulu-Natal and the Eastern Cape. All clinical staff receive pre-
or in-service three-day training in Adult HIV Management, which is accredited by the Health Professions
Council of South Africa for the provision of continuous professional development. The course focuses on
HIV infection and disease progression, staging, opportunistic infections including TB/HIV co-infection
focusing on TB screening, diagnosis and treatment, antiretroviral therapy, managing side effects, adverse
events, clinical monitoring, and adherence support.
In-service training is also provided on pediatric care and treatment and PMTCT for three days, covering
early diagnosis and treatment, TB prevention, screening and treatment, infant feeding and nutrition,
immunization, cotrimoxazole prophylaxis, adverse events, dosing and adherence. Training is provided both
pre-and in-service as well as through on-site mentoring.
ACTIVITY 6: Reporting and Quality Assurance/Improvement
New activity for FY 2009:
ACTIVITY 7: Construction and Renovation
of space in the form of temporary infrastructure, or renovating existing rooms to ensure more efficient
patient flow.
Activity Narrative: SUMMARY:
ARK's focus is to provide ART and accompanying support to HIV-infected caregivers of children, their
spouses, and children. Primary emphasis areas are renovation, human capacity development, and local
organization capacity building. Target populations include OVC, people living with HIV (PLHIV), HIV-
infected pregnant women, HIV-affected families, and caregivers.
communities affected by HIV and AIDS. In partnership with the KwaZulu-Natal Department of Health
(KZNDOH), ARK, as the implementing partner, has established an antiretroviral treatment program in
government primary health facilities and hospitals. Specifically, ARK works with the KZNDOH to identify
sites and areas for capacity building, including human resources, modest infrastructure support, and
organizational capacity development. PEPFAR funding has enabled ARK to successfully enroll over 15,000
patients in ART in KZN. FY 2008 funding will enable ARK to provide ARV treatment to existing and new
patients, strengthen the infrastructure of the ARV delivery system in targeted sites, provide human
resources, and build local institutional capacity to deliver ARV services. ARK provides treatment in
accordance with national treatment guidelines.
ACTIVITY 1: Support to KwaZulu-Natal Department of Health
ARK works with the KZNDOH to develop the necessary processes and systems to manage the ARV
program, to ensure that the model created is scaleable, sustainable and replicable elsewhere. Capacity-
building is site specific. Upon identification of a site, an analysis of the needs of each site will be done with
respect to staffing (doctors, nurses, pharmacists and pharmacy assistants), clinical equipment,
met in order to speed up the ability of patients to receive treatment. Where necessary ARK provides
ARK's ARV program focuses on a network of clinics operating within a district, in order to create a
sustainable and efficient system that supports the continuum of care and up and down referral. While
patients are being assessed for treatment, a community health worker (CHW) from ARK's palliative care
program is allocated to the patient. This CHW will conduct a pre-treatment home visit and will provide
ongoing support to the patient and his/her family. Should a patient be non-adherent or lost-to-follow-up, the
CHW will investigate the reasons for this, acting as the link between the patient and the clinic. ARK
facilitates the integration process for ART, TB, other palliative care, and maternal HIV services.
ACTIVITY 2: Human Resources
ARK conducts a thorough needs analysis of human resource capacity prior to initiating support to the
treatment program at each site. Once it has been determined that KZNDOH has budgeted for the identified
posts needed within a period of three years, ARK recruits all the necessary medical staff required for the
successful rollout of ART. The staff recruited vary from site to site but include doctors, nurses, pharmacists
and pharmacy assistants. In addition ARK employs data capturers for monitoring and evaluation of the
program.
Although ARK's primary goal is to provide ARV service support to primary caregivers with children, ARK
assists in the treatment of all HIV-infected adults and children requiring ART at ARK sites in KZN. All
patients considered for ART need to meet both medical and psychosocial criteria before starting therapy.
The psychosocial criteria are designed to ensure that the patient is prepared and ready to adhere to ART.
All patients being assessed undergo a treatment literacy program and are educated about positive living.
treatment program. Although ARK's treatment target population is predominantly mothers and children,
increased attention is being given to encourage and increase male partner (and men in general)
participation. ARK-employed doctors and nurses are responsible for treatment management, patient
consultations and the treatment of opportunistic and sexually transmitted infections. Pharmacists are
responsible for the dispensing of medication.
HIV-infected parents and caregivers will be encouraged and educated by the medical staff to get their
children tested and to enter the treatment program where indicated. Staff in the local midwifery and
obstetric units will be trained to refer HIV-infected mothers and their babies to the ARK ART program,
ensuring access to full ART services when indicated. All at-risk infected infants with HIV diagnosis
confirmed by PCR will be monitored, and have immediate access to ARVs and related services including
the preventive package of care. Children identified through ARK's OVC program (also PEPFAR-funded) will
be referred to the clinic by community care workers and social workers.
Activity Narrative: Key staff are provided with a two week orientation training which covers all aspects of ARK's ARV program
areas including employee policies and procedures, onsite mentorship from experienced ARK staff, and an
introduction to key performance areas. The areas covered in training include: ARV treatment guidelines for
adults and children, adherence, opportunistic and sexually transmitted infections as well as the value of
community access, adherence and refresher on prevention, including prevention for HIV-infected people.
death rates and loss-to-follow-up are closely monitored. Quarterly updates are provided to the KZNDOH
and information is used within the clinics to strengthen service delivery. To ensure high standards and
quality of care in line with the national guidelines, all ARK staff are provided onsite, on-the-job training. This
is followed up with regular onsite mentorship and site evaluation by ARK's national executive and provincial
treatment.
Continuing Activity: 13348
13348 3283.08 U.S. Agency for Absolute Return 6447 2787.08 $5,820,000
7507 3283.07 U.S. Agency for Absolute Return 4446 2787.07 $4,145,000
3283 3283.06 U.S. Agency for Absolute Return 2787 2787.06 $1,800,000
Construction/Renovation
Estimated amount of funding that is planned for Human Capacity Development $235,682
Table 3.3.09:
FY 2008 COP activities will be expanded to include:
-Expanding PEPFAR-funded treatment, care and support activities to the Eastern Cape (EC);
-For all key staff, Absolute Return for Kids (ARK) will provide training and follow-up refresher courses
covering all aspects of ARK's palliative care program;
- Patient advocates (PA) will ensure that all babies are brought back for their immunization and testing for
HIV;
- Linking Pediatric testing and ART services to PMTCT and TB services;
-Ensuring internet connectivity at all sites to facilitate information management activities; and
-Referral systems will be strengthened.
ARK's focus is to provide a comprehensive palliative care package to HIV-infected mothers and their
children through partnerships with government health facilities. ARK's primary emphasis areas are human
capacity development, local organization capacity development, and construction/renovation. The target
population is people living with HIV and AIDS.
(KZNDOH) ARK, as the implementing partner, has established an antiretroviral treatment program in
government primary health facilities and hospitals. Specifically, ARK works with KZNDOH to identify sites
and areas for capacity building, including human resources, modest infrastructure support, and
organizational capacity development.
ARK provides a comprehensive range of family-centered palliative care services to patients enrolled on
ART and their children. These services are supported by improvements in the infrastructure of targeted
sites, and the provision and training of human resources in partner health facilities to further strengthen their
capacity to deliver quality care and support for HIV-infected caregivers and their children. ARK provides
palliative care services in accordance with South African national treatment guidelines.
ACTIVITES AND EXPECTED RESULTS:
In FY 2009 ARK will expand PEPFAR-funded treatment, care and support activities to the Eastern Cape
(EC). ARK has been supporting the EC from 2006 and is currently working in eleven sites delivering care
and treatment activities and PMTCT services in one site.
FY 2009 PEPFAR funds will be used to strengthen pediatric support throughout KwaZulu-Natal (KZN) and
the EC. ARK is planning to scale up pediatric ART services in the primary care sites to reduce the burden
on the hospitals, as well as reduce waiting times for treatment. The community care component of ARK
employs and trains patient advocates who support families, including provision of the basic preventative
care package for HIV-infected children, testing and follow-up of HIV-exposed infants and children to ensure
early identification and enrollment of children on ART. Additional components include ARK's Child Services
component, which assists families to access birth certificates and SAG social grants. ARK will be working
closely with the pediatric clinics to ensure integrated services and support for children and their families.
ACTIVITY 1: Human Capacity Development
For all key staff, ARK will provide training and follow-up refresher courses covering all aspects of ARK's
palliative program including counseling and testing, screening for pain and symptoms, screening for
opportunistic infections (OIs) including the provision of cotrimoxazole prophylaxis, symptom control and
management of opportunistic and sexually transmitted infections, nutritional assessment and counseling,
adherence support, as well as community access, prevention with positives, and referral. Specific training
modules on clinical and care needs of children and adolescents is provided to clinical staff and patient
advocates. A pediatrician at the ARK National office as well as pediatricians and pediatric nurses in the
districts support clinical staff through training and mentoring to empower, up-skill and make staff more
confident in treating children. Staff are invited and encouraged to attend formal training offered by external
providers including other PEPFAR partners such as the Hospice Palliative Care Association (HPCA) and
Foundation for Professional Development (FPD).
ACTIVITY 2: Clinical Care
employed doctors and nurses provide comprehensive pediatric treatment management including patient
uptake, doctor consultations, counseling and testing, TB screening and management, pain management
and symptom control, treatment of opportunistic infections including the provision of cotrimoxazole, lab
testing and patient and caregiver education. Pharmacists are responsible for the dispensing of medication.
Pediatric ART and care services are linked to PMTCT and TB services. HIV-infected pregnant women will
be educated and encouraged during pregnancy to undertake post delivery testing for their babies. All
children born to HIV-infected mothers will be closely followed up for any evidence of early deterioration and
will receive NVP and AZT as per PMTCT protocol. At the six week visit, all HIV exposed babies will have a
PCR test done, will be given cotrimoxazole prophylaxis and multivitamins to await the PCR result. Babies
testing negative will be offered a PCR at 12 weeks after weaning if breastfeeding and if still negative an
ELISA at 18 months. HIV-infected babies will be immediately referred to ARK's ARV treatment program and
will have access to cotrimoxazole prophylaxis, multivitamin supplements and general nutritional advice, and
Activity Narrative: breastfeeding counseling and support for the mother.
ACTIVITY 3: Family-Centered Care and Support Services
In an effort to encourage adherence among mothers and ongoing care for their infants and children, ARK's
program takes an integrated maternal and child health care approach and extends care and support
(including treatment literacy and prevention education) to all members of a patient's household. Together,
facility-based counselors and patient advocates counsel mothers and their partners on treatment literacy,
nutrition, TB prevention and referral for care, safe infant feeding practices, and safe sex. All HIV-infected
pregnant women and HIV exposed infants will receive TB screening, prophylaxis and treatment if
appropriate. Patient advocates offer services within homes and provide encouragement and support to male
partners to serve as "adherence buddies" in the management of care during pregnancy and after delivery.
Patient advocates are also trained to provide basic psychosocial support and link children and mothers to
individual counseling services and/or support groups. The patient advocates (PA) will ensure that all babies
are brought back for their immunization and testing for HIV will be actively encouraged by the community
workers. Other children in the household will also be referred for testing.
ACTIVITY 4: Reporting and Quality Assurance/Improvement
ARK provides computers and employs data capturers at all sites. All sites will have internet connectivity to
facilitate information management activities. Data is captured from patient folders and transferred to ARK's
data center, allowing for ongoing evaluation and outcome analysis. Adherence rates, death rates and loss
to follow-up are closely monitored. Quarterly updates are provided to the KZNDOH and ECDOH and
management teams. Informal training sessions are conducted quarterly by national staff. The staff is also
ACTIVITY 5: Systems strengthening
Referral systems will be strengthened to ensure the easy, quick referral of patients between ARV, TB,
PMTCT and pediatric ARV services Tracing of lab results for early infant diagnosis will be conducted
proactively to ensure that bottlenecks in the system are addressed with DOH and the National Health
Laboratory Services (NHLS). Additional information management capacity will be added to sites including
data capturers and computers as needed. TB infection control practices are standard at ARK-supported
sites and include well-ventilated waiting areas and consulting rooms, safe sputum collection, and patient
and staff education on safe cough etiquette and hygiene.
New/Continuing Activity: New Activity
Continuing Activity:
Estimated amount of funding that is planned for Human Capacity Development $20,196
Table 3.3.10:
(KZNDOH), ARK, as the implementing partner, has established an antiretroviral treatment (ART) program in
organizational capacity development. ARK provides treatment in accordance with national treatment
In FY 2009, ARK will expand PEPFAR-funded treatment, care and support activities to the Eastern Cape
FY 2009 PEPFAR funds will be used to strengthen pediatric support throughout KZN and the EC. ARK is
planning to scale up pediatric ART services in the primary care sites to reduce the burden on the hospitals
as well as reduce waiting times for treatment. The community care component of ARK employs and trains
patient advocates who support families including provision of the basic preventative care package for HIV-
infected children, testing and follow-up of HIV-exposed infants and children to ensure early identification
and enrollment of children on ART, and referral to a range of social services including ARK's Child Services
component which assists families to accessing birth certificates and South African Government (SAG)
social grants and will be working closely with the pediatric clinics to ensure integrated services and support
for children and their families.
ACTIVITY 1: Support to KwaZulu-Natal Department of Health (KZNDOH) and Eastern Cape Department of
Health (ECDOH)
ARK works with the KZNDOH and ECDOH to develop the necessary processes and systems to manage
the ARV program, to ensure that the model created is scalable, sustainable and replicable elsewhere.
sustainable and efficient system that supports the continuum of care and up and down referral. Capacity-
building is site-specific. Upon identification of a site, an analysis of the needs of each site will be done with
met in order to speed up the ability of patients to receive treatment. Where necessary, ARK provides
Referral systems will be strengthened to provide effective referral of patients between ARV, TB, PMTCT
and pediatric ARV services to ensure that mothers and infants testing positive will be referred for early care
and treatment, and people co-infected with HIV and TB receive early diagnosis and appropriate care. TB
infection control practices are standard at ARK-supported sites and include well-ventilated waiting areas
Tracing of lab results for HIV-infected pregnant women and HIV-exposed infants for early infant diagnosis
will be conducted proactively to ensure that bottlenecks in the system are addressed with DOH and the
National Health Laboratory Services (NHLS).
successful roll-out of ART. The staff recruited vary from site to site but include doctors, nurses, pharmacists
and pharmacy assistants. In addition, ARK employs data capturers for monitoring and evaluation of the
appropriate services. ARK facilitates the integration process for ART, TB, other palliative care, and
maternal HIV services. ARK's PMTCT program will link into the adult ART and pediatric care component.
ARK assists in the treatment of all HIV-infected adults and children requiring ART. ARK-employed doctors
and nurses are responsible for treatment management, patient consultations and the treatment of
opportunistic and sexually transmitted infections. Pharmacists are responsible for the dispensing of
Activity Narrative: medication. ARK will also be providing integrated services for HIV and PMTCT as well as integrating TB
with HIV. All patients testing positive at the sites will have access to same day CD4 count. They will then
be brought back within one week for a review of the CD4 result as well as for their clinical staging. Those
eligible for treatment on the basis of the CD4 count as well as the WHO staging will start treatment.
While patients are being assessed for treatment, a patient advocate (PA) from ARK's palliative care
program is allocated to the patient. The PA conducts a pre-treatment home visit and provides ongoing
support to the patient and his/her family. All patients eligible for ART need to meet both medical and
psychosocial criteria before starting therapy. The psychosocial criteria are designed to ensure that the
patient is prepared and ready to adhere to ART. All patients being assessed undergo a treatment literacy
program and are educated about positive living. Patients are encouraged to motivate their
partners/spouses to get tested and, if necessary, enter the treatment program. Although ARK's treatment
target population is predominantly mothers and children, increased attention is being given to encourage
and increase male partner (and men in general) participation. Should a patient be non-adherent or lost-to-
follow-up, the PA will investigate the reasons for this, acting as the link between the patient and the clinic.
Pregnant women will also have access to testing. HIV-infected pregnant women will receive
comprehensive HIV care including TB and other OI screening and treatment, cotrimoxazole prophylaxis and
rapid enrollment for those eligible for ART. All HIV-infected pregnant women and HIV-exposed infants who
have a TB contact will receive TB screening, prophylaxis and treatment if appropriate.
TB services will be supported so that all patients presenting with TB symptoms are counseled and tested for
HIV. All HIV patients are also routinely screened for TB and other opportunistic infections. Patient
advocates provide TB prevention education and engage family members in assisting with treatment
adherence measures as part of creating a supportive environment that encourages full disclosure and
minimizes stigma within the family.
integrated management of childhood diseases. HIV-infected parents and caregivers will be encouraged
and educated by the medical staff and patient advocates to get their children tested and to enter the
treatment program where indicated. Staff will be trained to refer HIV-infected mothers and their babies to
the ARK ART program, ensuring access to full ART services when indicated. All children born to HIV-
infected mothers will be closely followed up for any evidence of early deterioration and will receive NVP and
AZT as per PMTCT protocol. All HIV-exposed infants will receive the basic preventative care package
including infant feeding and nutrition counseling, cotrimoxazole prophylaxis, early testing, and TB screening,
prophylaxis and treatment. At the six week visit, all HIV-exposed babies will have a PCR test done, will be
given cotrimoxazole prophylaxis and multivitamins to await the PCR result. Formula fed babies that test
12 weeks after weaning and if still negative an Elisa at 18 months.
HIV-infected babies will be immediately referred to ARK's ARV treatment program. Babies and children will
be assessed and managed by staff on-site and referred for care to secondary and tertiary institutions if
needed. Children identified through ARK's Child Services program will be referred to the clinic by
community care workers and social workers.
and ECDOH and information is used within the clinics to strengthen service delivery. Additional information
internet connectivity to facilitate information management activities. To ensure high standards and quality of
care in line with the national guidelines, all ARK staff are provided on-site, on-the-job training. This is
followed up with regular on-site mentorship and site evaluation by ARK's national executive and provincial
ACTIVITY 6: Construction and Renovation
These activities contribute to PEPFAR's 2-7-10 goals by increasing the number of South African children on
Estimated amount of funding that is planned for Human Capacity Development $26,187
Table 3.3.11:
NO FY 2009 FUNDING IS REQUESTED FOR THIS ACTIVITY:
This activity was approved in the FY 2008 COP, is funded with FY 2008 PEPFAR funds, and is included
here to provide complete information for reviewers. No FY 2009 funding is requested for this activity. This
program area was discontinued in FY 2009 as the costs for this activity were transferred to another donor
who was keen to assist with TB/HIV services. Therefore there is no need to continue funding this activity
with FY 2009 COP funds.
Continuing Activity: 13345
13345 7882.08 U.S. Agency for Absolute Return 6447 2787.08 $194,000
7882 7882.07 U.S. Agency for Absolute Return 4446 2787.07 $0
Table 3.3.12:
who was keen to assist with OVC services. Therefore there is no need to continue funding this activity with
FY 2009 COP funds.
Continuing Activity: 13346
13346 7886.08 U.S. Agency for Absolute Return 6447 2787.08 $970,000
Table 3.3.13:
BACKGROUND
FY 2009 funding will allow Absolute Return for Kids (ARK) to provide CT support within the prevention of
mother-to-child transmission (PMTCT) program to 13 sites in the Amajuba District of KwaZulu-Natal and to
a further three sites in the Eastern Cape. The Nelson Mandela Metropole in the Eastern Cape will be a
focus area for ARK with FY 2009 funding.
Activity three, referrals and linkages, will be modified in that all HIV-infected individuals will be referred for
tuberculosis (TB) screening and treatment as appropriate.
Alignment with HIV & AIDS and STI Strategic Plan for South Africa 2007-2011 and other South African
Government policies
CT activities align with the HIV & AIDS and STI Strategic Plan for South Africa 2007-2011 Key Priority
Areas 1 and 2, Prevention, Care and Treatment. Counseling is the doorway to knowing your status, which, if
negative, will encourage clients to remain so, thus assisting to achieve the goal of reduction in new
infections by 50%. It also opens the door to care and treatment in that, once found to be HIV-infected,
patients will be counseled to access care and treatment, thus ensuring access to care for 80% of those in
need.
Gender Related Activities
While ARK CT activities are not couple-focused, through our Community Access and Adherence (CAA)
programs, ARK patient advocates will assist the partners of HIV-infected women during home visits to be
tested, as well as facilitate this testing in any of the sites providing care for women including the family
planning clinics. The ARK patient advocate will offer support to all pregnant women for safe disclosure and
will also facilitate partner testing and male partner support for the pregnant women. The regular home visits
undertaken by ARK's patient advocates ensure that the entire family receives palliative care and male
partners are educated on prevention, testing, treatment and care.
---------------------
ARK's focus is to provide antiretroviral treatment (ART) and accompanying support to primary HIV-infected
caregivers with children. This includes the encouragement and support for the voluntary counseling and
testing (VCT) of partners and children, to ensure complete family coverage and earlier access to ongoing
treatment, care and support. Although the primary focus of ARK is on the caregivers of children, ARK offers
its services to the entire population in all of its service areas. CT services will be delivered in all of ARK's
supported communities.
The primary emphasis areas for these activities are community mobilization, local organization capacity
development, human resources, and training. Primary target populations include adult women and men and
their families.
communities affected by HIV and AIDS and poverty.
In partnership with the KwaZulu-Natal (KZN) provincial government, ARK has established a comprehensive
ART program in government primary health centers and hospitals. ARK works with the provincial
government to identify sites and areas for capacity building in areas such as human resources, human
capacity development, modest infrastructure improvements and service delivery. ARK's activities enable the
provincial government to increase the number of patients counseled, tested, and provided ART and related
services.
To date, PEPFAR funding has enabled ARK to provide over 15,000 patients with ART in KZN through the
sustained development of primary care facilities and their down referral sites in five districts, in primarily peri
-urban and rural communities.
With FY 2008 funding, ARK will focus on provider driven opt-out testing to all pregnant mothers entering the
antenatal clinics, and CT services to children and spouses/partners of caregivers and other household
members. This activity will be linked to home visits undertaken by ARK's community adherence workers.
Home visits serve to evaluate the psychosocial situation of patients, the degree of family support, and
issues related to disclosure. Although ARK's treatment target population is predominantly mothers,
caregivers, and their spouses/partners and children, increased attention is given to encourage men, single
women and children to come forward for testing and treatment.
ARK's primary objective is to keep mothers alive to continue caring for their children and to reduce the
incidence of orphans and vulnerable children (OVC). Early, widespread testing and access to ART reduces
the likelihood of morbidity and mortality from HIV. This, in turn, increases the likelihood of survival of family
units, which guard income security and ongoing nurturing required by children in these households.
Furthermore, the psychosocial component of counseling and testing forms a vital component for behavior
change.
Activity Narrative: ACTIVITY 1: Support to Provincial Government for CT Services
ARK works with the KZN provincial government to develop the necessary processes and systems to
manage a comprehensive HIV and AIDS treatment program, and to ensure that the model created is
scaleable, sustainable, and replicable elsewhere. ARK, in partnership with KZN provincial government, will
provide training and mentoring for government employed lay counselors and community adherence workers
working at these primary sites where ARK's ART program exists. ARK will ensure that management
systems are in place to support the work of the counselors and the delivery of CT.
ARK will strengthen or initiate CT services at all sites identified by the provincial health department and
assigned to ARK for support. To ensure sustainability, where possible, ARK will use the counselors
available through the district HIV program. ARK will also employ counselors and train existing employed
community care workers to provide counseling for CT services. Where infrastructure support is required,
ARK will, in consultation with the facility managers and district managers, decide on the most cost-effective
infrastructure support (prefab or modest renovations). ARK's OVC program, through the social workers and
community workers placed at schools, will establish links with clinic services to ensure better and more
efficient referral of children in need of testing and care, including their caregivers and immediate family.
Formal and informal training and on-site mentorship will be provided to all lay counselors in the program.
continue to develop and improve training modules for lay counselors. The areas covered in training include
reduction for HIV transmission, and safer sex. Counseling and ongoing training will be in line with the
National Department of Health's (NDOH) guidelines. ARK will provide mentorship and supportive
supervision to lay counselors in the program to ensure high-quality standards for CT. Nurses conduct
testing, in accordance with NDOH standards, at the CT sites. Support in terms of systems management and
coordination of lay counseling will be provided to CT sites.
ACTIVITY 3: Referrals and Linkages
Community care workers and social workers will be recruited to assist OVC and their caregivers in
accessing ARK-assisted primary health facilities for CT. They will coordinate the referral system between
caregivers, children and CT services. ARK will inform and coordinate activities with local NGOs, CBOs, and
FBOs to establish effective referral networks for CT services. Lay counselors will refer HIV-infected
individuals to ARK's ART sites.
Continuing Activity: 13347
13347 7883.08 U.S. Agency for Absolute Return 6447 2787.08 $194,000
7883 7883.07 U.S. Agency for Absolute Return 4446 2787.07 $0
Estimated amount of funding that is planned for Human Capacity Development $22,500
Table 3.3.14:
