PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
Using FY 2008 funding, the two existing Demonstration sites in KwaZulu-Natal (KZN) will be supported until
December 2009 and an additional site established in the Ethekwini District of KZN and NOT in the Eastern
Cape as proposed in the FY 2008 COP. Each of the three sites will develop a best practices model which
can be rolled out by the provincial departments of health and social development to the province.
FY 2008 funding will also be used to provide ongoing technical assistance and support to KZN at the district
level to ensure that program managers develop skills to conduct program level evaluations and can use
these evaluations to strengthen existing prevention of mother-to-child transmission (PMTCT) services.
Technical assistance will also be provided at the clinic level through the provision of a comprehensive
training and capacity-building program, and an onsite, mentorship and support program. A pilot program
utilizing Maternal Health Carrier Books will also be implemented to ensure continuum of care of HIV-
infected women. The Maternal Health Carrier Book issued to pregnant women at their first antenatal visit
serves to communicate essential health information between health service providers at primary health
clinics and hospitals and to assist primary health-care providers at primary health-care facilities to monitor
antenatal and postnatal progress.
FY 2008 Activities Include:
ACTIVITY 1: Continued Support of Demonstration Project:
This activity will continue to be supported in two sites, (i.e., Umzinto Clinic and GJ Crookes Hospital in Ugu
and Umlazi D Clinic and Prince Mshyeni Memorial Hospital in Ethekwini). The University of KwaZulu-Natal
(UKZN) will continue to support the Department of Health in the Districts of Ugu and Ethekwini to improve
the follow-up and continuum of care of women (HIV-infected and uninfected) and children in the PMTCT
program. This project is a holistic PMTCT program that focuses on enrolling women into PMTCT services,
PMTCT service delivery, and linking women and their infants to social welfare programs, treatment, care
and support.
ACTIVITY 2: Expansion of Demonstration Project
This activity will be expanded in KZN to an additional site in the Ethekwini District. An assessment of current
health and social systems in the community accessing care at the site will assist identification of suboptimal
outputs of service delivery. A strategy of providing an integrated comprehensive HIV health and social
service to women and children seeking care at the Newtown A Community Health Centre and the referral
facility, Mahatma Gandhi Memorial Hospital will be developed.
ACTIVITY 3: Technical Assistance
Technical assistance to the province will ensure the facilitation of linkages between family planning,
PMTCT, and treatment by supporting two districts in implementing a new patient-held information system
for use at primary health clinics. This system will improve continuity of maternal care by having one health
document that can be presented at different health facilities. The health book is patient-owned and is
designed to incorporate most existing medical records. Currently, women seeking antenatal care at primary
health clinics receive a Maternity Case Carrier Record (Record). This document is designed to obtain the
following patient information during antenatal care and delivery: basic particulars relating to patient (e.g.,
name, ID number, marital status, date of birth, contact details and dates of hospital admission and
discharge); details of current pregnancy (e.g., LMP, EDD, complaints); history of previous pregnancies;
laboratory tests (e.g., RPR, PAP and Rh), risk factors and recommendations; record of antenatal
attendances for the current pregnancy; clinical notes; record of labor; admission; labor history; a partogram;
details of mode of delivery; summary of labor; postdelivery record during hospitalization; and record of
maternal and infant condition during the puerperium period. Other information documented in the Record
include HIV information such as a PMTCT stamp indicating HIV status of the patient. This stamp can be
seen on the rear inner cover of the Record. Other information in the stamp would include the date of
nevirapine issued, CD4 test done and results, and proposed infant feeding method. The Record serves to
communicate essential information between health service providers at primary health clinics and hospitals
and to assist primary health-care providers at antenatal clinics to monitor antenatal progress. Unfortunately,
this communication of crucial patient information ends at the point of hospital discharge following delivery
since all Records are retained in the hospital registries. Upon hospital discharge, women are given an
Appointment Card for their scheduled postnatal visit and an infant Road to Health Chart for ongoing care
and immunization. The above patient held-information system has major drawbacks in ensuring continued
maternal care, while health services have previously focused only on infant health. These challenges have
recognized, particularly when implementing HIV programs.
Technical assistance will also include the implementation of an integrated training strategy which addresses
operational issues for the delivery of a comprehensive package of care for women and children. Training
health teams from each of the facilities and their associated ART sites will be conducted in direct
partnership with the district program managers. The training will establish and strengthen referral
mechanisms and a multidisciplinary team approach, thus ensuring that women and children have easy
access to continuum of care and ART. Three-day training courses will take place at the district level.
FY 2009 Activities:
ACTIVITY 1: Technical Assistance
UKZN will use FY 2009 funding to roll out the Maternal Health Book to all public health facilities in the
districts of Ugu and Ethekwini and to monitor usage during a two month period.
ACTIVITY 2:
Activity Narrative: Technical assistance will ensure the linkages between family planning, PMTCT, and ART, including
implementation of an integrated training strategy that will address operational issues for the delivery of a
comprehensive package of care for women and children. In addition to the 3-day training course supported
during FY 2008, an additional refresher training will occur over a 1-day period at 6 to 12 monthly intervals
depending on need and performance indicators.
The UKZN PMTCT project aims to increase uptake of counseling and testing, PMTCT, improve maternal
and infant follow-up, better ART and medical adherence rates associated with reduction in maternal and
child morbidity and mortality, improve health awareness and service delivery.
------------------------
SUMMARY:
UKZN proposes to use PEPFAR funding to strengthen existing prevention of mother-to-child transmission
(PMTCT) services, by continuing ongoing FY 2007 activities in the Eastern Cape province and providing
technical support to KwaZulu-Natal to facilitate better PMTCT implementation and integration with
treatment, care and support. Target populations for the project include pregnant women and infants born to
HIV-infected mothers, all cadres of health care workers engaged in maternal and child health services and
provincial PMTCT coordinators. Emphasis areas for the project include human capacity development, local
organization capacity building, and the provision of technical assistance. The UKZN PMTCT project has 2
components viz. (i) Expansion of the FY 2007 funded Demonstration Project which aims to create linkages
between health and social services in the EC; and (ii) Provision of technical assistance to 3 Health Districts
in KwaZulu-Natal with the highest antenatal HIV seroprevalence.
BACKGROUND:
MTCT rates prior to implementation of the national PMTCT program ranged between 20% - 34%. Since
2002, South Africa has made significant progress in the rapid expansion of PMTCT services. Several
national and provincial audits of the program have highlighted common gaps and challenges to
implementation, and as a result MTCT rates remain high, 20.8% at six weeks as compared to the
anticipated 12%-14%. Challenges to program implementation include: low uptake of CT, lack of ongoing
support for both HIV-infected and uninfected women, poor administration of ARV prophylaxis (less than
25%), policy confusion around nevirapine, poor postnatal follow-up (retention < 15%) and erratic and unsafe
infant feeding practices. In addition, with the implementation of ART programs, linkages between PMTCT
and ART programs have not been established successfully. In view of the above challenges and using FY
2006 and FY 2007 funding; the UKZN PMTCT project was conceptualized to begin to address these
deficiencies. Specific FY 2006 and FY 2007 activities included: establishing pilot sites in each province to
begin implementation of repeat HIV testing for pregnant women who were missed or who tested negative at
the first antenatal care visit. During FY 2006,, the project was completed in 12 primary health care clinics,
three in each of the provinces with the highest HIV antenatal prevalence, namely MP, FS, EC and GP and
using FY 2007 funds preparations for implementation in three primary health clinics in each of the remaining
provinces, namely North West (NW), Limpopo (LP), Western Cape (WC) and Northern Cape (NC) have
begun.
Using FY 2006 funding, a demonstration project aimed at improving follow-up and continuum of care of
women (HIV infected and uninfected) and children in the PMTCT program by fostering a partnership
between Health and Social Services in KwaZulu-Natal was implemented. This project serves as a
demonstration site for a holistic PMTCT program that focuses on enrollment of women into PMTCT
services, PMTCT service delivery and linking women and their infants to social welfare programs,
treatment, care and support. This project has commenced in collaboration with management of both
departments of Health and Social Development in KwaZulu-Natal and is due to be complete in July 2008.
Using FY 2007 funding, a demonstration site for holistic PMTCT service delivery is being set up in Eastern
Cape and expanded to two health facilities in KZN. Funding will ensure that each of the two provinces have
a best practices model which can be rolled out by the provincial departments of health and social
development. The project is supported by a trained team of clinicians, community health workers and social
workers who would perform a situational assessment of health service utilization and the provision of
comprehensive maternal and child health services among women and children, implement a
comprehensive package of clinical care for HIV infected and uninfected women and their children through
integrating HIV and PMTCT programs in routine maternal and child health services, establish a support
program for HIV-infected and uninfected women antenatally and postnatally until 18 months post-delivery
and facilitate and expedite access to social support services such as child support grants (CSG), child care
grants (CCG), and disability grants through interdepartmental collaborations viz. health, social welfare and
home affairs.
FY 2007 funding is also being used to provide ongoing technical assistance and support to four provinces,
namely Eastern Cape, Gauteng, Free State and Mpumalanga. Technical assistance will be provided at the
provincial level to ensure that provincial program managers develop skills to conduct program level
evaluations and can use these evaluations to strengthen existing PMTCT services. Technical assistance
will also be provided at the clinic level through the provision of a comprehensive training and capacity
building program, and an onsite, mentorship and support program.
FY 2008 Specific activities include:
ACTIVITY 1: Expansion of Demonstration Project
This activity will be expanded in the Eastern Cape to all peripheral clinics associated with Motherwell
Community Health Centre. UKZN will use PEPFAR funds to support the Department of Health in the EC in
its effort to improve the follow-up and continuum of care of women (HIV-infected and uninfected) and
children in the PMTCT program. To this end, UKZN will foster a partnership between Health and Social
Services in the EC. This project is a holistic PMTCT program that focuses on enrolling women into PMTCT
Activity Narrative: services, PMTCT service delivery, and linking women and their infants to social welfare programs,
treatment, care and support. An assessment of current systems of the provision of social services in these
communities will assist identification and networking of relevant stakeholders in the Departments of Health,
Home Affairs and Social Development. We will develop a strategy of facilitating rapid access to identity
documents and social grants for HIV infected women and children in consultation with the relevant role
players.
ACTIVITY 2: Support and Technical Assistance to KwaZulu-Natal
The premise behind this activity is to improve knowledge of health workers to ensure successful
implementation of a comprehensive HIV and AIDS plan at the primary health care facilities and to increase
awareness among patients regarding the availability of HIV and AIDS related health services at the facility
level. Technical assistance will ensure the facilitation of linkages between family planning, PMTCT, and
treatment. The focus of this activity includes the development of an integrated training strategy which
address operational and implementation issues for the delivery of a comprehensive package of care for
women and children affected by the HIV and AIDS pandemic. Technical assistance also target teams off
service providers from each of the facilities and their associated ART sites to establish and strengthen
referral mechanisms and a multidisciplinary team approach towards ensuring that women and children have
easy access to ARV treatment and continuum of care.
Training will take place at the facility level and will be implemented over three days per month. In addition to
on-site training and mentorship, audiovisual aids to promote education and communication at the health
facilities will also be implemented. These aids include video recordings, pamphlets and posters.
The UKZN PMTCT project aims to increase uptake of CT, PMTCT, improve maternal and infant follow-up,
better ART and medical adherence rates associated with reduction in maternal and child morbidity and
mortality, improve health awareness and service delivery. This project contributes to PEPFAR 2-7-10 goals
by preventing vertical transmission and linking women and infants to treatment programs.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13851
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13851 9083.08 HHS/Centers for University of 6633 519.08 $750,000
Disease Control & KwaZulu-Natal,
Prevention Nelson Mandela
School of
Medicine
9083 9083.07 HHS/Centers for University of 4414 519.07 Traditional $0
Disease Control & KwaZulu-Natal, Healers Project
Emphasis Areas
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* Safe Motherhood
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $14,440
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
The University of KwaZulu-Natal, Nelson Mandela School of Medicine will use a new strategic approach in
FY 2009. Traditional Health Practitioners (THPs) will use the knowledge acquired during training to
promote abstinence and being faithful (AB) in their day-to-day community activities (e.g., school visits,
religious functions and other community gatherings).
Usage of existing events such as annual reed dance, izimbizos, etc. will be part of the planned outreach
programs. Event calendars will be compiled, which will create ideal opportunities to spread AB messages
more effectively. Media that have been used in earlier COP activities to enhance the reach of the project
messages will now be recorded as an additional indicator. This activity will be implemented with immediate
effect.
Regarding point 5 in the COP 2008, the activity has been rephrased as follows: "to reinforce traditional ways
of abstinence, THPs participating in this project will communicate these messages at their monthly meetings
and other community meetings or events.
------------------------------
The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine (NMSM) uses PEPFAR funds
to work closely with the KwaZulu-Natal (KZN) and Ethekwini Traditional Health Practitioner Councils, to
tease-out, refine and outline culturally appropriate and effective behavior change messages focused on
preventing the spread of HIV through abstinence and being faithful in relationships. The emphasis areas
local and human capacity building. The target population is the general population which includes children,
youth and adults.
UKZN has an ongoing collaboration with associations of traditional health practitioners (THPs) in urban, peri
-urban and rural areas of Ethekwini District, KZN. THPs are influential and are a largely untapped resource
in HIV prevention and mitigation on the community level. THPs ascribe to and uphold traditional African
cultural values, including conservative attitudes toward sexual practices and abstinence that make them
natural partners in this effort. These values are a set of social and community norms that support delaying
sex until marriage and that denounce coerced sexual activity among married and unmarried individuals and
promote mutual monogamy. This THP cultural perspective has not been reinforced, nor has it been included
in public abstinence and being faithful (AB) campaigns in KZN. THP is often the first counselor sought for
married couples who wish to discuss issues related to marital relationships and couples counseling on HIV
and AIDS. Given the position the THPs hold in their social networks, working with the THPs holds great
promise for enhancing the uptake of a culturally appropriate version of the AB message. These activities
began in August 2005 with the arrival of FY 2005 PEPFAR funding. NMSM is implementing the project in
collaboration with the KZN and Ethekwini Traditional Health Practitioner Councils, with the eThekwini Health
Unit, and the eThekwini District Health Office of the KZN Department of Health.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Promotion of AB Messages
It is widely acknowledged among health professionals in KZN that the Abstinence, Be Faithful and correct
and consistent use of Condoms (ABC) messages are not having enough effect in this local cultural context.
This project trains and mobilizes THPs in KZN so that they will be effective promoters of HIV prevention
messages and strategies, including AB-focused behavior change messages. NMSM is adapting
Abstinence/Be Faithful messages to the cultural and healing contexts in KZN to inform and communicate
effective behavior change messages. NMSM is also developing prevention messages together with the
THPs and incorporating these messages into training workshops on an ongoing basis. NNSM is also
developing new prevention message formats for posters, pamphlets, instructional medical comic books, and
medical animations for training and for distribution to the THPs to use with their patients. These messages
are developed in Zulu and English, though they will be distributed primarily in Zulu. This project has also
been developing dramatic presentations that are used in the training workshops to deliver prevention
messages. These have been designed by the senior THPs on the project team and are embedded in Zulu
cultural practice. The prevention messages are developed jointly with the THP team members so that they
are culturally embedded and effective. Discussions with senior traditional healers on the PEPFAR-funded
team indicate they have a variety of interesting, potentially effective suggestions for ways to deliver modified
and improved prevention messages to the community that go beyond the confines of the traditional healer
practice sites. Using FY 2008 funding the following activities will take place:
(1) NMSM will call ongoing assessment workshops (usually one day) with the THPs to discuss the program
and assess the effectiveness of the prevention messages and materials for use in their practice.
(2) NMSM will continually assess the level of absorption and understanding (among the THPs) of the basic
scientific information underlying the rationale of the need for prevention activities, particularly in the value of
abstinence in preventing infection.
(3) The School will continually investigate and assess the value of partner reduction and faithfulness to one
partner, and the effectiveness of faithfulness if the other partner is not also being faithful (particularly
relevant in marriage situations).
(4) NMSM will facilitate meeting with indunas and amakhosi: these are headman and chiefs of the tribal
areas. Traditional healers meet with these leaders who command some authority in their communities, and
work together to speak to their constituents about prevention. Target communities include townships and
Activity Narrative: urban areas.
(5) The project will engaging parents. Modern mothers have often lost the knowledge of the traditional ways
of protecting their daughters and helping them to be abstinent. Traditional healers trained during this
program visit women's clubs and work with mothers to reintroduce these practices.
Formally integrating traditional healers into the public healthcare system is a stated objective of the National
Department of Health and the prevention objectives in the South African Strategic Plan for HIV and AIDS.
By expanding access to culturally and scientifically appropriate prevention messages, the Nelson Mandela
School of Medicine will directly contribute to the PEPFAR goal of preventing seven million new infections.
These activities also support the prevention objectives outlined in the USG Five-Year Strategy for South
Africa.
Continuing Activity: 13852
13852 3067.08 HHS/Centers for University of 6633 519.08 $100,000
7422 3067.07 HHS/Centers for University of 4414 519.07 Traditional $100,000
3067 3067.06 HHS/Centers for University of 2695 519.06 Traditional $180,000
Estimated amount of funding that is planned for Human Capacity Development $26,500
Table 3.3.02:
In FY 2009, the Nelson Mandela School of Medicine at the University of KwaZulu-Natal will implement a
new strategic approach will be used where traditional health practitioners (THPs) will use the knowledge
acquired during the training to promote other sexual prevention beyond abstinence and being faithful (AB) in
their community activities such as school visits, religious functions and other community gatherings.
Usage of already existing events such as the annual reed dance, izimbizos etc., which will be part of the
outreach programs planned through compiling event calendars, will create ideal opportunities to further
spread other sexual prevention beyond AB messages.. All these activities will carried forward into FY 2009.
-In so far as Activity 1 in the FY 2008 COP narrative is concerned, THPs are playing an important role in
counseling their patients instilling prevention messages. This is a community-based targeting and is not
specifically gender oriented. Participating THPs have modified their practices to minimize blood-to-blood
transmission of the HIV among their patients.
SUMMARY: The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine (NMSM) is using
PEPFAR funds to support the development and implementation of innovative prevention messages
specifically adapted to the cultural practices of traditional healers (izangoma and izinyanga) in KwaZulu-
Natal (KZN). The major emphasis area for this program is information, education and communication, with
minor emphasis placed on community mobilization and participation, human resources, policy and
guidelines, quality assurance and supportive supervision, and strategic information. The target population
includes traditional health practitioners (THPs) in the private and public sector who are members of the
KwaZulu-Natal KZN and Ethekwini Traditional Health Practitioner Councils, and THPs in Ilembe and
Umgungundlovu Districts (to the North and West of eThekwini respectively) who are also members of the
KZN THP Council. BACKGROUND:The University of KwaZulu-Natal (UKZN) has an ongoing collaboration
with associations of traditional healers in Ethekwini District, and the larger KwaZulu-Natal (KZN) province.
Traditional Healers are extremely influential in KwaZulu-Natal, and are a resource in HIV and AIDS
prevention and mitigation at the community level. They are also generally considered to hold conservative
attitudes towards sexual practices and abstinence that make them natural partners in HIV prevention
efforts. This project provides THPs with the necessary tools and training to act as effective HIV prevention
agents. The message of Abstinence, Be Faithful, and Condoms (ABC) has not been entirely successful in
the Zulu cultural context. These issues are continuously explored with the THPs in this program and UKZN
is constantly developing more effective ways of communicating prevention messages that resonate in the
Zulu cultural context. Project training, prevention message delivery and follow-up with the THPs emphasize
a clear understanding of the facts of viral transmission in sexual practices and the necessity of barrier
methods to prevent viral transmission during sex. THPs work with their patients and the community to
change cultural practices (non-sexual) that can contribute to viral transmission, such as blood-letting,
scarification (use of razor blades to make incisions for rubbing herbs directly into the bloodstream), and skin
puncturing using porcupine quills that are frequently used in an African type of acupuncture. Prevention
messages delivered in training courses and follow-up work with THPs emphasize the biomedical facts of
viral transmission and the vital necessity of safety precautions to prevent viral transmission in these cultural
practices. In FY 2005, with the arrival of PEPFAR funding, NMSM trained 224 traditional healers to deliver
HIV prevention messages to their clients and communities. NMSM will implement the project in
collaboration with the KZN and Ethekwini Traditional Healer Councils, with the eThekwini Health Unit, and
the eThekwini District Health Office of the KZN Department of Health. ACTIVITIES AND EXPECTED
RESULTS: NMSM will build on English and Zulu language prevention messages developed with the
traditional healers by the KZN Provincial Department of Health. This project will also promote the
understanding of infectious disease in the traditional healer culture. Engagement with THPs through this
project both in training workshops and follow-up work have made it clear that the majority of THPs were
previously uncertain about what HIV is, that there is a "virus" that is transmitted, how this virus is transmitted
both sexually and through cultural healing practices, and how to prevent this transmission. Similarly most
THPs were unclear about what the virus does inside the body, how the activity of the virus leads eventually
to AIDS, and what steps could be taken to slow this progression. It was also unclear to most THPs what the
relationship was between HIV transmission and other sexually transmitted infection (STI) transmission, and
why it was so important to treat and clear up other STI pathologies. In KZN, HIV and AIDS are a
heterosexual pandemic, and largely a behavior-driven epidemic. The following activities will be
achieved:ACTIVITY 1: Increasing Uptake of Prevention MessagesNMSM will work to increase uptake of
HIV prevention messages from the healers by both genders (increasing gender equity in HIV and AIDS
programs), specifically looking into novel ways to instill behavior change ideas into their patients through
counseling on the need for prevention. In addition, Traditional Healers have specific practices that include
use of scarification to introduce herbs directly into the bloodstream, and use of porcupine quills to introduce
herbs through the skin. Both of these practices are discussed in prevention training sessions and
modification of these practices to ensure there is no blood to blood transmission of the virus by the razor
blades, porcupine quills, or fingers of the THPs is ensured. ACTIVITY 2: Community MobilizationTHPs will
organize Imbizos (community gatherings) with their traditional leaders and or village chiefs in the
community. These gatherings will be used to discuss a number of topics including male norms and
behavior, including domestic violence in the context of the Zulu culture. Community
mobilization/participation will be used to enhance the capacity of traditional healers to deliver prevention
messages as they work with their patients and their families. A small number of medical school faculty,
support staff and traditional healers will receive salaries in order to facilitate this project. Specifically, they
will be responsible for monitoring and evaluation and training. ACTIVITY 3: Monitoring and
EvaluationMonitoring and evaluation activities will measure the effectiveness of these interventions.
Supervision and monitoring will be achieved through regular site visits. Data from these activities will
contribute to the development of policies and guidelines for working with traditional healers.ACTIVITY 4.
Building Local Organization CapacityLocal organization capacity development will expand the capacity of
the School of Medicine, the Ethekwini and KZN Traditional Health Practitioner Councils. Through regular
staff site visits, quality assurance and supportive supervision, the development and implementation of
prevention messages will be carried out. Expected results of this initiative for FY 2008 include the
development of new, innovative prevention messages in English and Zulu, including messages to change
Activity Narrative: cultural practices (non-sexual) that can contribute to viral transmission; the development of better
understanding of cultural perceptions, leading to better prevention messages;-training of THPs and
improving their prevention message delivery capacity as they work with their patients and the patient
families. In addition, increased correct and consistent condom usage among sexually active community
members who are not amenable to abstinence/be faithful prevention messages; the assessment of the
effectiveness of Other Prevention approaches within the Zulu cultural context in Ethekwini will also be
achieved. By expanding culturally and scientifically appropriate prevention messages to communities that
receive much of their healthcare from traditional healers, the Nelson Mandela School of Medicine will
directly contribute to the realization of PEPFAR's goal of preventing 7 million new infections. These activities
will also support efforts to meet the prevention objectives outlined in the USG Five-Year Strategy for South
Continuing Activity: 13853
13853 3068.08 HHS/Centers for University of 6633 519.08 $200,000
7423 3068.07 HHS/Centers for University of 4414 519.07 Traditional $100,000
3068 3068.06 HHS/Centers for University of 2695 519.06 Traditional $180,000
Estimated amount of funding that is planned for Human Capacity Development $23,904
Table 3.3.03:
The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine (NMSM) has further refined
the definition of palliative care. The number of patients reported as receiving palliative care refers only to
those patients who visited the Traditional Health Practitioners (THPs), were suspected of being HIV-
infected, and received palliative care services. These services include: clinical/medical and/or traditional
medicines; pre-pre test counseling and/or spiritual advice; and/or referral to grant office or social worker.
THPs often provide palliative care services which sometimes cannot be accessed from public health care
centers. At the beginning of the project, home-based care kits provided by the project were to have been
replenished by the eThekwini District Health Department. However, for reasons beyond the control of this
project, this has not materialized. It is incumbent on the project to continue this necessary aspect of care
for the very needy patients. NMSM will replenish the kits using its existing mechanism of visiting THPs.
The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine (NMSM) is using PEPFAR
funds to support the implementation and refinement of common clinical guidelines for HIV and AIDS
management by traditional healers, including: the standardization of HIV clinical staging for traditional
healers; collaborative introduction of Patient Record Keeping, Monthly Data Sheets, and Data Transfer to
the Medical School; and provision of basic medical supplies to trained healers. The main emphasis area is
training, with minor emphasis placed on human resources, logistics, policy and guidelines, quality
assurance and supportive supervision, and strategic information. The target population includes Traditional
Health Practitioners (THPs) in the private and public sector who are members of the KwaZulu-Natal (KZN)
and Ethekwini Traditional Health Practitioner Councils.
UKZN has an ongoing collaboration with associations of traditional healers in rural areas of Ethekwini
District. Traditional healers are extremely influential and are a largely untapped resource in HIV and AIDS
prevention and mitigation on the community level. These activities began in August 2005 with the arrival of
FY 2005 PEPFAR funding. NMSM is implementing the project in collaboration with the KZN and Ethekwini
Traditional Healer Councils, with the eThekwini Health Unit, and the eThekwini District Health Office of the
KZN Department of Health.
The principal focus of this project will be training and equipping traditional healers to better deal with the HIV
epidemic in KZN.
ACTIVITY 1: Training
Training will be provided through workshops run by the project training team (including senior traditional
healers). Trained THPs will be provided with a customized version of the home-based care medical kit
currently used by the KZN Department of Health (DOH), modified to include the elements of the Adult
Preventive Care Package including, nutritional referral, personal care, counseling, screening for pain and
symptoms, recognition of signs and symptoms of opportunistic infections, worsening condition such as
increased pain or wasting, and knowledge of when to refer to clinical providers. Treatment adherence,
prevention (including prevention with positives) and other holistic care activities as allowed (bathing, wound
care will also be covered. Training includes the refinement and implementation of common clinical
guidelines for HIV and AIDS patient management by traditional healers, including the standardization of HIV
clinical staging, the introduction of patient record keeping, monthly data sheets, and transfer of these data to
the Medical School.
ACTIVITY 2: Referrals:
NMSM is working closely with South African Government colleagues to establish viable bi-directional
referral pathways (including referral forms); formalizing and enhancing what is currently happening. This
process has involved consultation with municipal and district health authorities on the following:
1) the clinics that are near to the THPs and to which the THPs can send referrals;
2) the sharing with the government of the database of THPs registered with the project; this database
provides (in addition to other information) details on the location of each THP practice site, their contact
details, and the clinics to which these THPs are currently referring patients (informally);
3) a commitment by the government to include notification of referrals received by THPs in their Health
Information System; and
4) formalization of a referral form, already reviewed and approved by municipal and district Health, for THPs
to use in sending patients to clinics. Since current legislation does not permit public health officials to refer
patients to THPs formally, the referral form has a simple tear off sheet to give to the patients to take back to
THPs, simply acknowledging whether the patient was attended to at the health facility, and by whom.
ACTIVITY 3: Monitoring and Evaluation-patient record system
NMSM will also ensure that traditional healers have adequate stocks of appropriate medical supplies,
through collaboration with the provincial Department of Health. Regular site visits will be conducted to
monitor the implementation of these guidelines and data management protocols. THPs are visited regularly
by a team of 12 project data monitors to collect anonymous copies of patient record data for entry into the
project database. NMSM has determined that the optimum method is to use carbonized patient record
forms, patient follow up forms (both in book form) and referral forms (in tear-off pads) and provide patient
Activity Narrative: cards to the THPs. Each patient card is linked to a unique patient record identifier number, pre-printed on
the first-visit patient record forms. THPs must enter the patient record number on the patient follow-up forms
and patient card. The patient takes the card with them and brings it back to facilitate the THP's use of the
patient record system. The referral forms include a tear off sheet for use by the clinic, that the patient is
expected to bring back to the THP.
ACTIVITY 4: Medical Kit Supply
Initial medical kits are supplied to the THPs registered with the project using project funds and logistics.
These kits are a modification of the type of home-based care kits used by the Municipality and Province,
and contain additional items specific to the THP needs. The re-supply in eThekwini District is being provided
the District Health approved National Integrated Program (NIP) sites, and other NGO sites approved by
District Health. These sites are normally used by DOH to re-supply the DOH Home-based Care (HBC)
workers, and therefore are equipped with stock control staff and keep a registry of HBC workers using the
material. DOH has agreed to add the THPs on the project to this system, and is exploring with the project
the variable amounts of re-supply needed by different THPs (some are much busier than others), and the
specific needs of THPs that may vary from those of HBC workers.
ACTIVITY 5. Clinical Management Follow-Up
In the refresher training sessions and workshops with THPs already on the project, NMSM concentrates on
ensuring that fundamental facts about HIV, patient management, and referral criteria are clearly understood.
Discussions between traditional health and biomedical practitioners in these sessions focus on optimizing
patient management.
Expected Results:
1. Refine and implement Standardized Clinical Guidelines for HIV and AIDS management for traditional
healers.
2. Develop Standardized Therapeutic Protocol for HIV and AIDS patient management by traditional healers.
3. Improve collaboration and referral between biomedical and traditional healers.
4. Improve record keeping by traditional healers and availability of the anonymous data to public health
authorities.
5. Provide adequate basic care package to trained traditional healers.
6. Assess the usefulness of working with traditional healers to enhance their capacity to provide palliative
care to HIV-infected patients.
7. Human resources: Through this activity, traditional healers will be trained, equipped, with basic medical
supplies and enhanced clinical care knowledge. A small number of medical school staff, traditional healer
representatives, and support staff receive salaries from the project for administration, training, THP support
and monitoring and evaluation.
Logistics: Includes managing the medical kit supply and re-supply, with the trained traditional healers and
government colleagues. This overlaps with commodity procurement since NRMSM funds will purchase the
initial medical kits. Through regular site visits quality assurance and supportive supervision will be
conducted on the use of adapted clinical guidelines and HIV staging, medical kits and record keeping
systems.
Through training, monitoring and evaluation, medical supply and referral system implementation in
partnership with local government, policy and guidelines for working with traditional healers will be
developed.
By providing new tools and materials to traditional healers working with HIV and AIDS patients, this project
will expand basic care and support services in KZN, contributing to the PEPFAR goal of providing care and
services to ten million HIV-affected individuals. These activities will also support efforts to meet the care and
treatment objectives outlined in the USG Five-Year Strategy for South Africa.
Continuing Activity: 13854
13854 3069.08 HHS/Centers for University of 6633 519.08 $250,000
7424 3069.07 HHS/Centers for University of 4414 519.07 Traditional $250,000
3069 3069.06 HHS/Centers for University of 2695 519.06 Traditional $375,000
Estimated amount of funding that is planned for Human Capacity Development $53,304
Table 3.3.08:
The Nelson Mandela School of Medicine will monitor the following parameters to measure the impact of
traditional healer involvement in improving the health and wellbeing of OVC:
1. Numbers of OVC and household in the care of traditional healers;
2. Description of the psychosocial context and needs of OVC and their extended families;
3. Changes in utilization public sector services;
4. Changes in school attendance;
5. Access to social and welfare grants; and,
6. Access to preventative and curative health care services, including antiretrovirals, immunization, growth
and nutrition monitoring.
-------------------------
The Nelson Mandela School of Medicine will introduce additional training modules to explore developmental
disability prevalence and interventions for orphans and vulnerable children (OVC) seeing Traditional Health
Practitioners (THPs), either directly as patients or as family members of patients. The primary emphasis
area will be training, with minor emphases in information, education and communication and needs
assessment. The target populations are OVC, their caregivers and traditional healers.
It is estimated that 6 to 11 percent of South African children under 15 years of age are orphaned due to loss
of one or both parents due to HIV and AIDS. These children are particularly vulnerable to neglect within
households, marginalization within communities, and are less likely to receive adequate, education, growth
and nutrition, regular healthcare and social services. Many of these children may be infected with HIV
themselves. This emphasizes the need to address the bio-psychosocial problems facing this group of
children in addition to access to antiretroviral drugs. Traditional healers may facilitate preventive care in
these households and children.
This traditional healer and the biomedical collaboration will facilitate the following specific activities:
ACTIVITY 1: VCT
Provide support for voluntary counseling and testing (VCT) of OVC, families and child caregivers, including
HIV prevention and treatment education.
ACTIVITY 2: Psychosocial Support
Provide psychosocial support to OVC, their caregivers and families by introducing coping strategies, mental
health assistance, counseling and referral for problems that can be dealt with on the biomedical side.
ACTIVITY 3: Training
Activities 1 and 2 will be included in one-day training modules for THPs (entire FY 2006 cohort) on a ten-
question screen for pediatric developmental disabilities as well as for HIV that lay counselors can also use.
This will be introduced and adapted to THP practice. OVC are especially at risk for developmental
disabilities, delayed school entry, etc. Field evaluation will follow to validate negative or positive screens of
OVC. Workers from the Department of Community Health at the Nelson Mandela School of Medicine
(NMSM) will apply an inter-rater reliability test for sample THP groups.
ACITIVITY 4: Stigma and Discrimination
A pilot workshop will be held with smaller group of THPs from FY 2006 cohort to explore assistance and
biomedical-traditional healing collaboration on managing stigma and discrimination problems for OVC.
Advise will be provided on treatment availability and confidentiality. In addition, the NMSM will explore joint
strategies with THPs on disclosure of child's status and daily drug regimens.
ACTIVITY 5: HBC
Integrating child health and wellbeing into home-based care (HBC) for the sick will be done in collaboration
with current HBC training modules. THPs visiting patients and patient families can do rapid checks on kids
when visiting homes or dealing with parents and determine if OVC are receiving government grants. This
will be added to the monitoring and evaluation practices.
ACTIVITY 6: Public Sector Services
NMSM will work to improve utilization of public sector services - such as social welfare and health, including
facilitating access to antiretrovirals. They will ensure that all THPs in the program are fully aware of social
security grants available and special facilities for kids, people in communities who receive special training to
engage children in early education activities, before pre-school. The same is true for care dependency
grants, foster care grants, disability grants. This training and collaboration will form part of training sessions
Activity Narrative: discussed in item 3 above. THPs could help direct children and their caregivers to social workers at
community level instead of patients only meeting a social worker at the tertiary level and having to be
referred back to the community level social worker (a common situation currently). NMSM will conduct
training and interact with THPs to include discussion of advocacy on behalf of children on issues of
guardianship, school attendance, and legal issues.
ACITIVITY 7: M&E
NMSM will carry out follow-up sessions with THPs on these issues during the course of the year to explore
implementation successes and failures and needs for modification of training.
The following parameters will be monitored to measure the impact of traditional healer involvement in
improving the health and wellbeing of OVC:
1. Numbers of OVC and households in the care of traditional healers;
5. Access to social and welfare grants;
6. Access to preventative and curative healthcare services, including antiretrovirals, immunization, growth
Continuing Activity: 13855
13855 6421.08 HHS/Centers for University of 6633 519.08 $50,000
7426 6421.07 HHS/Centers for University of 4414 519.07 Traditional $50,000
6421 6421.06 HHS/Centers for University of 2695 519.06 Traditional $90,000
Estimated amount of funding that is planned for Human Capacity Development $7,011
Table 3.3.13:
NO FY 2009 FUNDING IS REQUESTED FOR THIS ACTIVITY:
This activity was approved in the FY 2008 COP, is funded with FY 2008 PEPFAR funds, and is included
here to provide complete information for reviewers. No FY 2009 funding is requested for this activity.
University of KwaZulu-Natal (UKZN), Nelson Mandela School of Medicine is funded to empower Traditional
Healers Practitioners (THPs) and strengthen their work in the prevention of HIV and AIDS. One of the aims
of the project was to train THPs to counsel and test their clients for HIV, however, the project has since
been informed that although THPs handle blood on a daily basis in their practice during scarification
practice, they are not by law permitted to perform HIV tests. THPs are now referring their clients for and HIV
test to the nearest clinic. Therefore there is no need to continue funding this activity with FY 2009 COP
funds.
Continuing Activity: 13856
13856 3070.08 HHS/Centers for University of 6633 519.08 $150,000
7425 3070.07 HHS/Centers for University of 4414 519.07 Traditional $250,000
3070 3070.06 HHS/Centers for University of 2695 519.06 Traditional $375,000
Table 3.3.14:
