ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

The South to South Partnership for Comprehensive Pediatric HIV Care and Treatment Initiative

(S2S) will adopt a dynamic and contextualized strategy to support each implementing partner to implement

programs with a family-centered approach at the site level. The site support will be dynamic and

continuously customized to address site attributes and existing resources. While the support and program

area emphasis will vary, all designated sites will benefit from the following activities:

Systems will be implemented to ensure that all pregnant and post-partum women and those of child-bearing

age that visit the antenatal care (ANC), maternity and maternal and child health (MCH) facilities will be

routinely offered an HIV test with same day results (with routine CD4 testing, if positive). HIV testing and

counseling will be reframed to ensure informed consent via group pre-test information sessions, and in-

depth support and individual counseling post-test. Disclosure support and testing will also be offered to

partners and other family members (including children).

Partner testing will be strengthened to integrate the family into PMTCT. Staff will be trained to address

gender issues and their impact on PMTCT and the family. Women will be encouraged and empowered to

bring partners to ANC and follow-up visits to participate in pregnancy or child care; learn about HIV, pre-

and post-natal care, support for males and couples; test for HIV; link to services for HIV men and children;

learn about prevention services for HIV negative men in discordant couples.

MCH services will be enhanced to address the needs of HIV-infected pregnant women. Services include

primary HIV prevention; STI screening and syndromic management; maternal cotrimoxazole per South

African government (SAG) policy; safer sex practices; nutrition; malaria screening, prophylaxis and

treatment; TB screening; immunizations; family planning; delivery preparedness; and community-based

support services/linkages.

All HIV-infected women enrolled in the PMTCT program will be evaluated for clinical and immunologic

status. CD4 count and WHO clinical staging will be used to determine eligibility for highly active

antiretroviral therapy (HAART) during pregnancy. Women who do not meet national eligibility criteria will

receive multidrug ARV prophylaxis, according to national guidelines, and be enrolled in HIV care services

for close monitoring. Women who present in labor without documented HIV status will receive rapid HIV

testing and counseling (if positive and in the first stage of labor, ART will be administered, per national

policy). Women presenting in labor will be referred to HIV care services for a full evaluation post partum.

PMTCT sites will provide quality labor and delivery services to help reduce the risk of MTCT. This includes

implementing safe obstetric practices and standards; reducing invasive procedures; taking universal

precautions; implementing biosafety; following up and referrals post-partum; and linking to care and

treatment services.

Infant feeding education, counseling and support will be initiated at the point of diagnosis (ideally in the

antenatal period) and continued throughout the postnatal period. This support will be routinely integrated

into all visits as part of the continuum of care. S2S will work with site staff to improve the quality of infant

feeding counseling and assessment whether it is acceptable, feasible, affordable, sustainable and safe

(AFASS) so that women can make informed choices to support exclusive infant feeding. Infant feeding

support will be offered at every encounter including after an HIV-positive test result but before delivery;

within the first 10 days after delivery; during the time of early infant diagnosis; at 6 months; and whenever

the mother plans to change her feeding practice.

S2S will use site information to improve programmatic activities and provide training to clinic staff to

enhance effectiveness of existing client tracking systems and, when needed, supplement with additional

systems to improve clinic management and client care.

S2S aims to decrease the morbidity and mortality among HIV-infected mothers, their partners and children

by engaging infected/affected people into care and treatment services. PMTCT sites will establish functional

referral mechanisms to care and treatment services. This will include routine CD4 testing at point of HIV

diagnosis so eligible women can begin HAART as early as possible in their pregnancies, thus reducing viral

load and significantly reducing the risk of transmission. Women not eligible for HAART will be provided with

appropriate multi-drug ARV prophylaxis and will be referred to HIV care and treatment services for long-

term and aggressive follow-up care.

S2S will ensure that there are dynamic systems within a facility and between hospitals and clinic facilities to

offer HIV care and treatment to all eligible HIV-infected pregnant women, post-natal women and women of

childbearing age. This will vary by site but can include offering comprehensive ART services at the

ANC/MCH facility, conducting initial ART assessment at the clinics and referring to ART services, or offering

HIV care at the MCH facility with strong referral and follow-up systems to ensure the pregnant woman and

her family access and are retained in treatment services at the ART facility.

Based on the tenets of the MTCT-Plus model of care, S2S will work closely with implementing partners to

provide all HIV services with a family focus. This will be comprised of HIV care, including access to

standardized antiretroviral options, for HIV-infected women and children identified in PMTCT programs, and

for their infected partners and other family members. The model of care will include engaging more women

and families in long-term care including regular follow-up visits, regular immunological and clinical

monitoring, OI prophylaxis when needed, counseling and psychosocial support and referrals to community

resources and support groups; and early identification of women who need ART during pregnancy at all

points of entry.

S2S will ensure that all HIV-infected pregnant women are assessed for treatment eligibility. Eligible women

will be fast-tracked to treatment regardless of ANC progress and point of entry. Women accessing MCH at

hospital facilities will initiate treatment at the nearest ART site with coordinated visits to ensure that both her

Activity Narrative: MCH and HIV needs are met. Women accessing MCH at sites with no ART services will either be referred

to the nearest ART facility for rapid initiation of treatment and (as much as possible) managed and

monitored at the MCH facility, or, be initiated on ART and managed directly at the MCH facility.

S2S will support the initiation and management of coordinated and comprehensive HIV care services for

families in accordance with SAG policy. This can include, depending on available resources, conducting

rapid ART eligibility assessment of the HIV-infected pregnant woman, HIV staging, OI screening and when

feasible OI management, OI and cotrimoxazole prophylaxis, immune monitoring, psychosocial and

adherence support, active referrals (and referral follow-up), pain management, alcohol and substance

abuse referral and support, and communication with the local ART clinic. S2S may adapt/develop an

appropriate package of HIV care and the development of simple HIV care information systems (client card,

registers, and referral tools) at MCH and/or clinic level.

Because of the rapid roll out of HIV services, there is a large population of HIV-infected women that know

their status and are enrolled in HIV care and treatment services. To ensure that women of reproductive age

are supported to make safe and informed contraception, family planning and reproductive health decisions

in the context of their HIV infection S2S can sensitize site staff to the sexual and reproductive health rights

and needs of all people living with HIV, particularly those of reproductive age.

S2S will work with implementing partners to foster linkages with other resources, programs, and partners to

ensure that resources and expertise are properly leveraged within the context of the USG and country

national plans. In this way, expertise is maximized to reduce duplication of efforts and to optimize existing

resources.

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

SUMMARY:

Columbia University International Center for AIDS Care and Treatment Program (ICAP) will use FY 2008

funding to apply its PMTCT capacity building activities in 30 sites located in Limpopo, Northwest, Gauteng,

Mpumalanga, Northern Cape, and Western Cape provinces. ICAP's capacity building model is based on its

support of the South-to-South Partnership for Comprehensive Pediatric HIV and AIDS Care and Treatment

Training Initiative (S2S) in the Western Cape, which emphasizes site level training; namely, continuous and

supportive onsite presence, onsite dynamic skills-building events such as on-the-job training, clinical

mentoring, modeling and site implementation workshops and case-based learning. The core activity for FY

2008 involves designing and implementing PMTCT performance action plans and establishing long-term

monitoring systems so that increased quality of service delivery can be sustained over the long term. This

activity will be implemented in collaboration with the Foundation for Professional Development (FPD),

BroadReach Healthcare and Right to Care.

BACKGROUND:

A main focus of ICAP support on the site level is to build provider and system capacity with a focus on

continuous quality improvement. Shortages of health care workers are exacerbated by the gap between the

knowledge and skills required to provide HIV and AIDS services. Additionally, poor design of facility

systems and services, lack of patient scheduling systems, inefficient provider placement and scheduling

and irregular supervision by senior management continue to weaken already stressed HIV services. ICAP's

site level support is dynamic and continuously customized to consider site attributes and existing resources.

During FY 2008 this capacity building model will support the continuation and expansion of the S2S

Partnership with Tygerberg Children's Hospital-Stellenbosch University in the Western Cape. The S2S

program, experiences and materials will support the activities within this initiative aimed at supporting

pediatric HIV and AIDS.

ACTIVITIES and EXPECTED RESULTS:

ACTIVITY 1: Basic Capacity Building Model

While the technical support and capacity building focus varies according to site attributes, all sites benefit

from ICAP support to: (1) jointly develop or review/revise existing site specific work-plans (with clear

benchmarks, targets, and activities) to outline action steps on how to achieve related goals, including setting

site specific benchmarks and targets (in close collaboration with USAID-SA partners); (2) leverage and

maximize efficiency of existing site and regional level human and commodity resources; (3) deliver a quality

package of PMTCT-Plus and family-centered HIV services to clients; (4) implement active referrals and

linkage systems; (5) efficiently operate with an integrated approach to caring for the HIV-infected pregnant

woman/mother and her family; (6) facilitate and lead site level system improvements that improve quality of

care, support optimal patient flow, and decrease patient wait time; and (7) initiate a multidisciplinary

approach to service delivery.

ACTIVITY 2: Exposed Infant Follow-up/Care and Pediatric HIV Care and Treatment

ICAP will continue to support pediatric activities in close collaboration with the S2S program to rapidly

expand access to HIV care and treatment for infants and children. Through its basic capacity building model

ICAP will support the implementation of comprehensive care services for the HIV-exposed child at all sites,

including growth monitoring, neuro-developmental screening, and cotrimoxazole prophylaxis. ICAP will

capitalize on IMCI, EPI, and under-5 services to identify infants at peripheral sites that should be referred for

HIV testing, and use aggressive pediatric case finding by supporting clinical/immunological presumptive

diagnosis and/or early infant diagnosis services. The ICAP model will be used when appropriate to expand

provider-initiated in-patient testing in pediatric wards, and to assist in the implementation of routine

pediatric psychosocial assessments to appraise readiness and support needs prior to initiating treatment.

ACTIVITY 3: Expansion of Early Infant Diagnosis (EID)

The ICAP capacity building approach will support implementation and expansion of EID services. This

includes the improvement of follow-up services, including improving counseling to ensure that caregivers

Activity Narrative: understand the importance of returning for services and developing mechanisms to identify and trace

caregivers who have not returned for follow-up and test results.

ACTIVITY 4: HIV-infected Women of Childbearing Age and their Partners

ICAP plans to strengthen the quality of the clinical and psychosocial services available to women of

childbearing age and males (especially partners) enrolled in care and treatment services. This activity

Includes supporting facilities to offer services and referrals to counsel HIV-infected women and partners,

specifically on family planning.

By strengthening PMTCT services, these activities contribute to PEPFAR 2-7-10 goals, averting new

infections among infants exposed to HIV as well as increasing access to treatment care and support for HIV

-infected women and their infants.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13739

Continued Associated Activity Information

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

System ID System ID

13739 12237.08 U.S. Agency for Columbia 6590 6156.08 $550,000

International University

Development Mailman School of

Public Health

12237 12237.07 U.S. Agency for Columbia 6156 6156.07 $550,000

International University

Development Mailman School of

Public Health

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Safe Motherhood

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $891,200

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $111,400

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Estimated amount of funding that is planned for Water $111,400

Table 3.3.01:

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.

Because the South-to-South program of Columbia University focuses solely on improving care and

treatment for children, the FY 2009 funding was moved from Treatment Services to the new categories of

Pediatric Care and Pediatric Treatment. Therefore there is no need to continue funding this activity with FY

2009 COP funds.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13741

Continued Associated Activity Information

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

System ID System ID

13741 12341.08 U.S. Agency for Columbia 6590 6156.08 $1,164,000

International University

Development Mailman School of

Public Health

12341 12341.07 U.S. Agency for Columbia 6156 6156.07 $2,600,000

International University

Development Mailman School of

Public Health

Table 3.3.09:

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

FY 2008 COP activities will be expanded to include:

-Supporting the rapid expansion, uptake and decentralization of family centered HIV care and treatment

services.

SUMMARY:

International Center for AIDS Care and Treatment Program at Columbia University (ICAP) will continue to

partner with Stellenbosch University to support the South-to-South Partnership for Comprehensive Family

HIV and AIDS Care and Treatment Training Initiative (S2S) and apply its PMTCT and Pediatric HIV Care

and Treatment, and TB capacity building activities in 60 sites located in Limpopo, Northwest, Gauteng,

Mpumalanga, Northern Cape, and Western Cape provinces. S2S's capacity building model emphasizes site

level training; namely, continuous and supportive onsite presence, onsite dynamic skills-building events

such as on-the-job training, clinical mentoring, modeling and site implementation workshops and case-

based learning. The core activity for COP09 involves supporting the rapid expansion, uptake and

decentralization of family centered HIV care and treatment services. This activity will be implemented in

collaboration with the Foundation for Professional Development (FPD), BroadReach Healthcare, M2M and

several Orphan and Vulnerable Children Organizations.

BACKGROUND:

A main focus of S2S support on the site level is to build provider and system capacity with a focus on

continuous quality improvement. Shortages of health care workers are exacerbated by the gap between the

knowledge and skills required to provide HIV and AIDS services. Additionally, poor design of facility

systems and services, lack of patient scheduling systems, inefficient provider placement and scheduling

and irregular supervision by senior management continue to weaken already stressed HIV services. S2S

site level support is dynamic and continuously customized to consider site attributes and existing resources.

During FY 2009 this capacity building model will support the continuation and expansion of the S2S

Program.

ACTIVITIES and EXPECTED RESULTS:

Technical, Program, and Systems Capacity Building Approach: S2S will adopt a dynamic and

contextualized strategy to support each implementing partner to operationalize programs with a family

centered approach at the site level. The site support will be dynamic and continuously customized to

address site attributes and existing resources. However, while the support and program area emphasis will

vary, all designated sites will benefit from the following illustrative activities:

ACTIVITY 1: Linkages to follow-up, HIV care and treatment for HIV-exposed infants

S2S will support sites to develop infant follow-up services by capitalizing on existing infant programs to

ensure continuity of care, early diagnosis, growth monitoring, and cotrimoxazole prophylaxis for infants.

Those identified as HIV-infected will be referred to ART clinics for chronic care and follow-up. A system for

tracking and assessing outcomes among HIV-exposed and at risk infants will be developed. The key

components of S2S support will include: 1) early identification, follow-up and referral for diagnosis of HIV-

exposed infants and young children in the under five clinics, paying special attention to provision of

cotrimoxazole prophylaxis, vaccination, nutrition and growth monitoring and early HIV diagnosis; and 2)

providing support for the development of systems that will link follow up of HIV-exposed and HIV-infected

children with the under-five clinic services.

ACTIVITY 2: Early Infant Diagnosis

S2S will support the development and site level implementation of the system for supporting early infant

diagnosis. This will include the development of services to offer early infant diagnosis, reporting tools, and

HCW skills training on infant diagnosis including: 1) support early infant diagnosis program with PCR testing

for all children <18 month identified through linkage with PMTCT program or rapid test screening;

2) enhance the logistics and transport system for DBS; 3) enhance PCR results reporting systems to

decrease post-test counseling turnaround time; 4) ensure that families receive results promptly, accurately

and as part of a counseling session; and 5) engage and retain infants who are breast fed in HIV care until

final infection status is determined.

ACTIVITY 3: Comprehensive pediatric HIV care services (please refer to pediatric treatment program area

for complete description of this program element that targets HIV-infected children on treatment)

S2S will build on site capacity by supporting systems and healthcare workers to institute program elements

that consider the multiple and changing needs of pediatric clients. S2S will support sites to apply a

developmental approach to pediatric care, understanding that abilities (cognitive and physical) evolve and

mature over time and through various life stages and cycles. This should apply to all critical HIV care and

treatment issues such as -adherence, disclosure, physical examination, normative laboratory values which

change over time and over life stages.

ACTIVITY 4: Basic and Quality Pediatric Care

The platform for quality and comprehensive pediatric HIV care and treatment services is quality and

comprehensive pediatric services. Since there is a need to engage non-pediatric trained clinicians to

support Pediatric HIV services, S2S will support adult and other non-pediatric clinicians to learn the basic

pediatric care skills in order to provide accurate and quality services. This will include supporting staff to

understand and implement the corner stone of pediatric HIV assessment such as growth monitoring. This is

a simple and very cost effective way of assessing any child's growth but most importantly to identify children

Activity Narrative: who are failing to thrive and need clinical interventions such as HAART to improve health status. Other care

elements such as the pediatric physical exam, assessing the child's progress via the caregiver, and

pediatric drug and laboratory basics will be emphasized.

HIV specific issues will include: 1) quality and continuous clinical care for all infected children; 2) monitoring

and assessment of all infected children for treatment eligibility; 3) increased linkage and coordination

between pediatric and adult care and treatment services; and 4) implementation of comprehensive care

package for the HIV-exposed and infected child at all ARV sites, including cotrimoxazole prophylaxis,

growth monitoring, and neuro-developmental assessments.

ACTIVITY 5: Neurodevelopmental Screening and Capacity Building

In FY 2009, ICAP will work to ensure that child development and pediatric neurodevelopment

issues/approaches are integrated and applied in the comprehensive care of the HIV-infected child. Systems

will be established and clinicians will learn how to offer comprehensive and integrated services to address

the medical, developmental and/or behavioral challenges of the HIV-infected child. This includes developing

and/or enhancing neurodevelopment and child development assessment, monitoring and management

systems and tools.

ACTIVITY 6: Malaria

Where relevant, S2S can help strengthen malaria prevention interventions including 1) administering

prophylaxis, 2) supplying bed nets to clients upon enrollment, 3) educating caregivers on prevention,

warning signs, and action steps.

ACTIVITY 7: Sexual abuse

While sexual abuse is an under-reported mode of pediatric HIV transmission, it is increasingly important to

have facilities be well equipped with quality services to address such a complex and fragile situation. S2S

can provide support to deal with the acute cases and the more chronic cases where sexual abuse is

suspect long after the initial incident(s). This will include the clinical management of cases such as HIV

testing protocol, PEP, psychosocial support and the long term psychosocial counseling needed for the HIV-

infected child and caregiver from sexual abuse.

ACTIVITY 8: Linkage, referral and coordination with care and treatment programs for caregivers and family

members.

ICAP will enhance and support the coordination and integration of a HIV/AIDS family service model by S2S:

1) formalize linkage and relationship with adult ART facilities at facility and catchment area level;

2) initiate counseling and testing of care takers and household members of enrolled children and offer

referrals to adults determined to be HIV-infected into care and treatment services and vice versa; 3)

enhance the formal referral system between clinics and Adult ART sites; and 4) support a system of follow-

up during pediatric visits to ensure referrals are activated.

ACTIVITY 9: Community HIV care for HIV-exposed and infected children

Since over 95% of a child's care is provided by caregivers, family members in the community, or OVC and

community/faith-based organizations it is essential to ensure that those responsible for: 1) monitoring for

danger/warning signs; 2) administering ARVs and other drugs; 3) ensuring the child comes to appointments;

4) providing the daily psychosocial and emotional support to the child; and 5) assuring that referral

personnel are accurately educated and properly skilled. S2S will address this need in two ways 1)

supporting clinic sites to orient caregivers on these issues and to implement caregiver skills building

programs to support the child's care needs throughout the lifecycle 2) reaching out directly with OVC and

community/faith-based organizations working with orphans and HIV-infected children in the community to

support them to develop and maintain strong linkages to HIV care and treatment services, recognize signs

and symptoms of HIV related illness, provide psychosocial support, monitor growth and child development

stages (for warning signs and rapid referral to clinical services), support adherence to care and treatment

for children, and either conduct or actively link with HIV testing services.

ACTIVITY 10: Pediatric HIV Case Finding

The focus of this activity is to support pediatric case finding at both clinical and non clinical settings such as

health facilities and in the community by ensuring all children that have high risk for HIV infection are given

an HIV test and if HIV-infected are rapidly engaged into HIV care and treatment services. This includes the

children in the care of adults engaged in HIV treatment services, routine provider initiated HIV testing of

hospitalized children, and strong and active linkages with community support groups and OVC associations

to test all orphans and vulnerable children for HIV.

ACTIVITY 11: Pediatric HIV Testing in Clinical Settings

S2S can support active case finding in health facilities and clinical settings by: 1) supporting the

implementation of provider initiated inpatient testing and counseling in all pediatric wards (especially

malnutrition and TB/infectious disease), including offering testing and counseling for PCR tests for children

less than eighteen months of age; 2) supporting ART facilities to actively screen for and engage children of

all ART and PMTCT clients to be tested for HIV (This could be supported by introducing healthy family days

at the ART facility where activities are implemented to encourage parents to bring in children, such as a

child play area, child care whilst being seen by health workers, healthy family skills building sessions and

healthy family commodities such as safe water tools); and 3) supporting HIV testing and counseling

services at all points of encounter children have with clinical services, whether it be immunization, TB, under

-5, malnutrition, physical and/or rehabilitative therapy.

Activity Narrative: ACTIVITY 12: Pediatric HIV Testing in Community and Nonclinical Settings

S2S can support active case fining in community and nonclinical settings such as OVC programs, faith-

based and community-based service organizations by supporting staff and providers within those

designated institutions: 1)to know the HIV status of all children under their care; 2) to screen for HIV risk

and refer for testing at health facility; 3) perform HIV testing as part of admission intake, and/or

4) have clinical staff conduct HIV screening services on a scheduled basis at the OVC program.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $420,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $90,000

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Estimated amount of funding that is planned for Water $90,000

Table 3.3.10:

SUMMARY:

The International Center for AIDS Care and Treatment Program at Columbia University (ICAP) will continue

to partner with Stellenbosch University to support the South-to-South Partnership for Comprehensive Family

HIV and AIDS Care and Treatment Training Initiative (S2S) and apply its PMTCT and Pediatric HIV Care

and Treatment, and TB capacity building activities in 60 sites located in Limpopo, North West, Gauteng,

Mpumalanga, Northern Cape, and Western Cape provinces. S2S's capacity building model emphasizes

site-level training; namely, continuous and supportive on-site presence, on-site dynamic skills-building

events such as on-the-job training, clinical mentoring, modeling and site implementation workshops and

case-based learning. The core activity for FY 2009 COP involves supporting the rapid expansion, uptake

and decentralization of family-centered HIV care and treatment services. This activity will be implemented in

collaboration with the Foundation for Professional Development (FPD), BroadReach Healthcare, Mothers 2

Mothers (M2M) and several orphan and vulnerable children organizations.

BACKGROUND:

A main focus of S2S support at the site level is to build provider and system capacity with a focus on

continuous quality improvement. Shortages of health care workers are exacerbated by the gap between the

knowledge and skills required to provide HIV and AIDS services. Additionally, poor design of facility

systems and services, lack of patient scheduling systems, inefficient provider placement and scheduling

and irregular supervision by senior management continue to weaken already stressed HIV services. S2S

site level support is dynamic and continuously customized to consider site attributes and existing resources.

During FY 2009 COP this capacity building model will support the continuation and expansion of the S2S

Program.

ACTIVITIES and EXPECTED RESULTS:

Technical, Program, and Systems Capacity Building Approach: S2S will adopt a dynamic and

contextualized strategy to support each implementing partner to operationalize programs with a family-

centered approach at the site level. The site support will be dynamic and continuously customized to

address site attributes and existing resources. However, while the support and program area emphasis will

vary, all designated sites will benefit from the following illustrative activities:

ACTIVITY 1: Comprehensive Pediatric HIV Care and Treatment Services

ICAP will build on-site capacity by supporting systems and health-care workers to institute program

elements that consider the multiple and changing needs of pediatric clients. ICAP will support:

1) Quality and continuous clinical care for all infected children

2) Monitoring and assessment of all infected children for treatment eligibility

3) Continuous assessment of all children enrolled in care and treatment services for treatment

complications, outcomes, and failure

4) Increased linkage and coordination between pediatric and adult care and treatment services

5) Implementation of comprehensive care package for the HIV-infected child at all ARV sites, including

cotrimoxazole prophylaxis, growth monitoring, and neuro-developmental assessments

6) Pediatric adherence and psychosocial programs, including support groups for HIV-infected children on

treatment

ACTIVITY 2: Psychiatric and Psychological Issues and Support

The HIV-infected child is at increased risk for primary or secondary psychiatric and psychological conditions

and problems. This includes depression, mood and psychotic disorders, and anxiety directly related to a

variety of factors including: the HIV infection, HAART, predisposing conditions, and/or the

environmental/social circumstance the child is exposed to. This important but oftentimes overlooked issue

greatly affects a child's ability to adhere to care and treatment, understand his/her condition, integrate

seamlessly into society, progress well in school and form healthy social and familial relationships with those

around them. Consequently, we will aim to draw this issue to the forefront as a key component of quality

HIV care and treatment services and not an auxiliary pediatric service that should be integrated into the

competency of all health-care workers and providers to at a minimum assess and refer for additional

support.

Adolescents: Depending on the population, clinics will be designed to support HIV-infected adolescents,

targeting psychosocial and supportive activities for their specific needs

ACTIVITY 3: Pediatric Pain/Symptom Relief Assessment and Management

Pain and symptom relief in HIV-infected infants and children often go improperly assessed and poorly

treated for various reasons. ICAP will support targeted sites to institute systems to accurately assess,

classify and treat the pain and symptoms pediatric clients commonly experience. This will include

conducting proper history and physical with the child (and as relevant with caregiver) to assess the source

and potential cause of symptoms and pain, providing tools to measure pain in children including self-report

tools and behavioral measures, supporting supply chain of necessary drugs.

ACTIVITY 4: Sexual abuse

While sexual abuse is an under-reported mode of pediatric HIV transmission, it is increasingly important to

have facilities be well equipped with quality services to address such a complex and fragile situation. ICAP

can provide support to deal with the acute cases and the more chronic cases where sexual abuse is

suspect long after the initial incident(s). This will include the clinical management of cases such as HIV

testing protocol, PEP, psychosocial support and the long term psychosocial counseling needed for the HIV-

infected child and caregiver from sexual abuse.

ACTIVITY 5: Cross-Cutting Issues

Following is an illustrative list of crosscutting issues that affect all aspects of family-centered HIV care and

will need to be considered and contextualized for each specific service, especially as they apply to pregnant

women and children.

Activity Narrative: Strengthening laboratory services: S2S will work with implementing partners and the site to improve HIV

related laboratory services that directly impact the delivery of family-centered C&T services such as rapid

HIV tests, CD4 cell count, early infant HIV testing.

Strengthening pharmacy and other commodities services: As necessary, S2S can support sites to improve

the supply chain management of ARVs, infant formula and other HIV related drugs in order to ensure

adequate stocks for the projected increase in pregnant women and children in need of drugs and its

complementary commodities. Site staff will be supported to dispense and inventory drugs (AZT, NVP CTX

etc.) if they will be issued at the place of service delivery.

Adherence and Psychosocial Support: Adherence and psychosocial support is the cornerstone to

successful HIV C&T services, especially for the pregnant woman and her family. It will be critical to ensure

that an HIV-infected women eligible for ART during her pregnancy are successfully maintained on treatment

during and after her pregnancy and likely during her subsequent pregnancies so that her clinical status is

maintained and MTCT rates are reduced. Consequently, S2S can work closely with partners to establish

site level programs that will consider various models and approaches to comprehensive psychosocial and

adherence programs for families, but particularly women and children. High adherence rates are found

where a range of interventions are implemented and therefore, multiple strategies can be implemented

including:

Development of comprehensive psychosocial and adherence program: Evidence shows that a single

intervention to support the multitude of issues that impact adherence is not enough, as a result, services will

be developed that address the needs of the new, mature and defaulted client. As much as possible, an

individualized approach to adherence will be considered due to the variety of risk factors for non-adherence.

Additionally, on-site support programs that target HIV-infected pregnant women, mothers and female PLHIV

of childbearing age can be implemented to discuss and resolve issues unique to the HIV-infected women,

including challenges to C&T such as adherence, disclosure, infant feeding support, and other issues. This

will serve as a platform for PLHIV to access support and real-life solutions from one another through the

facilitation of experienced site level staff.

MDT approach to adherence support: S2S can strengthen the roles of specific health-care workers to

support adherence and psychosocial programs, including pharmacists, counselors, nurses and doctors.

Currently, psychosocial and adherence support is limited to counselors and pharmacists and S2S can help

integrate this focus into part of each cadres routine practice.

Education, behavior and support: Adherence interventions aim to inform people about HIV treatment to

generate behavior change through incentives, suggestions or emotional support. S2S will employ cognitive,

behavioral and affective interventions to support adherence by developing, piloting and distributing these

tools on site.

Client adherence tools: S2S will work with site level staff and PLHIV to design context specific reminders,

aids, and monitoring tools to support adherence.

Pharmacy procurement support: Complex medication regimens can compromise adherence for clients with

multiple psychosocial issues. S2S will work closely with pharmacies and dispensaries to ensure that fixed

dose combinations are procured and when feasible prioritized for clients at high risk for non-adherence.

Community linkages: S2S can develop linkages with community-based organizations and health workers to

support clients by developing realistic approaches to adhering to C&T services. Active outreach programs

can be conducted in the community to locate and engage persons in C&T that miss scheduled clinic visits.

Additionally, pregnant women (and their exposed infants) that do not present after delivery as scheduled

can be traced into the community and supported to return for follow up care.

Client Follow-up Systems: S2S can provide support to sites that do not have systems and resources to

directly identify, contact, trace and support defaulting clients. For example, if an outlet site does not have

access to a direct telephone line to make outside calls and communicate with clients who have access to

telephones or with community-based workers to support client follow-up, S2S can support the site to

establish a system to use cellular phones to enhance client adherence, follow-up and retention. S2S can

support sites to implement a multifaceted program to follow up and track women and children who are lost

to follow up. This may include empowering active involvement of PLHIV in improvement and design of

family-centered services: S2S will explore the feasibility of engaging clients and caregivers into a routine

process of giving inputs and feedback to the site they receive services in the form of a formal community

advisory board.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $560,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $70,000

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Estimated amount of funding that is planned for Water $70,000

Table 3.3.11:

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

Technical, Program, and Systems Capacity Building Approach: The South to South Partnership for

Comprehensive Pediatric HIV Care and Treatment Initiative (S2S) will adopt a dynamic and contextualized

strategy to support each implementing partner to implement programs with a family-centered approach at

the site level. The site support will be dynamic and continuously customized to address site attributes and

existing resources. However, while the support and program area emphasis will vary, all designated sites

will benefit from the following illustrative activities:

TB/HIV and the family: Considering the TB burden in South Africa, S2S can support the integration of

routine TB screening for all pediatric clients by introducing the regular use of simple screening

questionnaires, symptom checklists, evaluation of household contacts and referral algorithms. S2S can also

help strengthen linkages between TB prevention and treatment programs including (1) referral of clients

and family for assessment, (2) administering prophylaxis, and (3) educating clients and caregivers on

prevention, warning signs and actions steps. Following is additional detail on each component:

- Administer brief TB screening questionnaire evaluating signs and symptoms of TB (prolonged cough,

weight loss, family contact, fevers) at first visit and regular intervals thereafter;

- Routinely screen all children for history of adult household contact with symptoms of TB or receiving

treatment for TB;

- Administer brief TB screening twice yearly to adult caretakers attending the pediatric clinic; and

- Establish referral mechanisms for further evaluation and diagnosis of children and family members with a

positive screen for TB.

Furthermore, S2S will also work with site staff to ensure that all children under 5 years living in the

household of an adult or an orphanage with active TB disease are evaluated for TB infection and, if found to

be well, receive isoniazid (INH) prophylaxis. Co-treatment of HIV and TB is particularly complex especially

in young children when diagnosis is difficult and drug-drug interactions are common. Similarly, diagnosis

and treatment of TB during pregnancy poses unique challenges. S2S will support site staff to co-manage

these infections in children and pregnant women including monitoring toxicities, modifying doses, enhancing

and monitoring adherence and assessing clinical outcomes.

TB/HIV and Pregnant Women: TB disease and infection is under-recognized during pregnancy and can

lead to significant maternal and infant morbidity and mortality. S2S can support the integration of routine TB

screening for all women attending antenatal care (ANC) services by introducing the regular use of simple

screening questionnaires, symptom checklists, evaluation of household contacts and referral algorithms.

S2S can also help strengthen linkages between TB prevention and treatment programs including (1) referral

of clients and family for assessment, (2) administering prophylaxis, and (3) educating clients and caregivers

on prevention, warning signs and actions steps. Following is additional detail on each component:

- Administer brief TB screening questionnaire evaluating signs and symptoms of TB (prolonged cough, poor

weight gain or weight loss, family contact, fevers) and history of household contacts with symptoms of TB at

first ANC visit; and

- Establish referral mechanisms for further evaluation and diagnosis of pregnant woman and her children

and family members with a positive screen for TB.

Furthermore, S2S will work with site staff to ensure that all children and partners of pregnant women

identified with TB are screened and receive prophylaxis when applicable. The diagnosis and treatment of

TB during pregnancy poses unique challenges. S2S will support site staff to co-manage these infections

among pregnant women including monitoring toxicities, modifying doses, enhancing and monitoring

adherence, and assessing clinical outcomes.

Testing for TB with HIV: To foster greater integration and synergy between HIV and TB services, where

relevant, S2S can support the introduction of routine HIV testing for all children and family members being

treated for TB.

Supporting TB Infection Control: S2S will support infection control in the context of the family unit at the

health facility, in the community and at home. This includes supporting facilities to implement appropriate

infection control procedures (within the context of existing resources) and supporting facility staff to properly

counseling and support clients to protect others and themselves. This includes (1) supporting safe sputum

collection by working with sites to identify a safe and confidential space to collect sputum; (2) supporting

health workers on how to counsel and educate clients on cough etiquette and hygiene; and

(3) supporting site staff to implement a protocol to screen all clients for TB, prioritize the triage of women

and children who are TB suspect and ensure active referral to TB clinic for rapid screening and treatment if

necessary.

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

SUMMARY:

Activities support implementation and expansion of best-practice models for integration of tuberculosis (TB)

and HIV services in public sector facilities in Eastern Cape (EC) and KwaZulu-Natal (KZN). TB/HIV activities

are implemented through technical assistance and will result in a decrease of TB in HIV-infected children

and adults, increase prevention and early detection of TB in HIV-infected children and adults, and provide

overall support to provincial TB/HIV activities. The emphasis area for this program will be human resources.

The target population will include infants, children and youth (non-OVC), men and women (including

pregnant women and family planning clients), people living with HIV (PLHIV) and public and private sectors.

BACKGROUND:

Columbia University (Columbia) began TB/HIV integration activities in FY 2006. Health facilities initially

identified in EC included 3 TB hospitals (Nkqubela, Fort Grey and Empilweni Hospitals) and 8 HIV care and

treatment sites (Holy Cross, St. Patrick's, Rietvlei, Cecilia Makhiwane, Frere, Dora Nginza and Livingstone

Hospitals, Ikhwezi Lokusa Wellness Center). In the TB hospitals inpatients are counseled and tested for

HIV, initiated on cotrimoxazole prophylaxis if they are found to be HIV-infected and if they are eligible,

Activity Narrative: started on antiretroviral treatment (ART). On discharge from TB hospitals, patients are linked to primary

health care clinics or nearest facility where they can access HIV and TB treatment services. In FY 2006,

Columbia began training of nurses, doctors and lay health workers on TB/HIV integration in both

programmatic and clinical aspects: active TB case finding among HIV-infected patients, ART for eligible

TB/HIV co-infected clients, and leveraging existing referral services to provide comprehensive HIV support.

In FY 2008 Columbia will continue to implement activities in these 3 TB hospitals and 38 HIV care and

treatment sites, for a total of 42 health facilities, in EC and KZN. Four new health facilities in Free State (FS)

will be identified in FY 2008 for TB/HIV support. In FY 2007, Columbia formed a new partnership with Yale

University AIDS Program in support of TB/HIV integration activities in Tugela Ferry, KZN, which will

continue in FY 2008.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: TB hospitals in Eastern Cape

Activities will include:

1. Provide ongoing TB/HIV clinical support by conducting didactic and onsite TB/HIV training for doctors,

nurses and lay health staff to improve knowledge and practice around managing TB/HIV patients. Provide

clinical mentorship through case presentations and discussion.

2. Continue to support the hiring and placement of doctors, nurses, and peer educators to improve uptake

of HIV counseling and testing and to increase enrollment of TB/HIV co-infected patients into ART.

3. Provide technical support for monitoring and evaluation (M&E) activities by implementing a system to

track/monitor referrals and patients between HIV and TB programs. This activity includes training and use of

the pre-ART and ART facility registers.

ACTIVITY 2: HIV Care and Treatment Sites

Activities in the 38 HIV care and treatment sites will be focused on strengthening:

1. TB case-finding among clients enrolled into HIV care and ART. Columbia is in the process of

implementing a facility held patient record that captures information on TB case finding within the patient

record. Columbia is training doctors and nurses in the supported facilities to use the patient record to

improve TB/HIV clinical care and treatment. These staff will be routinely mentored by Columbia nurse

mentors/clinical advisors.

2. Referral linkages with the TB program to initiate TB therapy for those in HIV care and/or ART. The

Columbia supported community health centers and primary health clinics (PHCs) with HIV care and

treatment services also have TB services on site where Columbia supports TB services by improving

referrals of TB/HIV co-infected clients on ART to on site TB services to receive TB treatment. This includes

development of a referral slip to the TB services and also ensuring the facility held patient record in the HIV

clinic is updated with the relevant TB information.

With FY 2008 reprogramming funding, Columbia will support infection control activities in the EC.

ACTIVITY 3: Yale University Partnership

Columbia will partner with the Yale University to develop the following services at the Church of Scotland

Hospital (COSH), Tugela Ferry:

1. Increase HIV counseling and testing (CT) of clients accessing TB services in the COSH. This will be

implemented through the introduction of various models of provider-initiated CT at the TB treatment

programs (drawing on experiences from other settings) that is inclusive of training of TB treatment staff in

HIV CT, training in HIV pre- and post-test counseling with establishment of strong linkages to laboratory HIV

diagnostic services, and training of TB treatment staff in the referral of TB patients to CT services.

2. Prevent the development of multidrug-resistant tuberculosis (MDR-TB) cases and improving treatment

completion rates by strengthening the existing TB DOTS program and integrating with HIV treatment. Under

the Yale partnership the program components for this specific program activity will include:

-Defining the baseline TB treatment completion and cure rates

-Overall program improvement by: providing routine HIV counseling and testing, developing effective TB

screening tools for HIV-infected patients, use of a standardized once-daily ARV regimen to be administered

concurrently with standard TB regimen for TB/HIV co-infected patients, using modified observed therapy,

family and community-based health workers as treatment supporters, providing TB treatment literacy

materials at ART initiation and training of case management teams to strengthen treatment follow-up and

completion by tracing defaulters in the community

3. Prevent nosocomial transmission of MDR-TB and extensively drug-resistant tuberculosis (XDR-TB) by

instituting infection control. This will include; a. evaluation of nosocomial spread of MDR and XDR-TB by

supporting sputum culture testing on all new and suspected TB cases (months 0, 2, 6), spoligotyping on

selected isolates and confirmed MDR-TB isolates to determine timing of acquisition and possibility of

nosocomial spread; spoligotyping of sensitive TB isolates and non HIV infected TB patients to determine if

KZN strain confined only to MDR and XDR and HIV or more widely distributed; b. Improve program

implementation by screening HIV-infected patients for TB, creating isolation facilities, improving air handling

within wards, educating healthcare staff in personal infection control practices and provide personal

protective equipment to minimize their risk, minimizing number of TB patients hospitalized, decreasing the

length of stay for all TB patients by developing and evaluating protocols for earlier hospital discharge, and

increase community-based care for TB treatment to absorb shift of TB care from inpatient to outpatient

Activity Narrative: setting.

4. Implement a decentralized MDR-TB treatment program. Patients found to have MDR-TB travel 120 km to

Durban to be admitted to King George V Hospital for second line therapy however the average waiting time

for a bed is 2-3 weeks. Key components would include: Sputum culture testing on all suspected and

confirmed TB cases in both inpatient and outpatient settings to identify cases of MDR-TB; Initiate a

treatment program to provide second line TB treatment locally; Develop a contact tracing program for all

MDR-TB and re-treatment cases to identify MDR-TB cases in community; spoligotyping MDR-TB isolates

5. Screen for active TB among HIV-infected patients through use of standardized screening questionnaires

and/or algorithms by all types of healthcare workers followed by standardized follow-up and diagnostic

algorithms of TB suspects and supported by the introduction of effective recording and reporting systems for

these activities.

Originally support to COSH was to include a PHE, but as this PHE was not approved, the funding is

reprogrammed back into the TB-HIV services to support service delivery in Tugela Ferry, in partnership with

Yale.

ACTIVITY 4: Scale up use of TB screening tool at HIV care and treatment facilities

Columbia will ensure that the PHC record (which incorporates TB signs and symptoms) is used at all

supported HIV care and treatment outlets. This TB screening tool will improve the quality of TB services

provided at the HIV clinic and also increase TB case finding in this high risk population. In addition, this

activity will dovetail with the proposed TB screening PHE about to be conducted in select health facilities.

ACTIVITY 5: Targeted TB prevention and control strategies

TB infection control activities targeted at 2 health facilities in EC (Motherwell Community Health Centre in

Port Elizabeth and Cecilia Makiwane Hospital in East London). The objective of this activity is to minimize

the risk of nosocomial TB transmission through minimizing source infectiousness. Activities include:

assessing TB infection control procedures for gaps and needs for each facility; establishing work practice,

clinical management and administrative procedures to minimize the nosocomial transmission of TB;

assessing the impact of these interventions; and developing practice manual and educational tools for

health care workers. New health facilities in FS will be determined in collaboration with the Health

Department to receive support for TB/HIV and proposed activities to be implemented include those outlined

above.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Health-related Wraparound Programs

* Child Survival Activities

Refugees/Internally Displaced Persons

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $240,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $30,000

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Estimated amount of funding that is planned for Water $30,000

Table 3.3.12: