ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

To create an inclusive identity, PATH changed its name to Khusela Project (Khusela), which means in

isiXhosa, to prevent, to protect, and to handle with care. Khusela will scale up the revised PMTCT policy in

all its facilities, including adoption of dual therapy; routine offer of counseling and testing; CD4 testing;

enabling women to make, and adhere to informed infant feeding choices; linking women to comprehensive

care and treatment programs; assuring infant diagnosis and treatment as necessary; and integrating

reproductive health and family planning services.

Khusela was unable to begin work in the Cacadu district (Eastern Cape) as projected in COP 2008, due to

change of plans by Eastern Cape Department of Health (ECDOH). Instead, work was moved to three sub-

districts in the Eastern Cape: Mbashe and Mnquma in Amatole District and King Sabata Dalindyebo in OR

Tambo District. Khusela works in 40 facilities (50%) in the sub-districts. In FY 2009, the project will add 40

new facilities using a phased approach. Training and supervision will continue in the existing 40 sites, which

will require two additional full-time training and supervision advisors. The ECDOH has requested that

Khusela expand services to Amalathi sub-district, because of the great need in the area.

ACTIVITY 4 was modified. The systems assessment to assist the transition to dual therapy will be

completed in FY 2008, and will be implemented in Khusela's sites.

ACTIVITY 5 has been modified to include development, production and dissemination of nutrition and

informed infant feeding materials by the end of FY 2008 pending permission from the National Department

of Health.

ACTIVITY 6: The two activities evaluating linkages between reproductive health and PMTCT will continue

into FY 2009 due the multiple Institutional Review Board requirements.

Khusela will continue to support the Midwives Alliance and implementation of advocacy strategies that

emerge from FY 2008 activities. If successful, the pilot nevirapine pouch for homebirths will be rolled out to

additional locations.

Training will be provided to existing and new sites, including training on basic PMTCT, refresher training on

PMTCT, and training on infant feeding. Nurses, clinical supervisors lay counselors, and traditional birth

attendants will be trained. Classroom and on-site training to improve M&E will be implemented among

district data information officers, data capturers and managers.

Khulesa will improve referral systems to care and treatment sites and pediatric centers. Milk registers will be

revised so that all babies can be traced. By FY 2009 all parallel reporting systems will be eliminated.

Community engagement in promoting, supporting and utilizing PMTCT service will be enhanced. This

includes reducing stigma, generating demand for services, working with partners and families of HIV-

infected women, developing community networks for client follow-up, and strengthening tangible links

between the community and the facility. Community interventions will include start-up activities including

hiring additional field staff, facility assessments, mapping and zoning, community focus group discussions,

revision of communication strategy, NGO/CBO capacity assessment, training new field staff, and

implementation of project interventions as described above.

Field staff will continue to work with designated NGOs to expand the Magnet Theatre, a participatory

community theatre that inspires critical reflection using incomplete enactments of community dilemmas.

Facility-based Closed Support Groups will be managed by facility staff, who will help community members

to form support groups, identify group leaders, arrange for support group facilitation skills training (through

MANEPHA), and monitor ongoing support groups. Historically these groups have been short-lived (six

weeks) but with improved facilitation, there should be deeper discussion, greater support, and potential for

greater sustainability.

Field staff will continue to oversee the heterogeneous Dialogue Groups, in communities near health

facilities. These are voluntary (fixed and committed membership) groups that meet regularly to participate in

facilitated discussions on HIV and PMTCT issues. The local Chief, community members and CBOs

participate. Field staff will oversee the Open Dialogue Groups (ODG). These groups will emerge from local

facility-based support groups and will be led by trained HIV-infected women. Grandmothers play a vital role

in enabling mothers to realize comprehensive PMTCT interventions. These voluntary dialogue groups will

include mothers (and mothers-in-law) and daughters to encourage discussion of PMTCT issues. The cross-

generational interaction may have a huge impact PMTCT uptake.

Khusela aims to accredit the lay counselor curriculum and make this available to Khusela project sites, and

eventually to all PEPFAR partners.

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

SUMMARY: The PATH prevention of mother-to-child transmission (PMTCT) project will improve the quality,

availability, and uptake of comprehensive PMTCT services in Eastern Cape by strengthening systems that

support the delivery of high-quality, comprehensive PMTCT services, building the capacity of health

facilities and staff to provide comprehensive PMTCT services, and increasing community engagement and

leadership in promoting, supporting, and utilizing PMTCT services. Emphasis areas include training and

community mobilization/participation, with minor emphasis on quality assurance and supportive supervision.

Primary target populations include people living with HIV (PLHIV), pregnant women, HIV-exposed and

infected infants, South African-based volunteers and nurses, and provincial and district HIV and PMTCT

coordinators. BACKGROUND: With FY 2007 funding, PATH in collaboration with the Eastern Cape

Department of Health (ECDOH) initiated a PMTCT program in Amatole, OR Tambo and Cacadu districts.

The PATH PMTCT program supports the South African Government's HIV/AIDS/STI Strategic Plan for 2007

-2011, the Eastern Cape's Comprehensive HIV/AIDS/STI/TB Program, and the Strategic Plan for US-SA

Cooperation. PATH, the prime partner, provides technical, programmatic, and financial leadership. The

Activity Narrative: ECDOH, provides all the facilities, systems, and local personnel. Health Information Systems Program

(HISP) is responsible for monitoring and evaluation. South African Partners, an NGO, leads the community

support and mobilization interventions. There is also a small grants program for community-based

organizations. PATH will address the root causes of gender inequity by examining values and norms. The

project provides information and support for infant feeding choices and helps clients assess their needs,

considering issues such as the risk of stigma and discrimination associated with not breastfeeding. The

project provides holistic psychosocial support to HIV-infected women. Community mobilization is led by

PLHIV leaders--the majority of whom are women, to increase knowledge about PMTCT, promote

understanding of PMTCT as the equal responsibility of men and the community, and work toward

transforming current norms, stigma and discrimination that hold women solely responsible for having HIV

and transmitting HIV to children. ACTIVITIES AND EXPECTED RESULTS: This program will strengthen the

ability of current PMTCT facilities to provide a minimum package of services, enable the ECDOH to expand

PMTCT services by training and supporting providers such that they can provide comprehensive services,

and raise awareness of and support for PMTCT service use within communities. The project is focused on

the public sector and dependent communities only.

ACTIVITY 1: Systems strengthening Building on FY 2007 activities, FY 2008 resources will be used to

ensure continuity of system strengthening activities. One set of interventions will strengthen human

resource capacity: training existing but untrained facility staff (e.g., nurses, midwives, lay counselors) to

provide PMTCT services, reinforcing the skills of current PMTCT staff, and orienting other staff (e.g.,

child/wellness clinic nurses, community health workers) who help ensure a continuum of care. Training will

focus on HIV counseling and testing, measuring CD4 cell counts, clinical staging, psychosocial support,

antiretroviral treatment (ART), and follow up and care for the exposed child, including piloting polymerase

chain reaction (PCR) testing. A second set of interventions will ensure that monitoring and supervision

systems are fully operational at all levels (district, local service area, facility), providing on-site technical

support as needed. A third set of interventions will strengthen ECDOH data and logistic systems, improving

the quality of data recorded, collected, reported, and used at all levels. The project will also work with the

ECDOH to address specific policy and guideline issues that directly affect PMTCT services. Finally, the

project will improve referral systems, especially referral of pregnant or postpartum women and their children

to antiretroviral (ARV) care and treatment sites and pediatric centers.

ACTIVITY 2: Capacity building The project works at all levels of service delivery to strengthen the provision

of high-quality, comprehensive PMTCT services. The project will focus on priority hospitals and select

feeder-community health centers and clinics to ensure that women have access to the full continuum of

PMTCT services, from the first antenatal care visit through follow-up of the mother and baby after birth. The

package of interventions will be tailored to each facility's needs and may include training in essential

PMTCT skills, monitoring and supervision to maintain high-quality services and/or upgrade staff skills, data

management for ongoing corrections and decision-making, integration of services to give women and

babies necessary care and treatment, and linkages to the community so that PMTCT is accepted and used

widely.

ACTIVITY 3: Increasing community engagement and leadership One of ECDOH's priorities is to broaden

the role of the community in promoting, supporting, and utilizing PMTCT services. This includes providing

health education, reducing stigma, generating demand for services, working with the partners and families

of HIV-infected women to increase support for PMTCT, developing community networks for client follow-up,

and strengthening tangible links between the community and the facility. Underlying these interventions is

the need to build capacity of community networks and organizations to implement and monitor programs.

Interventions will strengthen HIV prevention programs, provide PMTCT information, and reduce stigma in

the community; strengthen peer support for HIV-infected pregnant women to increase demand for and

adherence to PMTCT and ARV regimens; and improve community-facility collaboration to increase local

ownership and utilization of services. The ECDOH is the driving force of this project and all of the

investments in human capital will benefit their workers and the communities. Human capacity development

is at the center of this project as described in the training and systems strengthening activities above.

ACTIVITY 4. Preparing for a transition to dual therapy for PMTCT The new HIV & AIDS and STI Strategic

Plan for South Africa calls for a new policy on the drug regimen used in PMTCT, suggesting that the policy

should be updated according to the WHO Guidelines. The purpose of this activity is to conduct an

assessment to assist ECDOH in planning for the implementation of the policy change and to suggest a set

of criteria to inform how and when the introduction of dual therapy should be introduced at the facility level.

The assessment will look at the critical components of the health system including policy, financing, human

resources, training, supply systems, service management and referrals, and information and monitoring

systems to establish what will be needed to implement the pending policy. PATH will also establish a pilot

project in six sites in the EC (upon ECDOH approval) and implement dual therapy services to establish a

"better practice" model. This will be rolled out to other districts and facilities. In addition, PATH will work

with the ECDOH to strengthen referral systems for HIV-infected pregnant women ensuring that all treatment

eligible pregnant women are fast- tracked to treatment programs.

ACTIVITY 5: Maternal nutrition and infant feeding job aids and materials In FY 2007 PATH developed a

series of job aids and print materials for both health workers and mothers such as handouts on feeding

options, flip charts and/counseling cards for infant feeding counselors on feeding options, AFASS, lactation

and breastfeeding, etc., basic maternal nutrition guidance, a wall chart linking each antiretroviral drug with a

statement on its implications for food intake at the time when it is taken, etc. FY 2008 activities will focus on

dissemination and utilization of these materials. ACTIVITY 6. Creating Linkages between Reproductive

Health (RH) and PMTCT This activity will effectively link prevention of HIV and prevention of unintended

pregnancies into PMTCT settings in the EC. The work will provide evidence-based information and

recommendations for decision-makers and program managers to improve policy and practice for integrating

RH services into PMTCT settings. Current integration policy and practices will be explored, as will client

fertility intentions and desires. The community will be consulted on what services should be integrated and

to strengthen community ownership of service delivery and to increase demand for RH services. The

PMTCT continuum will be analyzed to determine when clients are most likely to want internalize information

that could influence their uptake of services. Lay counselors and professional nurses will be trained and

community mobilization will be expanded to improve access to and utilization of RH services. ACTIVITY 7.

Preparing nurse/midwives to expand their role in HIV and AIDS prevention and treatment This activity

targets professional nurses from maternity wards and expand their roles and responsibilities in terms of HIV

prevention and treatment. The focus will be on hospitals where the need for task shifting is greatest.

Activity Narrative: Activities will improve attitudes, motivation, knowledge and skills. Participatory training approaches will be

used to work with this cadre to define the problems and to create solutions to ensure quality comprehensive

services.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14261

Continued Associated Activity Information

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

System ID System ID

14261 8248.08 HHS/Centers for Program for 6757 4756.08 $3,104,000

Disease Control & Appropriate

Prevention Technology in

Health

8248 8248.07 HHS/Centers for Program for 4756 4756.07 New APS 2006 $2,010,008

Disease Control & Appropriate

Prevention Technology in

Health

Emphasis Areas

Health-related Wraparound Programs

* Family Planning

* Safe Motherhood

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $491,225

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.01: