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:
Provider-Initiated Testing and Counseling (PITC) was successfully piloted in one clinic during COP 2007.
PITC will be rolled out to all the clinics during COP 2008 and COP 2009. The uptake for HIV testing among
pregnant women is higher than 90% in the pilot site and all the other 15 clinics in the Hlabisa sub-district,
but with PITC offered to all patients attending the clinic, Africa Centre anticipates an increase close to
100%. This routine offer of counseling and testing (CT) is aligned with the South African government's CT
guidelines, and rapid testing is used. CT will be offered during the first antenatal clinic visit, and because of
the high HIV incidence in the area, re-testing will be done in the last trimester. All 16 clinics are staffed with
2 or more counselors that ensure that all pregnant women are offered CT, and a PMTCT stamp with a sub-
district specific code to indicate HIV status is placed in the woman's antenatal care (ANC) card. This stamp
and the code assist in identifying women who were missed or those who refused to be tested, and thus
make it easy to offer CT to women who have not tested in their subsequent ANC visits.
The Africa Centre dietician will develop appropriate nutrition-related curricula, adapted from international
and national policy to suit the local, rural community. This curricula will be used in pre- and post-service
training programs and to develop appropriate job aids for health-care workers. The dietician will train
nurses, counselors, home-based caregivers and support group members using the existing South African
curriculum and the in-house curriculum, to enhance their ability to carry out nutritional assessment,
counseling and support for pregnant women
Partner testing is routinely offered and systems will be set in place to make the service more male friendly.
Antiretroviral treatment (ART) and cotrimoxazole will be offered to all eligible women following South African
Department of Health (DOH) guidelines. Women will receive optimum counseling on feeding options,
cotrimoxazole prophylaxis, TB screening and treatment, and immunizations.
More and more HIV-exposed children are referred to the clinic. The pediatrician also works at the Hlabisa
Hospital's pediatric unit, where she is able to down refer some of these children for follow up at the family
clinic. Referrals of children who need to be followed or have missed their clinics are transferred to the home
-based care nurses and the tracking nurse for follow up, and children who need other support services are
referred appropriately, e.g. to the ART social worker.
Infant diagnosis is aligned with South African and WHO guidelines. Polymerase chain reaction (PCR)
testing will be done at six weeks and again at six months, and at any point in time for children that were lost
to follow-up. A system will be set in place to track all children lost to follow up: the tracking nurses, support
group members and home based care workers will track the children. The Vitamin A Campaign (March and
September) will also be used as a vehicle to identify all children lost to follow up and all HIV- exposed
children within the sub-district.
Cotrimoxazole prophylaxis will be offered to all children from six weeks to one year or stopped sooner if
confirmed HIV negative and the child has stopped breast-feeding. Efforts to increase sustainable infant
feeding choices and early infant diagnosis will be strengthened. This will be done through follow up of
mother and baby pairs postnatally.
Support groups will be strengthened during COP 2009 and will focus on pregnant women.
In COP 2007 the wellness program was started to strengthen and integrate PMTCT within maternal-child
health by addressing sexually transmitted infections screening (STI). The wellness program will address STI
screening, family planning and prevention with positives. Monitoring and evaluation of the program will be
strengthened through standardizing the PEPFAR data collection tool to include South African government
PMTCT indicators, and to ensure that all know efforts made in the program.
---------------------------------------------
SUMMARY:
The Africa Centre for Health and Population Studies, in partnership with the Hlabisa Department of Health
(DOH), based in Hlabisa Health District in rural KwaZulu-Natal, operates the Hlabisa antiretroviral treatment
(ART) program and aims to deliver safe, effective, efficient, equitable and sustainable ART to all who need it
in Hlabisa district. The program emphasizes integration of the government Prevention of Mother-to-Child
Transmission (PMTCT) Program and Antiretroviral Treatment (ART) Program. The target population for the
integrated PMTCT and ART Program are people living with HIV and AIDS (of all ages), HIV-infected
pregnant women and HIV-infected infants (0 to 5 years). The major emphasis area of this program is
development of network/linkages/referral systems, and minor emphasis areas include information,
education and communication, local organization development and training.
BACKGROUND:
The Africa Centre, a population research department of the University of KwaZulu-Natal, implements a
PMTCT program in partnership with the KwaZulu-Natal Department of Health (DOH). The program is based
in Hlabisa sub-District, a rural health district in northern KwaZulu-Natal that provides healthcare to 220,000
people through one government district hospital and 15 peripheral clinics. The ART Program is embedded
in the DOH ART rollout whereby the Africa Centre and KwaZulu-Natal DOH work to complement each
others abilities and resources in providing ART. The Africa Centre has expertise in infectious diseases and
management that is not available at the district DOH. In addition to clinical staff, and infrastructure, the
district DOH provides the necessary drugs and laboratory testing for effective ART rollout.
With FY 2008 funds, the Africa Centre will continue partnering with the district DOH to improve and expand
PMTCT services by providing additional human resources and training. In addition, Africa Centre will
integrate PMTCT services with its tuberculosis (TB)/HIV, palliative care, counseling and testing, and
Activity Narrative: treatment programs. Increased attention will be given to addressing gender inequality (including increasing
male involvement in PMTCT) and promoting HIV service delivery among men and children.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Partnership with South African Government (SAG)
All government clinics within Hlabisa District offer PMTCT services. However, many of these clinics are
under-resourced and require additional human capacity to ensure that HIV-infected women are enrolled in
the PMTCT program. Africa Centre provides training, supervision, mentoring, and systems strengthening in
support of PMTCT services in Hlabisa district. The PMTCT program is the main referral base for assisting
HIV-infected women with ART. Africa Centre aims to address the lack of human resources with the district
DOH to recruit and place nurses and treatment counselors at government facilities to assist with pre and
post-test counseling and appropriate infant feeding counseling. During pregnancy, if criteria are met, or
during post delivery when women become eligible, nurses will provide HIV rapid testing, CD4 counts and
referrals to trained ART counselors. Counselors will offer pre and post-test counseling and further facilitate
enrollment into the ART program. In addition, counselors will offer pregnant women continued follow-up and
support and facilitate testing of all exposed infants at 6 weeks of age, with referral to the ARV program if
they are HIV-infected.
Africa Centre conducts workshops and meetings with DOH promoting linkages between PMTCT and ART
programs and educates clinic staff about available services. Africa Centre will develop and distribute
informational materials for wider circulation in the hospital and clinics and will target pregnant women.
ACTIVITY 2: PMTCT and Treatment
Africa Centre will provide clinics with clinical services (via the provision of doctors and other health workers)
to initiate HIV pregnant women enrolled in the PMTCT program on ART. Africa Centre's assistance provides
the full package of PMTCT services in line with the National Department of Health's PMTCT standards.
Doctors will be present in clinics at appointed times, on a weekly or fortnightly basis, as appropriate, and will
provide treatment management including work-up (complete medical history and medical examination),
consultation, screening, symptom and pain management, and patient counseling (including maternal
nutrition and family planning). PMTCT clients will be referred to Africa Centre-supported ART services.
These services will also provide patients who experience adverse side effects or treatment failure with
additional monitoring and support. Africa Centre-supported home-based care organizations will provide
ongoing care and monitoring support to ensure treatment adherence. All patients transferred into the ART
program from the PMTCT program will be tested for TB and receive TB treatment if necessary.
ACTIVITY 3: Counseling and Support
To reduce vertical transmission of HIV from mother-to-child, treatment counselors will provide counseling on
appropriate infant feeding and support into routine PMTCT in line with the newly published WHO guidelines
on infant feeding. The selection of counseling content and material will be informed by the results from a
large local vertical transmission study conducted by the Africa Centre. All HIV-uninfected women will be
counseled on exclusive breastfeeding from birth to six months, with continued breastfeeding to at least 2
years of age, and on safe sex. HIV-infected women will receive individual counseling and it is anticipated
that most women will choose to breastfeed given the results of previous work in this area and the lack of
resources to fulfill the AFASS criteria for replacement feeding (AFASS: acceptable, feasible, affordable,
sustainable and safe). Women who do not wish to test and who, therefore, do not know their status will be
counseled on infant feeding practices as per HIV-uninfected women (i.e. exclusive breastfeeding to six
months) in line with WHO policy. Opportunities to counsel women and their partners on infant feeding will
be taken at every visit, both antenatally and postnatally. HIV-infected women who choose to exclusively
breastfeed, whatever their CD4 counts, will receive a monthly food parcel from the government, as do
mothers who do not breastfeed. In addition, counseling on family planning will be offered. The program will
address gender by attempting to increase gender equity by promoting the involvement of male partners in
the PMTCT and family planning sessions. The PMTCT counselors will ask pregnant women and mothers to
come with their male partners during follow-up visits. During road shows (a form of "edutainment," which
successfully disseminates information through entertainment since 2004) a special focus will be the
involvement of men. Men are still underrepresented in the clinics not only for being tested, but especially for
getting treatment. The main objective will be to make men aware of their responsibility concerning the
response to HIV. Male involvement will be strengthened using existing materials when appropriate. The
possibility of family testing in the home will be investigated.
Finally, counselors will refer eligible patients to the government services that are available (for instance, for
food aid or to a social worker if domestic violence is suspected).
ACTIVITY 4: Human Capacity Development
The South African DOH and Africa Centre counselors and nurses will be trained in the full PMTCT package
according to government guidelines and standards. Refresher and on-the-job training will be provided as
needed, keeping healthcare providers up to date in the delivery of PMTCT services. All healthcare providers
will receive training on HIV and ART. A baseline course is based on the DOH curriculum and comprises four
sessions of three hours each. The four sessions cover basics of HIV and ART, follow-up of patients,
assimilation of follow-up and practical work with a patient (including blood taking for CD4 counts and viral
loads).This training will be enhanced with clinic visits from training officers, during which the officers will
monitor counseling and provide individual mentoring. In addition, nurses and treatment counselors will be
offered the opportunity to participate in short courses covering the management of ART side effects,
opportunistic infections, and pediatric ART. When necessary additional space may be renovated or park
homes provided to increase facility capacity.
Activity Narrative: Due to the shortage of staff and to the increasing number of patients and increasing workload, additional
staffing will be provided in close cooperation with the facility and wherever possible SAG positions will be
created. It is estimated that one position for each of the 14 sites is necessary and all of these will be staffed
by SAG employees as soon as they can be recruited.
ACTIVITY 5: Monitoring and Evaluation
Africa Centre's Vertical Transmission Study published in the Lancet in 2007 (369: 1107-16) had major
impact on the guidelines of the WHO. It showed that exclusive breastfeeding reduces the risk of Mother-to-
Child transmission compared to mixed feeding. With dedicated Health Workers in the clinics and a strong
M&E system, PEPFAR funding will be used to continue monitoring and evaluation activities.
Africa Centre's integrated PMTCT and ART program contributes to PEPFAR's 2-7-10 goals for South Africa
by improving capacity, access and demand for PMTCT and ART for pregnant women and mothers. These
activities ensure that new infant infections are averted and the HIV-infected treatment-eligible women are
referred and initiated on treatment in a timely matter.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13367
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13367 7914.08 U.S. Agency for Africa Center for 6453 397.08 $339,500
International Health and
Development Population Studies
7914 7914.07 U.S. Agency for Africa Center for 4364 397.07 $175,000
Emphasis Areas
Construction/Renovation
Gender
* Addressing male norms and behaviors
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $40,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $15,000
and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $10,000
Economic Strengthening
Estimated amount of funding that is planned for Economic Strengthening $34,000
Education
Water
Table 3.3.01:
Africa Centre (AC) will expand home-based care (HBC) activities with the appointment of a social worker for
assisting in social (access to social security services for women and children as indicated in the South
African Government's National Strategic Plan) and legal protection of patients.
The AC Support Group Coordinator will work with support groups to strengthen income generating project
activities, linkages with other programs and sector. Support will also be given to male involvement in HIV
prevention, care and treatment and to reduce stigma and violence against women.
The dietician will train HBC workers and support groups on nutrition care and support. A referral system
between the community and the clinic and food security projects will be implemented. This will be used to
refer children and adults with poor nutritional status to and from the clinic and community, and will
strengthen efforts to manage malnutrition in the community.
Tracking of children and adults will now be expanded to the whole sub-district.
Africa Centre will develop food and nutrition policies and guidelines which are adapted to the local, rural
community.
The dietician in the program will train nurses, counselors and home-based caregivers in nutritional
assessment and counseling.
Anthropometric tools required to conduct effective nutritional assessment will be procured with PEPFAR
funding.
For long-term food security, support groups will be getting guidance how to establish community gardens.
---------------------------
The Hlabisa ART program aims to deliver safe, comprehensive, effective, efficient, equitable and
sustainable ART to all who need it in Hlabisa District, in rural KwaZulu-Natal province. Hlabisa District is
characterized by a high HIV prevalence (about 22%), high HIV incidence, unemployment and poverty. Basic
care and support services are part of the overarching HIV Care and Treatment program that is jointly run by
the Africa Centre for Health and Population Studies, University of KwaZulu-Natal, and the Habisa District
Department of Health (DOH). In FY 2008, the program will for the first time provide mobile palliative care
teams that bring HIV care to people's homes and support the families of HIV-infected people. Major
emphasis is on development of linkages and referral systems. This will be done through support to the
SAG, clinical and physical care, home-based care and human capacity development.
The Africa Centre is a department within the University of KwaZulu-Natal, fully funded by grants from mostly
overseas institutions. The Program is based in Hlabisa sub-District, a rural health district in northern
KwaZulu-Natal which provides healthcare to 220,000 people at one district hospital and 14 peripheral
clinics. In September 2004 the program started delivery of ART in Hlabisa and has since expanded ART
services to 14 clinics in the sub-district. The Africa Centre and KwaZulu-Natal DOH work to complement
each other's abilities and resources in providing care and treatment. The Africa Centre has expertise in
infectious diseases and management that are not available at the district DOH. The district DOH has clinical
staff and infrastructure on which to build a care and treatment program. The Africa Centre contributes
nurses, treatment counselors and physicians to the DOH staff, organizes trainings, supports the
management of the supply chain and conducts monitoring and evaluation in cooperation with the DOH. The
Africa Centre's basic care interventions are largely focused on care support, the period from when a patient
tests positive until such time as s/he requires ART. The basic preventive care package is part of the
program, as is symptom and pain management.
With FY 2008 funds the Africa Centre will continue to support the functions mentioned above and expand its
support for the DOH. Specifically, Africa Centre involvement will strengthen the palliative care, TB/HIV
Program, PMTCT, provision of ART and counseling and testing. Increased attention will be given to address
gender issues and to promote the care and treatment services among men and children.
ACTIVITY 1: Support to SAG in Hlabisa District through home-based care
FY 2008 funding will be used to provide support to five existing home-based care organizations which are
located in the least served areas within the sub-district. These HBC organizations are operating on an ad-
hoc basis. They are made up of committed caregivers who are passionate about serving their community,
but do not have access to resources or training opportunities. Africa Centre will ensure that the HBC
organizations will not only take care of the patients, but assess the situations in the households and take
care of other family members if necessary. The identified HBC organizations will also be located near DOH
clinics where ART initiations are taking place in order that Africa Centre staff at the clinic can serve as a
point of contact. The Africa Centre will facilitate the distribution of HBC kits and food parcels, supplied by
DOH to the home-based care organizations.
Capacity building will play a major role in the support of the HBC organizations. Africa Centre will ensure
ongoing supportive supervision and mentoring. Training will include DOH-approved HBC, ART literacy,
social grants (process for referral of HIV patients who qualify for disability grants) and HIV Counseling,
Activity Narrative: Funding will help to support volunteer stipends and equipment (for example computers and bicycles) to
further enable these organizations to better manage and support their volunteers.
The funding will also go towards financing additional professional staff, including nurses and social workers
who will constitute the core of a mobile team to provide home-based palliative care. In addition, funds will be
used to finance a car, pharmaceuticals and other necessary supplies. The nurses in the mobile team will
provide basic HIV-related care including prevention messages and symptom and pain screening and
management, and the social worker will refer families for psychosocial services provided by the government
(government food aid, government grants and the services of social workers). A partially financed physician
will visit patients who need more specialized care. The target population for home-based care via the mobile
team is non-ambulatory patients who cannot access treatment in clinics and ambulatory patients who
request a home visit.
Africa Centre's involvement in the existing HBC structure within the sub-district will facilitate a more
cohesive referral system between the DOH, AC and HBC organizations. It will also ensure that more home-
based caregivers are provided with essential training and resources to better serve the needs of PLHIV in
their communities.
ACTIVITY 2: Clinical and physical care
HIV-infected people who are not yet eligible for ART will receive palliative care consisting of screening and
treatment of TB, screening for pain and symptoms and elements of the preventive care package such as
prophylactic treatment with cotrimoxazole, INH and fluconazole. Africa Centre supported HBC organizations
will provide ongoing care and monitoring support, including counseling. Patients will be advised to return to
the clinic every six months for a CD4 test and clinical assessment. DOH funds are used for laboratory
services (CD4 counts, viral loads, and routine and routine blood and urine tests) and drugs (ARV
medication, drugs to treat and prevent opportunistic infections (OIs), and drugs to treat non-HIV-related
diseases in HIV-infected patients). Patients on ART and those who are monitored for ART eligibility will be
referred to a physician for further care if required. A pharmacy assistant will be trained to assist the DOH
pharmacist to facilitate faster treatment of OIs and pain.
ACTIVITY 3: Nutrition
All participants will be referred for nutritional assessment and monitoring for food aid (Philani porridge,
sugar beans) from the DOH. In order to ensure nutrition and food security, PEPFAR funding will be used to
employ a dietician to teach families the basics of good nutrition. Volunteers will be recruited to train the
community in nutrition and food preparation. Africa Centre will seek to establish public-private partnerships
(PPPs) with other organizations (e.g. Kellogg Foundation, Garden Africa, Seeds for Africa) for sustainability
of these activities.
ACTIVITY 4: Income generating programs for PLHIV
Poverty, unemployment and unpleasant socioeconomic status are prevalent to PLHIV in the area. Some are
receiving disability grant which is still limited to meet their daily basic needs. In order to uplift their economic
status and their nutrition there is a need for those able to be engaged in poverty relief projects/ income
generating projects such as beadwork, woodwork, sewing, food gardens, poultry farming and sleep mats.
Africa Centre has a Community Development Department, which has, over the past several years,
successfully developed income generating programs in the rural area of Hlabisa Sub-district. PEPFAR
funding will be used to strengthen the department through additional staff. These staff members will then
develop business plans for the PLHIV groups and supervise their activities.
ACTIVITY 5: Referrals and linkages
In order to ensure delivery of holistic palliative care, counselors will be trained on available government
support structures to link PLHIV and their families to other government programs, like screening for TB/HIV,
PMTCT clinics, food aid, legal assistance and social workers, who can assist the families with applying for
government grants.
ACTIVITY 6: Caring for Carers
ART Lay Counselors and Nurses are tasked with counseling and caring for patients affected and infected by
HIV and AIDS. On a daily basis, during counseling sessions where they must disclose the patient's HIV
status, they must deal with the trauma of the varied reactions of patients who are hearing for the first time
that they are HIV-infected. To keep staff dedicated and motivated towards achieving their daily demands
there is a need to minimize burnout and work-related stress. The Caring for Carers program aims to protect,
support and care for employees tasked with caring responsibilities. The program started in FY 2007 and will
have a focus on the new staff joining Africa Centre in FY 2008. The program will develop appropriate team
building activities and staff retention strategies.
ACTIVITY 7: Human Capacity Development
The South African DOH and Africa Centre counselors and nurses in the hospital and clinics will be trained in
all aspects of care according to government guidelines and standards. Refresher and on-the-job training will
be provided as needed, keeping healthcare providers up to date in the delivery of care.
Due to the shortage of staff in the clinics and due to the increasing number of patients and increasing
workload, additional staffing in clinics and the hospital will be provided.
ACTIVITY 8: Care Support Program
Activity Narrative: Services for the persons who have newly tested positive for HIV but are not yet eligible for treatment must
be improved. A care support program will be established including: screening for TB, screening for STIs,
PAP smears, treatment and prophylaxis of opportunistic infections, immunizations, nutritional information,
counseling on family planning and help with grant applications.
Continuing Activity: 13368
13368 2996.08 U.S. Agency for Africa Center for 6453 397.08 $727,500
7274 2996.07 U.S. Agency for Africa Center for 4364 397.07 $350,000
2996 2996.06 U.S. Agency for Africa Center for 2659 397.06 $300,000
* Increasing gender equity in HIV/AIDS programs
* Increasing women's access to income and productive resources
Estimated amount of funding that is planned for Human Capacity Development $110,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $50,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $30,000
Estimated amount of funding that is planned for Economic Strengthening $25,000
Table 3.3.08:
The most important task for FY 2009 is to develop systems of task shifting. If the Department of Health
(DOH) allows the Africa Centre (AC) to start nurse lead antiretroviral therapy (ART) initiations, this will be
started with FY 2009 funding. In addition, further task shifting from nurses to lay counselors will be a priority.
A family approach will be established to make sure that families will be appropriately counseled, tested and
treated. In FY 2007, AC started family clinics in the two biggest sites and this year will try to make this
approach available to other clinics. The wellness clinic will increase cervical screening and will make family
planning services more accessible. Provision of psychosocial support where within the clinics and support
groups will be available.
The incorporation of provider-initiated testing and counseling (PITC) for all patients attending clinics will
improve the numbers of people knowing their status and for those accessing ART, if eligible. A wellness
program will be available for patients not yet eligible for treatment. Pre-ART registers have been developed
in FY 2007 COP and the wellness clinic will help to identify changes in clinical staging.
community. The dietician in the program will train nurses, counselors and Home-based Caregivers in
nutritional assessment and counseling. Anthropometric tools will be bought with PEPFAR funding. For long-
term food security support groups will be getting guidance how to establish community gardens.
Micronutrient supplementation will be made available following DOH and WHO guidance. Women are
encouraged to exclusively breastfeed. However, if the mother chooses replacement feeding, formula will be
made available according to the AFASS criteria. Food parcels and porridge will be made available for
severely malnourished patients.
Counselors and nurses who work in the ART program receive in-service training in ART care based on
DOH curriculum and comprised of four sessions of three hours each, covering ART eligibility, ART, side
effects, Pregnancy HIV and ART, TB HIV and ART, adherence follow up of patients, changing regimens
and practical sessions like taking routine monitoring bloods. Training primarily takes place on sites at the
district clinics by Africa Centre training officers in collaboration with DOH trainers. In addition, individual
mentoring of nurses is also done.
All newly-employed healthcare workers in the ART program will receive pre-employment training in all
aspects of the full ART, PMTCT and TB package according to government guidelines and standards. This
training lasts for two weeks and covers HIV and AIDS, TB, palliative care, drug toxicities, pediatric HIV,
pregnancy HIV, adherence, HIV pathophysiology, HIV resistance, and Post-Exposure Prophylaxis (PEP).
Nurses and counselors will also attend educational workshops, as part of long-term training, conducted
every month with the aim of improving the quality of care offered to the HIV-infected clients. The scope
comprised of the induction training above and other training topics such as syndromic management of STIs,
PAP smears and pain management. The training will also be supported with a training-of-trainers approach,
will enhance the sustenance of training activities.
AC also offers certificate courses such as supervision, assertiveness, diversity management, facilitation,
problem solving and decision making skills, of which all ART staff will be given an opportunity to attend.
Some of the staff members are doing post-graduate courses and other courses related to the program
where a portion of their tuition is contributed by the employer.
Human resource information systems in the form of HIV and AIDS mini-libraries will be maintained within
the clinics to provide information and education to healthcare staff and patients in the clinics. In addition, the
training will also be supported with training-of-trainers approach. This approach will enhance the
sustenance of training activities.
Poverty, unemployment and unpleasant socioeconomic status are prevalent to people living with HIV
(PLHIV) in the area. AC has a Community Development Department, which has, over the past several
years, successfully developed income generating programs, such as beadwork, woodwork, sewing, food
gardens, poultry farming and sleep mats, in the rural area of Hlabisa Sub-district,
Income generating activities have been started in FY 2008 and will continue in FY 2009. PEPFAR funding
will be used to strengthen the community development department through additional staff. These staff
members will then develop business plans for the PLHIV groups and supervise their activities.
-----------------------------
The Africa Centre Hlabisa antiretroviral treatment (ACHART) program aims to deliver safe, efficient,
equitable and sustainable ART to all who need it in the Hlabisa district through the district health
department, rural KwaZulu-Natal. The target population for the treatment program is people living with HIV
(PLHIV), HIV-infected pregnant women and HIV-infected infants and children. The emphasis area of this
program is human capacity development, renovation, and local organization capacity building.
The ACHART Program is a partnership between the KwaZulu-Natal (KZN) Department of Health (DOH) and
the Africa Centre, a population research department of the University of KwaZulu-Natal. The DOH program
is based in Hlabisa sub-district, and provides health care to 220,000 people at a government hospital and
14 fixed peripheral clinics. The ACHART Program is embedded in the DOH antiretroviral therapy rollout
where the Africa Centre and KZNDOH work to complement each other's abilities and resources in providing
ART. The Africa Centre has expertise in infectious diseases and management that are not available at the
Activity Narrative: district DOH. In addition to clinical staff and infrastructure, the district DOH provides the necessary drugs
and laboratory testing for effective rollout.
With FY 2008 funds the Africa Centre will continue to support the provision of ART and expand its support
for the KZNDOH. Increased attention will be given to address gender issues (especially reaching men) and
to promote the ART services among men and children.
ACTIVITY 1: Support to South African Government (SAG)
The ART program is jointly run by the KZNDOH and Africa Centre. The Africa Centre contributes human
resources and co-finances facility needs and supplies. The Africa Centre supports the KZNDOH with
strategic planning and the implementation of the SAG National Strategic Plan 2007-2011 for HIV & AIDS
and STI. This includes the establishment of an up and down referral system that ensures that HIV-infected
people are treated at the optimal level of care at each stage of the disease. The Africa Centre support
further extends to operating the supply chain of drugs from the central pharmacy to the peripheral clinics
and the transport of blood samples from the peripheral clinics to the central laboratories. In addition to this,
Africa Centre also supports the monitoring and evaluation of the ART program and the development of
management and treatment algorithms.
With FY 2008 funding, additional support will include park-homes (inexpensive portable prefab long-lasting
structures) which will be set up in peripheral clinics where patient load exceeds facility capacity.
Operational assistance will be in the form of funding to support training of staff, transport, logistics, IT
support and administrative assistance to smaller peripheral clinics.
ACTIVITY 2: ARV Treatment
The Africa Centre will continue to support the expansion of the ART program at Hlabisa hospital and the 14
KZNDOH clinics. ARV treatment is following the DOH guidelines. Patients with stage IV disease or CD4
count <200 are eligible for treatment. After the necessary baseline investigations (blood tests, screening for
TB) have been performed, the patients are initiated for treatment in 14 government clinics and the hospital.
Through CT, TB and the mobile ART and palliative care programs, the Africa Centre will work to increase
uptake of ART among targeted communities. Africa Centre's goal is to test babies at 6 weeks after delivery
and get them on treatment if required. Mobile teams of nurses and counselors will provide ART in the
clinics, and community mobilization activities will be used to enhance community awareness and uptake of
services. The Africa Centre will investigate the best possible way to roll out ART in the mobile clinics, which
are serving the population. The mobile team will twin with the DOH mobile clinic team, and visit the service
points together.
In FY 2008, additional mobile teams will visit clinics bi-weekly to provide onsite training, assess complicated
patients, and do quality assurance checks. This process will institute a continuous process of quality
improvement. Data capturers, supervised by the M&E officer, will move with these teams to capture data
from the clinics. A doctor will join the mobile team to initiate patients on ART at smaller clinics and assist
with treatment of side-effects and adverse events. All patients will be trained in prevention of HIV
transmission and the importance of treatment adherence. Prophylaxis against common opportunistic
infections includes cotrimoxazole prophylaxis in all patients with CD4 count under 200. Data from these
activities will be monitored to ensure that clients receive comprehensive services and that all eligible
individuals are put on prophylaxis at the earliest opportunity.
Two mobile teams of the DOH are tracking TB patients who don't pick up their treatment. Africa Centre will
integrate the tracking of TB patients by forming two more teams. With that support all four teams are then
able to track TB and HIV patients, thus preventing duplication of tracking and expanding the coverage of
both groups of patients.
ACTIVITY 3: Human Capacity Development
KZNDOH and Africa Centre counselors and nurses who work on the program will receive training on HIV
and ART. The baseline course is based on the KZNDOH curriculum and comprises four sessions of three
hours each, covering basics of HIV and ART; follow-up of patients, assimilation of a follow-up, and practical
work with a patient (including blood taking for CD4 counts and viral loads). Counselors, nurses and
physicians will receive additional training, emphasizing side-effects and second-line treatment to treat
patients with therapeutic failure of first-line therapy. The program will finance a diploma course for a
pharmacy assistant to assist with a satellite dispensing service at the clinics to support the KZNDOH
pharmacist at Hlabisa Hospital. This trainee was recruited locally in June 2007. Doctors and nurses
working on the ART program will attend the AIDS Certification Course, run by another PEPFAR partner, the
Foundation for Professional Development. Due to the shortage of staff in the clinics and due to the
increasing number of patients and increasing workload, additional staffing in clinics and hospital will be
provided.
ACTIVITY 4: Human Resources
Africa Centre staff provides clinical care alongside KZNDOH staff in the clinics in order to support the
ongoing ART program and to facilitate skills transfer to build sustainability. The sustainability of the
program largely depends on availability of skilled staff, which is difficult to attract to this rural area. The
Africa Centre is continuously working on recruiting physicians and pharmacists. In FY 2008, Africa Centre
staff in the ART program will be increased including nurses, HIV trainers, HIV counselors, doctors, social
workers, 1 pharmacist, 1 dietician, M&E officers and data capturers. All staff are mentored and supervised
by Africa Centre staff.
Activity Narrative: ACTIVITY 5: Surveillance Systems
The Africa Centre will establish clinic-based ART drug resistance surveillance. In order to choose the best
second-line therapy, information about the drug resistance in the case of first-line therapy is needed.
Routine ARV drug resistance testing is not part of the South African treatment plan. Including drug
resistance testing in the ACHART program will directly benefit the patients. The findings may benefit other
sites in resource-limited settings. If the Africa Centre finds that most treatment failures are due to
resistance against stavudine (and not lamivudine or nevirapine), the overall quality of choice of second-line
drugs may be improved without genetic drug resistance testing. PEPFAR funding will finance laboratory
equipment and transport costs to set up ART drug resistance surveillance.
ACTIVITY 6: Quality Improvement
In June 2007 a team for Quality Management was introduced in all the clinics. This group provides
leadership and support centrally and to the clinics. In FY 2008 this group will increase capacity to identify,
develop and implement quality improvement interventions internal to the program as well as for identified
problems at the sites being supported.
ACTIVITY 7: Systems Development
With increased funding the Monitoring Evaluation and Reporting systems will be further strengthened to
support the internal and external data needs of the program. The existing databases will be reviewed and,
if appropriate, adapted, and staff will be trained. Additional staff will be needed to cope with the increased
number of data to be collected and used for improvement of the program.
ACTIVITY 8: HIV Awareness
Health education has to be prioritized in the sub-district. The knowledge about ART and other health issues
must be improved. Initial analyses of Africa Centre data shows that a huge number of people don't know
about ART and a large number of those who know about ART don't know where to get treatment. In July
2007 Africa Centre approached the Amakhosi (the highest traditional leaders in the area after the king) to
involve them in the response to HIV. In this area traditional leaders are playing a major role. Billboards at
different places will be placed with messages from the Amakhosi concerning testing and treatment. The
improvement of this knowledge regarding testing and treatment will contribute to PEPFAR'S goals to
increase the community access to ART services.
Africa Centre contributes to PEPFAR's 2-7-10 goals for South Africa by increasing community access to
ART services by facilitating scale up of the SA Government efforts.
Continuing Activity: 13371
13371 2997.08 U.S. Agency for Africa Center for 6453 397.08 $2,619,000
7275 2997.07 U.S. Agency for Africa Center for 4364 397.07 $1,720,000
2997 2997.06 U.S. Agency for Africa Center for 2659 397.06 $900,000
Estimated amount of funding that is planned for Human Capacity Development $120,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $40,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $20,000
Estimated amount of funding that is planned for Economic Strengthening $50,000
Table 3.3.09:
-Expand activities home-based care (HBC) services to include social and legal services for children;
-Dietician will train HBC workers and support groups on nutrition care and support for pediatric clients;
-Anthropometric tools required for nutritional assessment of pediatric clients will be procured; and
-Long-term food strategies will be developed to ensure ongoing nutritional support for pediatric clients.
ACTIVITY 1:
Africa Centre (AC) will expand activities home-based care (HBC) services with the appointment of a social
worker for assisting in social (access to social security services for women and children as indicated in the
NSP) and legal protection of pediatric patients.
ACTIVITY 2:
refer children and adults with poor nutritional status to and from the clinic and community and will
Africa Centre will develop food and nutrition policies and guidelines adapted from the South Africa
Government (SAG) nutrition policies which are applied to the local, rural community settings. This will cover
both adults (pregnant women) and children.
The dietician in the program will train nurses, counselors, Home-based Caregivers and support group
members in nutritional assessment and counseling and tools. For example, the nutrition risk score will be
used to identify children at risk of malnutrition and will refer these children for food security support.
ACTIVITY 3:
Anthropometric tools required (adult and pediatric scales, stadiometers, mid upper arm circumference
[MUAC] measuring tapes, and measuring mats) to conduct effective nutritional assessments will be
procured with PEPFAR funding. Children will be weighed at all visits and during the well-baby clinics.
Nurses will be trained on IMCI as a tool to manage malnutrition and other childhood illnesses.
ACTIVITY 4:
For long-term food security, support groups will be getting guidance on how to establish community
gardens. All adults with HIV and TB will be referred to these support groups. All children with poor nutritional
status will be referred to the Supplementary Feeding Scheme (PEM Scheme) and their mothers will also be
referred to support groups to benefit from the Food Security Programs.
New/Continuing Activity: New Activity
Continuing Activity:
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $20,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $15,000
Table 3.3.10:
equitable and sustainable pediatric antiretroviral therapy (ART) to all children who need it in the Hlabisa
district through the district health department of rural KwaZulu-Natal. The target population for the pediatric
treatment program is all infants and children born to HIV positive women and children living with HIV
(PLHIV). The emphasis area of this program is human capacity development, renovation of clinics, and
local organization capacity building.
16 fixed peripheral clinics. The ACHART Program is embedded in the DOH ART roll-out where the Africa
Centre and KZNDOH work to complement each other's abilities and resources in providing ART. The Africa
Centre has expertise in infectious diseases and management that are not available at the district DOH. In
addition to clinical staff and infrastructure, the district DOH provides the necessary drugs and laboratory
testing for effective rollout.
With FY 2009 funds, the Africa Centre will continue to support the provision of ART including provision to
children and expand its support for the KZNDOH. Increased attention will be given to improving the
proportion of children on treatment.
strategic planning and the implementation of the South African Government (SAG) National Strategic Plan
2007-2011 for HIV & AIDS and STI. This includes the establishment of an up and down referral system that
ensures that HIV-infected infants and children are treated at the optimal level of care at each stage of the
disease. The Africa Centre support further extends to operating the supply chain of drugs from the central
pharmacy to the peripheral clinics and the transport of blood samples and TB samples from the peripheral
clinics to the central laboratories.
In addition to this, Africa Centre also supports the monitoring and evaluation (M&E) of the ART program and
the development of management and treatment algorithms. Monitoring, evaluation and reporting of the
program will be done using both PEPFAR and the SAG (DOH) indicators. Reports on progress will be
submitted to both PEPFAR and the SAG.
With FY 2009 funding, additional support will include park-homes (inexpensive portable prefab long-lasting
ACTIVITY 2: Pediatric ARV Treatment
The Africa Centre will continue to support the expansion of the pediatric ART program at Hlabisa hospital
and the 16 KZNDOH clinics. The pediatric ARV treatment is following the DOH pediatric guidelines
including screening for TB.
Through counseling and testing (CT), TB and the mobile ART and palliative care programs, the Africa
Centre will work to increase uptake of ART among targeted communities. Africa Centre will conduct
polymerase chain reaction (PCR) testing on all HIV exposed babies at six weeks after delivery and provide
them with cotrimoxazole. Mobile teams of nurses and counselors will provide ART in the clinics, and
community mobilization activities will be used to enhance community awareness and uptake of services.
The Africa Centre will investigate the best possible way to roll out pediatric ART in the mobile clinics, which
are serving the population. The mobile ART team will twin with the DOH mobile clinic team, and visit the
service points together.
In FY 2009, additional mobile teams will visit clinics bi-weekly to provide onsite training, assess complicated
infections includes cotrimoxazole prophylaxis in all exposed children and children who are not on treatment.
Data from these activities will be monitored to ensure that clients receive comprehensive services and that
all eligible children are put on prophylaxis at the earliest opportunity.
Africa Centre plans to increase pediatric ART uptake from the current 10% coverage to 15%. Nurses and
counselors who will provide ART services in the mobile clinics and a tracking nurse will be appointed.
Activity Narrative: The pediatric and family clinic that is only done in two of the sixteen clinics will be expanded two other
clinics, and the dietician will also see some of the children referred by the pediatrician. Two of the AC
physicians (one is a Wellcome Trust-funded pediatrician) will continue to support the DOH by visiting the
pediatric ward at Hlabisa hospital daily. These children are discharged from the hospital and followed up by
Africa Centre physicians at the pediatric/family clinics.
Pediatric anthropometric tools, including Mid-Upper Arm Circumference (MUAC) tapes to conduct effective
nutritional assessment, will be procured with PEPFAR funding, and this will assist in improving the
proportion of children provided with food support.
Africa Centre will also work with the Mothers to Mothers Program that is in three of the 16 clinics to ensure
that mothers of exposed children are monitored and followed up.
With the integration of the Africa Centre tracking team and the DOH TB tracking team and greater
involvement of PLHIV (support groups), tracking of children lost-to-follow-up for PCR testing will be
improved.
ACTIVITY 3: Nutrition support
Africa Centre will develop food and nutrition policies and guidelines adapted from the SAG nutrition policies
which are adapted to the local, rural community with a special target on children. The Africa Centre will
make formula available to mothers who are unable to breastfeed their babies.
The dietician in the program will train nurses, counselors and Home Based Caregivers and support group
members in nutritional assessment and counseling and tools like the nutrition risk score will be used to
identify children' risk of malnutrition and for proper referral for food security support.
Anthropometric tools required (pediatric scales and stadiometers) to conduct effective nutritional
assessment will be procured with PEPFAR funding. Children will be weighed and screened at all visits.
For long term food security, support groups will receive guidance on how to establish community gardens.
Micronutrient supplementation will be made available following DOH and WHO guidelines. The
supplements will have both meal and multivitamin supplements.
Food parcels and vitamin and mineral enriched porridge, which will provide between 60 - 80% of the
recommended daily amount of food according to the SAG guidelines, will be made available for severely
malnourished infants and nutritional status will be assessed using the nutrition risk score. Africa Centre will
provide food parcels and meal supplements in emergency situations or instances where the SAG cannot
provide for this. This is part of strategies to mitigate the impact of poverty.
Foundation for Professional Development.
Both Africa Centre and DOH nurses will be trained in integrated management of childhood illness (IMCI) (an
effective strategy for identifying children exposed to HIV and TB), provider-initiated testing and counseling
(PITC) for children, which will increase the proportion of HIV-infected children on treatment and those
receiving cotrimoxazole, safe infant and young child feeding practices to prevent mixed feeding and reduce
the under-five Infant Mortality Rate, and the WHO Ten Steps to manage Malnutrition over and above the
pediatric ART training.
workload, additional staffing in clinics and hospital will be provided.
ACTIVITY 5: Human Resources
Africa Centre is continuously working on recruiting physicians and pharmacists. In FY 2009, Africa Centre
workers, one pharmacist, one dietician, M&E officers and data capturers. All staff are mentored and
supervised by Africa Centre staff.
In June 2007, a team for Quality Management was introduced in all the clinics. This group provides
leadership and support centrally and to the clinics. With FY 2009 funding, this group will increase capacity
to identify, develop and implement quality improvement interventions internal to the program as well as for
identified problems at the sites being supported.
Activity Narrative: ACTIVITY 7: Systems Development
With increased funding the Monitoring, Evaluation and Reporting systems will be further strengthened to
must be improved. Initial analyses of Africa Centre data shows that a huge number of people do not know
2007, Africa Centre approached the Amakhosi (the highest traditional leaders in the area after the king) to
Estimated amount of funding that is planned for Human Capacity Development $30,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $10,000
Table 3.3.11:
The Africa Centre for Health and Population Studies (Hlabisa ART Programme) first implemented TB/HIV
activities in FY 2007. Africa Centre will continue to coordinate TB and HIV programs in FY 2009.
All clients receiving HIV and AIDS services are routinely screened for TB (through intensive case finding)
and all TB positive patients receive provider-initiated HIV counseling and testing. The possibility of referral
for X-rays by a private physician has made accessibility to TB diagnoses much easier.
Africa Centre has supported the Department of Health (DOH) in several ways since 2007. Africa Centre has
ensured good practices in collection of quality sputum specimens, and collecting sputum in all the clinics
each day, so that clients with TB symptoms can be fast tracked for diagnosis and thus, TB treatment as
soon as possible. Training for all health-care workers is essential, and this has been done in collaboration
with the DOH. Training materials on key topics are either adapted to the local context or if necessary newly
developed.
In FY 2008, the provision of Isoniazid Preventive Therapy was be piloted and eventually rolled out to all
eligible HIV-infected persons in whom active TB disease has been ruled out.
Infection control plans will be developed in partnership with the DOH. This will enable the clinics to prevent
the transmission of TB among PLHIV as well as among health-care providers. Infection control plans will be
based on national and international guidelines.
The home-based care program will refer all clients receiving HIV services that are TB suspects to the clinic
to undertake TB diagnosis and referral. DOTS and patient support, contact tracing and coordination with the
South African government's HIV program will be strengthened.
--------------------------
The Hlabisa antiretroviral treatment (ART) program aims to deliver safe, effective, efficient, equitable and
sustainable ART to all who need it in Hlabisa district in rural KwaZulu-Natal. The program emphasizes the
integration of the government PMTCT and Care and Treatment Programs. An important part of the Care
and Treatment Program is the diagnosis and management of TB. Co-infection rates are high and the
Medical Research Council estimates that 58% of people with TB also have HIV. The target population is
people affected by HIV and AIDS. The major emphasis area is development of linkages and referral
systems.
The Africa Centre for Health and Population Studies (Hlabisa ART Programme) is a partnership between
the KwaZulu-Natal (KZN) Department of Health (DOH) and the Africa Centre, a population research
department of the University of KwaZulu-Natal. The DOH program is based in Hlabisa sub-District, a rural
health district in northern KZN, and provides healthcare to 220,000 people at one government district
hospital and 14 fixed peripheral clinics. The comprehensive ART Program, which includes TB services, is
embedded in the DOH antiretroviral therapy roll-out. TB/HIV services are considered part of the
comprehensive ART roll-out. The Africa Centre and KZN DOH work to complement each others' abilities
and resources in providing TB/HIV and related services. The Africa Centre has expertise in infectious
diseases and management that is not available at the district DOH. In addition to clinical staff and
infrastructure, the district DOH provides the necessary TB/HIV drugs and laboratory testing for effective roll-
out.
With FY 2008 funds, the Africa Centre will continue to partner with the district DOH to improve and expand
TB/HIV services by providing additional human resources and training. In addition, Africa Centre will
continue to provide comprehensive and integrated services for TB/HIV, palliative care, PMTCT, CT and
ART.
With FY 2008 funding the Africa Centre will improve TB and HIV screening and diagnosis for patients and
their families. Specifically, Africa Centre involvement will strengthen the TB/HIV Program, palliative care,
provision of ART and CT. Increased attention will be given to address gender issues through a greater
involvement of men and to promote TB and ART services among men and children.
Africa Centre will continue to work with the national and provincial Departments of Health and specifically
with the HAST (HIV, AIDS STI, and TB) managers to prioritize interventions designed to address
weaknesses (identified by the departments of health) in the DOTS and TB/HIV programs. Africa Centre will
focus on improving policy adherence and patient follow-up. Individuals will be hired for each site as tracers
to track patients and ensure that referrals are completed. Africa Centre is setting aside funding to develop
(with other relevant partners or agreement counterparts) standardized tools to ensure that policies and
guidelines recommended by NDOH are followed, including guidelines for infection control. Africa Centre will
continue to integrate TB/HIV interventions with existing agreement programs as Africa Centre works
seamlessly and side by side with government employees at government facilities.
ACTIVITY 1: Partnership with South African Government
Africa Centre will expand TB/HIV screening and diagnosis services in collaboration with the DOH TB
program and will explore other options for TB screening (including CT and PMTCT). Services will be
expanded at all 14 facilities. The Africa Centre will work closely with the DOH to ensure that all patients who
Activity Narrative: enter the ART program are screened for TB and treated, if necessary. In addition, Africa Centre will provide
training and mentorship to medical staff in order to strengthen the referral of people who receive DOTS for
HIV testing.
ACTIVITY 2: Screening and Diagnosis
As part of general patient work-up for the ART program, Africa Centre-placed staff in close collaboration
with DOH physicians and nurses will ensure that all patients in the ART program receive TB screening and
diagnosis. For those individuals who are unable to produce sputum for TB diagnosis, Africa Centre and
DOH staff in line with current SAG standard practice will refer patients for chest x-rays. Currently, patients
either incur large transportation costs or pay for the chest x-rays out of their own pockets at private
providers. In FY 2006 the ART program contracted a private physician in Mtubatuba sub-District to provide
chest x-rays for free for patients in the ART program. This has substantially reduced the expenses and time
costs of a large proportion of ART patients in having chest x-rays. Contracting the services of more
accessible service providers ensures increased access to the service for patients who need it.
ACTIVITY 3: Treatment
All individuals in the ART program who are diagnosed with TB are treated through the DOT support
program in close collaboration with the existing DOH TB program. Africa Centre, in addition to initiating TB
screening in all individuals who are enrolled in the ART program, monitors the completion of TB treatment
both in individuals in the monitoring cohort and before ART initiation.
In accordance with the South African national HIV and AIDS treatment guidelines, all HIV-infected patients
who are coinfected with TB will receive a full course of TB treatment independent of their HIV stage. In
addition, before TB patients can receive ART, they will have been treated for TB (for two months if CD4
count >50, at least for two weeks if CD4 count <50). All patients who receive treatment for TB will also
receive cotrimoxazole prophylaxis. A family centered approach will be adopted. Given the contagious nature
of TB, patients with TB will be encouraged to bring their families in to be screened. Africa Centre will use
this approach to increase male participation.
The mobile team initiative started in FY 2006 with the goal to provide ART in all 15 DOH clinics, instead of
only in 3 DOH clinics as in FY 2005. In FY 2008, this concept will be extended to provide home-based
palliative care, with a team consisting of nurses, counselors, social worker and the assistance of a physician
when required. Home-based palliative care will include educating patients about the need to screen for TB
and to treat TB, if necessary.
The target population for home-based care is non-ambulatory patients who cannot access treatment in
clinics and ambulatory patients who request a home visit, for instance to involve their partners and other
family members in their care. The team will be able to provide ART and symptom relief, including
symptomatic management of pain. The social worker will provide social counseling and information to the
household on how to access available government psychosocial services (food aid, social workers, and
government grants).
The nurses and the social workers who form the palliative care mobile team will receive intensive training. A
baseline course is based on the DOH curriculum and is comprised of four sessions of three hours each;
covering the basics of HIV and ART and TB, follow up of patients, and practical issues (including blood
taking for CD4 counts and viral loads). In addition, the mobile care team will be specifically trained in
administering and managing palliative care in the family setting.
This training will be further supported with clinic visits from training officers, during which the officers will
encouraged to participate in short courses covering, the management of ART side effects, TB and HIV, and
pediatric ART and TB. Counselors and nurses will be trained to provide TB care with a focus on the family.
Counselors will be trained on available government support structures to link PLHIV and their families to
other government programs, like ART services, PMTCT clinics, food aid and social workers, who can assist
the families with applying for government grants. All patients who have TB will be tested for HIV and
referred to the ART clinic if tested positive.
Individuals presenting to the DOH TB program independently from the ART program, will be routinely
referred to CT. In order to start this activity, TB staff will be systematically and repeatedly informed where to
access CT and how to talk to patients about HIV.
These activities will contribute to the PEPFAR goals of 2-7-10 by contributing to the goal of 10 million
people receiving care through PEPFAR assistance.
Continuing Activity: 13369
13369 7913.08 U.S. Agency for Africa Center for 6453 397.08 $291,000
7913 7913.07 U.S. Agency for Africa Center for 4364 397.07 $150,000
Table 3.3.12:
In partnership with the Department of Health, and as part of increasing counseling and rapid testing
accessibility to the Hlabisa sub-district, and thereby increasing access to HIV treatment, the ART program
has initiated two additional strategies. Two voluntary counseling and testing (VCT) models are going to be
introduced in the communities, mobile VCT and home-based VCT.
Mobile VCT
This strategy involves partnership with the sub-district's traditional and political leadership in which the main
purpose is to gain permission to deliver the service in the various communities. Various parking spots will
be identified such as market places, schools, pension points, recreational facilities, in addition the
counseling and testing trailer will also be part of the continuous road shows around the sub-district to
encourage people to test .Various mobilization strategies will be used to invite the community to get tested
for HIV near their homes. The trailer will comprise of confidential counseling and testing space and will be
complemented with extra tents which will be used as additional counseling spaces as well as education
area.
Home-based VCT
A portion of the sub-district will be allocated to deliver counseling and testing in homes. A group of trained
counselors will work on a schedule to approach various households where they will offer counseling and
testing to all family members. Since there is not much data on the effectiveness of home-based VCT, the
cost-effectiveness of the component will be evaluated through administering a basic questionnaire to those
visited in their homes.
Counselors have been trained in couple counseling and at the clinic level people living with HIV and AIDS
(PLHIV) are encouraged to bring their partners to the clinics. Strategies will be developed to make services
more male friendly in an effort to reach couples. Also, rapid tests are offered in all the clinics. Training will
focus on advanced skills (family, couples children counseling) and healthcare providers will be trained on
routine offer CT. Training will be a major focus in the activities around CT and will be held in all the rural
clinics. CT will be linked to the wellness program and will include STI screening.
Funding from CT will be needed for the HIV awareness campaign and for community mobilization.
-------------------------------------------
The Hlabisa antiretroviral treatment (ART) program aims to deliver comprehensive, integrated, safe,
effective, efficient, equitable and sustainable ART and related services to all who need it in the community.
Counseling and testing (CT) is part of this program in the Hlabisa District set in rural KwaZulu-Natal, South
Africa. The target population for the program is adults and people affected by HIV and their families. The
major emphasis area of this program is community mobilization/participation. Minor emphasis areas include
information, education and communication (IEC), local organization capacity development, and quality
assurance and supportive supervision.
The Africa Centre for Health and Population Studies' Hlabisa ART program is a partnership between the
KwaZulu-Natal Department of Health (KZNDOH) and the Africa Centre, a population research department
of the University of KwaZulu-Natal. The Hlabisa ART program is comprehensive and integrated. CT-related
activities fall within this program. The program is based in Hlabisa District, a rural health district in northern
KwaZulu-Natal, and provides health care to 220,000 people at one government district hospital and 13 fixed
peripheral clinics. The ART program is embedded in the Department of Health's antiretroviral therapy rollout
district Department of Health (DOH). In addition to clinical staff and infrastructure, the district DOH provides
the necessary drugs, laboratory tests, and rapid test kits for effective rollout.
With FY 2008 funds, the Africa Centre will continue to improve and expand CT services by providing
additional human resources and training. Africa Centre will link CT services to prevention of mother-to-child
transmission (PMTCT) services, TB/HIV, palliative care, and treatment programs. Increased attention will be
given to addressing gender inequality (including increasing male involvement in CT and care) and to
promoting ART services among men and children.
Africa Centre will expand CT and provider-initiated testing and counseling (PITC) in collaboration with DOH.
The Africa Centre will work closely with the DOH to ensure that all patients who enter the 14 clinics will be
offered an HIV test.
ACTIVITY 2: Counseling
Counseling centers were established in partnership with another of Africa Centre's donors, the Wellcome
Trust-UK. PEPFAR funds will be used to expand and promote the center at Mtubatuba. Another testing
center will be established at Hlabisa. A mobile testing center will be used during road shows and other
public events. The traditional leaders will be approached for testing in their Isigodi. (Isigodi is the
Activity Narrative: geographical area where a traditional Zulu authority called the Induna is in charge.)
The Africa Centre covers a research area of approximately 90,000 people in 11,000 households. Funded by
the Wellcome Trust UK, all inhabitants older than 15 years are offered an HIV test annually. Approximately
10,000 people are participating in that study each year. This study is one of the most reliable sources for
incidence data in Africa. The method used for HIV testing is a dried blood sample on filter paper analyzed in
the Africa Centre Virology Lab in Durban. The Africa Centre will return the test result within three weeks of
testing; clients will be provided with post-test counseling together with their test results at one of the Africa
Centre centers. PEPFAR funds will be used to fund HIV counselors accompanying the study team.
Counselors will offer rapid tests for HIV. A small study suggested that 20% of the participants of the study
are interested in a rapid test.
Moving away from clinics and offering the CT in a broader range of settings (e.g. close to a supermarket, in
town), Africa Centre hopes to attract hard-to-reach people to CT. Further, it is hoped that CT centers in non-
clinical settings will help to minimize the stigma attached to taking up HIV testing and counseling. The
counseling centers will offer rapid testing with pre- and post-test counseling. CT services will follow South
African government protocols. CT counselors will refer clients to appropriate further services, including the
ART programs, TB programs and government support services (disability grant, food help). CT counselors
will encourage clients to disclose their status to partners. Prevention counseling will be specifically aimed at
people who are at increased risk for HIV and will be tailored to the individual needs of the patient. Clients
will be counseled on personal risk reduction including messages about partner reduction and behavioral
changes to achieve healthy life styles. Counseling and testing takes place in separate closed rooms in order
to ensure confidentiality. All clients will receive their test results during the post-test counseling session.
ACTIVITY 3: Community Mobilization
For several years, the Africa Centre has been conducting road shows to provide information, education and
communication (IEC) services to rural Zulu communities. These road shows and other community events
will be used to promote CT. Specifically, the community will be informed that rapid testing will be offered at
the CT sites. The road shows will also be a forum to reduce the stigma around visiting a CT center.
Appropriate materials will be developed for informing the community about CT and other services offered
through the Africa Centre. All possible efforts will be made to encourage couples and youth to receive
counseling and testing. PLHIV have to play a major role in the community mobilization. Africa Centre will
involve PLHIV in educating the community about HIV, sharing their experiences with the people, and
through that getting more people tested. A behavior change communication specialist will be employed to
develop an appropriate strategy (such as the Stepping Stones strategy).
ACTIVITY 4: Referral and Linkages
Africa Centre will strengthen the referral system from the Department of Health's TB program to CT by
providing training to direct observation treatment supporters (DOTS) on the need for HIV testing for patients
who receive TB treatment. HIV-infected people will be referred for CD4 testing and treatment where
applicable. The counselors will inform clients on where to enroll in the ART program and on how to access
government support programs, such as disability grants and food aid.
ACTIVITY 5: Human Capacity Development
PEPFAR funding will be used to provide CT centers with additional CT counselors. As part of capacity
building, counselors are recruited from the local area, and trained and provided with mentoring and
supervision on a regular basis by Africa Centre. In addition, Africa Centre will conduct counselor-debriefing
sessions to discuss their work with their peers and support staff. Counselors will participate in short courses
to refresh their counseling skills. These courses will incorporate education on new initiatives that had not
been a part of their initial training. In addition, Africa Centre will provide training and mentorship to medical
staff in order to strengthen their knowledge about CT and to introduce provider-initiated testing and
counseling into the clinics.
Funding will also be used for additional staffing in clinics and hospital.
These activities will contribute to the PEPFAR goals of 2-7-10 by contributing to the 10 million people who
will receive care through PEPFAR assistance by providing counseling and testing to many individuals in
Hlabisa district.
Continuing Activity: 13370
13370 7911.08 U.S. Agency for Africa Center for 6453 397.08 $824,500
7911 7911.07 U.S. Agency for Africa Center for 4364 397.07 $580,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $45,000
Estimated amount of funding that is planned for Economic Strengthening $70,000
Table 3.3.14:
