Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 416
Country/Region: South Africa
Year: 2009
Main Partner: BroadReach Healthcare
Main Partner Program: South Africa
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $18,653,699

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $800,511

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In late 2006, BroadReach Healthcare (BRHC) began capacity-building work with South African government

(SAG) sites, initially with four hospital systems in KwaZulu-Natal. As of June 2008, BRHC was reporting

data from 110 sites, including 11 hospitals, 62 private General Practitioner (GP) practices and 37 SAG

clinics. Almost 20,000 patients are receiving treatment, care and support services at BRHC-supported sites

as of 30 June 2008. At the request of a district Department of Health (DOH), BRHC has committed to

continued expansion and plans to be supporting 19 complete hospital systems by September 2009. With

FY 2009 funds, BRHC expects to be active at 250 sites, including 25 SAG hospital systems.

In FY 2009 BRHC will focus on the following enhancements:

SCALE UP OF DUAL THERAPY PMTCT: In FY 2009 BRHC will aim to scale up PMTCT significantly by

working with provincial and district DOH in line with the revised PMTCT policy (dual therapy). Dual therapy

has only been recently introduced in South Africa based on revised policy and guidelines. BRHC was one of

the first partner agencies asked to roll out training on dual therapy and training has been done in one sub-

district of Gauteng province for 92 health workers, primarily doctors and nurses.

ROUTINE OFFER OF COUNSELING AND TESTING, INFANT PCR AND IMPROVED LINKAGE AND

REFERAL: BRHC will continue to support the offering of group education sessions and routine offer of

counseling and rapid testing at the nearly 200 SAG sites supported by the organization. BRHC will also

support the roll out of re-testing of women who tested negative earlier in their pregnancy at 32 weeks.

Partner testing is encouraged and BRHC uses a number of health education modalities centered on a

family model of care to promote this (e.g., educational videos in local language, flip chart tools for small

group presentations, counseling sessions and community mobilization model).

An additional critical area of focus will be to increase coverage of infant polymerase chain reaction (PCR)

testing where currently the major bottleneck is training of nurses to perform the test. A key weakness of the

current system is that women are tested with relatively good coverage, however, there remains a systematic

gap in follow up and tracking between the hospitals (where delivery occurs) and the originating clinics that

referred them. For example, almost all HIV-infected women who deliver, receive a CD4 test at the hospital,

but the results tend to arrive after they have been discharged. These results typically accumulate at the

hospital and are not returned to the originating clinic which the mother will visit for subsequent follow up

maternal-child health (MCH) services and immunization. Furthermore, in addition to sub-optimal levels of

infant PCR (due to lack of training), it is systematically difficult to link a child born to an exposed mother to

the mother's medical record. Currently policy does not allow the mother's status to be reflected on the

baby's road-to-health card, which would allow the child to be identified as at risk and monitored during other

interactions with the health system like well-baby visits and immunization. BRHC, under its data

management initiative, will work to ensure that the mothers' and children's data is linked between hospitals

and clinics to effective referral both ways and subsequent follow-up of mothers and children in their local

clinics and communities. Treatment eligible women will be fast tracked into antiretroviral therapy (ART) at

whatever point in the patient flow that they are identified or captured.

CARE AND TREATMENT FOR WOMEN AND CHILDREN: A major area that BRHC is supporting is the

scale up of ART and care at hospitals and supporting clinics (through a down referral model). Within this

scale up, pregnant women and children are prioritized. This includes the provision of highly active

antiretroviral therapy (HAART) per national and new WHO guidelines for children, opportunistic infections

management, treatment of TB co-infection, cotrimoxazole prophylaxis, support for optimal feeding options

(promoting replacement feeding if acceptable, feasible, affordable, sustainable and safe (AFASS) or

exclusive breast-feeding) and improved linkages and referral to other child survival interventions such as

the Expanded Program on Immunization and nutritional and micro-nutrient support.

PREVENTION: BRHC has always emphasized prevention with HIV-infected clients and views treatment,

care and prevention as an inextricably linked and integrated package of services. Patient and client health

education will continue to be provided through the BRHC Information, Education and Communication

program (an area of key distinction for BRHC having developed the first treatment-related integrated

messaging to support HAART rollout in Botswana). This package includes education to encourage testing

for HIV, TB and sexually transmitted infections (STIs) (individual and partner testing), appropriate condom

use (male and female), importance of avoiding re-infection, provision of psychosocial support via facility-

based staff and community-based support groups and linkage/referral to and from services such as family

planning, STI clinic services and other MCH and primary care programs (e.g. IMCI).

COMMUNITY LINKAGES: BRHC is developing a signature community mobilization program through which

a large array of community- and home-based services will be delivered, monitored and reported. In each

geographical area where BRHC works, the community mobilization program will be the vehicle through

which the defined care package will be delivered and home- and community-based follow-up and patient

tracking and monitoring accomplished. The aim of this model will be to ensure that every single patient can

be reached reproducibly through defined and stereotyped channels. This will involve non-governmental and

community, local leader and traditional healer partnerships. BRHC has already pioneered a model whereby

Community Support Organizations such as churches are formally capacitated to serve as an extension of

the care team and to assist in monitoring and provision of support for patients at community and home level.

BRHC will be extending this model across new high potential partners to provide comprehensive community

coverage. A critical function of the community model will be to provide referral and linkage services to and

from other critical social welfare services (e.g., Department of Social Development programs, income

generation projects, gender and legal support services, etc.).

HEALTH SYSTEMS STRENGTHENING: As mentioned, BRHC approaches prevention, treatment and care

in an integrated fashion. In this regard, BRHC has been strengthening health systems through key initiatives

such as augmenting Department of Health staff and infrastructure (across all cadres), training (didactic and

mentorship, including training on rapid tests and infant PCR), strengthening data management and

Activity Narrative: monitoring, evaluation and reporting systems, and providing management and leadership training at

national, provincial, district and health facility level. BRHC is also leading the development of a centralized

disease control and monitoring hub for the country of South Africa (and ultimately the region) through a

separate project with Virgin Unite and the National Department of Health.

-------------------------------

SUMMARY:

BroadReach Healthcare (BRHC) supports integrated ARV services that include PMTCT, doctor

consultations, lab testing, adherence support, patient counseling, remote decision support, quality

assurance (QA), and data management. The main emphasis area is capacity building, with minor emphasis

on strategic information and human capacity development (training). The primary target population is

pregnant women.

BACKGROUND:

PEPFAR funds support BRHC initiatives that provide HIV and AIDS clinical management, care and support

services to HIV-infected individuals in areas where the SAG rollout has not yet been implemented and

assists ART rollout in the public sector. The BRHC PEPFAR program began in May 2005 and now operates

across 5 provinces. BRHC is supporting approximately 5000 individuals directly with care and treatment and

15,000 indirectly. BRHC taps private sector health professionals to provide comprehensive care and

treatment, fostering capacity-building initiatives within the public health system, and supporting community-

based programs. BRHC leverages PLHIV support programs to identify and assist with treatment literacy,

adherence support and ongoing community mobilization, prevention education activities, and positive living

initiatives. BRHC also works to build capacity in public health facilities, focusing efforts on human capacity

development (HCD) activities, including clinical didactic training, clinical mentorships, patient training and

operational assistance training. BRHC is expanding its provision of staff and infrastructure support to SAG

facilities. Finally, BRHC is expanding its involvement in the design of scaleable down referral models in

partnership with faith-based organizations (FBOs), community-based organizations (CBOs), and public-

private partnerships (PPPs).

ACTIVITIES AND EXPECTED RESULTS:

To ensure that patients are armed with accurate and practical HIV prevention strategies, BRHC will carry

out the following activities:

ACTIVITY 1: Clinical Services

BRHC patients will be treated in accordance with national guidelines by ensuring that all elements for

effective treatment are provided in a coordinated manner. Patients see doctors regularly, and will receive

laboratory tests, HIV and AIDS education (complete with prevention messages), management of sexually

transmitted infections (STIs), adherence support, counseling, cotrimoxazole prophylaxis and linkage to

other support and wellness services. Pregnant women identified through the BRHC program and partner

sites will be offered PMTCT services in line with SAG guidelines. PMTCT services include counseling and

testing (see subsequent activity); counseling and support for maternal and infant nutrition; access to ARV

treatment and safe infant feeding practices. Linkages will be made to pediatric treatment. At each facility a

"tracer" will be employed full time to ensure that appointments are kept, opportunistic infections are treated,

CD4 counts monitored and referrals completed.

ACTIVITY 2: Human Capacity Development (HCD)

BRHC will provide comprehensive HIV and AIDS training that includes PMTCT to its network of providers

including doctors, nurses, pharmacists and other healthcare professionals through a variety of initiatives

including remote decision support, telemedicine, web-based training, didactic training, and clinical

mentoring from experienced clinicians. Comprehensive HIV and AIDS training for health professionals

includes prevention and management of sexually transmitted infections, PMTC, ART management,

tuberculosis (TB), adherence, management of complications and side-effects, and pediatric HIV

management. BRHC will continue to train patients and support group facilitators on topics including

prevention and PMTCT, HIV and AIDS, ART, adherence, living positively, and accessing psychosocial

support in communities.

ACTIVITY 3: Counseling and Testing

BRHC will work with partner sites to ensure that pregnant women are counseled and tested for HIV, and

offered access to PMTCT. This will be done by both private general practitioners who are in the BRHC

network and at the government facilities where BRHC works.

ACTIVITY 4: Support to SAG

BRHC will conduct an initial needs assessment at each SAG partner facility. The assessments will identify

problems that impact overall capacity and efficiency. Solutions for each institution include recruitment and

salary support for doctors, nurses, and pharmacy staff. BRHC general practitioners provide part-time

services at SAG facilities, and train SAG staff in HIV care and treatment and related management. Other

support may include infrastructure, such as refurbishment, equipment and supplies procurement. This will

also include strengthening linkages between essential HIV support services such as PMTCT to ensure clear

referral procedures, patient tracking, and reporting of intervention results.

These activities directly contribute to the PEPFAR 2-7-10 goals by attempting to prevent new infections

among infants.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13700

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13700 13700.08 U.S. Agency for Broadreach 6576 416.08 $824,500

International

Development

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $40,711

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $3,884

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01:

Funding for Sexual Prevention: Other Sexual Prevention (HVOP): $0

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

SUMMARY:

In FY 2009, funding is requested to maintain and build on activities described in the FY 2008 COP.

BroadReach Healthcare (BRHC's) approach will be to strengthen prevention within the scope of its existing

programs and activities by selecting appropriate and targeted messages to deliver sustained behavior

change. Selected interventions with general populations outside of treatment settings will be undertaken to

address clear gaps and needs in prevention programming in the catchment areas of BRHC sites.

BACKGROUND:

BRHC approaches all of its work with the concept of developing scalable solutions which can help to bolster

the South African Government's (SAGs) HIV/AIDS efforts across the country. To do this, BRHC breaks

down the problem into demand-side and supply-side. Demand-side addresses the patients and

communities to ensure that solutions are in place to mobilize, generate demand for testing, provide

education including treatment literacy, provide ongoing adherence and psychosocial support to PLHIV and

the affected/unaffected community members. BRHC generally does this by training and capacitating

community organizations such as PLHIV support groups, faith-based organizations (FBOs), non-

governmental organizations (NGOs) and SAG facilities to carry out these activities. The supply-side

addresses the provider of services such as hospitals, clinics, healthcare workers, labs, pharmacies, etc. and

focuses on solutions such as training, service delivery integration and re-engineering, operations

improvement, equipment and infrastructure upgrade, etc. The goal is to build capacity in a scaleable way to

address the demand for HIV/AIDS services. It is BRHC's philosophy that solutions cannot be scalable if

they do not address both demand and supply sides and work to balance both.

ACTIVITY 1: Prevention Training (HCD)

Training in the provision of other sexual prevention services will be extended to community-based

organizations (CBOs), NGOs and community health workers in the catchments areas of BRHC-supported

SAG sites. Training will aim to alleviate capacity building and human resource constraints faced by the local

NGOs, CBOs and community health workers with which BRHC builds partnerships.

ACTIVITY 2: Strategic Prevention Partnerships with SAG and NGOs/CBOs

BHRC will partner with district and provincial Directorates of Health Promotion, Directorates of Social

Mobilization and HIV/AIDS/STI/TB (HAST) units to support and strengthen existing prevention programs in

the districts where BRHC supports SAG sites in the provision of antiretroviral (ARV) treatment. Technical

assistance will be provided to ensure coordinated, multi-level prevention programming is provided at the

scale and intensity required to achieve behavioral objectives in specific populations. Building capacity to

design, implement, monitor and evaluate comprehensive prevention programming will lead to sustainable

programming. Before launching new prevention initiatives or developing new materials, BRHC will conduct

a thorough review of materials and activities already at local, provincial and national levels. BRHC will also

ensure any interventions are evidenced-based, draw on best practices in South Africa and the region, and

are consistent with the latest epidemiological evidence of the drivers of HIV transmission in that

geographical area. Formative assessments and situational analysis will be used to identify any missing data

on local context. We will provide added value by identifying gaps (geographical, target population, technical,

human resource) and filling them through partnership building and technical assistance.

Community health workers (lay and volunteer) present an ideal opportunity to bring prevention messages

and materials directly into the home, while also providing a direct linkage to screening for HIV and

tuberculosis (TB). BRHC will coordinate with local NGOs and CBOs to provide the deep penetration and

coverage of prevention messaging in critical areas. Finally, BRHC will assist NGO and CBO programs to

standardize prevention messages and align local activities with national mass-media campaigns and

education programs.

BRHC is launching a new large scale comprehensive community mobilization program within which

provision and support of wellness at community level is the key priority. Prevention will be a central tenet of

this model. This model will be scaled up through new programs such as workplace, door to door campaigns,

engagement of local traditional leadership and traditional healers, improved referral systems for social

welfare services and partnering with local agencies to jointly provide as comprehensive a set of care

interventions as possible. The community mobilization model will become the large scale distribution

platform for an array of prevention programs now aimed at the general public that BRHC is in the process of

developing.

Under the above described programs BRHC will continue production and dissemination of existing IEC

materials including condom leaflets, patient education videos and patient education flipcharts. The patient

education videos and flipcharts include various prevention messages within the context of comprehensive

care and treatment services. Messages emphasize the important of testing and disclosure, couples

counseling and testing, prevention messages for positive people and sero-discordant couples and positive

living.

BRHC is currently embarking on an evaluation of risk perceptions and vulnerabilities of our current

constituents to guide us in determining new, innovative and impactful prevention interventions that actually

work. These will be scaled up and continuously evaluated for efficacy. BRHC has also been requested by

North West province to assist them in developing and rolling out a prevention strategy for their high risk

populations and this will be a signature initiative in FY 2009.

Activity 3: Condom Distribution

Activity Narrative: Increasing condom availability and condom distribution networks will be an important component of all

BRHC other sexual prevention activities. Condom distribution will be coupled with comprehensive

prevention messages (ABC), and education on correct and consistent condom use as a method of

preventing HIV infection. BRHC will work with SAG sites and distribution centers to ensure a consistent

supply of quality condoms, addressing issues of proper handling and storage where necessary. Community

mobilization activities involve male and female condom demonstrations, and involve the dissemination of

informational materials on proper condom use.

Activity 4: Prevention Integration

In FY 2009 prevention integration activities will be expanded to include other departments and hospital

wards including ante-natal clinics, inpatient medical wards, TB clinics, and maternal and child health

services. Prevention messages will be culturally appropriate and address the risks of multiple, concurrent

partnerships and abuse of alcohol and drugs. Women in their twenties will also be targeted for messages

around transactional and cross-generational sex. New prevention messages will be developed to assist

patients who have been successful on treatment for a long period of time to prevent complacency. BRHC

will use quality assurance/quality improvement methodologies to monitor the consistency and accuracy with

which prevention messages are integrated into clinical encounters. Activities will also include referrals for

counseling and testing and for the diagnosis and treatment of sexually transmitted infections.

--------------------

SUMMARY:

BroadReach Healthcare (BRHC) supports integrated ARV services that include doctor consultations, lab

testing, adherence support, patient counseling, prevention, remote decision support, quality assurance

(QA), and data management. BRHC's emphasis areas are capacity building (major); with minor emphasis

on strategic information and human capacity development (training). Primary target populations include

adolescents, adults, and people living with HIV.

BACKGROUND:

The BRHC PEPFAR program began in May 2005 and now operates across five provinces. BRHC is

currently supporting approximately 5000 individuals directly with care and treatment and 15,000 indirectly.

Prevention is a new activity area for BRHC. BRHC will endeavor to understand SAG priorities around

prevention, including those articulated in the new National Strategic Plan (NSP), and formulate site-specific

prevention plans that reflect SAG priorities and facility needs. BRHC prevention activities will take two

forms: first, as stand alone prevention interventions; and second, as integrated interventions within BRHC

treatment program activities. In response to site specific needs, BRHC prevention activities will support

ongoing prevention activities within SAG facilities, as well as support new initiatives that fill gaps in

prevention priorities identified by the site and SAG guidelines.

ACTIVITIES AND EXPECTED RESULTS:

To ensure that patients are armed with accurate and practical HIV prevention strategies, BRHC will carry

out the following activities:

ACTIVITY 1: Prevention Training (HCD)

BRHC will provide HIV and AIDS prevention training to its network of healthcare providers including doctors,

nurses, pharmacists and other healthcare professionals, as well as public sector health professionals at its

partner sites through a variety of initiatives including remote clinical decision support, telemedicine, web-

based training, didactic training, and clinical mentoring from experienced clinicians. More specifically, the

topic of HIV prevention is covered in the three day training for Nurses and Lay Counselors; in the five day

University of KwaZulu-Natal training for Professional Nurses; the 10 module HIV/AIDS Clinical Training

online course for Doctors; and the 1-3 day HIV Treatment Literacy training for ARV Coordinators and

Counselors. In addition BRHC will integrate a prevention module into the one day quarterly Adherence

Training for BRHC patients.

ACTIVITY 2: Strategic Prevention Partnerships (Outreach)

BRHC will form strategic partnerships with local CBOs and FBOs and companies that are actively engaged

in prevention activities in the BRHC catchment area in order to support existing activities that are aligned

with SAG policy, and to help create new programs should any gaps exist. Support to CBOs/FBOs may

include provision of resources to support approved prevention activities (human resources, funds,

equipment). BRHC will also leverage these strategic partnerships for condom distribution and educational

materials on the proper use of condoms.

ACTIVITY 3: Condom Distribution

BRHC will distribute condoms and materials on proper condom use through a variety of channels.

Distribution channels will include GP offices (~50 outlets); public sector hospitals and affiliated clinics (~100

sites); and through the BRHC IEC program to patient support groups (~10). As stated previously, BRHC will

also provide condoms to partner CBOs/FBOs that are active in prevention activities in the community. The

BRHC IEC team will run prevention outreach campaigns to local companies and engage them in prevention

activities such as the distribution of condoms and prevention messages to employees.

ACTIVITY 4: Prevention Integration

BRHC will integrate prevention activities and messages into its treatment program activities. This will be

Activity Narrative: accomplished in two principle areas: 1) Prevention with Positives (PwP) in the Clinical Setting; and 2)

Prevention in the Counseling Setting. PwP activities will be coordinated through BRHC public sector sites

and GP offices, and will involve the distribution of targeted prevention messages [printed materials] for HIV-

infected individuals by the BRHC IEC team; prevention education sessions for patients, buddies and family

members conducted by the BRHC IEC team; and condom distribution at all clinical service outlets. Second,

BRHC will also utilize the CT setting to distribute targeted prevention materials [printed materials] and will

review counseling guidelines to ensure that prevention messages are delivered during counseling sessions.

This will be made available at all sites where BRHC supported CT services are offered. Condoms will also

be supplied and made available to individuals undergoing counseling and testing services.

These activities directly contribute to the PEPFAR 2-7-10 goals by attempting to prevent new infections.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13699

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13699 13699.08 U.S. Agency for Broadreach 6576 416.08 $776,000

International

Development

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $66,552

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.03:

Funding for Care: Adult Care and Support (HBHC): $873,814

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In FY 2009, BroadReach Health Care (BRHC) will expand on and strengthen existing capacity building

activities all conducted at the request of and in partnership with the South African Government (SAG). The

FY 2008 narrative primarily describes activities under BRHC's general practitioner (GP) program with

private providers which offers services to HIV-infected persons through three different treatment models.

This program was designed to ease the burden on the public sector to provide treatment services by

strategically leveraging capacity in the private sector in underserved areas. The GP program will be

maintained in FY 2009, but the majority of funding requested under this program area will be for the

intensification of BRHC's program to build capacity in public sector (SAG) health facilities. All proposed

activities will be aligned with the National Strategic Plan (NSP), national antiretroviral (ARV) guidelines and

other national guidelines governing care and treatment of HIV-infected and affected people. BRHC's overall

goal under this program area is to promote creative, sustainable and comprehensive treatment programs

that improve the quality of life of people living with HIV (PLHIV) and increase resilience in the public health

care system.

In late 2006, BRHC began capacity building work with SAG sites and was initially assigned to four hospital

systems in KwaZulu-Natal (KZN). As of June 2008, BRHC was reporting data from a total of 110 sites in five

provinces. Almost 20,000 patients are receiving treatment, care and support services at BRHC-supported

sites as of 30 June 2008 which exceeds the September 2008 target by nearly 250%. At the request of the

district DOH, BRHC has committed to continued expansion and plans to be supporting 19 complete hospital

systems by September 2009. With FY 2009 funds, BRHC expects to be active at 250 palliative care sites,

including 25 SAG hospital systems.

Activity 1: Clinical Services and Operations

BRHC will place particular emphasis this year on expanding wellness programs for HIV-infected people not

yet eligible for ART, and their family members. The goal will be to ensure early referral and enrollment into

comprehensive care programs to maintain CD4 >200, and to reduce loss to initiation. 'Wellness programs

will provide a basic care package, consisting at a minimum of: repeat CD4 testing per national guidelines,

cotrim prophylaxis, screening and treatment for opportunistic infections (OIs), ongoing counseling and

psychosocial support, nutritional assessment and supplementation, pain assessment, and prevention

messages as part of routine care. Wellness programs will also provide necessary referrals to other health

services such as reproductive health, family planning, immunization, and routine-offer HIV testing. BRHC

support to facilities will focus heavily on integration of TB and HIV services.

Activity 2: Human Capacity Development

BRHC provides a combination of in-house and outsourced training courses aimed at ensuring quality

delivery of treatment services. Alignment with SAG training plans and service providers ensures training is

provided with the appropriate intensity to all cadres of staff. All BRHC-implemented or sponsored training

courses use DOH-approved curricula. Training will emphasize provision of cotrim prophylaxis, pain

assessment/mgmt and nutritional assessment and counseling. BRHC will engage additional qualified

clinical mentors and preceptors to ensure supportive supervision within the work setting. BRHC will continue

to provide salary support to SAG for clinical and lay staff on a temporary basis to fill critical vacancies.

Activity 3: Referrals and Linkages across the Health System and Community

BRHC assists each site it supports to strengthen or develop active defaulter tracing programs for HIV-

infected patients by providing technical assistance, personnel and transportation solutions as required.

Defaulter tracing models are built on best practices and adapted to the individual needs of a particular

health system. In most areas where BRHC works, BRHC's site includes an entire health system, which

allows for the creation and testing of scaleable approaches to patient tracing across large, rural

geographical areas.

BRHC takes a family-centered approach to providing comprehensive care and treatment services and will

intensify efforts in this area to build HIV and AIDS-competent communities. In FY 2009, BRHC will expand

partnerships with non-governmental organizations (NGOs) and community-based organizations (CBOs) to

ensure uninterrupted service delivery and community-level support for PLHIV and their families. Training,

institutional strengthening, monitoring and evaluation (M&E) and other technical assistance and HR support

will be provided to NGOs/CBOs to enable them to meet the demand for community-based services for care

and support, especially those organizations specializing in HBC. Community-based services will extend and

complement facility-based services by: addressing issues of water, sanitation and hygiene; providing

linkages to wrap around programs (particularly food and nutrition programs), provide consistent prevention

messages; spiritual support; and assistance in accessing social grants. BRHC will play a critical role in

providing coordination between SAG facilities and communities, creating sustainable coordination

mechanisms and mutually beneficial partnerships. The goal is to furthermore ensure coordination and

referral mechanisms are in place such that patients are able to navigate the health and social welfare

systems successfully, and that facilities are able to track and locate patients at any time throughout this

process. Linkages with family planning, maternal and child health, gender-based violence, Directly

Observed Treatment, Short-course (DOTS) and nutrition programs will be strengthened.

--------------------

SUMMARY:

BroadReach Health Care (BRHC) activities include doctor consultations, lab testing, adherence support,

patient counseling, remote decision support, quality assurance monitoring, training for both patients and

health professionals, support groups and data management. Basic Care and Support activities are in

support of individuals participating in an antiretroviral therapy (ART) program, largely representing the

population of those HIV-infected, but not yet eligible for ART. The major emphasis is on human resources

with minor emphasis on quality assurance and training. These emphasis areas are realized through clinical

and non-clinical services, human capacity development, quality assurance, referrals and linkages and South

Activity Narrative: African Government (SAG) support including meeting equipment, infrastructure and human resource needs.

Primary target populations include people living with HIV and AIDS (PLHIV) and their families/households,

program managers, public and private doctors, nurses, laboratory workers, pharmacists, other health care

workers, the business community/private sector, CBOs, FBOs, and NGOs.

BACKGROUND:

PEPFAR funds support BRHC initiatives which provide HIV and AIDS clinical management, care and

support services to HIV-infected, uninsured individuals in public sector government facilities and areas

where the SAG ART roll-out has not yet reached or where there is high demand. The BRHC PEPFAR

program began in May 2005 and now operates in 15 communities across five provinces. Today, BRHC is

supporting approximately 3,500 individuals directly with care and treatment and 15,000 indirectly. The

BRHC mission is to tap into private sector health professionals to provide comprehensive care and

treatment, fostering capacity building initiatives and service delivery within the public health system, and

partnering with and supporting community-based programs with sustainable impact on long-term patient

care. BRHC leverages the community-based PLHIV support programs to identify and assist with treatment

literacy, adherence support and ongoing community mobilization, prevention education activities, and

positive living initiatives. In addition, BRHC works to build capacity in public health facilities, focusing on

human capacity development including clinical training, clinical mentorships, patient training and operational

assistance training. BRHC is expanding its provision of additional staff and infrastructure support to SAG

facilities. Finally, BRHC is expanding its involvement in the design of scaleable down referral models in

partnership with FBOs, CBOs, and as a partner in innovative public-private partnerships (PPPs).

ACTIVITIES AND EXPECTED RESULTS:

The primary goal of this program area is to ensure that new patients are started on ART when clinically

qualified and enrolled patients continue to receive outstanding care and support.

ACTIVITY 1: Clinical Services

BRHC patients will be treated in accordance with SAG ARV National Guidelines and provided regular

doctor visits, laboratory tests, HIV and AIDS education, counseling, TB screening, and cotrimoxazole

prophylaxis. Using a family-centered approach, BRHC will recruit eligible family members of HIV-infected

patients - including greater numbers of men and children - in order to improve the health of

families/households and facilitate family doctor visits and drug pick ups. Care includes the preventive

package, symptom and pain management, a care support program (during the time from when a patient

finds out his or her HIV-infected status until eligible for ART), are care during and after the initiation and

possibly failure of ART. Patient nutrition and wellness needs will be met by the provision of multivitamin

supplements, and doctor, patient and facilitator training in nutrition.

ACTIVITY 2: Human Capacity Development

1) BRHC will continue to provide training to its network of providers including doctors, nurses, pharmacists

and other healthcare professionals through a variety of initiatives including remote decision support,

telemedicine, web-based training, didactic training, and clinical mentoring from experienced HIV and AIDS

clinicians. Comprehensive HIV and AIDS training for health professionals includes ART Management, TB,

adherence support, management of complications and side-effects, prevention and pediatric HIV

management.

2) BRHC will continue to focus on community training on topics including HIV and AIDS, ART, adherence

support, living positively and prevention with positives, universal precautions and accessing psychosocial

support in communities. BRHC will continue to train support group facilitators on topics including HIV and

AIDS, ART, adherence, disclosure, and linking patients with psychosocial services in the community.

ACTIVITY 3: Support to SAG

BRHC will support capacity development for care and support services at partner SAG facilities. According

to SAG articulated needs, these services will include commodity procurement, healthcare financing, human

resource recruitment and salary support (for doctors, nurses, pharmacy staff etc.), BRHC doctors providing

temporary services at SAG facilities, training of SAG staff in HIV care and treatment and/or ART program

management, and physical infrastructure building/refurbishment and equipment procurement. BRHC will

work with SAG staff to improve operational efficiency in SAG facilities through needs assessments including

identification of key bottlenecks and then generate and implement solutions. Additionally, BRHC will support

SAG National Department of Health (NDOH) efforts, by assisting with development of down referral models.

Finally, BRHC will build on its existing public-private (PPP) model (SAG - BRHC - Daimler Chrysler) in East

London and develop new PPPs to further involve small to medium enterprises in supporting employees and

dependents in the communities where they operate, alleviating some of the burden on government services.

ACTIVITY 4: Referrals and Linkages

Development of linkages and referral systems will be provided through strengthened referral networks

between the public and private sectors (including referring stable patients back to the SAG ARV program),

assistance to local clinics to facilitate SAG down referral process. Finally, BRHC will continue to expand its

community-based linkages with CBOs in order to refer patients in need of non-USG funded food parcels

and other wraparound services intended to support patients.

ACTIVITY 5: Quality Assurance/Quality Improvement (QA/QI):

Recognizing the critical role of monitoring and evaluation in ensuring a successful program, BRHC QA/QI

activities include regular internal data and systems audits, collection of patient level surveillance data,

Activity Narrative: exception reports, doctor-specific feedback report, and doctor decision-making support. The BRHC

adherence program monitors and evaluates patient adherence through monitoring of drug pick up

information, clinical reports, self-reported adherence, and pill counts.

All BRHC activities articulated in the FY 2007 COP will be scaled up significantly in FY 2008 through its

partnerships with 15 SAG hospital systems (which include hospitals and affiliated CHCs and PHCs).

With FY 2008 funding, BRHC's palliative care activities will be expanded and enhanced as follows:

-BRHC will continue to support QA/QI at each of its public sector partner hospitals through QA

assessments, systems re-engineering, and the development of reporting systems that provide program

management feedback that is used to improve program performance and more closely monitor patient care.

-Strengthen down referral activities between public sector hospital partners and their affiliated clinics

(PHCs) by re-engineering referral processes, improved data management and patient tracking, and training.

-Training for health professionals at all public sector sites (hospitals and PHCs)

-HIV and AIDS Literacy training for patients as part of community mobilization

-Expanded care and treatment activities through the BRHC PPP to additional Daimler Chrysler supply chain

companies/employees and their families and communities.

-Staff augmentation: BRHC will provide additional salary support to fill key positions within SAG partner

hospital sites. BRHC will also work with the site to motivate for the creation of permanent posts where

needed and ensure that BRHC/PEPFAR supported staff are incorporated into subsequent site budgets to

ensure a sustainable staffing solution

BRHC Basic Healthcare and Support activities directly contribute to the 2-7-10 objectives of supporting 10

million people with basic healthcare and support by expanding these services in South Africa.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13693

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13693 3007.08 U.S. Agency for Broadreach 6576 416.08 $1,000,000

International

Development

7511 3007.07 U.S. Agency for Broadreach 4449 416.07 $800,000

International

Development

3007 3007.06 U.S. Agency for Broadreach 2663 416.06 $751,000

International

Development

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $323,876

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $100,401

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.08:

Funding for Treatment: Adult Treatment (HTXS): $12,518,262

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

In FY 2009, BroadReach Health Care (BRHC) will expand capacity building activities all conducted at the

request of and in partnership with the South African Government (SAG). The FY 2008 narrative primarily

describes activities under BRHC's general practitioner (GP) program with private providers which offers

services to HIV-infected persons through three different treatment models. The GP program will be

maintained, but the majority of funding for this program area will be for the intensification of BRHC's

program to build capacity in SAG facilities. All proposed activities will be aligned with the National Strategic

Plan (NSP), national ARV guidelines and other national guidelines governing the care and treatment of HIV-

infected people.

Activity 1: Clinical Services

The majority of BRHC support for accreditation has been aimed at district and regional hospitals. In FY

2008 and increasingly in FY 2009, BRHC support for accreditation will shift from hospitals to community

health centers (CHCs) and primary health clinics (PHCs) where in line with district/provincial priorities for

ART roll-out. Other support for accreditation includes human resources, training, equipment, refurbishment

or creation/expansion of space. BRHC will continue to prioritize down referral as a solution to bottlenecks

and overcrowding at hospital initiating sites. BRHC takes a holistic approach to down referral, viewing an

initiating site and all PHCs as part of one interdependent health system supported by a single information

system.

BRHC will employ both facility and community-level approaches to improving the integration of services and

referral systems within facilities. The goal is to ensure that at whatever point a patient accesses the health

care system (outpatient departments, in patient wards, mobile counseling and testing (CT), antenatal care

(ANC), TB clinic, community health workers, home-based care) that a comprehensive package of

prevention, care and treatment services are made available to that patient and family and household

members. These services will include cotrimoxazole prophylaxis, targeted prevention messages, nutritional

counseling, micronutrient supplementation, and routine offer and provider initiated CT. Linkages with family

planning, maternal and child health, gender-based violence, directly-observed treatment, short course

(DOTS) and nutrition programs will be strengthened.

BRHC support to facilities will focus heavily on integration of TB and HIV services, where routine offer of CT

of HIV patients for TB, and of TB patients for HIV is provided in accordance with national guidelines.

Importance will be placed on infection control measures in health facilities and in the home and community.

BRHC will build on existing DOTS infrastructure, programs and personnel to assist with smooth integration

of TB and HIV services.

BRHC's program will include strategic support for strengthening of supply chain for lab and pharmacy as

appropriate, and may involve partnership with other PEPFAR partners with this expertise. BRHC engages

with the National Health Laboratory System (NHLS) at both facility and district levels to improve systems for

collection and transportation of lab tests. Assistance to pharmacy is provided in the form of HR and

streamlining of dispensing and drug delivery processes, particularly in down referral settings. All ARVs used

at BRHC-supported SAG facilities are procured through SAG.

Activity 2: Human Capacity Development (HCD)

HCD activities will focus on creative problem solving to expand access to comprehensive and integrated

treatment services at lower level facilities. Approaches will include training, operations and mentoring

support to shift tasks such as treatment initiation and ARV prescription renewals from doctors to nurses.

BRHC will review existing best practices before designing new approaches, and use monitoring and

evaluation (M&E) of HCD interventions to inform strategies for scale-up.

BRHC provides a combination of in-house and outsourced training courses aimed at ensuring quality

delivery of services in the SAG facilities it supports. Training workplans are designed in cooperation with

district/provincial authorities and are harmonized to address gaps and increase training volume and

coverage. All BRHC implemented/sponsored training courses use nationally certified or DOH-approved

curricula. BRHC will engage additional qualified clinical mentors and preceptors to ensure supportive

supervision within the work setting.

BRHC provides salary support to SAG staff on a temporary basis to fill critical vacancies. This support will

be coupled with budgeting and planning technical assistance (TA) to assist SAG to take over full support of

these staff in future budget cycles. BRHC will explore innovative strategies for ensuring retention of health

workers, maintaining a healthy and productive workforce, and optimizing workstreams.

Activity 3: Referrals and Linkages

BRHC assists each site to strengthen or develop active defaulter tracing programs by providing TA,

personnel and transportation solutions as required. Defaulter tracing models are built on best practices and

adapted to the individual needs of a particular health system. In most areas where BRHC works, BRHC's

site includes an entire health system, which allows for the creation and testing of scaleable approaches to

patient tracing across large geographical areas. BRHC takes a family-centered approach to providing

comprehensive care and treatment services and will intensify efforts in this area to build HIV and AIDS-

competent communities. BRHC will expand partnerships with non-governmental organizations (NGOs) and

community-based organizations in the catchment areas of BRHC sites to ensure uninterrupted service

delivery and community-level support for people living with HIV (PLHIV) and their families. Training,

institutional strengthening, M&E and other TA will be provided to NGOs/community-based organizations

(CBOs) to enable them to meet the demand for community-based services. BRHC will help coordination

between SAG facilities and communities.

Activity 4: Information systems/M&E/Quality Assurance & Quality Improvement (QA/QI)

In anticipation of SAG decisions-mandating software, BRHC aims to provide temporary solutions that

improve the ability of sites to meet SAG reporting requirements. Information systems build on existing paper

Activity Narrative: -based and register systems, providing added value by improving data quality and information use. BRHC

will expand systematic QA/QI approaches across all sites to promote consistent quality of care for all HIV-

infected and affected people who seek services in the public sector, and to provide ongoing monitoring and

support of training that has been provided. BRHC will focus on the use of patient treatment outcomes,

especially viral load suppression, patient retention, and patient adherence, to monitor the progress and

quality of programs.

-------------------------

SUMMARY:

BroadReach Healthcare's (BRHC) antiretroviral (ARV) services activities include training for health

professionals, management support, laboratory support, quality assurance, and community outreach.

BRHC's emphasis areas are human capacity development, local organization capacity building, and

strategic information. Primary target populations include children, adolescents, adults, pregnant women,

and people living with HIV (PLHIV).

BACKGROUND:

PEPFAR funds support BRHC initiatives that provide HIV and AIDS clinical management, care and support

services to HIV-infected individuals in areas where the SAG rollout has not yet been implemented and

assists ART rollout in the public sector. The BRHC PEPFAR program began in May 2005 and now operates

across 5 provinces. Activities will expand to a sixth province in FY 2008. BRHC is supporting approximately

5000 individuals directly with care and treatment and 15,000 indirectly. BRHC taps private sector health

professionals to provide comprehensive care and treatment, fostering capacity-building initiatives within the

public health system, and supporting community-based programs. BRHC leverages PLHIV support

programs to identify and assist with treatment literacy, adherence support and ongoing community

mobilization, prevention education activities, and positive living initiatives. BRHC also works to build

capacity in public health facilities, focusing efforts on human capacity development (HCD) activities,

including clinical didactic training, clinical mentorships, patient training and operational assistance training.

BRHC is expanding its provision of staff and infrastructure support to SAG facilities. Finally, BRHC is

expanding its involvement in the design of scaleable down referral models in partnership with faith-based

organizations (FBOs), community-based organizations (CBOs), and public-private partnerships (PPPs).

ACTIVITIES AND EXPECTED RESULTS:

To ensure that new patients are started on ART when clinically qualified and enrolled patients continue to

receive quality care and support, BRHC will carry out the following activities:

ACTIVITY 1: Clinical Services

BRHC patients will be treated in accordance with national guidelines by ensuring that all elements for

effective treatment are provided in a coordinated manner. This includes addressing issues of human

resources, provision of technical expertise, training, information, education and communication (IEC),

community mobilization, laboratory and testing, drug logistics, equipment and supplies, physical space,

M&E, and other cross-cutting support functions such as budgeting, finance, policy, and planning support.

Patients see doctors regularly, and will receive laboratory tests, HIV and AIDS education, adherence

support, counseling, cotrimoxazole prophylaxis and linkage to other support and wellness (including

prevention) services. Patient nutrition and wellness needs will be assisted by local FBOs and NGOs (e.g.

food parcels). BRHC supports patients through the private sector until those patients can access treatment

through public services. BRHC continues to expand its support to strengthening services in the public

sector.

ACTIVITY 2: Human Capacity Development (HCD)

BRHC will provide comprehensive HIV and AIDS training to its network of providers including doctors,

nurses, pharmacists and other healthcare professionals through a variety of initiatives including remote

decision support, telemedicine, web-based training, didactic training, and clinical mentoring from

experienced clinicians. Comprehensive HIV and AIDS training for health professionals include ART

management, tuberculosis (TB), adherence, management of complications and side-effects, prevention,

and pediatric HIV management. BRHC human capacity development activities, such as training and clinical

mentoring, will also take place within SAG facilities. BRHC will continue to train patients and support group

facilitators on topics including HIV and AIDS, ART, adherence, living positively, and accessing psychosocial

support in communities. The BRHC adherence program supports patients by providing features such as

treatment buddies, support groups, cell phone message reminders, a patient call center and adherence

counseling.

ACTIVITY 3: Support to SAG

BRHC will conduct an initial needs assessment at each new SAG partner facility. The assessments will

identify problems that impact overall capacity and efficiency. Solutions for each institution include

recruitment and salary support for doctors, nurses, and pharmacy staff. BRHC will also work with the site to

motivate for the creation of permanent posts where needed and ensure that BRHC/PEPFAR supported staff

are incorporated into subsequent site budgets to ensure a sustainable staffing solution. BRHC general

practitioners provide part-time services at SAG facilities, and train SAG staff in HIV care and treatment and

related management. Other support may include infrastructure, such as refurbishment, equipment and

supplies procurement. Finally, BRHC will build on its existing public-private partnership (PPP) model with

SAG and Daimler Chrysler in East London and develop new PPPs to further involve private companies in

supporting small business employees and dependents in communities where they operate.

ACTIVITY 4: Referrals and Linkages

Activity Narrative: Support systems for treatment will be provided by strengthening referral networks between the public and

private sectors, including referring stable patients back to the SAG ARV program, and support to local

clinics to facilitate SAG up and down referral. Finally, BRHC will continue to expand its linkages with CBOs

in order to refer patients in need of food and other community services.

ACTIVITY 5: Quality Assurance/Quality Improvement (QA/QI)

Recognizing the critical role of M&E in a successful treatment program, BRHC QA/QI activities include

regular internal data and systems audits, collection of patient-level surveillance data, exception reports,

doctor-specific feedback report, and doctor decision-making support. The BRHC adherence program

monitors patient adherence through monitoring of drug pick-up information, clinical reports, self-reported

adherence, and pill counts. BRHC will also work with SAG facilities to improve data management and

medical records systems.

ACTIVITY 6: Pediatric care and treatment

BRHC will expand pediatric enrollment using a family-centered approach. BRHC will encourage testing of

families/households, using patients already enrolled in the BRHC program as the index case and point of

entry into the household. By recruiting eligible family members, BRHC will enroll greater numbers, including

children, into the program. Finally, the family-centered approach will allow BRHC to link an entire household

to a single doctor in order to facilitate doctor visits and drug pick ups.

All BRHC activities articulated in the FY 2007 COP will be scaled up significantly in FY 2008 through its

partnerships with 15 SAG hospital systems (which include hospitals and affiliated community health centers

(CHC) and primary health care clinics (PHCs).

All of the above activities will serve to greatly enhance sites' ability to enroll significantly greater numbers of

patients onto ARV treatment.

These activities directly contribute to the PEPFAR 2-7-10 goals by increasing the number of people

receiving ARVs, improving access to HIV services, and increasing the capacity of local organizations.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13697

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13697 3006.08 U.S. Agency for Broadreach 6576 416.08 $14,326,000

International

Development

7510 3006.07 U.S. Agency for Broadreach 4449 416.07 $9,200,000

International

Development

3006 3006.06 U.S. Agency for Broadreach 2663 416.06 $3,600,000

International

Development

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $1,270,998

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Care: Pediatric Care and Support (PDCS): $97,090

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

FY 2008 COP activities will be expanded to include:

-Infants and children by strengthening linkages with existing services;

-Increase routine offer and provider-initiated testing to identify HIV-infected children;

-Expanding wellness programs for HIV-infected infants and children not yet eligible for ART;

-Employing a pediatric AIDS care and treatment specialist who will ensure integration of pediatric initiatives

across all BroadReach Healthcare (BRHC) PEPFAR-funded activities; and

-Strengthening of care and treatment programs for children and their families in Khayelitsha, the largest

township in Cape Town.

SUMMARY:

BRHC's pediatric care and treatment activities include training and salary support for health professionals,

management support, quality assurance, operations support, strategic communications, and community

outreach to increase the number of children on anti-retroviral therapy (ART) on BRHC-supported anti-

retroviral (ARV) programs. The activities described in this program area are linked closely with activities

described under adult treatment, pediatric and adult care and support, TB/HIV, PMTCT, ARV drugs, and

counseling and testing (CT). BRHC has been a recipient of PEPFAR funds to provide ARV services in

South Africa since 2005.

BACKGROUND:

As of June 2008, the BRHC program operates in five provinces and has almost 20,000 people currently

receiving treatment services. Of this total, 7.8% are pediatric patients (excludes Edendale Hospital where

pediatric patients are reported by EGPAF). Under PEPFAR funding BRHC has two treatment programs

designed to support expanded treatment capacity for the South African Government (SAG). The first

program began in May 2005 and consists of three different models providing treatment to eligible patients

through networks of private GPs. Two of the models represent partnerships between the public sector and

private GPs. This program was designed to ease the burden on the public sector to provide treatment

services by strategically leveraging capacity in the private sector in underserved areas. The second

program, which began in November 2006, is a program of technical assistance to SAG hospitals to assist

with expansion and scale-up of the availability of treatment services in the public sector. The funds

requested in FY 2009 are primarily for activities under the second program working with public sector sites.

All proposed activities will be aligned with the NSP, national ARV guidelines and other national guidelines

governing the care and treatment of HIV-infected and affected people.

In late 2006, BRHC began capacity building work with SAG sites and was initially assigned to 4 hospital

systems in KwaZulu-Natal (KZN). As of June 2008, BRHC was reporting data from a total of 110 sites,

including 11 hospitals, 62 private GP practices and 37 SAG Primary Health Center/Community Health

Center (PHCs/CHCs) across districts in Eastern Cape (EC), KZN, Mpumalanga (MP), Gauteng province

(GP) and North West (NW). At the request of District Departments of Health, BRHC has committed to

continued expansion and plans to be supporting 19 complete hospital systems by September 09. With FY

2009 funds, BRHC expects to be active at 250 palliative care sites, including 25 SAG hospital systems.

ACTIVITIES AND EXPECTED RESULTS:

Note: Pediatric patients will benefit from all of the activities described in program area "Adult Care and

Support", and the activities described here In the pediatric care and support program area BRHC is

highlighting activities which are specifically targeted to pediatric patients:

ACTIVITY 1: Target infants and children by strengthening linkages with existing services

BRHC will employ both facility and community-level approaches to improving the integration of services and

referral systems within facilities, and between facilities and communities. The goal is to ensure that at

whatever point a pediatric patient accesses the health care system (Outpatient Department (OPD), in-

patient wards, mobile CT, ante-natal clinic (ANC),TB clinic, community health worker, Home-based Care

(HBC), well-child care, outreach program) that a comprehensive package of prevention, care and treatment

services are made available to that child and his/her family and household members. These services will

include cotrimoxazole prophylaxis from age 6 weeks for HIV-exposed infants, targeted prevention

messages, nutritional counseling, micronutrient supplementation, and routine offer and provider initiated CT.

The goal is to furthermore ensure coordination and referral mechanisms are in place such that pediatric

patients and their caregivers are able to navigate the health and social welfare systems successfully, and

that facilities are able to track and locate patients at any time throughout this process. Linkages with

malaria, family planning, Maternal and Child Health (MCH), gender-based violence, Directly Observed

Treatment/Therapy Short Course (DOTS) and nutrition programs will be strengthened. BRHC takes a family

-centered approach to providing comprehensive care and treatment services and will intensify efforts in this

area to build HIV and AIDS-competent communities. During FY 2009, BRHC will expand partnerships with

NGOs and community-based organizations in the catchment areas of BRHC sites to ensure uninterrupted

service delivery and community-level support for pediatric patients and their families. Training, institutional

strengthening, M&E and other technical assistance and human resource support will be provided to

NGOs/CBOs to enable them to meet the demand for community-based services for CT, prevention, home-

based care, access to social grants and support for OVC. Part of this support will be towards ensuring that

the proper community-based support systems are in place and strengthened to increase HIV awareness

and to create demand for testing, by providing resources for ongoing education on treatment literacy,

providing adherence support, and providing support to the families of HIV-infected pediatric patients. BRHC

will play a critical role in providing coordination between SAG facilities and communities, creating

sustainable coordination mechanisms and mutually beneficial partnerships. Most importantly, pediatric

patients and their families will benefit from programs that aim to provide longer, healthier lives.

ACTIVITY 2: Increase routine offer and provider-initiated testing to identify HIV-infected children

BRHC will support SAG sites to target infants and children for HIV testing at all service entry points,

especially ANC, maternity and in-patient pediatric wards. Protocols for the follow up of HIV-exposed infants

Activity Narrative: will adhere to national guidelines. BRHC support to facilities will focus heavily on integration of TB and HIV

services, where routine offer of CT of HIV patients for TB and of TB patients for HIV is provided in

accordance with national guidelines. Using family-centered approaches to comprehensive care and

treatment services, BRHC will ensure the screening and treatment of children of people who test positive for

HIV or TB. BRHC will build on existing DOTS infrastructure and community health workers to identify

children for HIV care and support as part of routine interactions with the households of TB patients.

ACTIVITY 3: Clinical services and operations

BRHC will place particular emphasis this year on expanding wellness programs for HIV-infected infants and

children not yet eligible for ART. The goal will be to ensure early referral and enrollment into comprehensive

care programs for children who are HIV-exposed or HIV-infected. Wellness programs will provide a

preventive care package, consisting at a minimum of: PCR testing for infants, cotrimoxazole prophylaxis,

screening and treatment for opportunistic infections (OIs) (especially TB) ongoing counseling and

psychosocial support, nutritional assessment and supplementation, pain assessment, provision of infant

feeding support, and prevention messages as part of routine care. Wellness programs will also provide

necessary referrals to other health services such as well child care, nutritional supplementation and

immunization services as part of IMCI services. BRHC support to facilities will focus heavily on integration of

TB and HIV services, and use the opportunity of ill adults attending health facilities to also reach their

infants and children with screening and referrals for HIV and TB. BRHC will increase access to PCR testing

by purchasing equipment where requested by district and provincial DOHs, or by strengthening

transportation and referral systems. It will also build laboratory capacity for early infant diagnosis by

providing technical assistance and human resources to improve quality assurance and testing turnaround

times

ACTIVITY 4: Human capacity development

In FY 2009, BRHC will employ a pediatric AIDS care and treatment specialist who will ensure integration of

pediatric initiatives across all BRHC PEPFAR-funded activities. The specialist will take the lead in

supporting sites to pilot innovative approaches to increasing testing of children, improve quality of care for

children, and will ensure consistent application of family-centered approaches to the care and treatment of

children. BRHC will engage additional qualified clinical mentors and preceptors to ensure supportive

supervision within the work setting at BRHC-supported health facilities.

BRHC will enhance training content on care and treatment of pediatric patients in existing BRHC training

offerings. BRHC provides a combination of in-house and outsourced training courses aimed at ensuring

quality delivery of treatment services in the SAG facilities it supports. All BRHC implemented or sponsored

training courses use nationally certified or DOH-approved curricula. Most courses are modular and cover a

range of relevant topics including CT, TB, ARV therapy, and management of OIs. Additionally, BRHC will

partner with programs such as the South-2-South Partnership for Pediatric HIV Care and Treatment to

leverage existing training courses and expertise. If requested by SAG and Regional Training Centers,

BRHC will assist to create new courses specifically for the care and treatment of pediatric patients. Pediatric

course content, either through existing modular or newly developed training courses, will be provided to all

professional and lay staff who have routine contact with children, regardless of ward or department. Training

will emphasize the importance of testing and early infant diagnosis for children entering the health system

through any service point: in-patient wards, OPD, ANC, MCH services, TB clinic, and community-based

services, as well as in providing a package of preventive care services specific to the needs of pediatric

patients. BRHC will continue to provide salary support to SAG for clinical and lay staff on a temporary basis

to fill critical vacancies. This support will be coupled with budgeting and planning technical assistance to

assist SAG sites to take over full support of these staff in future budget cycles thereby ensuring program

sustainability and continued growth. Through this mechanism BRHC will ensure adequate human resources

are available for the care and treatment of pediatric patients at BRHC-supported SAG sites.

ACTIVITY 5: Outreach to Children in Khayelitsha

BRHC has been asked by the WC Department of Social Development to assist with strengthening of care

and treatment programs for children and their families in Khayelitsha, the largest township in Cape Town.

This activity involves strengthening the existing Sizis'ukhanyo (NGO) resource center to serve as a

coordination and referral hub for children requiring a range of health, social and educational services. BRHC

will train resource center staff to provide community education programs on HIV and AIDS, monitor

referrals, and provide training to community members and parents/caregivers. Technical assistance from

BRHC will be used to expand and solidify linkages between the departments of health, education and social

development in the community, ensuring that children and their families can access the comprehensive HIV

and support services that they need. Referrals and linkages with other NGOs and CBOs providing services

for children in Khayelitsha will also be strengthened. The activity may also include providing health and

wellness for services for HIV-infected and affected children in the resource centre itself. Details of this

activity are still under development.

Activity 6: Information systems/M&E/Quality Improvement and Quality Assurance

BRHC will continue to support the use of interim software solutions for management of patient data at

BRHC-supported SAG sites with the goal of empowering site level staff to use routinely collected statistics

for planning and decision making. In anticipation of national, provincial or district-level decisions mandating

software for electronic patient record systems, BRHC aims to provide temporary solutions that improve the

ability of sites to meet SAG reporting requirements. Information systems build on existing paper-based and

register systems, providing added value by improving data quality and information use. Special attention will

be paid to the challenges posed by monitoring and tracking of pediatric patients, from identification of HIV-

exposed babies before birth, to PCR testing, to the commencement of pediatric treatment if necessary.

Information systems will be designed to closely track mother-infant pairs as they move through the health

system from pregnancy to well-child care, ensuring timely and comprehensive prevention, care and

treatment services are provided to both. In FY 2009 BRHC will expand systematic quality assurance and

quality improvement (QA/QI) approaches across all public sector sites. The purpose of this activity is to

promote consistent quality of care for all HIV-infected and affected pediatric patients who seek services in

the public sector, and to provide ongoing monitoring and support of training that has been provided. BRHC

Activity Narrative: will focus on the use of patient outcomes to monitor the progress and quality of programs. Pediatric patients

will be monitored according to the following age bands: 0-2, 2-4 and 5-15 years of age.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $3,576

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $3,822

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.10:

Funding for Treatment: Pediatric Treatment (PDTX): $1,390,918

SUMMARY:

BroadReach Healthcare's (BRHC) pediatric antiretroviral (ARV) services activities include training and

salary support for health professionals, management support, quality assurance, operations support,

strategic communications, and community outreach to increase the number of children on antiretroviral

therapy (ART) on BRHC-supported ARV programs. The activities described in this program area are linked

closely with activities described under adult treatment, pediatric and adult care and support, TB/HIV,

prevention of mother-to-child transmission (PMTCT), ARV drugs, and counseling and testing (CT). BRHC

has been a recipient of PEPFAR funds to provide ARV services in South Africa since 2005.

BACKGROUND:

As of June 2008, the BRHC program operates in five provinces and has almost 20,000 people currently

receiving treatment services. Of this total, 7.8% are pediatric patients (excludes Edendale Hospital where

peds are reported by EGPAF). Under PEPFAR funding BRHC has two treatment programs designed to

support expanded treatment capacity for the South African government (SAG). The first program began in

May 2005 and consists of three different models providing treatment to eligible patients through networks of

private general practitioners (GPs). Two of the models represent partnerships between the public sector

and private GPs. This program was designed to ease the burden on the public sector to provide treatment

services by strategically leveraging capacity in the private sector in underserved areas. The second

program, which began in November 2006, is a program of technical assistance to South African

Government (SAG) hospitals to assist with expansion and scale-up of the availability of treatment services

in the public sector. The funds requested in FY 2009 are primarily for activities under the second program

working with public sector sites. All proposed activities will be aligned with the National Strategic Plan,

national ARV guidelines and other national guidelines governing the care and treatment of HIV-infected and

affected people. BRHC's overall goal under this program area is to promote creative, sustainable and

comprehensive pediatric treatment programs that improve the quality of life of people living with HIV

(PLHIV) and increase resilience in the public health care system in South Africa.

In late 2006, BRHC began capacity building work with SAG sites and was initially assigned to four hospital

systems KwaZulu-Natal (KZN). As of June 2008, BRHC was reporting data from a total of 110 sites,

including 11 hospitals, 62 private GP practices and 37 SAG clinics across districts in Eastern Cape

province, KZN, Mpumalanga province, Gauteng province, and North West province. At the request of

District Departments of Health, BRHC has committed to continued expansion and plans to be supporting 19

complete hospital systems by September 2009. With FY 2009 funds, BRHC expects to be active at 180

treatment sites, including 25 SAG hospital systems.

BRHC approaches all of its work with the concept of developing scalable solutions which can help to bolster

SAG's HIV and AIDS efforts across the country. To do this, BRHC breaks down the problem into demand-

side and supply-side. Demand-side addresses the patients and communities to ensure that solutions are in

place to mobilize, generate demand for testing, provide education including treatment literacy, provide

ongoing adherence and psychosocial support to PLHIV and the affected/unaffected community members.

BRHC generally does this by training and capacitating community organizations such as PLHIV support

groups, faith-based organizations, non-governmental organizations (NGOs), and SAG facilities to carry out

these activities. The supply-side addresses the provider of services such as hospitals, clinics, health-care

workers, labs, pharmacies, etc. and focuses on solutions such as training, service delivery integration and

re-engineering, operations improvement, equipment and infrastructure upgrade, etc.

ACTIVITIES AND EXPECTED RESULTS:

Note: Pediatric patients will benefit from all of the activities described in program area 'Adult Treatment.' In

the pediatric treatment program area BRHC is highlighting activities which are specifically targeted to

pediatric patients:

ACTIVITY 1: Target infants and children by strengthening linkages with existing services

BRHC will employ both facility- and community-level approaches to improving the integration of services

and referral systems within facilities, and between facilities and communities. The goal is to ensure that at

whatever point a pediatric patient accesses the health care system (out-patient departments (OPDs), in-

patient wards, mobile CT, antenatal care (ANC), TB clinics, community health worker, home-based care,

well-child care) that a comprehensive package of prevention, care and treatment services are made

available to that child and his/her family and household members. These services will include cotrimoxazole

prophylaxis from age 6 weeks for HIV-exposed infants, targeted prevention messages, nutritional

counseling, micronutrient supplementation, and routine offer and provider-initiated CT. The goal is to

furthermore ensure coordination and referral mechanisms are in place such that pediatric patients and their

caregivers are able to navigate the health and social welfare systems successfully, and that facilities are

able to track and locate patients at any time throughout this process. Linkages with family planning,

maternal and child health (MCH), gender-based violence, directly-observed treatment, short-course (DOTS)

and nutrition programs will be strengthened.

BRHC takes a family-centered approach to providing comprehensive care and treatment services and will

intensify efforts in this area to build HIV and AIDS-competent communities. During FY 2009, BRHC will

expand partnerships with NGOs and community-based organizations in the catchment areas of BRHC sites

to ensure uninterrupted service delivery and community-level support for pediatric patients and their

families. Training, institutional strengthening, monitoring and evaluation (M&E) and other technical

assistance and human resource support will be provided to NGOs/community-based organizations (CBOs)

to enable them to meet the demand for community-based services for CT, prevention, home-based care,

access to social grants and support for OVC. BRHC will play a critical role in providing coordination

between SAG facilities and communities, creating sustainable coordination mechanisms and mutually

beneficial partnerships. Most importantly, pediatric patients and their families will benefit from programs that

aim to provide longer, healthier lives.

Activity Narrative: ACTIVITY 2: Increase routine offer and provider-initiated testing to identify HIV-infected children

BRHC will support SAG sites to target infants and children for HIV testing at all service entry points,

especially ANC, maternity and in-patient pediatric wards. Protocols for the follow up of HIV-exposed infants

will adhere to national guidelines. BRHC support to facilities will focus heavily on integration of TB and HIV

services, where routine offer of CT of HIV patients for TB, and of TB patients for HIV is provided in

accordance with national guidelines. Using family-centered approaches to comprehensive care and

treatment services, BRHC will ensure the screening and treatment of children of people who test positive for

HIV or TB. BRHC will build on existing DOTS infrastructure and community health workers to identify

children for HIV testing as part of routine interactions with the households of TB patients.

ACTIVITY 3: Clinical services and operations

BRHC will build laboratory capacity for early infant diagnosis by providing technical assistance and human

resources to improve quality assurance and testing turn around times. As enrollment of pediatric patients

scales up, BRHC will work with SAG sites to project ARV and commodities requirements to ensure an

uninterrupted supply of pediatric formulations. All ARVs and medical commodities used at BRHC-supported

SAG facilities are procured through SAG.

ACTIVITY 4: Human capacity development

With FY 2009 funding, BRHC will employ a pediatric AIDS care and treatment specialist who will ensure

integration of pediatric initiatives across all BRHC PEPFAR-funded activities. The specialist will take the

lead in supporting sites to pilot innovative approaches to increasing testing of children, improve quality of

care for children, and will ensure consistent application of family-centered approaches to the care and

treatment of children. BRHC will engage additional qualified clinical mentors and preceptors to ensure

supportive supervision within the work setting at BRHC-supported health facilities.

BRHC will enhance training content on care and treatment of children in existing BRHC training offerings.

BRHC provides a combination of in-house and outsourced training courses aimed at ensuring quality

delivery of treatment services in the SAG facilities it supports. All BRHC implemented or sponsored training

courses use nationally certified or DOH-approved curricula. Most courses are modular and cover a range of

relevant topics including CT, TB, ARV therapy, and management of opportunistic infections. Additionally,

BRHC will partner with programs such as the South-2-South Partnership for Pediatric HIV Care and

Treatment to leverage existing training courses and expertise. If requested by SAG and Regional Training

Centers, BRHC will assist to create new courses specifically for the care and treatment of pediatric patients.

Pediatric course content, either through existing modular or newly developed training courses, will be

provided to all professional and lay staff who have routine contact with children, regardless of ward or

department. Training will emphasize the importance of testing and early infant diagnosis for children

entering the health system through any service point - in-patient wards, OPD, ANC, MCH services, TB

clinic, and community-based services.

BRHC will continue to provide salary support to SAG for clinical and lay staff on a temporary basis to fill

critical vacancies. This support will be coupled with budgeting and planning technical assistance to assist

SAG sites to take over full support of these staff in future budget cycles thereby ensuring program

sustainability and continued growth. Through this mechanism BRHC will ensure adequate human resources

are available for the care and treatment of pediatric patients at BRHC-supported SAG sites.

ACTIVITY 5: Outreach to Children in Khayelitsha

BRHC has been asked by the Western Cape Department of Social Development to assist with

strengthening of care and treatment programs for children and their families in Khayelitsha, the largest

township in Cape Town. This activity involves strengthening the existing Sizis'ukhanyo (NGO) resource

center to serve as a coordination and referral hub for children requiring a range of health, social and

educational services. BRHC will train resource center staff to provide community education programs on

HIV and AIDS, monitor referrals, and provide training to community members and parents/caregivers.

Technical assistance from BRHC will be used to expand and solidify linkages between the departments of

health, education and social development in the community, ensuring that children and their families can

access the comprehensive HIV and support services that they need. Referrals and linkages with other

NGOs and CBOs providing services for children in Khayelitsha will also be strengthened. The activity may

also include providing health and wellness for services for HIV-infected and affected children in the resource

centre itself. Details of this activity are still under development.

ACTIVITY 6: Information systems/M&E/Quality Improvement and Quality Assurance

BRHC will continue to support the use of interim software solutions for management of patient data at

BRHC-supported SAG sites with the goal of empowering site level staff to use routinely collected statistics

for planning and decision making. In anticipation of national, provincial or district-level decisions mandating

software for electronic patient record systems, BRHC aims to provide temporary solutions that improve the

ability of sites to meet SAG reporting requirements. Information systems build on existing paper-based and

register systems, providing added value by improving data quality and information use. Special attention

will be paid to the challenges posed by monitoring and tracking of pediatric patients, from identification of

HIV-exposed babies before birth, to polymerase chain reaction (PCR) testing, to the commencement of

pediatric treatment if necessary. Information systems will be designed to closely track mother-infant pairs as

they move through the health system from pregnancy to well-child care, ensuring timely and comprehensive

prevention, care and treatment services are provided to both and loss to initiation is minimal.

With FY 2009 funding, BRHC will expand systematic quality assurance and quality improvement (QA/QI)

approaches across all public sector sites. The purpose of this activity is to promote consistent quality of care

for all HIV-infected and affected pediatric patients who seek services in the public sector, and to provide

Activity Narrative: ongoing monitoring and support of training that has been provided. BRHC will focus on the use of patient

treatment outcomes - especially viral load suppression, patient retention, and patient adherence- to monitor

the progress and quality of programs. Pediatric patients will be monitored according to the following age

bands: 0-2, 2-4 and 5-15 years of age.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $82,864

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.11:

Funding for Care: TB/HIV (HVTB): $1,412,666

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The National Department of Health (NDOH) has asked BroadReach Health Care (BRHC) to expand support

to 19 complete hospital systems. BRHC will support 250 palliative care sites, including 25 South African

government (SAG) hospital systems in FY 2009. Although BRHC has only reported TB data from four sites

in 2008, all sites provide TB services or refer TB suspects for services. All proposed activities will be aligned

with the updated SAG guidelines and updated policies and guidelines will be implemented.

ACTIVITY 1:

BRHC will continue to build capacity, but the number of SAG facilities will be increased. Training for

healthcare workers on isoniazid preventive therapy (IPT), intensified case finding (ICF), DOT and patient

support, TB infection control, prevention, diagnosis and management of MDR/XDR-TB, operational

integration of HIV and TB services, diagnostic algorithms and procedures to diagnose smear negative, extra

pulmonary and pediatric TB will be provided. All training will be SAG-accredited. Additionally, BRHC will

train home-based care workers to ensure that they receive accredited training, and for those who qualify, a

refresher training course.

BRHC will scale up its interventions to cover more communities and topics. BRHC will continue to partner

with SAG facilities, community- and faith-based organizations, PLHIV support groups, and NGOs to provide

training of trainer courses and patient/community training programs, to develop staff and volunteers within

these organizations and communities who can (i) raise awareness about TB/HIV prevention and control; (ii)

serve to provide education, infection control, treatment literacy training in SAG facilities and in the

community to those who are TB/HIV infected and affected; and (iii) provide ongoing adherence support

including DOTS. BRHC will continue to produce SAG approved patient videos, speaking books, flipcharts,

posters, treatment diaries, etc.

ACTIVITY 2:

BRHC will cover more areas and address more issues at the national, provincial and district levels. BRHC

has assisted with developing strategic plans for rolling out comprehensive HIV/AIDS programming,

including TB. BRHC will continue to do this and focus on assisting the SAG to (i) develop and implement

SAG approved models such as health-care worker participation in prevention and adherence; (ii) linkages at

all levels of SAG including laboratories; (iii) down-referral approaches; and (iv) human resource planning,

training materials and approaches.

ACTIVITY 3:

BRHC will continue to integrate and upgrade services at TB and HIV facilities, including joint planning,

supervision, staffing, medical records, protocols and procedures, fast-track processes for suspected clients,

monitoring of outcomes and referral systems, and equipment/infrastructure upgrade. BRHC will support

SAG hospitals, community and primary health clinics to ensure continuity of care for patients up and down

the referral chain by strengthening or establishing referral systems. BRHC will ensure that ICF, IPT and TB

infection control procedures are implemented correctly across sites through clinical mentorship and quality

assurance activities. Activities to ensure IPT is provided according to national guidelines will be

simultaneously addressed in ARV and TB clinics, and in patient settings.

In alignment with SAG district and provincial priorities, BRHC will support TB/HIV interventions at primary

and community health clinics, and at secondary level public health facilities. BRHC technical assistance will

be focused intensively at two hospitals: Dunstan Farrell (KwaZulu-Natal) and Umlamli (Eastern Cape).

Support will include risk assessments for TB transmission using the SAG TB Infection Control Guidelines

and assessment tools. Following assessments, BRHC will assist sites to implement infection control

procedures through changes to patient flow, fast tracking of TB suspects, cough etiquette and improved

ventilation. Infection control procedures will be tailored to the facility.

BRHC will strengthen the lab lifecycle including appropriate and safe sputum/specimen collection, timely

specimen transport, improved reporting of results from labs to clinics, upgrade lab equipment and

infrastructure, and ensure that all staff are trained in accordance with SAG policies. BRHC will assist

laboratories at sites to adhere to QA procedures for sputum smear microscopy. BRHC will work with the

National Health Laboratory Service to decentralize sputum smear microscopy services as requested by

DOH, and where deemed necessary to improve accessibility to TB diagnostic services.

ACTIVITY 4: QUALITY ASSURANCE

BRHC will expand M&E programs with emphasis on new reporting systems for the new PEPFAR TB/HIV

indicators, monitoring integration of services, implementation of and coordination of reporting systems within

SAG at all levels, and staff augmentation to support these efforts.

------------------

SUMMARY:

BroadReach Healthcare's (BRHC) activities include doctor consultations, lab testing, adherence support,

patient counseling, remote decision support, quality assurance monitoring, training for both patients and

health professionals, support groups and data management.

BACKGROUND:

PEPFAR funds support BRHC initiatives that provide HIV and AIDS clinical management, care and support

services to HIV-infected individuals in areas where the SAG rollout has not yet been implemented and

assists ART rollout in the public sector. BRHC taps private sector health professionals to provide

comprehensive care and treatment, fostering capacity-building initiatives within the public health system,

and supporting community-based programs. BRHC leverages PLHIV support programs to identify and

assist with treatment literacy, adherence support and ongoing community mobilization, prevention education

activities, and positive living initiatives. BRHC also works to build capacity in public health facilities, focusing

efforts on human capacity development (HCD) activities, including clinical didactic training, clinical

mentorships, patient training and operational assistance training. BRHC is expanding its provision of staff

Activity Narrative: and infrastructure support to SAG facilities. Finally, BRHC is expanding its involvement in the design of

scaleable down referral models in partnership with faith-based organizations (FBOs), community-based

organizations (CBOs), and public-private partnerships (PPPs).

ACTIVITIES AND EXPECTED RESULTS:

BRHC 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 (directly observed therapy short-course) DOTS and TB/HIV

programs. BRHC 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. BRHC 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.

BRHC will continue to integrate TB/HIV interventions with existing agreement programs as BRHC works

seamlessly and side by side with government employees at government facilities.

ACTIVITY 1: Human Capacity Development (HCD)

This program aims to provide TB care and treatment for HIV-infected patients by strengthening the TB skills

of health professionals through didactic training and clinical mentorships focusing on TB, TB/HIV coinfection

and systems integration. Health professionals will also receive decision support and training from the BRHC

clinical expert panel and disease management system for difficult cases. At the local level, HCD efforts will

target the communities in which the program operates by providing training and information, education and

communication (IEC) to patients and support group facilitators on TB, as well as HIV/AIDS, ART,

adherence, living positively, and accessing clinical psychosocial support and linkages to other sectors and

initiatives in their communities.

ACTIVITY 2: Support to SAG

This program will support the SAG TB program to increase the capacity of facilities in the testing and

identification of TB patients. This will be accomplished through general healthcare financing which could

include commodity procurement such as screening equipment to salary support of TB-focused clinical staff.

Salary support would be given in line with government facility rates along with transition plans for the

government facility to absorb the staff into their budget within a finite period. Alternatively staff would be

financed on a contract basis while plans were implemented in government facilities to accommodate staffing

needs. Further assistance could be given in assisting with health professional recruitment and developing

retention strategies, as well as supporting BRHC network doctors who assist with TB/HIV care and

treatment within government health facilities in their communities in order to increase treatment capacity.

Training of these doctors assists with sustainability as it provides ongoing stable support to government

facilities and allows government infrastructure to cope with fluctuating need through the provision of

sessionals. Finally, BRHC will support SAG TB/HIV efforts through infrastructure upgrade by building and/or

refurbishing hospital/clinic/lab space and purchasing equipment as needed, in order to support government

clinic activities such as screening, diagnosis and closely supervised treatment. The approach would be to

address the individual needs of each facility within areas where BroadReach provides assistance in the

form of ARV treatment or CT services across the provinces.

BRHC activities in support of TB treatment will be guided by consultations at national, provincial and district

level re: government identified shortcomings in TB programs. These interventions may include human

resource support, equipment, facility-specific policy development and business systems according to SAG

articulated needs. BRHC program support priorities will reflect SAG-identified priorities. Moreover, BRHC

HIV and TB/HIV integrated activities will build on and support pre-existing initiatives at sites, and integrate

with the facility, and district, provincial and national TB and TB/HIV programs. TB/HIV services will also be

integrated with all other related care and support services offered at facility level.

ACTIVITY 3: Referral Networks

Additional support to SAG will be provided in the form of systems strengthening around TB/HIV activities.

This will include improvement of referral linkages between the private sector general practitioners (GPs) and

public sector facilities that treat BRHC patients for TB infection in the BRHC Comprehensive Care model. In

addition, BRHC may work with government sites to facilitate linkages between TB and HIV clinics, as well

as creating capacity and linkages within communities to support BRHC patients with TB/HIV coinfection

within the context of a BRHC supported public-private partnership with Daimler Chrysler (PPP). These

linkages will be established by implementing referral processes between caregivers by holding workshops,

creating referral material (referral forms that inform the receiving provider where the patient originated and

the findings of the original provider), and informing various groups of activities in the area. Processes will

specify whether HIV patients with TB are referred to HIV clinics or TB clinics or vice versa. The expected

outcome is that patients are treated holistically and not in isolation by various providers. Since these

diseases are closely linked it is important that the treating physician treats the patient for TB and HIV so that

s/he is able to manage treatment regimes. BRHC will institute processes to ensure smooth referrals and

coordinated patient management for co-infected patients. These processes may include employing TB/HIV

case managers, integrating HIV and TB databases to facilitate patient tracking, support DOTS programs,

utilize home-based carers to monitor and support patients. Patients with TB should have access to HIV

testing and should they require ARV therapy, they would need to be treated or referred to an ARV facility.

ACTIVITY 4: Quality Assurance/Quality Improvement (QA/QI)

TB/HIV activities will benefit from the same level of oversight and quality control as all other aspects of the

BRHC treatment program including regular internal data and systems audits, collection of patient level

surveillance data, exception reports, doctor-specific feedback report, and doctor decision making support,

and community-based modified DOTS programs. TB/HIV quality assurance is further enhanced by the

tracking of co-infected patients through screening, diagnosis and treatment through the use of improved

clinical forms and referral forms. A clinical oversight committee provides any guidance to GPs regarding

complicated cases presenting with TB/HIV coinfection. Data collection and reporting on TB, and TB/HIV

coinfection will be integrated into ARV Program management reports to ensure constant monitoring of

patients and to facilitate program improvement.

Activity Narrative: All BRHC activities articulated in the FY 2007 COP will be scaled up significantly through partnerships with

15 SAG hospital systems (which include hospitals and affiliated CHCs and PHCs). With FY 08 funding,

activities will be expanded/enhanced (i.e. no new activities) as follows:

-BRHC supports QA/QI at each of its public sector partner hospitals through QA assessments, systems re-

engineering, and the development of reporting systems that provide program management feedback to

improve program performance.

-As part of systems re-engineering BRHC will focus on improving integration between HIV/AIDS treatment

programs and TB programs for testing, treatment coordination and referrals.

-Strengthen down referral activities between public sector hospital partners and their affiliated clinics by re-

engineering referral processes, improved data management and patient tracking, and training.

-Training for health professionals at all public sector sites (hospitals and PHCs) covers TB/HIV co-

management.

-HIV/AIDS literacy training for patients as part of community mobilization.

-Staff augmentation: BRHC will provide additional salary support to fill key positions within SAG partner

hospital sites. BRHC will also work with the site to motivate for the creation of permanent posts where

needed and ensure that BRHC/PEPFAR supported staff are incorporated into subsequent site budgets to

ensure a sustainable staffing solution.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13694

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13694 7939.08 U.S. Agency for Broadreach 6576 416.08 $1,455,000

International

Development

7939 7939.07 U.S. Agency for Broadreach 4449 416.07 $450,000

International

Development

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $124,785

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

Funding for Testing: HIV Testing and Counseling (HVCT): $844,687

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

BACKGROUND AND SUMMARY:

In FY 2009 BroadReach Healthcare (BRHC) will significantly expand counseling and testing (CT)

accessibility by supporting CT across an increased number of sites. In addition to activities of FY 2008,

specific focus will be placed on ensuring quality of testing, targeting of specific groups and testing facilities,

referrals and prevention education. BRHC will work with government facilities to expand and enhance CT

services within hospital systems and will aim to mobilize communities by driving large scale CT campaigns,

in addition to implementing or expanding home-based testing initiatives. BRHC will partner with community

groups and CT partners in order to obtain the necessary reach. To meet these objectives, BRHC, in

conjunction with key personnel of partner sites, will design and develop programs, processes and operating

procedures, source and develop education materials, design and implement data collection and monitoring

tools, align resourcing needs and assist with implementation.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Quality Assurance/Quality Improvement

BRHC will promote the use of rapid tests as a diagnostic tool in both clinical and community settings.

Partner sites will be assisted in creating, formalizing and standardizing standard operating procedures and

quality assurance programs to ensure quality around testing. This program will include proficiency testing

for those conducting rapid tests and on-site monitoring. BRHC will assist sites in taking ownership of the

program and will provide support in extending quality assurance programs from medical facilities to home-

based CT. BRHC will focus training efforts on the management of CT services aligned to the quality

program.

ACTIVITY 2: Targeted Groups and Testing Facilities

BRHC will work with government sites to ensure that HIV CT is routinely provided at the hospital level and

extended to linked community health centres (CHCs) and primary health centres (PHCs) where counselors

are trained to provide CT. Per a government request, BRHC will also be pioneering a program to train

traditional healers to perform rapid tests. Specific focus will be placed on tuberculosis (TB) , sexually

transmitted infection (STI), family planning and out-patient clinics, as well as pediatrics. BRHC will work with

sites to implement policies whereby providers initiate and offer HIV testing to all patients and ensure CT

services (including pre-test information and post-test counseling) are available on site. BRHC will promote

utilization of counselors as opposed to clinical staff in performing counseling duties to avoid diverting clinical

staff from their medical duties. In addition, BRHC will target specific audiences that engage in high risk

behavior such as sex workers through dedicated campaigns. Increased CT initiatives (campaigns and

increased facility CT services) will be planned and co-ordinated with district and hospital management to

ensure facilities are able to cope with demand for care and treatment services. Family members will be

targeted through the home-based program focusing on family members of patients receiving HIV care and

treatment. Counselors will receive advanced CT training focusing on family and child counseling.

Grassroots (including door-to-door and engagement of local leaders) campaigns will be used to mobilise

community members en masse for testing.

ACTIVITY 3: Referrals and Linkages

Underpinning all BRHC work is the concept of developing scalable solutions which can help to bolster THE

South African Government's (SAGs) HIV/AIDS efforts across the country. To do this, BRHC breaks down

the problem into demand-side and supply-side. Demand-side addresses the patients and communities to

ensure that solutions are in place to mobilize, generate demand for testing, provide education including

treatment literacy, provide ongoing adherence and psychosocial support to PLHIV and the

affected/unaffected community members. BRHC generally does this by training and capacitating community

organizations such as people living with HIV and AIDS (PLWHA) support groups, faith-based organizations

(FBOs), non-governmental organizations (NGOs) and SAG facilities to carry out these activities. The supply

-side addresses the providers of services such as hospitals, clinics, healthcare workers, labs, pharmacies,

etc. and focuses on solutions such as training, service delivery integration and re-engineering, operations

improvement, equipment and infrastructure upgrade, etc.

BRHC will work with partner sites to ensure all TB patients and (and those suspected of having TB) are

routinely tested for HIV, and all newly diagnosed HIV-infected people are referred for TB testing. BRHC will

specifically focus on referral of patients from testing to care and treatment. Processes and systems are put

in place to prevent lost to initiation with registers and monitoring mechanisms to ensure patients are

monitored within the system. HIV negative clients are registered for ongoing prevention education.

ACTIVITY 4: Prevention

BRHC recognizes that CT is an important HIV prevention opportunity. Prevention messaging is therefore a

key component of post-test counseling, providing in-depth individualized counseling tailored to the client's

needs (positive or negative). Prevention messaging is incorporated into mobilization and VCT campaigns.

BRHC will promote disclosure of HIV status to sexual partners and family members as a routine part of CT

services and will work with sites to implement processes that encourage partner referrals and partner

notification. BRHC has also developed a series of patient education videos that are to be shown in various

settings and takes a family approach to encouraging testing (including partner testing), disclosure, the

importance of TB screening, positive living and wellness, how to manage HIV in children, antiretroviral

therapy and importance of adherence. The videos also demonstrate the appropriate use of male and

female condoms (BRHC's experience to date is that shockingly large numbers of adults have never seen

these demonstrated or handled them).

Activity Narrative: ---------------------------

SUMMARY:

The primary goal of BroadReach Healthcare's (BRHC) counseling and testing (CT) is to ensure that those

testing positive for HIV are started on antiretroviral treatment (ART) when clinically qualified and enrolled

patients continue to receive outstanding care and support. CT is the entry point for this goal. BRHC also

supports activities that include test-kit procurement, meeting infrastructure and human resource demands,

increasing testing uptake, prevention, patient counseling, referral systems, and training. Primary target

populations include children, adolescents, adults, pregnant women, and people living with HIV (PLHIV).

BACKGROUND:

PEPFAR funds support BRHC initiatives that provide HIV and AIDS clinical management, care and support

services to HIV-infected individuals in areas where the South African Government (SAG) rollout has not yet

been implemented and assists ART rollout in the public sector. The BRHC PEPFAR program began in May

2005 and now operates across five provinces. BRHC is supporting approximately 5,000 people directly with

care and treatment and 15,000 indirectly. BRHC taps private sector health professionals to provide

comprehensive care and treatment, fostering capacity-building initiatives within the public health system,

and supporting community-based programs. BRHC leverages PLHIV support programs to identify and

assist with treatment literacy, adherence support and ongoing community mobilization, prevention education

activities, and positive living initiatives. BRHC also works to build capacity in public health facilities, focusing

efforts on human capacity development (HCD) activities, including clinical didactic training, clinical

mentorships, patient training, and operational assistance training. BRHC is expanding its provision of staff

and infrastructure support to SAG facilities. Finally, BRHC is expanding its involvement in the design of

scaleable down referral models in partnership with faith-based organizations (FBOs), community-based

organizations (CBOs), and public-private partnerships (PPPs).

ACTIVITIES AND EXPECTED RESULTS:

The primary goal of the program is to ensure that those testing positive for HIV are started on ART when

clinically qualified and enrolled patients continue to receive outstanding care and support. CT is the entry

point for this goal.

ACTIVITY 1: Voluntary Counseling and Testing

BRHC will provide access to rapid voluntary counseling and testing (CT) at enrollment sessions and, where

available, CD4 testing services for patients who test positive to determine eligibility for treatment. In

accordance with SAG guidelines, BRHC patients will be properly counseled (pre- and post-test), tested, and

referred as appropriate to a BRHC network doctor or to an accredited SAG facility.

ACTIVITY 2: Support to South African Government

BRHC will expand access and availability of CT by (1) procuring testing materials (rapid test kits when

unavailable through the government system); (2) improving operational efficiency through needs

assessment, identification of operational bottlenecks, implementing solutions to address bottlenecks; (3)

assisting with refurbishing physical space at government clinics/hospitals; and (4) advising SAG partner

clinics on increasing CT uptake and improving the percentage of results received. BRHC will further support

SAG efforts in meeting the increased demand created by testing. This will range from providing salary

support for counselors to improved processes and systems for enrolling and following up greater numbers

of new patients.

ACTIVITY 3: Outreach

Using a family-centered approach to care and treatment, BRHC will encourage the testing of families and

households, utilizing patients already enrolled in the BRHC program as a point of entry. BRHC will also

promote community-based programs such as support groups, CBOs, and churches as entry points for CT

services.

ACTIVITY 4: Referrals and Linkages

All HIV-infected patients identified through BRHC-supported CT efforts, will be linked (via BRHC network

doctors, home-based care (HBC) and support groups) to other services such as TB care, nutrition and

wellness, and psychosocial support.

ACTIVITY 5: Human Capacity Development

BRHC may enhance the quality of CT services at selected sites (assigned by the relevant district

authorities) through training and mentoring for counselors, health professional staff, outreach workers and

support group facilitators. In addition to training, BRHC will assist CT programs at sites by providing salary

support to counselors as sites expand access to CT services.

BRHC's CT activities directly contribute to the 2-7-10 objectives by identifying infected individuals who are

unaware of their HIV status and who may be eligible for treatment. Greater numbers of people tested

means meeting the treatment and care and support objectives. Moreover, prevention messages given to

both infected and uninfected individuals during post-test counseling will contribute to the goal of averting 7

million infections.

All BRHC activities articulated in the FY07 COP will be scaled up significantly in FY 2008 through its

partnerships with 15 SAG hospital systems, which include hospitals and affiliated community and primary

Activity Narrative: health centers.

The FY 2007 activities will be expanded and enhanced in FY 2008 as follows:

BRHC will support quality assurance at each of its public sector partner hospitals through quality assurance

assessments, systems re-engineering, and the development of reporting systems that provide program

management feedback that is used to improve program performance and more closely monitor patient care.

This includes monitoring, tracking and reporting on CT activities at partner sites.

As part of systems re-engineering BRHC will focus on improving CT referrals at sites to boost the number of

patients tested, and the numbers that receive their results and ultimately enroll in treatment. A special effort

will be made to test family members of patients in an effort to boost family-centered care initiatives at sites

through partnerships with CBOs and home-based care organizations.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13695

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13695 3136.08 U.S. Agency for Broadreach 6576 416.08 $870,000

International

Development

7513 3136.07 U.S. Agency for Broadreach 4449 416.07 $220,000

International

Development

3136 3136.06 U.S. Agency for Broadreach 2663 416.06 $62,000

International

Development

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

* Reducing violence and coercion

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $44,614

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.14:

Funding for Treatment: ARV Drugs (HTXD): $715,751

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

BroadReach Health Care (BRHC) implements several treatment models in South Africa using PEPFAR

funds. BRHC uses PEPFAR funding to procure antiretrovirals (ARVs) for two treatment models involving

private sector general practitioners. BRHC uses the majority of its PEPFAR funding to support expanding

capacity of South African Government (SAG) health facilities to provide comprehensive care and treatment

services. BRHC does not procure ARVs using PEPFAR funding for SAG sites. All ARVs at these sites are

provided through the government of South Africa.

-------------------------------------------

SUMMARY:

BroadReach Healthcare's (BRHC) antiretroviral (ARV) drug activities include drug procurement and

distribution, training for health professionals on drugs, supporting pharmacy staff salaries, training patients,

quality assurance (QA), and data management. BRHC's emphasis areas are human capacity development,

local organization capacity building, and strategic information. Primary target populations include children,

adolescents, adults, pregnant women, and people living with HIV (PLHIV).

BACKGROUND:

PEPFAR funds support BRHC initiatives that provide HIV and AIDS clinical management, care and support

services to HIV-infected individuals in areas where the South African Government's (SAG) rollout has not

yet been implemented and assists ART rollout in the public sector. The BRHC PEPFAR program began in

May 2005 and now operates across five provinces. An additional province will be added in FY 2008. BRHC

is supporting approximately 5,000 individuals directly with care and treatment and 15,000 indirectly. BRHC

taps private sector health professionals to provide comprehensive care and treatment, fostering capacity

building initiatives within the public health system, and supporting community-based programs. BRHC

leverages PLHIV support programs to identify and assist with treatment literacy, adherence support and

ongoing community mobilization, prevention education activities, and positive living initiatives. BRHC also

works to build capacity in public health facilities, focusing efforts on human capacity development (HCD)

activities, including clinical didactic training, clinical mentorships, patient training and operational assistance

training. BRHC is expanding its provision of staff and infrastructure support to SAG facilities. Finally, BRHC

is expanding its involvement in the design of scaleable down referral models in partnership with faith-based

organizations (FBOs), community-based organizations (CBOs), and public-private partnerships (PPPs).

ACTIVITIES AND EXPECTED RESULTS:

The primary goal of this program area is to ensure that new patients are started on antiretroviral treatment

(ART) when clinically qualified, and enrolled patients continue to receive high-quality care and support.

Monitoring of CD4 counts, viral loads, and resistance testing are part of the monitoring system. For

continued program sustainability, BRHC continues to work on the transference of costs to government, and

already in the North West province, the provincial government provides all drugs.

ACTIVITY 1: Drug Procurement and Distribution

BRHC will continue commodity procurement of ARVs through its supply chain vendors including its courier-

based pharmacy partners. BRHC will oversee the delivery of drugs to the accredited community-based

providers. In some instances, the community-based providers will be paid a capitated rate per patient and

those providers will be procuring drugs according to PEPFAR standards and national guidelines. BRHC will

negotiate best available pricing for USG and SAG approved ARV drugs. Community-based providers are

trained in drug forecasting, procurement and supply chain management.

BRHC partners with a private mail order pharmacy provider, Pharmacy Direct (PD), in its procurement and

distribution efforts for the BRHC general practitioners (GP) network. Pharmacy Direct liaises directly with

the BRHC GP network to manage patient prescriptions, dosing, medicine delivery and pick-up of returned

medicines. In partnership with Pharmacy Direct, BRHC manages patient adherence through monitoring of

medicine collection and regular data reports.

ACTIVITY 2: Human Capacity Development (HCD)

BRHC will continue to provide comprehensive HIV and AIDS training to its network of providers including

doctors, nurses, pharmacists and other healthcare professionals through a variety of initiatives including

remote decision support, telemedicine, web-based training, didactic training, and clinical mentoring from

experienced HIV and AIDS clinicians. Topics include drug supply chain logistics, operational improvements

for drug management, tracking for expiration dates, comprehensive ART management, adherence,

management of complications and side-effects, prevention and pediatric HIV management. BRHC-

supported human capacity development activities, such as training and clinical mentoring, will also take

place within SAG facilities.

ACTIVITY 3: Support to SAG

BRHC will support capacity development for drug procurement and pharmaceutical management at partner

SAG facilities. BRHC has conducted a needs assessment that examined the operational processes for drug

procurement, forecasting, stock management, and dispensing, and has used this assessment to streamline

its supply chain management.

ACTIVITY 4: Quality Assurance/Quality Improvement

BRHC maintains a close relationship with its drug procurement and distribution client. The client provides

regular feedback and reports to BRHC regarding delivery problems, missed medicine pick-ups, and collects

Activity Narrative: all unused medicines. Drug distribution, pick-up, and returns data is collected and maintained in the BRHC

program database. This data feeds into numerous reports including doctor-specific feedback reports and

patient exception reports.

This activity facilitates the ARV service delivery component of the project, which contributes directly to the

PEPFAR 2-7-10 goal of two million people receiving treatment. BRHC will contribute to PEPFAR's vision

outlined in the Five-Year Strategy for South Africa by expanding access to ART services for adults and

children, building capacity for ART service delivery, and increasing the demand for and acceptance of ARV

treatment.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13696

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13696 3133.08 U.S. Agency for Broadreach 6576 416.08 $737,200

International

Development

7512 3133.07 U.S. Agency for Broadreach 4449 416.07 $2,950,000

International

Development

3133 3133.06 U.S. Agency for Broadreach 2663 416.06 $1,687,000

International

Development

Table 3.3.15:

Cross Cutting Budget Categories and Known Amounts Total: $2,066,083
Human Resources for Health $40,711
Food and Nutrition: Policy, Tools, and Service Delivery $3,884
Human Resources for Health $66,552
Human Resources for Health $323,876
Food and Nutrition: Policy, Tools, and Service Delivery $100,401
Human Resources for Health $1,270,998
Human Resources for Health $3,576
Food and Nutrition: Policy, Tools, and Service Delivery $3,822
Human Resources for Health $82,864
Human Resources for Health $124,785
Human Resources for Health $44,614