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:
ACTIVITY 1: PMTCT at Clinics and Maternity Obstetric Units
The International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University will support
implementation of rapid screening for antiretroviral treatment (ART) eligibility through continuous mentoring
for health-care professionals, regular patient file reviews, and monitoring and evaluation (M&E) activities.
Program feedback will be provided to the sites and improvements be monitored. This will have a direct
impact on pregnant women's access to care and CD4 testing within a month of diagnosis.
Challenges identified during FY 2008 will be addressed through training health facility staff, provision of
essential equipment, and psychosocial support. In addition, regular multidisciplinary team meetings and
program feedback sessions will be instituted to ensure service gap identification and corrective strategies.
Site-specific interventions will be implemented to fast track ART-eligible women to receive highly active
antiretroviral therapy (HAART). The interventions include improved communication and feedback between
the antenatal care (ANC) and ART sites, and prioritizing ART-eligible mothers for timely prevention of
mother-to-child transmission (PMTCT) services.
Routine counseling and testing (CT) of all pregnant women on first visit will be expanded to all supported
sites. Additional health-care workers will be trained on routine CT using the opt-out approach. M&E
activities will focus on measuring the numbers of women counseled and tested on first visit, proportion that
receive test results and get CD4 done. Program information will be routinely fed back to the providers.
Partner testing will be encouraged for both HIV-infected and negative women.
All women who test HIV negative during their first visit will undergo a repeat test at 32 weeks of pregnancy.
Prevention counseling for HIV negative mums will be intensified.
Cotrimoxazole (CTX) prophylaxis will be ensured based on the National Department of Health guidelines. A
monitoring system will be implemented for the CTX uptake in pregnant women.
Tuberculosis (TB) screening for all women at the PMTCT site will be conducted at every visit, followed by
sputum exam and culture for those suspected with TB disease. Through collaboration with the TB treatment
sites, all TB infected pregnant women will be treated. Routine mentorship will be conducted to ensure
appropriate TB/HIV collaboration activities with PMTCT.
HIV-infected women will be provided with other routine ANC services including sexually transmitted
infections screening, multivitamin supplementation, infant feeding counseling and nutritional support.
Routine CT for women with unknown HIV status in labor and post-natal clinics will be instituted using lay
counselors deployed in the hospitals and postnatal clinics. All these activities will be monitored using the
registers currently under review by the Eastern Cape Department of Health (ECDOH). Women found to be
HIV infected during labor will be provided with appropriate interventions and enrolled into care and
treatment prior to discharge from the hospital.
ACTIVITY 2: Provide HIV Care, Treatment and Support
ICAP will ensure the extension of services beyond PMTCT include partner/couple counseling and testing
using standard operating procedures, provision of comprehensive care and treatment during pregnancy,
post delivery and ongoing care and treatment for the woman and her family. Care and treatment will include
screening for opportunistic infections, ART for eligible mothers, monitoring for toxicity, nutritional counseling
and support, family planning post delivery, HIV prevention with positives and psychosocial support.
ACTIVITY 3: Provide Early Diagnosis, Care, Treatment and Support to Infants and Children who are
Exposed or Infected
ICAP will review the systems for early diagnosis of the HIV exposed and infected infant (HEI) to increase
the uptake at 4 - 6 weeks and to ensure testing using rapid tests at 12 - 18 months facilitated by the
registers currently under review at the ECDOH. The site support teams will continue mentor the health-care
workers on the management of HEI. Infants who are HIV infected will be fast tracked to start HAART.
Enhanced counseling in antenatal and maternity settings will be promoted to minimize loss to follow-up
(LTFU). LTFU will be analyzed and interventions planned and implemented for consistency of messages
and effectiveness of delivery messages.
ICAP will enhance the use of partners and family members as infant feeding supporters. HIV-infected
pregnant women will be encouraged to disclose their status and to be accompanied by infant feeding
supporters during their ANC visits to promote adherence to infant feeding choices. ICAP will provide
adequate information that will enable mothers make an appropriate feeding choice. Health-care workers will
be trained on infant feeding using National Department of Health guidelines.
Postnatal clinics will be revived and integrated with the integrated management of childhood illness (IMCI)
clinics to ensure infant follow-up and continuity of care. This activity will include counseling on infant
feeding. Health-care providers will be trained and mentored to ensure that the CTX prophylaxis for HEI,
growth monitoring, developmental and TB screening, immunizations and vitamin A supplementation will be
provided at every visit.
------------------------------
SUMMARY:
ICAP will support implementation and expansion of comprehensive prevention of mother to child
Activity Narrative: transmission and linkages with treatment, care and support. The target population includes infants, men and
women, pregnant women, family planning clients, people living with HIV (PLHIV) and healthcare workers in
the public and private sectors.
BACKGROUND:
ICAP has been a PEPFAR partner since FY 2004, and supports services to strengthen integration of
PMTCT activities into HIV chronic care in all supported HIV care and treatment outlets. ICAP's geographical
coverage includes the Eastern Cape (EC) and KwaZulu-Natal (KZN) provinces. FY 2008 funding will ensure
expansion to the Free State (FS). ICAP's PMTCT component is designed to support the national scale-up of
PMTCT programs by assisting the government in implementation of strategies and plans; capacity building
and training, infrastructure support; monitoring and evaluation support; and development of key tools and
standard operating practices (SOPs) for program implementation.
ACTIVITIES AND ANTICIPATED RESULTS:
ICAP's PMTCT comprehensive approach will focus on HIV counseling and testing (CT) to all pregnant
women seeking care; ARV prophylaxis for PMTCT; and, counseling and support for infant feeding. The
interventions will be underscored by treatment, care and support including maternal health for women living
with HIV, their children and families. The planned activities will ensure that HIV-infected pregnant women
are identified early and enrolled into treatment, care and support programs. This approach will ensure that
prevention, care, treatment and support services cover pregnancy, delivery, neonatal, and infancy periods.
ACTIVITY 1: PMTCT at clinics and maternity obstetric units
ICAP will improve the quality of antenatal care and maternity services at the 14 sites and integrate key
interventions to prevent MTCT. This will ensure that women have greater access to high-quality antenatal,
labor, delivery and postpartum care, including counseling and support for infant feeding, and use existing
services more frequently and earlier in pregnancy. CT will be the pivotal component of the PMTCT program.
Expanding provision of PMTCT services to include both antenatal clinics and maternities at the sites will
significantly increase access to both maternal and infant HIV prophylaxis regimens. The program will focus
on:
1. Conducting readiness assessments for implementation of basic PMTCT services
2. Conducting infrastructure renovations/refurbishment to allow for PMTCT implementation
3. Providing supplies and additional equipment as needed
4. Hiring additional health workers to provide support to sites
5. Training staff in CT within ANC setting
6. Implementing routine rapid CT as an integral part of antenatal care
7. Providing simple/short course prophylaxis regimens for PMTCT, with access to more complex and
effective regimens as capacity and national guidelines allow
8. Developing replicable models of PMTCT in the 14 sites of EC, KZN and FS
9. Provision of CT during labor and delivery for pregnant women of unknown HIV status
10. Promoting safer delivery practices
11. Devising referral mechanisms to ensure patient follow-up post-delivery
12. Improving activities for optimal obstetric care including development/adaptation of SOPs.
ACTIVITY 2: Provide HIV-related care, treatment and support
ICAP will ensure extension of services beyond the PMTCT to the treatment and care services for the HIV-
infected women, their infants and family members. This will be done through the early identification and
referral of HIV-infected pregnant women who are eligible for treatment, enhanced laboratory capacity to
monitor and conduct CD4 and other recommended tests for HIV care and treatment; establishment of
mechanisms for prioritization and fast tracking of HIV infected pregnant women for ART; providing
screening, diagnosis and treatment of TB; providing screening, diagnosis and treatment of STIs; providing
cotrimoxazole prophylaxis to eligible mothers according to national guidelines; establishing a family
centered case management approach with particular attention to establishing continuity of care; enhancing
referral systems to ensure continuum of care post-partum; providing counseling and care relating to
maternal nutrition and psychosocial support; establishing appropriate linkages and referral for HIV negative
mothers tested; develop best practice models in pediatric and maternal care which can be replicated at
national level and other sites; support continuation of routine health care including VIA for cancer of the
cervix screening; and testing other family and household members and enroll them into care and treatment
programs within clinic setting.
ACTIVITY 3: Provide early diagnosis, care and support to infants and children who are HIV-exposed or
infected
ICAP will institute regular infant follow-up care. This includes infants who have received ARV prophylaxis,
because HIV exposure increases risk of illness and failure to thrive, whether or not the infant has HIV
infection. In addition, the PMTCT interventions will only reduce, but not eliminate the risk of HIV
transmission from the mother to the infant. The focus of interventions will be to ensure PCR testing at 6
weeks and enrollment in ART for eligible infants. In order to scale up PCR testing, health care workers will
be trained to identify HIV exposed infants and to ensure follow-up, provide cotrimoxazole prophylaxis. In
addition, health care workers will be trained to provide counseling and support for infant feeding options and
to establish functional appointment systems for regular health assessment and promotion visits for HIV-
exposed infants. Particular attention will be given to establish functional linkages between the MCH health
care workers with the care and treatment sites for follow-up of HIV infected women and HIV-exposed
infants. Technical laboratory assistance for early infant diagnosis that includes training and providing
essential lab equipment in the EC and FS will be provided. ICAP will hire a laboratory adviser and support
staff for technical expertise and mentoring on early infant diagnosis. With FY 2008 reprogramming funding,
ICAP will strengthen support in Free State, including strengthening early infant diagnosis and additional
Activity Narrative: space in some facilities.
ACTIVITY 4: Promote linkages to community-based services and psychosocial support for comprehensive
family care
ICAP will establish formal links with community resources through ICAP's adherence and social support unit
to provide the resources that can help women cope with the impacts of HIV diagnosis. The focus of
interventions will be to: increase behavior change communication activities focusing on access to PMTCT
and treatment literacy to mobilize community in PMTCT and to develop/adapt tools to improve the follow-up
of HIV-infected mothers and tracking at community level
ACTIVITY 5: Mentor Mothers Approach
ICAP proposes to expand the scope of services of the mothers to mothers program (m2m) - a PEPFAR
prime partner since FY 2007 - through an existing sub-agreement. The mentor mothers will provide support
to the PMTCT component. Based in the antenatal, delivery and post-natal units, the primary duties of these
mentor mothers will include: promoting counseling and testing among the pregnant women; linking mothers
who test positive to PMTCT services; providing psychosocial support and education (individual and group)
to mothers in PMTCT programs; forming and facilitating support groups of HIV-infected mothers; linking
PMTCT mothers with necessary HIV care and treatment.
ACTIVITY 6: Engaging Stakeholders
ICAP will engage stakeholders in the planning and management of the program through meetings,
sensitization workshops and feedback reports. The stakeholders include: DOH officials, District Managers,
Health Facility managers, Clinic supervisors, Laboratory personnel, Staff representatives (doctors, nurses
etc) and community members. In addition, Columbia will engage any other PEPFAR partners engaged in
PMTCT activities in the same provinces in the stakeholder planning and management.
ACTIVITY 7: Quality of Care
ICAP will focus attention on the quality of PMTCT services provided in each of the facilitie. Particular
attention will be given to ensuring quality in service delivery during the site level operational planning,
implementation and M&E of the program in order to support two overarching principles of quality assurance
i.e. supporting clients' rights and addressing providers' needs. Clients' rights will be addressed by: ensuring
provision of complete and accurate information to the mothers; facilitating access to all the PMTCT and
ART services; ensuring safety of PMTCT service delivery; providing privacy and confidentiality; ensuring
provisions that take into account patients dignity, comfort and expression of opinion and ensuring continuity
of care from PMTCT, to treatment, care and support.
Systems and capacity will be developed by: Establishing good quality management and supervisory support
at all levels; provision of adequate information, competence-based training and skills development; and
provision of adequate supplies, equipment and infrastructure.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13736
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13736 13736.08 HHS/Centers for Columbia 6587 2797.08 $1,387,087
Disease Control & University
Prevention Mailman School of
Public Health
Emphasis Areas
Health-related Wraparound Programs
* Safe Motherhood
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
Consolidation of Columbia activities in the Northern Cape (NC) and Free State (FS) will necessitate
strengthening elements of programmatic start-up mode with establishment of comprehensive care at the
sites.The International Centre for AIDS Care and Treatment Programs (ICAP) plans to support the following
aspects of the adult care package, with an emphasis on ensuring quality, integration and comprehensive
care:
Cotrimoxazole - This will be routinely given as a part of adult care for all patients with WHO stage 2-4,
and/or for those with CD4 count below 200.
Palliative care - ICAP will expand its field caregiver (FCG) program to all the sites in the Eastern Cape (EC),
to enhance home-based care (HBC) and support systems. All FCG will be trained in home-based care
(HBC) methods and provided with standard HBC kits. Through regional referrals directory projects,
collaborations will be sought with community-based organizations (CBOs) and institutions to provide
palliative care, including pain management.
Early referral and retention in care and support - ICAP will initiate and emphasize: treatment buddy
selection and involvement; sexual partner tracing; engaging families in care; coordinated visits and
assessment of family members; couple counseling. ICAP will expand FCG to all supported primary health
clinic (PHC) and community health centre (CHC) sites. Support groups that have been formed at all the
facilities, will be strengthened to gain greater independence, sustainability and empowerment leading to a
greater network of support for patients, including those ineligible for antiretroviral therapy (ART). ICAP has
begun an initiative, aimed at group application for non-profit organization (NPO) status thus opening up
more funding opportunities, income generation activities, and participatory community development tools.
Psychosocial support - Psychosocial support for people living with HIV (PLHIV) are in place at all facilities
supported and will continue to be enhanced through additional Peer Educators (PE) and FCG, greater
collaboration with the Department of Health (DOH) lay counselors and outreach workers, and monthly
refresher trainings. Treatment literacy and adherence counseling will be enhanced through established
patient competencies and adaptation of supportive tools. For better outreach and tracing of defaulters, a
project will be carried out in Nelson Mandela Metro (NMM) to improve retention and tracing mechanisms
which includes computerized text messages to clients for reminders and notices of missed appointments
(with consent). Food and nutritional support will be addressed through continued multivitamin and other
supplementation, provided by DOH through wellness program collaboration with dieticians.
Mental health services - Counseling provided by PE, FCG and DOH lay counselors will be supported and
strengthened through newly hired regional psychologists, who will provide mentorship among sites on a
rotational basis, especially for referred difficult cases, and referrals for any special treatment needed.
Prevention of cervical cancer - The above initiative will be evaluated, strengthened and rolled out to
additional sites in 2009. Cervical cancer screening began in Greenville primary health care clinics: ICAP
activities will include:
a) In-service sensitization of nurses on the need for cervical cancer screening among HIV-infected women
b) Building collaboration with DOH/stakeholders for routine single visit approach
c) Writing protocols for routine programming
d) Training of providers/in-service -start-up of service delivery
e) Developing M and E systems with specific attention to feasibility questions to be answered
f) Community mobilization and education
g) Purchase of supplies and equipment
Prevention with positives - All elements of prevention with positives are in place at facilities supported,
primarily through PE and FCG. Tools will be developed in order to standardize approaches used, focusing
on: routine counseling and testing of sexual partners, children; couples counseling for discordant couples;
condom promotion and distribution; assistance with disclosure; provider-initiated behavioral risk reduction
interventions; assessment, diagnosis and management of sexually transmitted infections (STIs); adherence
to prophylaxis and treatment; referrals to family planning; alcohol assessment; counseling and referrals for
needed professional services.
TB/HIV services - The NMM outreach project will incorporate TB screening of HIV clients and family
members in the home, with referrals for testing when needed. PE will continue to give counseling as a part
of routine counseling and testing in supported TB hospitals, and home-based follow up will be enhanced for
those with HIV who are discharged, to ensure access of ART programs at local clinics. In addition, a TB
infection control project at all the sites will focus on preventing transmission among patients and staff in
clinical facilities and in the home.
Quality of care and support services - ICAP will implement standards of care (SOC) and associated tools for
measuring quality of care, in the clinic and in the home. These SOC cover activities within all major
categories of adult and pediatric care and support, psychosocial and adherence support, and prevention.
Monitoring and reporting - PEPFAR and DOH indicators related to care will be collected, reported, shared
and utilized for continuous quality improvements by ICAP as well as site staff. Monitoring of indicators
related to psychosocial support will be strengthened, with development of standardized tools, procedures
documentation and reporting forms.
Human capacity development and continuous provider training - FCG in each region will be trained in HBC
and receive standard kits. More DOH lay counselors and community health workers in each region will be
trained in ART and adherence. The care givers program will be expanded through interventions by the
program psychologists, group debriefing and individual counseling for lay staff and DOH professional staff.
Activity Narrative: The use of local CBOs to mentor care givers in HBC will be initiated with the NMM outreach services
integration project.
Columbia University carries out activities to support implementation and expansion of comprehensive HIV
treatment and care. The major emphasis area for this program will be human resources, with minor
emphasis on infrastructure development, technical assistance and training, community mobilization, quality
assurance and supportive supervision and strategic information. The target population will include infants,
children and youth (non-OVC), men and women (including pregnant women and family planning clients),
people living with HIV (PLHIV) and healthcare workers in the public and private sectors.
Columbia, with PEPFAR funds, began supporting comprehensive HIV care and treatment activities in South
Africa, in 2004. HIV palliative care has included training of healthcare workers in providing standard care for
opportunistic infections (OI) management, use of cotrimoxazole prophylaxis for common OIs, and the
provision of information on when and where to refer for end-of-life care. In FY 2006, in response to
provincial HIV care and treatment priorities, Columbia began strengthening the down-referral of services
from hospitals to primary health clinics. This resulted in a total of 42 health facilities receiving technical and
financial support from Columbia, including public hospitals, community health centers, primary health care
(PHC) and an NGO-run care support center. In FY 2007 additional health facilities in KwaZulu-Natal (East
Griqualand and Usher Memorial Hospital and the Kokstad Community Clinic) received technical and
financial assistance for HIV care and treatment services.
In FY 2008 Columbia will expand its reach by providing basic care and support to PLHIV in Free State. The
health facilities to be supported will be determined after negotiations with the Free State DOH.
ACTIVITIES AND EXPECTED RESULTS:
All activities are in line with South African Government (SAG) policies, and activities will be undertaken to
create sustainable comprehensive HIV care and treatment programs and primarily include four activities:
ACTIVITY 1: Training and Onsite Clinical Mentoring
Currently healthcare providers rendering services at ART sites participate in ongoing didactic training
events and are continuously supported with regular clinical and supportive supervision. In FY 2007
Columbia initiated a Nurse clinical training with emphasis on the development of a comprehensive HIV
nurse preceptor (NP) training and support program. The outcome of this training was to have NPs; situated
at the Columbia-supported ART sites, focusing on building the capacity and skills of facility-based nurses to
deliver high quality HIV patient care and treatment including elements of the preventive care package for
adults and children including OI screening and prophylaxis (including cotrimoxazole, TB
screening/management), counseling and testing for clients and family members, safe water and personal
hygiene strategies to reduce diarrheal disease. Initially, trained NPs would be responsible for providing daily
clinical guidance and constructive feedback, using custom designed assessment and training tools, to
facility-based site nurses providing basic HIV patient care and treatment. In keeping with the Department of
Health HIV and AIDS and STI strategic Plan 2007-2011 (NSP) objective of increasing the level of nurse
participation in management of HIV individuals including those on ART - with nurses initiating ART in 20%
and 50% of eligible HIV-infected adults in 2008 and 2009, respectively. The NP program has included: (1)
one-week didactic training that includes clinical material currently in development by the WHO as part of
their second-level, competency-based 'Integrated Management of Adolescent and Adult Illness' (IMAI)
training program; (2) onsite mentoring of patient triaging, provision of complex care and treatment, modeling
on how to conduct basic and complex patient case conferences, evaluation of nurses' basic HIV care and
treatment skills and developing instructional plans to address the performance gaps and assisting NPs in
practicing teaching; and (3) a series of at four continuing education sessions lasting two to three days.
By FY 2008 the first nurse mentorship initiative training would have been completed and Columbia will
review the recommendations of this initiative to make a determination as to whether similar training activities
need to be rolled out in the Eastern Cape, KwaZulu-Natal and/or in Free State.
ACTIVITY 2: Community-based Support
Columbia is involved in the implementation of Peer Educator (PE) programs to enhance retention into care
and to maximize adherence to treatment. More than 30 Columbia-supported PEs are currently working at
St. Patrick's, Holy Cross, Frere and Cecilia Makiwane, Dora Nginza and Livingstone Hospitals. PEs work
under supervision of the ART site coordinator or his/her designee to provide: elements of the preventive
care package, education on HIV and AIDS care, living positively; psychosocial counseling and emotional
support; adherence to care and treatment support; promoting referral linkages to clinic/hospital and other
networks; where possible conduct home visits; and attend PE-specific and general PLHIV support groups.
Approaches to PLHIV support were initially centralized with the development of care support centers; the
current implementation strategy through FY 2007 will be supporting the decentralization of PLHIV services.
In Free State, Columbia proposes to implement Peer educator programs, provide HIV clinical training and
mentorship for health professional staff, support the design and implementation of HIV information system
and support the integration of PMTCT and TB programs into HIV chronic care
ACTIVITY 3: Strengthening Program Integration Activities
District hospitals and public healthcare facilities have co-located TB, PMTCT and STI services, and
integration activities to strengthen these services with holistic palliative care will be carried out in
Activity Narrative: collaboration with the following programs at district and provincial levels:
a. PMTCT: Support early infant diagnosis through the use of dry blood spots (DBS) for PCR testing. This
activity will include training PMTCT nurses in specimen collection, information gathering to assess the
uptake of DBS and referral linkages of HIV-infected children to chronic care, ensure that HIV-exposed
children receive cotrimoxazole. DBS training activities will be carried out in collaboration with the Local
Service Area authority and the National Health and Laboratory Services (NHLS).
b. TB: Support active TB case finding and referral for TB treatment for the TB/HIV co-infected. Columbia will
support the implementation of TB screening and diagnosis algorithm for HIV-infected patients to include the
adaptation of a simple questionnaire for use as a screening tool for active TB at the designated HIV clinics
and incorporating the questionnaire into routine clinical care.
ACTIVITY 4: HIV Care and Treatment Information System
Columbia will continue to support the implementation of a provincial information system that captures
information on HIV palliative care and ART. Activities in FY 2008 will include:
a. Implementation of facility paper-based non-ART registers that captures non-ART indicators. These facility
registers will be introduced mainly at the primary and community health clinics that are designated by the
provinces as down-referral sites for HIV care and ART services.
b. In collaboration with the Department of Health and other partners in the Eastern Cape, support the
development and implementation of standardized individualized patient records for use at health facilities.
c. Strengthen the paper-based data collection systems at HIV care and treatment sites in the Eastern Cape
in preparation for computerization of a minimum set of key data elements.
d. Work with ART managers and facility site staff to support the utilization of information to improve service
delivery and patient care.
In all of the above activities, PLHIV will receive at least one clinical and one other category of palliative care
service. Palliative care to family members of PLHIV or OVC will be provided in at least two or the five
categories of palliative care services.
With FY 2008 reprogramming funds, Columbia will facilitate greater adherence and reduce loss to follow-up
through starting a pilot to using text messaging with cell phones.
Continuing Activity: 13731
13731 3319.08 HHS/Centers for Columbia 6587 2797.08 $1,523,546
7304 3319.07 HHS/Centers for Columbia 4371 2797.07 $1,350,000
3319 3319.06 HHS/Centers for Columbia 2797 2797.06 $1,000,000
Table 3.3.08:
This PHE activity, 'Identifying Optimal Models of HIV Care and Treatment in South Africa,' was approved for
inclusion in the COP. The PHE tracking ID associated with this activity is ZA.07.0117
New/Continuing Activity: New Activity
Continuing Activity:
Estimated amount of funding that is planned for Public Health Evaluation $89,286
Table 3.3.09:
ACTIVITY 4:
Disease Management System (DMS) Program will now only be supported at three Columbia sites, as one
of the sites has been taken over by another partner.
Columbia will provide comprehensive services in:
Prevention - Columbia will address the uptake of prevention of mother-to-child transmission (PMTCT)
programs, partner testing, prevention with positives (provider-initiated testing and counseling (PITC) couple
counseling, condom promotion and distribution, encouragement of disclosure, behavioral risk reduction
interventions, assessment, diagnosis and management of sexually transmitted infections (STIs), effective
family planning referrals, and alcohol assessment and counseling. Columbia will also ensure that
counseling and testing is offered routinely to clients seeking care in the antenatal clinic, family planning and
STI clinics.
Pre-antiretroviral therapy (ART) care - Columbia will use pre-ART registers to keep clients in care, inform
timely referral for ART and ensure that pre-ART service providers are sensitized to the eligibility criteria for
ART initiation, capacitate feeder sites to manage pre-ART clients until they are eligible for ART, and
increase the number of clients enrolled onto pre-ART care following a positive HIV test.
Early referral and retention in care and support - Columbia will initiate and emphasize treatment buddy
assessment of family members; couple counseling; support groups; and cohesive care plan for family.
Treatment adherence - Columbia will provide pill boxes, adherence counseling, sensitization of pharmacy
staff and community workers on conduct adherence counseling, pill counts at every visit, and educational
materials.
Cotrimoxazole (CTX) prophylaxis - Columbia will educate staff on the indications for CTX, providing
education materials, trainings, onsite mentoring, pharmacy support to ensure uninterrupted supply of CTX,
and providing alternate prophylaxis if CTX is contraindicated.
Family-focused care - Columbia will enroll and assess family members of people living with HIV (PLHIV) as
a priority of clinical support activities. The tools to assist this process include family counseling and
checklists to ensure mentoring activities identify and address bottlenecks in the family-focused approach.
Pharmacy support - Columbia is currently involved in facilitating the two-year Pharmacy Assistant training
program. This training is coupled with field work which assists with decongesting current treatment sites.
The regional Columbia pharmacy advisors are supported by one central Pharmacy Advisor who provides
onsite mentoring, support with ensuring functioning pharmacy systems are in place at all sites, and regularly
communicating with district and provincial departments of health.
Infrastructure support - Columbia will support necessary renovations and site remodeling to ensure suitable
space to provide all aspects of the comprehensive program is available. This includes minor structural
renovations, alterations to patient flow patterns, and the provision of a project manager to provide expertise
and advice.
Interventions for FY 2009 to address challenges around the quality of patient care will include:
- Continuing Medical Education to be incorporated with onsite mentoring on lab staging, and monitoring with
particular emphasis on regular monitoring tests (CD4, VL)
- Capacitating clinical teams to identify treatment related complications such as adverse events, side-
effects and the formulation of management plans
-Staging of disease is routine at every clinical visit by chart reviews, precepting, case-based learning, and
utilizing IEC materials (posters, flip-charts)
-Increasing the number of clients with undetectable viral loads after 12 months of treatment by promoting
adherence strategies, prompt follow-up of missed visits, regular lab and clinical staging, early identification
and management of treatment related complications, and opportunistic infections.
-Down referrals of stable clients to feeder sites for continuation of ART as part of the chronic care model,
with relevant up-referrals for management of complications
-Capacity development of feeder sites to manage ART clients, with the ultimate goal of achieving ART
Accreditation
Staffing: to meet the demands of the growing site programs, and Columbia geographical expansion during
the FY 2008, there is a need to increase both Columbia staff complement, and DOH staff supported by
Columbia. Most supported sites are faced with human resource constraints, and Columbia intends assisting
by the direct recruitment of staff, health systems strengthening to retain current staff, and promoting other
programs to retain staff (team focused site support, recognition of staff achievements, debriefing sessions,
attending to operational issues in a timely manner).
-------------------------------
Activity Narrative: Activities are carried out in FY 2008 to support implementation and expansion of comprehensive HIV
treatment and care primarily through human resources and infrastructure development, technical assistance
and training and community education and support, primarily in public sector facilities in the Eastern Cape,
Free State (new geographic focus area) and KwaZulu-Natal (KZN). Columbia University will support these
activities by using funds for human capacity development, local organization capacity building, and strategic
information. The degree of activity effort will vary in each site, but the emphasis areas will be addressed in
all sites. The target population will include infants, children and youth, men and women (including pregnant
women) and people living with HIV (PLHIV). Columbia will continue to support the recruitment of doctors,
nurses, pharmacists and pharmacist assistants.
Columbia University (Columbia), with PEPFAR funds, began supporting comprehensive HIV care and
treatment activities in FY 2004. Health facilities were initially identified in the Eastern Cape and in FY 2006,
due to new boundary demarcations and additional PEPFAR funds, Columbia started providing similar
assistance in KZN. In FY 2006, in response to provincial HIV care and treatment priorities, Columbia began
strengthening the down referral of services from hospitals to primary health clinics. This resulted in a total of
36 health facilities receiving technical and financial support from Columbia, including public hospitals,
community health centers, primary health clinics and a non-governmental wellness center. In FY 2007 an
additional two health facilities in KZN received technical and financial assistance for HIV care and treatment
services.
All activities are in line with South African government (SAG) policies and protocols, and activities will be
undertaken to create sustainable comprehensive HIV care and treatment programs, and primarily include
six programmatic areas:
ACTIVITY 1: Support Recruitment and Placement of Health Staff
Since FY 2005 Columbia has been involved in the recruitment of staff to support the HIV comprehensive
program at health facilities. High staff attrition rates of Department of Health (DOH) recruited personnel
have been a challenge in guaranteeing a steady enrolment of eligible PLHIV into care and treatment.
Columbia will continue to support the recruitment of doctors, nurses, pharmacists and pharmacist assistants
through existing partnerships with University of Fort Hare, Nelson Mandela Bay Metropolitan Municipality,
Ikhwezi Lokusa Wellness Center, University of KwaZulu-Natal Cato Manor, and the Foundation for
Professional Development (FPD). Columbia supported the recruitment and placement of approximately 15
doctors, 30 nurses (registered and enrolled nurses), 4 pharmacists, 7 pharmacist assistants and 15 trainee
pharmacist assistants. These health personnel provide direct patient care in the hospitals and clinics
including: clinical assessment, screening for tuberculosis (TB) and antiretroviral treatment (ART) eligibility,
opportunistic infections (OI) diagnosis and management, offering OI prophylaxis and treatment, and ART.
The health providers also develop patient treatment plans as part of the multidisciplinary team in the health
facility; and assist patients to access relevant SAG social grants.
ACTIVITY 2: Training and Clinical Mentoring
Columbia has established a partnership with FPD to provide ARV didactic training in all supported health
facilities. A second partnership with Stellenbosch University assists the rural health facility staff (St.
Patrick's, Holy Cross and Rietvlei hospitals and their referral clinics), with the management of patients on
ART by conducting case discussions on a monthly basis. Columbia has clinical advisors as part of its South
African team consisting of nurse mentors, and medical officers who provide day-to-day clinical guidance on
the management of patients on ART.
ACTIVITY 3: Strengthen ART Down and Up Referral Linkages Between Hospitals and Primary Healthcare
Clinics
In the early phases of the ART program, all patients are evaluated and initiated on therapy at hospital level.
Within three to six months of providing support to the hospital-based ART program, designated referral
clinics are integrated into the services. In the rural health facilities, a small team of health providers, usually
comprising of a medical officer, professional nurse and peer educator, travel to the primary healthcare
clinics (PHC) to screen patients for OIs and to determine suitability for ART. This approach has enabled
expansion of ART services at PHC level and has resulted in improving and increasing access to treatment.
The team of health providers has also developed capacity of the onsite health providers and the goal is to
have the onsite DOH health staff eventually provide the full package of HIV care and treatment services. In
FY 2008, Columbia will continue to support linkages with the public clinics and the development of a more
sustainable system of service provision.
information regarding HIV palliative care and ART. Activities in FY 2008 will include:
(a) Continued implementation of facility paper-based ART registers that capture both adult and pediatric
ART indicators.
(b) In collaboration with the Eastern Cape Department of Health (ECDOH) and other partners in the Eastern
Cape, support the development and implementation of standardized individualized patient records for use at
health facilities that incorporates information on client ART use.
(c) Implement an ART software system. In FY 2007, Columbia in partnership with Africare (a PEPFAR
Activity Narrative: partner) and Health Information System Program (HISP) customized and developed ART software that
captures and collates HIV and AIDS program data. This is being adapted for data entry, and installation is
expected before the end of FY 2007. The system is being piloted at three health facilities in East London. In
FY 2008, after assessing results from the pilot sites, Columbia will engage the ECDOH in discussion on
how the module could be added into the existing District Health Information System to efficiently generate
reports on the HIV program, and thereafter implemented at more ART services outlets.
In addition, in 2007 Columbia begun a new partnership with Disease Management system (DMS) - a patient
-centered health management information system (HMIS) that operates at the patient level of care to assist
health care professionals initially at 4 identified Columbia supported health facilities in Port Elizabeth to
provide comprehensive care management of people living with HIV, as well as providing management
information for relevant stakeholders. In FY 2008, with lessons learned from the implementation of this
system, Columbia in partnership with ECDOH proposes to extend the use of this information system in all
HIV and ART service delivery points, where feasible. In addition, by FY 2008, Columbia will support the
implementation of similar program activities (as specified above) in newly identified health facilities in the
Free State (to be determined).
d. In an effort to improve and monitor quality of activities being implemented, Columbia in FY 2007
developed a standard operating procedure (SOP) for data quality. Dissemination and use of this SOP is
currently underway in all Columbia-supported facilities. In FY 2008, Columbia plans to recruit a quality
assurance officer who will be responsible to monitor quality of implemented activities from both a data and
program perspective.
ACTIVITY 5: Improve Retention into Care and Treatment and Reduce Loss-to-Follow-Up
In FY 2006/7 Columbia begun implementing strategies to establish and mitigate the losses to follow-up in
the HIV program. In the supported sites in East London, dedicated staff were hired to assist tracing and re-
introducing patients lost-to-follow-up. In partnership with the Buffalo City Municipality and the ECDOH,
Columbia has created an external referrals director for HIV and AIDS services for the East London environs.
With the lessons learned in this initial work of tracing patients in HIV care and treatment and the
development of the referral directory, Columbia plans to initiate similar support across all supported facilities
in FY 2008. In addition, Columbia is developing Adherence and Social Support Unit guidelines to
standardize procedures used across supported health facilities. Dissemination of these guidelines will take
place in early 2008.
ACTIVITY 6: Improve and Increase Enrollment of Infants and Children into HIV Chronic Care and Treatment
In the Eastern Cape, pediatric ART enrollment is centralized at the regional and tertiary facilities, where
pediatricians are heavily involved in the care and treatment of children and infants and decentralization of
pediatric ART services to PHCs that are providing ART for adults has been very slow. In FY 2007 services
of pediatricians were retained to train and/or mentor health staff at the facilities to improve pediatric HIV
care and treatment, and this will continue in FY 2008. In addition, Columbia will continue to take advantage
of the established partnership with Stellenbosch-Tygerberg to train nurses and doctors in pediatric HIV care
and treatment. Recruitment for a pediatrician to spearhead all pediatric HIV activities in the Eastern Cape,
KZN and Free Sate is currently ongoing.
Continuing Activity: 16321
16321 16321.08 HHS/Centers for Columbia 6587 2797.08 $0
FY 2008 COP activities will be expanded to include:
-Testing and counseling for infants, children and adolescents and their families;
- Provision of cotrimoxazole (CTX) to all HIV-exposed infants until HIV infection is excluded and infants is
no longer at risk from breastfeeding and to all eligible HIV-infected children;
-Provision of a comprehensive prevention package;
-Building a system of referrals between PMTCT, ART, Maternal and Child Health (MCH), Integrated
Management of Childhood Illness (IMCI), TB and Community care;
-Building competency and skills of the health care providers working within the pediatric services; and
-Ensuring development of best practice models in pediatric care at 46 sites.
The International Centre for AIDS Care and Treatment Programs (ICAP) will support the implementation
and expansion of pediatric HIV care and support. The focus areas for this program will be training, technical
assistance, supportive supervision, community education and quality assurance with minor emphasis on
human resources and infrastructure development.
ICAP has been supporting the comprehensive care of Persons Living with HIV/AIDS (PLHIV) since 2004 in
support of the Eastern Cape Department of Health (ECDOH) and KwaZulu-Natal Department of Health
(KZNDOH). ICAP supports early access to services, early diagnosis and enrolment and retention into care
of children through provision of family focused comprehensive HIV care and treatment. HIV-exposed infants
are tested using the dry blood spot (DBS) test for HIV DNA PCR at 6 weeks and 6 weeks post weaning for
those breastfeeding. Older children are diagnosed with antibody tests as per South African Department of
Health Guidelines. Clinicians are given initial training and are mentored on an ongoing basis to identify at
risk babies as well as shown how to collect DBS specimens. ICAP is supporting comprehensive HIV care
and treatment including the use of cotrimoxazole for all HIV-exposed and HIV-infected children until a
definite exclusion of HIV has been made or those that are infected are stable on ART as per guidelines.
Emphasis has been placed on integration of PMTCT, anti-retroviral therapy (ART) and primary health care
(PHC) as well as TB clinics, to identify children that are HIV exposed or infected and then assess them for
ART eligibility early initiation of ART for infants <12 months of age, and enroll them into care and support
services. In FY 2009 this integration of services as well as step up of counseling of care givers to bring back
children will be prioritized. ICAP will continue to provide technical assistance, mentoring and monitoring and
evaluation of the activities at 46 sites. Essential clinical equipment will be procured and the pediatric record
card together with the HIV care and treatment registers will be implemented to ensure quality of services
provided.
ACTIVITY 1: HIV Testing and Counseling for infants, children and adolescents and their families
a. Support routine testing and counseling in every clinic area including well-baby clinic, pediatric inpatient
settings, malnutrition units, TB clinics, and family assessments in adult ART clinics. Rapid HIV test kits will
be made available, providers will be trained, and support and monitoring of the process provided by ICAP
staff. Infants and children identified as HIV-infected will be enrolled in HIV care and treatment.
b. Increased early infant diagnosis (EID) with DBS at the level of the PHC, pediatric inpatient wards, at TB
clinics, PMTCT and post-Natal settings. A system for ensuring DBS test kit availability, as well as for
enhancing caregiver counseling, will be developed and implemented.
c. HIV counseling and testing (CT) extended to the families of pediatric patients at pediatric visits. The
caregiver will be encouraged to bring additional family members. This process will be documented and
evaluated.
d. Refresher trainings for providers will be incorporated into monthly in-service trainings for sites and feeder
clinics on identifying at-risk infants and children, as well as assessment, diagnosis and management of HIV
exposed and infected children.
e. Ongoing mentoring of health care providers on pediatric care and support. Focus will be on developing
and maintaining provider competency. Precepting checklists will be used to follow provider competency
over time.
ACTIVITY 2: Cotrimoxazole prophylaxis
Provision of cotrimoxazole (CTX) to all HIV-exposed infants until HIV infection is excluded and infants are
no longer at risk from breastfeeding and to all eligible HIV-infected children. Accurate and consistent
documentation of CTX will be ensured through refresher trainings, chart review and provider coaching.
Reliability will be evaluated per the patient held cards. The Department of Health (DOH) and ICAP
pharmaceutical advisors will work together to ensure proper stock level management to avoid stock outs of
CTX. Counseling on the importance of bringing the children back for the 6 week follow-up for diagnosis and
CTX prophylaxis will start during ANC and care givers will be provided with information on the benefits of
CTX prophylaxis whenever they bring the children for other health care services. This information will form
part of the counseling checklist, the use of which will be regularly reviewed.
ACTIVITY 3: Preventive Care Package
Ensure nutritional assessment, counseling, support and growth and developmental assessment at each
clinical encounter through availability of weight scales, measuring tapes and height boards and training
clinicians to accurately measure the anthropometric parameters, plot growth charts and diagnose growth
failure and developmental delays. Dietary and social history will also be taken form care givers. The new
pediatric care record cards with growth charts will be implemented for both exposed and infected infants
Activity Narrative: and children. ICAP will ensure accurate and consistent plotting of these charts, interpretation and that the
growth parameters are accurately reflected in the care registers and patient held cards by regular charts
and registers review. Nutritional support and safe feeding practices counseling will be given to care givers.
Daily multi-micronutrient supplementation will be provided for the undernourished children and therapeutic
or supplemental feeding as well as referral for ART for those with clinical malnutrition. These will include de-
worming and vitamin A supplementation as per SA guidelines. Infant feeding counseling and ongoing
support will be provided to all pregnant women and those HIV-infected. Women will be advised on exclusive
breastfeeding and ongoing support will be provided post delivery to ensure maximal survival of the HIV-
exposed infants. Basic ante-natal clinic (ANC) training will be provided that emphasizes infant feeding
counseling to all expectant mothers. HIV-infected mothers will be educated about exclusive breastfeeding,
and breastfeeding will be encouraged where acceptable, feasible, affordable, sustainable and safe (AFASS)
criteria are not met. Feeding counseling as well as the mothers feeding choice will be noted on the
antenatal cards, on the Road to Health Cards of the infants and on the PMTCT registers. Peer educators
and mentor mothers will provide support to the mothers and care givers. Routine and additional scheduled
immunizations will be provided to all HIV exposed and HIV-infected children according to national
guidelines. Screening for TB and active TB case finding, treatment and prophylaxis will be provided.
Clinicians will be trained and mentored to assess all children in contact with adults with active PTB and
screen them for TB at baseline using Tuberculin Skin Test (TST), gastric washings, sputum from older
children and/ or chest x-rays. Special emphasis will be on children under the age of five, those with HIV
infection, malnutrition and other immunosuppressive diseases. All HIV-infected children will be screened for
TB each clinical encounter. Implementation of the pediatric record card will ensure prompting for TB
symptom check. Children with TB infection will be treated and those without TB will be given isoniazid (INH)
prophylaxis according to guidelines.
ACTIVITY 4: Functional referrals between PMTCT, ART, Maternal and Child Health (MCH), Integrated
Management of Childhood Illness (IMCI), TB and Community care
Functional referral linkages between services will be established. Children will be assessed for eligibility for
ART by laboratory and/or clinical assessment and referred as necessary. HIV exposed children will be
followed up and final HIV status established using PCR. All infants <12 months of age who are HIV-infected
will be fast tracked to initiate Highly active antiretroviral therapy (HAART). Pediatric support services will be
incorporated into routine mother and child services. The HIV status will be documented on the child's Road
to Health card using the SA DOH recommended PMTCT stamp and/ or share code as per guidelines for
future reference. ICAP will ensure that formal referral forms are available and used to refer clients between
facilities or services and will also ensure that such referrals are communicated to the referral sites. This will
ensure continuous quality comprehensive care of the family unit. Mothers that were not on the PMTCT
program and those that delivered at home and had their first post-natal HIV test will be assessed for ART
eligibility and advised to bring their children for testing at six weeks. Formal referrals will be instituted
between MOUs and primary health care facilities where follow up of infants and mothers occurs as well as
between these facilities and hospitals, inpatient wards, ART sites and TB facilities. Measures such co-
scheduling appointments and treatment and counseling the family members together to ensure adherence
to care and follow up will be used to monitor this process. Community and home-based care referrals will be
established to ensure continuity of care and to improve access to services. ICAP will collaborate with
community-based organizations and use home-based care to follow up on clients in their communities for
adherence counseling and ongoing support. These community health workers will educate communities and
families on the benefits of adherence to care and follow up. In addition, ICAP will support the
implementation of Household and community integrated management of childhood illness (HH/C & IMCI) to
improve the first five years growth and development of pediatric clients through its adherence and social
support component. Health care worker knowledge and skills in HH/C IMCI will be improved through
training, technical support supervision, mentoring, and provision of adapted IMCI guidelines, tools and
standard operating procedures (SOPs). ICAP will also work with communities, the Department of Health
(DOH), nongovernmental organizations (NGOs), and community-based organizations (CBOs), to ensure
improved health systems to deliver quality care and IMCI. The DMT, community leaders, community
resource persons, households and child care givers will be sensitized and provided with skills that will
ensure child growth and development, home management and appropriate health seeking behaviors
including car for children affected by HIV and AIDS. Training and sensitization will be done through group
education, community outreach activities, and home visits. Monitoring and evaluation of activities will inform
the practice of quality care.
ICAP will work with DOH and other organizations in different districts to create external referrals directories
(for example, Buffalo City External referrals Directory developed by ICAP). Adherence and social support
referrals to care givers including issues of disclosure in children will be addressed. Counseling and support
to the care givers as well as older children will be provided. This will include establishing adolescent-friendly
services, such as: having a dedicated section or clinicians at site for consultation with adolescents,
formation of adolescent support groups to assist them in dealing with acceptance of their HIV status,
adherence issues in the context of their environment and changing physiological and biological states. This
will also address issues of prevention as well as the transition from pediatric into adult programs as well as
ART readiness and compliance for those already on ART.
ACTIVITY 5: Engaging stakeholders and other partners
The sustainability of the HIV care and support programs depends on ICAP collaborating with stakeholders.
The stakeholders in this instance are particularly the South African Department of Health through the
provincial ministries, district health teams (including HIV, AIDS, STI and TB [HAST] managers) as well as
facility managers and teams. Shared responsibility and co-planning will ensure ownership and rollout of this
program. ICAP will strengthen the current data feedback sessions with the facilities and providers and also
continue to attend HAST and District Health Management Team (DMT) meetings where programmatic
challenges are identified and solutions sought. ICAP will also endeavor to have regular focused meetings
with the clinic supervisors and program managers to analyze successes and challenges and plan the
necessary interventions. ICAP technical support teams will continue to support sites and mentor the site
Activity Narrative: teams and individual providers to ensure quality care of the pediatric HIV exposed and infected clients until
site independence can be achieved and the sites are less reliant on the ICAP teams. ICAP will continue to
work with partners of the South to South training program and the Ukwanda Stellenbosch University
outreach program to build competency and skills of the health care providers working within the pediatric
ACTIVITY 6: Quality of Care
ICAP will ensure development of best practice models in pediatric care at 46 sites. Quality, comprehensive
and family centered care will be ensured through capacity building at site and at provider level. This will
include human resources, provider skills development, infrastructural support and equipment procurement.
In essence ICAP will ensure that the minimum package of care (using the model) is in place at 46 sites. The
program will also ensure accurate documentation of care and support services through the implementation
of pediatric care record card and registers. The pediatric standards of care will be used to assess the
implementation and the quality of care that is provided to HIV exposed and HIV-infected children.
Monitoring and evaluation of the pediatric care and treatment services will also be a core activity.
Table 3.3.10:
SUMMARY
The high burden of pediatric Human Immunodeficiency Virus (HIV) infection in sub-Saharan Africa has
stimulated a re-alignment of HIV programs, and increased the focus on entry points into, and integration
with, pediatric care and treatment have increased in importance. The scope of such programs extends from
strengthened Prevention of Mother-to-Child Transmission of HIV (PMTCT) delivery, through early infant
diagnosis and follow-up, to robust, adolescent-friendly care. Initiation of Antiretroviral Therapy (ART) in HIV-
infected children under the age of 12 months will be encouraged. ICAP has been working with pediatricians
in the Eastern Cape to down-refer children stabilized on ART from tertiary facilities to Primary Health Care
and Community Health Centers.
BACKGROUND
Without treatment, 50% of HIV-infected children are dead by the age of two years, and mortality reaches
75% by five years due to inter-current infections such as TB, diarrheal illnesses, malaria and malnutrition.
In addition, HIV infection adversely affects a child's growth and neurological development. The Columbia
University International Center for AIDS Care and Treatment Programs (ICAP), with PEPFAR funding, has
been supporting comprehensive HIV care and treatment activities since 2004. The cooperative arrangement
was initially limited to the Eastern Cape, but has subsequently spread to facilities in KwaZulu-Natal and will
be expanding into Free State and Northern Cape in the later half of FY 2008 COP implementation. During
FY 2009 COP implementation, ICAP will further expand site support activities into the Northern Cape, and
reinforce pediatric HIV care and treatment programs at the current facilities by increasing early infant
diagnosis and raising the proportion of children on ART to 15% of all people on ART in South Africa.
ACTIVITIES AND EXPECTED RESULTS
The following four program activities will be implemented with FY 2009 funding to support a safe, evidence-
based, sustainable, comprehensive ART service for children:
ACTIVITY 1: Strengthen case identification and patient management, including linkages between health
services and referral mechanisms.
Public healthcare facilities offer a broad range of services, all of which are accessed by HIV-infected adults,
such as ANC, maternal and obstetric units (MOU), TB, sexually transmitted infections (STIs) and Family
Planning Clinics. In FY 2010, ICAP will support the heightening of awareness of HIV exposure and
encourage routine counseling and testing and appropriate referrals, so that HIV-exposed infants can be
identified.
ICAP staff will train and refresh all providers in Pediatric HIV Care and Treatment, and will monitor progress
of providers in appropriately starting ART in eligible children. (Additional training details are in Activity 3
below). Emphasis will be on ascertaining ART eligibility on clinical grounds, in addition to relying on
laboratory data. Initiation of eligible children onto ART will be carefully monitored by Nurse Mentors and
Clinical Advisors, and remedial action will be taken when gaps are identified. In addition, ICAP will regularly
review and develop Pediatric Standards of Care tools to prioritize initiation of children on ART.
ICAP staff will similarly monitor treatment failure in children taking ART. The indications that an ART
regimen is failing can be divided into clinical, immunological and virological categories. ICAP will assist in
the training of healthcare providers to recognize treatment failure, by regular mentoring and in-service
trainings. It is incumbent for service providers to understand that poor adherence is the commonest reason
for failure, and adherence strengthening should be explored initially. ICAP will develop and adapt referral
and supervisory systems to manage and monitor patients on ART, and support data recording and reporting
systems.
ICAP will train all facility staff in Provider-Initiated Counseling and Testing (PICT), and support the
procurement of rapid test kits. Facilities will be systematically surveyed in each region by ICAP site support
staff to dynamically determine gaps in PICT training and test kit availability.
In conjunction with PICT training, regular in-service training sessions arranged by ICAP Nurse Mentors will
provide opportunities for clinicians from different service areas in the facility to develop more formal referral
mechanisms. Emphasis will be placed on cross referral between TB and HIV services, and between
immunization/well baby clinics and ART clinics.
Efforts will be made to include PICT providers and representatives of referral endpoints in multidisciplinary
teams at sites. These efforts will be coordinated by the Nurse Mentors.
Although ICAP will continue to support the implementation of facility paper-based ART registers to capture
ART indicators, the expansion of the Health Information System Program (HISP) ART software will be
encouraged for the capturing and collating of HIV program data. These data will facilitate patient
management in areas of identifying gaps in services, tracing and tracking, and targeting intervention efforts
for special groups of children.
ICAP will continue to collaborate with the Eastern Cape Department of Health (ECDOH) and other partners
in the Eastern Cape on the implementation of standard pediatric patient records that include comprehensive
HIV care and treatment, routine health maintenance, and TB screening.
ICAP multidisciplinary regional teams will provide systematic on-site mentorship to clinicians, pharmacists,
and data capturers. These mentorship efforts will focus on competency of on-site staff. Each site will have a
systematic plan for addressing gaps under the coordination of the Nurse Mentors.
ICAP Clinical Teams will be available by telephone and in person to assist in the management of
Activity Narrative: complicated cases.
ACTIVITY 2: Improve Follow-up of HIV-exposed Infants and Enhance Early Infant Diagnosis (EID).
ICAP has been strengthening EID by training PMTCT nurses in polymerase chain reaction (PCR) testing
through the use of dried blood spots (DBS), appropriate referral of patients into care, and provision of
cotrimoxazole.
With FY 2009 funding, ICAP will encourage early infant diagnosis by close tracking of HIV-exposed infants
identified from PMTCT programs at follow-up in all appropriate settings, such as immunization or well-baby
clinics and pediatric wards. In addition, ICAP will develop appropriate monitoring mechanisms to ensure that
follow-up appointments are kept. (Please refer to Activity 4 in the Pediatric Care and Support Section, and
Activity 3 in the Prevention Section).
All HIV-exposed infants will be commenced on cotrimoxazole at 6 weeks of age, will be closely followed up,
receive routine growth monitoring, counseling and support on infant feeding. (Please refer to Activities 2 and
3 in the Pediatric Care and Support Section.)
In addition, ICAP will promote routine testing of sick children, either within Integrated Management of
Childhood Illness (IMCI) settings, or hospitalized children with histories compatible with HIV or an
opportunistic infection (OI). HIV testing will be provided through polymerase chain reaction (PCR) testing
with dried blood spots (DBS) or plasma in infants younger than six months, and antibody testing in older
infants and children. A definitive diagnosis will be made in all HIV-exposed infants by 18 months as HIV-
infected children should be commenced on ART before the age of two years. Testing algorithms will
include recommendations for repeat testing of children who test HIV-negative but have ongoing HIV
exposure through breastfeeding, and children who test HIV-positive on antibody tests performed before 18
months of age. (Please refer to Activities 1 and 4 in the Pediatric Care and Support Section.) ICAP will
assist in the development of formal linkages between general pediatric OPD clinics, pediatric in-patient
wards and the ART clinic. These linkages will be regularly monitored and their efficacy evaluated by ICAP
Clinical Advisors.
In terms of TB/HIV co-infection, ICAP will contribute to the coordination between TB and HIV programs at
public health facilities to ensure a continuum of care for co-infected individuals. ICAP will assist in
decreasing of the burden of TB in people living with HIV (PLHIV) by ensuring routine screening for TB
disease, fast-tracking diagnosis and treatment of active TB disease, and preventing the development of
drug resistance. (Please refer to Activity 3 in the Pediatric Care and Support Section for more details.) ICAP
will support training of health care providers in identification of drug interactions, toxicities and adherence
difficulties of increased pill burdens. Through regular in-service training and clinical mentoring, clinicians
should follow country guidelines for ART drugs, but avoid altering recommended TB regimens.
Nutritional support of HIV-exposed and infected-children should expand on the training, counseling and
choices made by mothers post-delivery. Mothers who have opted for exclusive breast-feeding and rapid
weaning at six months will receive ongoing counseling at every clinic visit, and be assisted in achieving the
rapid weaning. Mothers who opt for formula feeding will require additional feeding options from four to six
months. ICAP will provide adherence and feeding counseling from mentor mothers. Care providers will be
trained to recognize growth failure early by proper completion of growth charts. (Please refer to Activity 3 in
the Pediatric Care and Support Section.)
In collaboration with other partners such as the Departments of Education and Social Welfare, community-
based organizations (CBOs) and faith-based organizations (FBOs), ICAP will provide outreach services
through OVC programs to HIV-exposed and infected children. Such services may include HIV testing, TB
and other OI screening, clinical staging, care and treatment. ICAP will assist in the tracking of all affected
infants by developing relevant tools for documentation, monitoring and evaluation.
ACTIVITY 3: Support Training in Pediatric HIV Care and Treatment.
In FY 2008, the ICAP partnership with Stellenbosch University and Tygerberg Hospital has trained 25 South
African clinicians, both nurses and doctors, in comprehensive pediatric HIV care and treatment. An
additional eight clinicians are yet to attend the two-week course. The clinicians support children seen at a
variety of out-patient clinics, including both primary and tertiary facilities.
In FY 2009, these clinicians will be encouraged to develop facility-based training programs for their
colleagues and other members of the multi-disciplinary team. This type of in-service training, which will
incorporate didactic teaching, precepting, mentoring and case-based review, will minimize disruption of
service delivery.
ICAP will continue to use local pediatricians in training and mentoring of staff through regular clinical
meetings.
In areas where local expertise is lacking, ICAP will assist in the provision of sessional doctors for service
delivery.
ICAP will support the development of monitoring and evaluation tools for training such as self-assessment
checklists.
ACTIVITY 4: Encourage Down Referral of Stable patients to Primary Health Care Clinics (PHCs).
In FY 2008, the decentralization of pediatric ART services in the Eastern Cape was commenced.
In FY 2009, in collaboration with the ECDOH and Stellenbosch University, ICAP will continue to improve
Activity Narrative: retention of patients in care and treatment, reduce patients lost-to-follow-up, and increase the clinical
pediatric skills of staff at smaller facilities. This will facilitate the down referral of patients who have been
stabilized on ART. Regular refresher in-service trainings in pediatric care and treatment will be coordinated
by the Nurse Mentors and Clinical Advisors. The multidisciplinary meetings will be encouraged to address
clinical issues, as well as logistical challenges.
ICAP will assist in the development of tools to improve adherence to ART at all levels of care and treatment.
Care providers will be trained in the establishment of adherence programs aimed at the patient and the
family, drug issues such formulation and toxicity, and healthcare system strengthening which will encourage
the establishment of long-term relationships among children, their families, and the clinic staff. All members
of the MDT will provide counseling, tracking and follow-up of children. Disclosure of the child's illness forms
an essential part of regular follow-up. ICAP will assist clinicians to be appropriately trained and sensitized to
the process.
ICAP, through the site support teams, will assist the PHC service providers recognize ART treatment failure,
and ensure the provision of mechanisms for up-referral.
Some elements of pediatric treatment are also addressed in more details in other linked areas of the COP,
including Pediatric Care and Support, Counseling and Testing, ARV Drugs, and Adult Treatment.
* Child Survival Activities
Table 3.3.11:
All the 46 HIV care, support and treatment sites supported by the International Center for AIDS Care and
Treatment Programs (ICAP) at Columbia University will provide tuberculosis (TB)/HIV integration
interventions including screening, referrals and TB infection control. The aim will be (a) to ensure at least
90% of HIV-infected patients at the sites are screened for TB at the initial and follow up visits; (b) to ensure
at least 80% of TB/HIV co-infected eligible patients are on cotrimoxazole preventive therapy; (c) to ensure
at least 90% of TB patients are offered routine HIV counseling and testing; and (d) to facilitate TB infection
control at all these facilities. The program will adapt a comprehensive, family focused, and continuous
minimum package of care for TB and HIV co-infection management at each of the 46 sites to provide high
quality TB/HIV care. The minimum package will include (a) a focus on the family as the foundation of care;
(b) optimized use of a multidisciplinary team of providers, lab and pharmacy staff, and administrative
support staff; (c) emphasis on adherence and prevention; (d) strong linkages across various clinical service
and strong linkages with community resources and organizations. ICAP will also focus on strengthening of
the health systems at the provincial, district, sub district/Local Service Area (LSA) and facility level to ensure
effective management of TB/HIV co-infection and creating appropriate conditions for the implementation of
related TB/HIV integrated activities.
The following activities will be implemented:
a) ICAP will support the interventions to reduce the burden of HIV among the TB patients, families and
community. Only three hospitals will be supported on management of TB patients co-infected with HIV,
while ICAP will collaborate and ensure functional referrals for TB management with other PEPFAR partners
in the remaining 39 sites. ICAP will support the following activities in COSH, Nkqubela and Empilweni
Hospitals:
(i) Routine HIV testing and counseling.
(ii) Cotrimoxazole preventive therapy for HIV-infected TB patients.
(iii) Linkages and functional referral system with the HIV care and treatment programs. The program will
strengthen the routine counseling and testing at the TB facilities, clinical staging and laboratory assessment
of co-infected patients, cotrimoxazole prophylaxis, preparation of eligible co-infected patients for highly
active antiretroviral therapy (HAART), and initiation of HAART. The patients will then be transferred to the
nearest antiretroviral treatment (ART) service point and follow-ups will be done through home-visits by the
lay counselors, field caregivers, and peer educators.
(iv) Isoniazid preventive therapy (IPT) for TB exposed children.
(v) Home visits to screen for TB and HIV. ICAP will review and adapt available tools with the SAG and other
PEPFAR partners.
(vi) ART for those who qualify.
b) ICAP will support the following activities to reduce the burden of TB among the people living with HIV,
their families and community:
(i) Intensified TB case finding among all clients receiving HIV services at the 46 health facilities, including
counseling and testing units, prevention of mother-to-child transmission services, other units in the facility,
and pediatric services.
(ii) Isoniazid preventive therapy for tuberculin test positive clients.
(iii) ART for eligible clients.
(iv) Linkages between TB diagnosis and TB treatment programs. All patients starting HIV care and
treatment programs will be screened for TB and those found with TB infection will be referred for diagnosis
and TB treatment at the nearest clinic.
c) Integration of TB-HIV Services at the community level: ICAP will support the full range of services, linking
the activities at clinic and the home. The activities will improve the coordination of counseling and testing,
HIV treatment and care, TB diagnosis and care and prevention of mother-to-child HIV transmission
d) Support the establishment of a sustainable mechanism for collaboration and coordination among the
government institutions (province, district, LSA and the health facilities), implementing partners, and the
beneficiaries.
f) Conduct/strengthen surveillance of HIV prevalence among TB patients and HIV among TB patients
including monitoring and evaluation activities.
g) Based on lessons learnt from the current ICAP TB Infection Control (TBIC) projects TBIC will be re-
conceptualized to focus on clinical actions by the health-care providers themselves that promote rapid
identification of TB disease, rapid initiation of TB treatment and ensuring adherence with treatment until
completion. Simple design elements will also be addressed to minimize nosocomial transmission of TB in all
the 46 facilities.
h) The Yale University partnership at Tugela Ferry will continue, with an extension of coverage and follow-
up regarding patients with MDR and XDR TB.
Activities support implementation and expansion of best-practice models for integration of TB and HIV
services in public sector facilities in Eastern Cape and KwaZulu-Natal. TB/HIV activities are implemented
through technical assistance and will result in a decrease of TB in HIV-infected children and adults, increase
prevention and early detection of TB in HIV-infected children and adults, and provide overall support to
provincial TB/HIV activities. The emphasis area for this program will be human resources. The target
population will include infants, children and youth (non-OVC), men and women (including pregnant women
and family planning clients), people living with HIV (PLHIV) and public and private sectors.
Columbia University (Columbia) began TB/HIV integration activities in FY 2006. Health facilities initially
identified in Eastern Cape included 3 TB hospitals (Nkqubela, Fort Grey and Empilweni Hospitals) and 8
Activity Narrative: HIV care and treatment sites (Holy Cross, St. Patrick's, Rietvlei, Cecilia Makhiwane, Frere, Dora Nginza and
Livingstone Hospitals, Ikhwezi Lokusa Wellness Center). In the TB hospitals inpatients are counseled and
tested for HIV, initiated on cotrimoxazole prophylaxis if they are found to be HIV-infected and if they are
eligible, started on antiretroviral treatment (ART). On discharge from TB hospitals, patients are linked to
primary health care clinics or nearest facility where they can access HIV and TB treatment services.
Patients from Empilweni TB hospital are referred to any of seven primary health clinics in Port Elizabeth. In
FY 2006, Columbia began training of nurses, doctors and lay health workers on TB/HIV integration in both
programmatic and clinical aspects: active TB case finding among HIV-infected patients, ART for eligible
TB/HIV co-infected clients, and leveraging existing referral services to provide comprehensive HIV support.
In FY 2008 Columbia will continue to implement activities in these 3 TB hospitals and 38 HIV care and
treatment sites, for a total of 42 health facilities, in the Eastern Cape and KwaZulu-Natal. Four new health
facilities in Free State will be identified in FY 2008 for TB/HIV support. In FY 2007, Columbia formed a new
partnership with Yale University AIDS Program in support of TB/HIV integration activities in Tugela Ferry,
KwaZulu-Natal, which will continue in FY 2008.
ACTIVITY 1: TB hospitals in Eastern Cape
Activities will include:
1. Provide ongoing TB/HIV clinical support by conducting didactic and onsite TB/HIV training for doctors,
nurses and lay health staff to improve knowledge and practice around managing TB/HIV patients. Provide
clinical mentorship through case presentations and discussion.
2. Continue to support the hiring and placement of doctors, nurses, and peer educators to improve uptake
of HIV counseling and testing and to increase enrollment of TB/HIV co-infected patients into ART.
3. Provide technical support for monitoring and evaluation (M&E) activities by implementing a system to
track/monitor referrals and patients between HIV and TB programs. This activity includes training and use of
the pre-ART and ART facility registers.
ACTIVITY 2: HIV Care and Treatment Sites
Activities in the 38 HIV care and treatment sites will be focused on strengthening:
1. TB case-finding among clients enrolled into HIV care and ART. Columbia is in the process of
implementing a facility held patient record that captures information on TB case finding within the patient
record. Columbia is training doctors and nurses in the supported facilities to use the patient record to
improve TB/HIV clinical care and treatment. These staff will be routinely mentored by Columbia nurse
mentors/clinical advisors.
2. Referral linkages with the TB program to initiate TB therapy for those in HIV care and/or ART. The
Columbia supported community health centers and primary health clinics (PHCs) with HIV care and
treatment services also have TB services on site where Columbia supports TB services by improving
referrals of TB/HIV co-infected clients on ART to on site TB services to receive TB treatment. This includes
development of a referral slip to the TB services and also ensuring the facility held patient record in the HIV
clinic is updated with the relevant TB information.
ACTIVITY 3: Yale University Partnership
Columbia will partner with the Yale University to develop the following services at the Church of Scotland
Hospital (COSH), Tugela Ferry (KwaZulu-Natal):
1. Increase HIV counseling and testing (CT) of clients accessing TB services in the COSH. This will be
implemented through the introduction of various models of provider-initiated CT at the TB treatment
programs (drawing on experiences from other settings) that is inclusive of training of TB treatment staff in
HIV CT, training in HIV pre- and post-test counseling with establishment of strong linkages to laboratory HIV
diagnostic services, and training of TB treatment staff in the referral of TB patients to CT services.
2. Prevent the development of multidrug-resistant tuberculosis (MDR-TB) cases and improving treatment
completion rates by strengthening the existing TB DOTS program and integrating with HIV treatment. Under
the Yale partnership the program components for this specific program activity will include:
-Defining the baseline TB treatment completion and cure rates
-Overall program improvement by: providing routine HIV counseling and testing, developing effective TB
screening tools for HIV-infected patients, use of a standardized once-daily ARV regimen to be administered
concurrently with standard TB regimen for TB/HIV co-infected patients, using modified observed therapy,
family and community-based health workers as treatment supporters, providing TB treatment literacy
materials at ART initiation and training of case management teams to strengthen treatment follow-up and
completion by tracing defaulters in the community
3. Prevent nosocomial transmission of MDR-TB and extensively drug-resistant tuberculosis (XDR-TB) by
instituting infection control. This will include; a. evaluation of nosocomial spread of MDR and XDR-TB by
supporting sputum culture testing on all new and suspected TB cases (months 0, 2, 6), spoligotyping on
selected isolates and confirmed MDR-TB isolates to determine timing of acquisition and possibility of
nosocomial spread; spoligotyping of sensitive TB isolates and non HIV infected TB patients to determine if
KZN strain confined only to MDR and XDR and HIV or more widely distributed; b. Improve program
implementation by screening HIV-infected patients for TB, creating isolation facilities, improving air handling
within wards, educating healthcare staff in personal infection control practices and provide personal
protective equipment to minimize their risk, minimizing number of TB patients hospitalized, decreasing the
Activity Narrative: length of stay for all TB patients by developing and evaluating protocols for earlier hospital discharge, and
increase community-based care for TB treatment to absorb shift of TB care from inpatient to outpatient
setting.
4. Implement a decentralized MDR-TB treatment program. Patients found to have MDR-TB travel 120 km to
Durban to be admitted to King George V Hospital for second line therapy however the average waiting time
for a bed is 2-3 weeks. Key components would include: Sputum culture testing on all suspected and
confirmed TB cases in both inpatient and outpatient settings to identify cases of MDR-TB; Initiate a
treatment program to provide second line TB treatment locally; Develop a contact tracing program for all
MDR-TB and re-treatment cases to identify MDR-TB cases in community; spoligotyping MDR-TB isolates
5. Screen for active TB among HIV-infected patients through use of standardized screening questionnaires
and/or algorithms by all types of healthcare workers followed by standardized follow-up and diagnostic
algorithms of TB suspects and supported by the introduction of effective recording and reporting systems for
these activities.
In FY 2008 Columbia will embark on these additional activities:
ACTIVITY 4: Scale up use of TB screening tool at HIV care and treatment facilities
Columbia will ensure that the PHC record (which incorporates TB signs and symptoms) is used at all
supported HIV care and treatment outlets. This TB screening tool will improve the quality of TB services
provided at the HIV clinic and also increase TB case finding in this high risk population. In addition, this
activity will dovetail with the proposed TB screening PHE about to be conducted in select health facilities.
ACTIVITY 5: Targeted TB prevention and control strategies
TB infection control activities targeted at 2 health facilities in the Eastern Cape (Motherwell Community
Health Centre in Port Elizabeth and Cecilia Makiwane Hospital in East London). The objective of this activity
is to minimize the risk of nosocomial TB transmission through minimizing source infectiousness. Activities
include: assessing TB infection control procedures for gaps and needs for each facility; establishing work
practice, clinical management and administrative procedures to minimize the nosocomial transmission of
TB; assessing the impact of these interventions; and developing practice manual and educational tools for
health care workers. New health facilities in Free State will be determined in collaboration with the Free
State Health Department to receive support for TB/HIV and proposed activities to be implemented include
those outlined above.
By providing palliative care TB/HIV support to co-infected persons in Eastern Cape, KwaZulu-Natal and
Free State, Columbia's activities will contribute to the realization of the PEPFAR goal of providing care to 10
million people.
Continuing Activity: 13732
13732 3320.08 HHS/Centers for Columbia 6587 2797.08 $2,530,267
7305 3320.07 HHS/Centers for Columbia 4371 2797.07 $1,700,000
3320 3320.06 HHS/Centers for Columbia 2797 2797.06 $1,400,000
* TB
Table 3.3.12:
This PHE activity, 'Operating characteristics and effectiveness of a screening instrument for the detection of
active tuberculosis in adult outpatients with HIV infection in the Eastern Cape, South Africa' was approved
for inclusion in the COP. The PHE tracking ID associated with this activity is ZA.06.0207.
Estimated amount of funding that is planned for Public Health Evaluation $0
In FY 2009, all 2008 activities will be continued, and new interventions will be added, as detailed below.
- The mobile counseling and testing (CT) project described in the FY 2008 COP will be conducted in FY
2009.
- Supervision of field caregivers (FCGs) and lay counselors will be systematized via development and
implementation of assessment tools (competency checklists).
- Monitoring systems for the multidisciplinary team (MDT) and interdepartmental transfer system, such as
back referral forms, systematic reporting of referrals during MDT meetings, and use of escort systems, will
be developed and implemented.
- Documentation of voluntary counseling and testing (VCT) registers will be enhanced.
- Data analysis and regular feedback on the yield of expanding VCT services to other departments beyond
the traditional ART site will be planned and conducted.
- Exposure of peer educators to infectious diseases will be minimized.
- Infection control training will be provided to peers in the following areas: hand-washing, cough hygiene and
disposal of body fluids.
- Home-based care (HBC) kits, with minimum infection control (IC) equipment (gloves/masks), will be
- A focus on stigma as an obstacle to VCT will be primary.
- The International Center for AIDS Care and Treatment Programs (ICAP) regional psychosocial staff, in
conjunction with peer educators, will focus on linkages with key informants in the community, and conduct
community outreach activities and community mapping, with an emphasis on identifying most at risk
individuals within communities. The ICAP gender-based programming will support these activities as well
(see below).
Space: ICAP will prioritize meeting space requirements for the expanding CT needs during infrastructural
developments and modifications (see under health systems strengthening interventions).
Partner disclosure and couple counseling: All antenatal care (ANC) clients identified to be HIV infected will
be supported to disclose their status to partners in the following ways through invitation letters for partners
to come to the health facility, home visits, men's HIV testing days, and making clinics male friendly. This
process will be monitored using standards of care (SOCs). ICAP's gender-based programming will support
Home-based counseling: Provided by FCG's initiative, to be expanded in FY 2009.
Rapid testing: Efforts will be continued in FY 2009 to standardize quality of rapid testing and perform quality
assurance.
Acute infection and window period: ICAP will develop and implement a systematic approach to encouraging
and educating patients, and tracking repeat testing for at-risk clients.
Prevention counseling: All elements of prevention with positives are in place at facilities supported,
primarily through peer educators and FCGs. Tools will be developed in order to standardize approaches
used, focusing on routine counseling and testing of sexual partners, children; couples counseling for
discordant couples; condom promotion and distribution; assistance with disclosure; provider-initiated
behavioral risk reduction interventions; assessment, diagnosis and management of STIs; adherence to
prophylaxis and treatment; referrals to family planning; alcohol assessment; counseling and referrals for
----------------------
Columbia University (Columbia) and its identified partners in the Eastern Cape have been supporting the
care and treatment of patients dually infected by HIV and tuberculosis (TB) since FY 2006. This activity
focuses on HIV counseling and testing (CT) for TB patients and will be an ongoing activity for Columbia in
FY 2008. The major emphasis area for this program will be human resources, with minor emphasis on
development of network/linkages/referral systems, linkages with other sectors, quality assurance and
supportive supervision, strategic information and training. The target population will include people infected
and affected by TB and HIV including infants, children and youth (non-OVC), men and women (including
pregnant women and family planning clients).
Columbia will use FY 2008 funds to continue strengthening the Eastern Cape Department of Health's
capacity to provide routine HIV counseling and testing (RCT) services to tuberculosis patients. In the latter
part of FY 2006, Columbia began RCT activities in three TB hospitals: Empilweni, Nkqubela and Fort Grey.
In FY 2008, PEPFAR funds will be used to continue to screen TB inpatients for HIV, implement TB/HIV
patient prevention education and to ensure that TBand HIV co-infected patients are referred for appropriate
HIV care and treatment services. Referral mechanisms with adjacent health facilities (including hospitals
and primary health clinics) have already been identified and established. Ongoing program emphasis area
will be on the development of network/linkage/referral systems that will eventually result in retention into HIV
treatment services for the TB and HIV co-infected after completing of TB treatment and improved
adherence to TB and HIV therapies.
In FY 2008 Columbia University will continue to implement four activities in three TB hospitals: Fort Grey,
Activity Narrative: Nkqubela and Empilweni.
ACTIVITY 1: Support Routine HIV Counseling and Testing for TB patients
Columbia will provide assistance through hiring and training of additional clinical staff (nurses and peer
educators) to increase the uptake of HIV testing among TB patients. Columbia will actively promote provider
-initiated testing and counseling for HIV (PITC) for TB patients. Registered nurses at each hospital will be
responsible for performing the HIV tests and post-test counseling, and trained peer educators will provide
pre-test counseling.
ACTIVITY 2: Provide Patient HIV Prevention Education
This activity will consist of collaboration with the Eastern Cape Department of Health, community-based
organizations and other local non-governmental organizations to provide information and education on
TB/HIV. In addition, trained peer educators will be actively involved in one-to-one patient education.
ACTIVITY 3: Referrals for TB Patients
Practitioners will continue to take advantage of and support the existing referral systems for TB patients into
HIV care and treatment activities, and where feasible, develop and promote more efficient referral linkages.
ACTIVITY 4: Monitoring and Evaluation
Data collection and reporting will be strengthened by training and hiring data staff, as needed, to collect
accurate counseling and testing patient information and to provide monitoring and evaluation technical
support for data interpretation and dissemination that will result in program improvement.
In FY 2008, Columbia proposes the following additional activities:
ACTIVITY 5: Strengthen Provider-Initiated HIV Counseling
Columbia will expand provider-initiated testing and counseling services to all the 36 antiretroviral treatment
(ART) sites that will be supported in FY 2008. With this approach, people attending the health care services
or those seeking specific medical attention can also receive CT. Pre-test counseling will be conducted by
peer educators and reinforced by the health unit staff or by HIV and AIDS counselors during post-test
counseling.
ACTIVITY 6: Provision of Mobile Counseling and Testing Services in KwaZulu-Natal
In order to make HIV and AIDS care and treatment more widely available to inaccessible populations, a
mobile clinic is being procured for the Kokstad area, in KwaZulu-Natal. A mobile CT team will be integrated
with the care and treatment team to provide services at fixed times at a variety of outreach sites in Kokstad.
Pre-advertising will be conducted (via fliers and public announcements), to provide potential clients with
information, maps and schedules for the mobile service. Rapid tests will be used to ensure immediate
results for clients within the same day and session.
Activity 7: Provision of Group Counseling at 36 ART sites
In the facilities supported by Columbia, the patients wait for some period of time after checking into the
clinics and before seeing the healthcare providers. Through peer educators, Columbia will motivate and
support this opportunity to tell the patients that it is recommended that all patients are tested for HIV and to
provide them with information about HIV and TB (group pre-test counseling). Brochures will be developed in
liaison with the Department of Health and will be given to patients when they check in to read in the waiting
room. Posters will also be placed in waiting rooms and throughout the clinic, noting the importance of
knowing one's HIV status to facilitate the pre-test counseling sessions. Those who opt for the test will then
be privately counseled post-test.
ACTIVITY 8: Creation of a Functioning Referral System for Counseled and Tested Patients
Functional links will be established between the different departments at the health facilities including the
ART clinics to facilitate cross-referral. Mechanisms for referral to post-test diagnostic and care services will
be established including regular clinical meetings.
ACTIVITY 9: Establishment of Quality Assurance Systems for Testing and Counseling Services
Columbia will support two overarching principles of quality assurance: (a) supporting clients' rights, and, (b)
addressing providers' needs. To meet the clients rights, Columbia will refurbish the facilities to ensure
private and confidential space (aural and visual privacy) at each of the facilities providing CT services. The
sites will be supported to undertake rapid counseling and testing. Mechanisms will be instituted for sample
referral for quality assurance testing (10% of samples to be confirmed centrally) in an external
facility/laboratory.
To support the work of providers, Columbia will guarantee accurate documentation and information
management procedures to ensure accuracy and confidentiality of all patient test and diagnostic
information. Adequate supply of simple/rapid tests, condoms and client information materials from the DOH
will also be ensured. In addition good quality management and supervisory support including information,
training and skills development will be supported by Columbia.
Activity 10: Engaging Stakeholders
Activity Narrative: Columbia will engage stakeholders in the planning and management of the program through meetings,
sensitization workshops and feedback reports. The stakeholders include Department of Health officials,
district managers, health facility managers, clinic supervisors, laboratory personnel, and staff
representatives, including doctors and nurses.
By providing HIV counseling and testing to patients on TB treatment, Columbia's activities will contribute to
the realization of the PEPFAR goal of providing care to 10 million people. These activities will also support
efforts to meet HIV and AIDS care and support objectives outlined in the USG Five-Year Plan for South
Africa.
Continuing Activity: 13733
13733 3321.08 HHS/Centers for Columbia 6587 2797.08 $436,500
7306 3321.07 HHS/Centers for Columbia 4371 2797.07 $150,000
3321 3321.06 HHS/Centers for Columbia 2797 2797.06 $100,000
Table 3.3.14:
The FY 2008 activities as outlined in FY 2008 COP will be continued. In addition, systems and structures
will be built at Ikhwezi Lokusa (ILWC) and Cator Manor to ensure program development and sustainability.
The main issue at Ikhwezi and Cator Manor is the growth of the institutions to a point where they have the
capacity to receive resources directly from the government and other donors.
Columbia University will support and strengthen the managerial, supervisory, logistics, financial and
technical structures within these institutions including the management of the outreach doctors at ILWC.
Monitoring and evaluation systems will be revamped to ensure quality, accurate and reliable information on
the activities of the outreach team. An additional data officer will be hired to support and complement the
current monitoring and evaluation support and to ensure focus and capacity at each of the sites. Issues of
regulation, supervision and management of the outreach program will be addressed. These interventions
will pave way for direct antiretroviral procurement and supply by the National Department of Health.
A service level agreement will be facilitated between the respective department of health and the Cato
Manor and ILWC. This agreement will pave way for the government to supply drugs and laboratory services
directly to these institutions while Columbia continues with technical support and assistance. In the longer
term, once capacity has been developed at the two institutions, interventions will focus on the accreditation
of the two centers for antiretroviral therapy.
------------------------------------
Columbia University (Columbia), in collaboration with the Eastern Cape Health Department (ECDOH) will
support antiretroviral (ARV) drug purchase for two treatment sites and support commodity supply chain-
related training, and logistics for 34 current antiretroviral treatment (ART) service delivery sites in the
Eastern Cape and two new ART sites in KwaZulu-Natal (KZN). Major emphasis is given to human capacity
development, local organization capacity building, and strategic information. The target population will
include infants, children and youth, men and women (including pregnant women) and people living with HIV
(PLHIV).
Columbia and the ECDOH will continue to support procurement and distribution of needed ARV drugs using
PEPFAR FY 2008 funds. In FY 2006 Columbia formed a partnership with the United Nations Children's
Fund (UNICEF) to procure ARV drugs from local pharmaceutical companies that are licensed by the South
African Medicines Control Council (MCC). These drugs are distributed to two non-governmental
organizations, Ikhwezi Lokusa Wellness Center (Ikhwezi) in East London and the Cato Manor Community
Health Center in Durban. Columbia purchases generic medications that are in compliance with the USG
PEPFAR Task Force requirement for both U.S. Federal Drug Administration and Medicines Control Council
(MCC) approval. Columbia provides technical assistance to improve HIV-related pharmacy practices in 34
public health facilities. In these 34 public sector sites, the relevant provincial department of health provides
all required HIV drugs.
In FY 2007 Columbia provided support for pharmaceutical services in the Qaukeni local service area in the
Eastern Cape and Sisonke districts in KZN. One of the challenges encountered while providing this
essential support is the regular stock-out of drugs such as cotrimoxazole. As a result Columbia provided in-
service trainings for pharmacists and pharmacy assistants on drug stock management, In addition,
Columbia purchased copies of the South Africa Medicines Formulary and the Daily Drug Use for 30 clinics
in the same catchment area. Columbia also distributed copies of the Essential Drug List for use in these
clinics.
Similar pharmaceutical services support is carried out in Port Elizabeth and this activity will continue into FY
2008.
Specific areas of programmatic focus include:
(1) Technical support for ARV stock management and distribution at the pharmacy depot (in Port Elizabeth)
and public ART sites. Activities include:
(a) Train pharmacists and pharmacist assistants in ARV stock management.
(b) Support the implementation of a province-endorsed pharmacy tracking tool to prevent ARV drug stock-
outs at health facilities.
(c) Support the province-endorsed training of pharmacist assistants at identified health facilities.
(2) Purchase and distribute ARV drugs for Ikhwezi Lokusa Wellness Center and Cato Manor community
health clinic. In FY 2006, Columbia initiated discussions with the ECDOH to propose that the ARV drug
procurement and distribution for Ikhwezi is managed by the ECDOH. In FY 2007, the ECDOH and Ikhwezi
developed an Memorandum of Understanding which will be signed before the end of FY 2007. The
ECDOH organized for Ikhwezi to be part of the Pfizer Diflucan donation program and currently patients with
cryptococcoal meningitis and esophageal candidiasis can obtain free Diflucan for this initiative. Similar
discussions with the KwaZulu-Natal Health Department (KZNDOH) are anticipated in FY 2008 and are
expected to begin for the Cato Manor community health clinic in Durban.
(3) Utilization of ARV drug pharmacy practice to improve clinical management. In a bid to improve ARV
prescribing practices in the Ikhwezi and Cato HIV treatment services, Columbia in FY 2007 and FY 2008,
will ensure that information generated that best describes and linkages between prescribed ARV drug
regimen and clinical outcomes and laboratory indicators is disseminated to the clinicians in these 2 facilities.
Activity Narrative: Columbia will continue collaborating with the South African Department of Health in support of ARV
procurement mechanisms to ensure uninterrupted ARV supply at Columbia-supported sites. The specific
quantities of ARV drugs that would be needed will take into consideration relevant medical conditions (TB,
adverse drug reactions). Columbia will continue to strengthen the ARV drug distribution system by providing
technical assistance at designated pharmacy depots to coordinate distribution of ARVs with the NDOH, as
well as participate in furthering the ARV quality assurances activity initiatives as developed by the NDOH.
In the Eastern Cape a public-private partnership consortium outsourced by the ECDOH will manage the
Department of Health pharmacy depots. Therefore Columbia will not be providing ongoing assistance at the
Mthatha Depot effective 2008. However, Columbia will continue to provide technical assistance for
Pharmaceutical services in all SAG supported health services.
By providing ARV drugs and related services, Columbia's activities will contribute to the PEPFAR goal of
providing treatment to 2 million people. These activities will also support efforts to meet HIV and AIDS care
and support objectives outlined in the USG Five-Year strategy for South Africa.
Continuing Activity: 13734
13734 3318.08 HHS/Centers for Columbia 6587 2797.08 $1,067,000
7303 3318.07 HHS/Centers for Columbia 4371 2797.07 $1,138,000
3318 3318.06 HHS/Centers for Columbia 2797 2797.06 $850,000
Table 3.3.15:
The International Centre for AIDS Care and Treatment Programs (ICAP) will enhance its technical, financial
and managerial support to the National Health Laboratory Services (NHLS) to strengthen the laboratory
infrastructure, capacity and services in the rural ART sites to ensure efficient and quality laboratory services
for care and treatment scale-up in the Eastern Cape (EC).
The National Guidelines for Antiretroviral Treatment (ART) recommends CD4 cell counts as a prerequisite
for the initiation of ART and subsequent six monthly monitoring of treatment outcomes. It also recommends
baseline plasma viral load before starting ART in addition to periodic monitoring. In the rural ART sites of
the EC and KwaZulu-Natal (KZN) provinces where the HIV epidemic is most severe, care and treatment
services are compromised by deficient and often non-existent laboratory infrastructure, expertise,
networking and access. As a result, laboratory services are often not performed in a timely manner, despite
the massive scale-up of care and treatment services. Therefore, ICAP supports the NHLS to strengthen the
laboratory infrastructure, capacity and services in the rural ART sites. With this support, an effective network
of laboratories and the rural ART sites have been established to ensure efficient and quality laboratory
The following activities will be supported and undertaken under the partnership:
ACTIVITY 1 : Assessment, gap identification and interventions to address laboratory unmet essential needs
and coverage in the EC, KZN, Northern Cape (NC) and Free State (FS)
ICAP will provide technical, managerial and financial support to the NHLS to overcome barriers that hinder
full implementation of laboratory support services for comprehensive HIV care and treatment programs by:
a) Enhancing laboratory infrastructure to support HIV DNA testing using dried blood spot (DBS) technology,
TB diagnosis, CD4 count and viral load testing;
b) Improving specimen transportation in currently under-serviced rural areas in OR Tambo and Sisonke
districts;
c) Improving IT and LIS to facilitate transfer of patient details and results between clinical service sites and
the laboratories;
d) Upgrading district hospital infrastructure for basic laboratory assays and specimens;
e) Expanding laboratory staff training to support increased need for DBS technology, CD4 testing and viral
load;
f) Supporting quality assurance (internal and external) and IT;
g) Identifying and supporting basic program evaluation priorities in affordable HIV-related diagnostics,
monitoring and surveillance.
ACTIVITY 2: Increase TB diagnostic services coverage
In the Eastern Cape the NHLS is performing 24 hour TB tests at the Port Elizabeth and Mthatha
laboratories due to the increasing workload and demand for TB diagnostic services. ICAP will provide
technical, financial and managerial support to expand access to quality sputum smear and culture. Further
decentralization of sputum smear-microscopy will be supported.
ACTIVITY 3: Best laboratory practices
ICAP will promote and strengthen standardized best laboratory/clinical practices (GCLP) and uniform quality
assurance measures in the supported laboratories and healthcare facilities in regards to monitoring
performance.
ICAP will establish links with institutions that offer GCLP courses and ensure that key NHLS and DOH staff
members attend and disseminate the information to others on their return.
Mthatha and Livingstone Hospital (Port Elizabeth) laboratories subscribe to two External Quality Assurance
schemes - CDC and Quality control programs for molecular diagnostics (QCMD), for DNA PCR and viral
loads. ICAP will support activities that strengthen existing External Quality Assurance (EQA) and
Proficiency Testing (PT) programs. Assistance in preparing for accreditation, measuring clinical
performance, reporting indicators, and disseminating performance reviews for action will be provided by
ICAP.
ACTIVITY 4: Strengthening of the Quality Management Systems (QMS)
ICAP will support the strengthening and provision for QMS training at all healthcare facilities and
laboratories that perform HIV rapid testing in line with South African national testing algorithms and policies.
ACTIVITY 5: Strengthening of the procurement systems
A unified approach to procurement and distribution of laboratory commodities will be supported by ICAP.
Provide financial support for a coordinated healthcare facility specimen collection and courier system.
ACTIVITY 6: Investigating new automated laboratory diagnostic equipment
ICAP will work with NHLS to investigate and acquire new automated and high capacity instrumentation for
Activity Narrative: high burden diagnostics in limited staff regions.
Table 3.3.16:
The International Center for AIDS Care and Treatment Programs (ICAP) will support the development and
functioning of the national health system in Eastern Cape (EC), KwaZulu-Natal (KZN), Free State (FS) and
Northern Cape (NC) provinces of South Africa, as guided by the Strategic Priorities for the National Health
System 2004-2009 focusing on: (i) strengthening the capacity of the Department of Health (DOH)
institutions (district, local service area (LSA) and health facilities) on planning, management and
implementation of HIV care, treatment and support programs, including the pharmaceutical procurement
and logistic systems; (ii) strengthening local partner organizations, particularly in management, leadership
and policy development; (iii) supporting construction and renovation; and (iv) human capacity development.
These activities relate to priorities four, five and six as indicated in the Strategic Priorities document.
ICAP has been a South African government (SAG) and PEPFAR partner since 2004. ICAP recognizes that
the rapid scale-up of HIV care and treatment programs in South Africa requires support for diverse needs in
the areas of human capacity development and health systems strengthening. Hence ICAP has developed a
comprehensive approach to health systems development and human capacity development - the Clinical
Systems Mentorship (CSM) program - in recognition of the fact that context, or systems, are fundamental to
the sustainability of HIV care and treatment programming. CSM is a methodology that broadens the
principles of traditional clinical mentorship to the context of public health programming and health systems
strengthening. The approach seeks to develop and improve competency and capacity in not only individual
providers (traditional clinical mentorship) but also teams of providers (including the patient), health care
facilities, local partners and the entire healthcare system. The foundation of CSM is a continuous process of
assessment, data-driven intervention, and re-assessment, which may occur in an integrated fashion at
multiple levels among ICAP staff or at the health facility, district, or provincial levels. The methodology relies
on the use of tailored assessments appropriate to the strategic priorities of the national health system. CSM
highlights the importance of integrating and aligning country program activities under a unified, tailored
initiative, so that support to sites, districts, and provinces are systematic, context-specific, concrete, and
oriented toward achieving the defined goals and objectives.
ICAP will carry out four separate activities in this program area.
ACTIVITY 1: Strengthening the capacity of the DOH institutions in planning, management and
implementation of HIV care and treatment programs, based on the clinical systems mentorship approach.
ICAP will conduct baseline and continuous assessments to ensure data-driven and continuous quality
improvement; a successful transition to a continuity of care model that provides high-quality,
comprehensive, family-focused HIV care and treatment services; and local capacity building for service
delivery at the district, sub-district and 46 ICAP supported sites. It will also participate and support the
creation of systematic plans for multi-tiered clinical systems mentorship roll-out from the province to the
facility level in EC, NC and FS. Technical experts/advisors will avail the DOH, districts and health facilities in
EC, FS, and NC to support the development of services and systems for comprehensive HIV care and
treatment programs in the following ways:
- Support the development of leadership and management skills for HIV care and treatment providers at
the facility, district and provincial levels through hands-on technical assistance; and support, training and
mentorship.
- Provide technical support to the DOH in the strengthening of site supervisory structures and systems at all
levels to oversee site level activities and ensure continuous quality improvement.
- Participate in technical working groups at the DOH on topics of PMTCT, TB/HIV, CT, psychosocial
support, pediatric and adult HIV care, pharmacy, laboratory, and M&E.
- Support the definition, development/adaptation and implementation of a facility specific comprehensive
package of HIV care and treatment services at 46 sites to provide general health services in support of HIV
care and treatment services.
- Facilitate the development and maintenance of multi-disciplinary teams (MDTs) at all levels: The ICAP-SA
clinical team will continue to ensure that all the 42 and additional 18 health facilities have MDTs that meet
regularly to discuss cases, attend educational presentations, and plan for the facility.
- Assess and support community involvement and enhance patient education, support and empowerment
through meaningful involvement in HIV care and treatment interventions.
- Facilitate the establishment of systems for linkages, referrals and communication within the health facilities
and with external organizations.
- Provide technical and managerial support for the implementation of appropriate procurement systems for
drugs (ARVs and OI Drugs), essential supplies and equipment to minimize shortages and stock outs.
- Integrate M&E and tracking systems into regular programming. M&E is a critical component of the
comprehensive HIV/AIDS plan. Technical support and assistance will be provided at the provincial, district
and site levels to ensure data use for program management in EC, KZN, NC and FS. ICAP has developed
an M&E framework that includes M&E tools for care of HIV-infected adults, care of HIV-infected and
exposed infants, care of HIV-infected pregnant women, TB/HIV integration, PMTCT, psycho-social support
and adherence support. The framework is designed to measure progress towards the achievement of
comprehensive HIV care, treatment and support components at each of the supported sites, as well as at
the district and provincial levels.
In FY 2009 the current mechanisms will be strengthened to improve data collection and flow to ensure data
quality, validity and accuracy for program use at the provincial, district and health facility levels. Existing
data collection mechanisms are being improved and new systems are being developed to respond to the
ever changing data needs of the SAG, USG, health facilities and the ICAP program based on the
components of comprehensive HIV care and treatment programs. The mechanisms are also designed in a
manner that ensures data confidentiality. Data collection, validation and use from the service point level up
Activity Narrative: to the national office will be facilitated by deployment and redeployment of essential M&E staff and creation
of commitment and dedication of members of the MDTs to use data collection tools and report data.
Information on the standard of care indicators will be available incrementally during FY 2009.
ACTIVITY 2: Strengthening local partner organizations, particularly in management, program
implementation, leadership and policy development, as follows:
- Disease Management Systems (DMS): ICAP will continue to support the DMS program in 3 sites of Port
Elizabeth to implement a patient-centered health management information system (HMIS) to allow for
improved efficiency in the treatment of HIV-infected patients at the ART sites.
- Health Information System Program (HISP): Managerial, technical and financial assistance will be
provided for HISP to implement a comprehensive patient level software and program database that will
improve and enhance HMIS.
- University of Fort Hare (UFH): ICAP will continue to provide managerial, technical and financial support to
the University of Fort Hare to place HIV care and treatment essential staff at the ICAP-supported health
facilities in East London, Eastern Cape.
- Ikhwezi Lokusa Community-based Organization: ICAP will continue to provide technical, managerial and
financial support to Ikhwezi Lokusa Wellness Center in Eastern Cape to ensure scale up of care and
treatment through private general practitioners in rural Eastern Cape.
- Nelson Mandela Metro Municipality (NMMM): Through its network of PHC clinics, ICAP will continue with
technical, financial and managerial resources support to NMMM to ensure human capacity and health
systems strengthening to scale up HIV/AIDS care, treatment and support services in 20 facilities in Port
Elizabeth, Eastern Cape.
- Foundation for Professional Development (FPD): ICAP will support capacity building for rural sites through
the provision of managerial, technical and financial support to FPD to ensure human capacity development
for comprehensive care in three hospitals and affiliated clinics in Qaukeni and Umzimkulu sub-districts.
ACTIVITY 3: Supporting the construction and renovation of health facilities to ensure appropriate space for
the implementation of HIV care and treatment programs.
ICAP will renovate 10 existing facilities in order to ensure appropriate space for patient privacy and
confidentiality in EC, KZN, FS and NC. It will also provide temporary structures to facilitate comprehensive,
family-focused care and treatment interventions based on assessment of space and priority needs in EC,
KZN, FS and NC.
ACTIVITY 4: Human capacity development, based on the South African National Department of Health
Human Resource Plan for Health (HRH), which underscores the need for continued training, mentoring and
skill development.
ICAP will assess and enhance key provider competency on HIV care and treatment at the district, LSA and
facility levels through one on one and small group teaching of clinical skills, support to professional
development and growth, and collegial support to clinicians and lay health workers on an ongoing basis at
the ICAP supported sites. It will do so through the following sub-activities:
- Ensure the availability of technical, financial, managerial and logistics support for the implementation of
training programs for the 46 supported sites in EC, KZN, NC and FS on the minimum package of care that
ensures comprehensive and family focused care and treatment programs.
- Support the development of non-traditional health care cadres and task shifting strategies through
trainings in collaboration with local accredited training partners (Foundation of Professional Development,
Small Projects Foundation and ATTIC) for peer educators and field caregivers on HIV care and treatment.
- Provide continuous mentorship to nurses to acquire appropriate knowledge and skills to provide
comprehensive HIV care and treatment services.
- In collaboration with the University of Fort Hare (UFH) Department of Nursing Science and the
Stellenbosch University (SU) Ukwanda unit, continue supporting the post-basic Advanced Certificate in
Clinical Management of HIV/AIDS course for 30 nurses with the aim of developing specialists in HIV care
and empowering them to take a leading role in the management of both adults and children with HIV
infection in the rural facilities.
- Provide technical and financial assistance to Small Projects Foundation (SPF) to continue with a training
program (accredited by the South African Health and Welfare Sector Education Training Authority) for 50
caregivers in Umzimkulu as ancillary healthcare workers.
- Support healthcare workers to attend a training program at Tygerberg Children's Hospital at the University
of Stellenbosch, in support of indigenous human capacity development to successfully implement pediatric
- Ensure continuous medical education through an outreach program and mentoring for clinicians in rural
Eastern Cape and KwaZulu-Natal to provide quality HIV care and treatment services in partnership with the
Stellenbosch University Ukwanda Project.
- Facilitate HIV specialist forums that bring together specialist physicians to discuss the clinical
management of more complex HIV issues. The ICAP clinical team will technically and logistically spearhead
these forums at the regional level.
- Produce and disseminate behavior change communication/information education and communication
materials in order to facilitate service delivery at all 46 sites. The ICAP-New York Clinical Unit and the South
African government will produce the materials..
- Provide technical, managerial and financial support to the ECDOH for the two-year basic pharmacist
assistant apprenticeship course designed in partnership with Frais Health Management Training and the
Nelson Mandela Metropolitan University to ensure regular availability of essential drugs (antiretrovirals
(ARVs) and opportunistic infection (OI) medications) and supplies at health facilities.
- Ensure availability of post exposure prophylaxis and psychosocial support for all health workers at the 46
facilities through the ICAP psychosocial support unit.
Table 3.3.18:
