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: 2007 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
BACKGROUND: TB Care Association will coordinate this activity in FY 2009 and University of the Western
Cape (not the Medical Research Council) will be the sub-partner.
ACTIVITY 1: Community TB/HIV Case Finding and Case Holding Among Women Participating in PMTCT
Rather than using community peer supporters, the project will train multi-skilled community health workers
to identify suspected TB cases in the households of pregnant mothers and other households and refer them
to the health services for TB diagnosis. They will encourage all community members, including pregnant
women, their partners and HIV-exposed infants to be tested for HIV and to access health services for
appropriate prophylaxis and antiretroviral therapy (ART). They will also provide adherence support for
household members on prophylaxis or treatment related to TB or HIV. The impact of community support on
integrated PMTCT/TB/HIV activities will be assessed by monitoring case finding and adherence. Through
funding from the TB/HIV program area, community outreach teams will be hired with an enrolled nurse
acting as a community health facilitator responsible for coordinating and supervising community health
workers and linking the community and the facility.
ACTIVITY 2: Integration of PMTCT with TB/HIV and ART Services
Additional to the activities listed in the COP 2008, the site manager will provide support to 24 health facilities
to implement provincially approved recording and reporting systems for voluntary counseling and testing,
PMTCT, HIV care and ART. She will train health workers and district coordinators on the collection, analysis
and quarterly reporting of key indicators for PMTCT/TB/HIV integrated activities.
---------------------------------------
SUMMARY:
TB Care Association's activities will be carried out to increase TB and HIV case finding and case holding
through community peer supporters as well as to support facility-based integration of prevention of mother-
to-child transmission (PMTCT) with TB/HIV and antiretroviral treatment (ART) services. The TB CARE
Association PMTCT project emphasizes gender issues by increasing access to PMTCT, TB/HIV and ART
services for women and their partners. A second emphasis area is in-service training. The target
populations for this activity include children under the age of five years, pregnant women, discordant
couples, people living with HIV and AIDS, families. The emphasis area for this program include gender, by
addressing gender equity in HIV and AIDS programs, human capacity development by providing in-service
training and local organization capacity building.
BACKGROUND
Although TB CARE Association is a new FY 2008 PMTCT partner, this is an ongoing activity. TB Care
Association was founded in March 1929 as a social support group for TB sufferers in Cape Town. The core
role of TB Care has remained largely unchanged in the intervening 70 years. TB Care provides a
comprehensive, developmental social support service to TB sufferers and their families in the City of Cape
Town. TB care operates from the community health centres which patients to take their daily treatment on
the street where they live under the supervision of specially trained community treatment supporters. In
FY07, TB CARE Association partnered with the Medical Research Council in FY 2007 and was a sub-
partner implementing these PMTCT activities. In FY 2008 PEPFAR funding will be coordinated by TB Care
Association and the Medical Research Council will be a sub-partner. The activity will be coordinated with
the provincial and district Departments of Health. TB CARE Association partnered with the Medical
Research Council in FY 2007 and was a sub-partner implementing this activity. FY 2008 PEPFAR funding
will be coordinated by TB Care Association and the Medical Research Council will be a sub-partner. The
activity will be coordinated with the provincial and district Departments of Health.
ACTIVITIES AND EXPECTED RESULTS
The Good Start Community Intervention Project (PEPFAR-funded since FY 2005) has trained and
employed community peer supporters to provide household-level support to improve postnatal care of
mothers served by PMTCT programs. In the TB/HIV component of the Community Intervention Project,
community peer supporters will identify suspected TB cases in the households of pregnant mothers and
refer them to the health services for TB diagnosis. They will encourage pregnant women, their partners and
HIV-exposed infants to be tested for HIV and to access health services for appropriate prophylaxis and
antiretroviral therapy (ART). They will also provide adherence support for household members on
prophylaxis or treatment related to TB or HIV.
This project will support a comprehensive best-practice approach to integrate PMTCT into TB/HIV care in
Sisonke District in KwaZulu-Natal. The project will improve screening of pregnant women for TB and HIV as
part of antenatal care. HIV-infected pregnant women will routinely have CD4 counts assessed and be
screened for full antiretroviral treatment. HIV-infected mothers will also be screened for prophylaxis
(isoniazid preventive therapy and cotrimoxazole prophylaxis). HIV-exposed infants will receive
cotrimoxazole prophylaxis and will have a PCR test at their six week immunization visit. PCR-positive
infants will have a CD4% test to determine their eligibility for ART. The project will establish a best practice
approach to integrated TB/HIV prevention and care in PMTCT services and will provide training to PMTCT
health care providers on integrated TB/HIV care. Project results and lessons learned will be shared with the
national and provincial Departments of Health to inform existing policies and guidelines on TB/HIV care. TB
patients and PLHIV are the principal target populations and include pregnant women (referred to PMTCT
Activity Narrative: services) and children (receiving ARVs if indicated).
These activities will contribute to PEPFAR's 2-7-10 prevention goals by reducing mother-to-child HIV
transmission. The prevention outcomes are also in line with the USG goal of integrating TB and HIV
services within primary care systems in South Africa.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13837
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13837 13837.08 HHS/Centers for Tuberculosis Care 6628 6183.08 $125,000
Disease Control & Association
Prevention
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
* Reducing violence and coercion
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $71,034
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
TB Care Association (TBCA) activities noted in the FY 2008 COP will continue in FY 2009. Activities are
planned and implemented in partnership with Department of Health coordinators for HIV/AIDS, STIs and TB
(HAST) at all levels of government.
The following additional activities will be occurring in FY 2009:
ACTIVITY 4: Provision of accredited training by becoming an Health and Welfare Sector Education and
Training Authority (HWSETA)-accredited provider
In FY 2007/08, TBCA began the process of seeking formal accreditation as a training provider with
HWSETA. It is anticipated that in FY 2008/09, approval will be granted and provision of accredited trainings
at National Qualifications Framework (NQF) levels 4 and 5 will be offered to community health workers, non
-governmental organizations, and provincial governments as needs are identified. Focus of trainings
offered will be on educating and working closely with the community with regard to sexually transmitted
infections (STIs), including HIV; applying listening skills in the care and support environment; providing
information about TB; developing and implementing a client antiretroviral (ARV) treatment plan; health
promotion in the community; and provision of primary health care in the community.
ACTIVITY 5: Support to Brooklyn Chest Hospital for Management of multi-drug resistant (MDR) / extremely
drug resistant (XDR) TB and HIV
Clinical and psychosocial support will be provided to Brooklyn Chest TB Hospital in the form of two social
auxiliary workers who will counsel MDR/XDR-TB patients and run group sessions in the hospital wards. We
will employ two lay counselors who will counsel MDR-TB patients attending the outpatient department.
These staff will be report to hospital management and be fully integrated into a multidisciplinary team.
Training and mentorship will be provided for clinicians to improve HIV care and treatment for co-infected
hospitalized patients. Funds will be used to improve the physical environment of the hospital to be more
pleasant for patients who are hospitalized for long periods of time. Referral systems will be put in place to
ensure that discharged patients complete their treatment, attend follow up visits and receive community-
based adherence support, for both TB and HIV.
-------------------------------
This is a new activity in FY 2008.
TB Care Association (TBCA) will support care and treatment services at three hospital-based clinics and
eight primary health clinics (PHC). Training and mentoring on topics to ensure provision of quality care will
be provided: clinical care, social support, monitoring and evaluation, and health system support. Referral
systems, including community adherence support and coordination of services between hospital and PHC,
will be strengthened through human resource, capacity development and programmatic support. People
infected and affected by HIV, including healthcare providers will be the beneficiaries of this PEPFAR-
supported program.
BACKGROUND:
TBCA has been providing community-based counseling, emergency material relief, and support, and TB
treatment support in the Western Cape since 1992. Support for HIV care and treatment services in the West
Coast Winelands is a new initiative. Training and mentoring activities will be done in collaboration with the
Department of Health (DOH). Support has been requested by the Western Cape province and all program
activities will occur within public health facilities. Essential drugs and ARVs will be procured through DOH,
and the National Health Laboratory Service (NHLS), through the DOH, will provide laboratory services. The
Western Cape has identified the West Coast Winelands as a district that would benefit from technical
assistance because the burden of TB with HIV co-infection is high. In Malmesbury, clinical support will be
provided at Swartland Hospital (ART site) and Dorp and West Bank clinics. In Saldanha, clinical support will
be provided in Dorp and Diaz Ville clinics. In Vredenburg, clinical support will be provided in Vredenburg
Hospital (ART site) and Dorp and Hannah Coetzee clinics. In Atlantis, clinical support will be provided in
Wesfleur Hospital (ART site) and Saxon Sea and Protea Park clinics. In summary, three hospitals and eight
clinics will be supported in the Western Cape province. TBCA is exploring the possibility of expanding
activities to the Northern Cape province.
ACTIVITY 1: Integration of Services and Quality Assurance
The first activity is human capacity development, focusing on integration of the HIV program into primary
healthcare services, including pediatrics. Under the guidance of the clinical coordinator, two TBCA-
employed nurse mentors with extensive experience in HIV care and treatment will work closely with the
DOH to identify training/mentoring needs. DOH clinicians will be trained through didactic and mentoring
sessions, on topics including identification and counseling of victims of abuse, reducing stigma, clinical
management of patients, integration of services, and clinical management of TB and HIV. HIV testing, care
and treatment will be strengthened by ensuring all clinicians involved in patient care (doctors, nurses,
pharmacists) in all areas of patient care services (outpatient services, pediatrics, TB, family planning,
antenatal services) are clinically competent in managing HIV-infected clients. A quality assurance program
will be implemented through support of the DOH multi-disciplinary team meetings, provision of clinical
updates and in-service mentoring, and introduction of a formal routine chart review, in collaboration with
clinic managers. National and provincial standards of care and guidelines will be followed. TBCA will work
closely with DOH to facilitate coordination of services among the three hospitals and their affiliated clinics,
anticipating provision of ART at clinic level by end of FY 2008. Systems support will be provided as needs
Activity Narrative: are identified (e.g., down referral of drugs, strengthening of patient referrals). Ten percent of the budget will
be spent on promoting pediatric services.
ACTIVITY 2: Community Mobilization Related to Care and Treatment
The second activity is to strengthen community involvement in HIV care and treatment services through
outreach services provided by community health workers (CHW). In consultation with the DOH, TBCA will
employ one community team leader and ten CHWs for each clinical site supported. The Western Cape
province has plans to expand CHW programs, therefore sustainability will be addressed. TBCA will train the
CHWs on priority health issues so that they are multi-skilled to provide integrated community care. The role
of the CHWs will be to promote information, education, communication (IEC) in the communities they serve.
IEC activities aim to increase awareness of the availability of comprehensive HIV services; tp promote HIV
prevention, including prevention with positives; to ensure family-centered care through referrals of family
members affected by HIV; and to ensure community-level follow-up of patients who have not returned for
routine care (in collaboration with M&E). Existing community groups will be encouraged to participate, and
through collaboration with existing home-based care programs, community-based wellness programs will
encourage patients to seek routine care. Peer counseling and education provided by the CHWs will target
male behaviors. The team leaders and TBCA-employed nurse mentors who supervise them will facilitate
links with social development programs, nutritional support programs, and other governmental and non-
governmental services.
ACTIVITY 3: Strengthening Clinical Services through Monitoring and Evaluation (M&E) Support
The final activity is to assist with monitoring and evaluation of the national comprehensive HIV care and
treatment program at supported sites. TBCA will employ a data capturer at each site to assist with TB/HIV
reporting. Coordination of M&E with clinical services will ensure prompt follow-up of patients enrolled in care
who do not return to clinic. Data collection will be facilitated through provision of computers to each clinic.
Training needs related to capturing quality data will be identified and addressed. Gender equity in the HIV
program will be revealed through collection of data showing breakdown of women and men receiving
prevention, care and treatment services. The data capturers will liaise with community team leaders to
follow up patients referred from TBCA-supported voluntary counseling and testing sites that tested HIV-
positive as well as those who have TB or STI symptoms.
These results contribute to the PEPFAR 2-7-10 goals by improving access to care and treatment services,
thereby increasing the number of persons receiving ARV services.
Continuing Activity: 13839
13839 13839.08 HHS/Centers for Tuberculosis Care 6628 6183.08 $910,000
* Safe Motherhood
Estimated amount of funding that is planned for Human Capacity Development $40,500
Table 3.3.09:
This is a new activity in FY 2009. Activities are planned and implemented in partnership with Department of
Health coordinators for HIV and AIDS, STIs and TB (HAST) at all levels of government. TB Care
Association (TBCA) will be supporting 11 ART sites in two provinces (Western Cape and KwaZulu-Natal)
through clinical care support and/or community-based adherence support: two in West Coast District; five in
Cape Town Metro District; one TB Hospital in Cape Town, and three in Sisonke District, KwaZulu-Natal
(KZN). In FY 2009/10, TBCA will provide support to an additional three sites in Enhlanzeni district,
Mpumalanga. Training and mentoring on topics to ensure provision of quality care will be provided: clinical
care, social support, monitoring and evaluation (M&E), and health system support. Referral systems,
including community adherence support and coordination of services between hospital and primary health
care (PHC), will be strengthened through human resources, capacity development and programmatic
support. Children infected and affected by HIV will be the beneficiaries of this PEPFAR-supported program.
TBCA has been providing community-based counseling, support, and TB treatment support in the Western
Cape since 1992. Support for HIV care and treatment services in KwaZulu-Natal and Mpumalanga is a new
initiative. Training and mentoring activities will be done in collaboration with the National Department of
Health (NDOH). Support has been requested by the provincial Departments of Health and all program
activities will occur within public health facilities. Essential drugs and ARVs will be procured through NDOH,
and the National Health Laboratory Service (NHLS), through the NDOH, will provide laboratory services.
The first activity is human capacity development, focusing on integration of the pediatric HIV program into
primary healthcare services. Under the guidance of the clinical coordinator, six TBCA-employed nurse
mentors with extensive experience in HIV care and treatment will work closely with the NDOH to identify
training/mentoring needs. NDOH clinicians will be trained through didactic and mentoring sessions, on
topics including identification and counseling of victims of abuse, early infant diagnosis, provision of
cotrimoxazole prophylaxis for HIV-exposed and infected infants, TB screening and assessment in children,
reducing stigma, and integration of services. HIV testing, care and treatment will be strengthened by
ensuring all clinicians involved in patient care (doctors, nurses, pharmacists) in all areas of patient care
services (outpatient services, pediatrics, TB, family planning, antenatal services) are clinically competent in
managing HIV-infected children. A quality assurance program will be implemented through support of the
NDOH multi-disciplinary team meetings, provision of clinical updates and in-service mentoring, and
introduction of a formal routine chart review, in collaboration with clinic managers. National and provincial
standards of care and guidelines will be followed.
ACTIVITY 2: Community-based Adherence Support
This activity will strengthen community involvement in HIV care and treatment services through outreach
services provided by community health workers (CHWs). In consultation with the DOH, TBCA has either
directly employed or will employ one community team leader (CTL) per facility supported and supports
CHWs in each catchment area. Community-based adherence support is provided through sub-contracts
with home-based care organizations operable in the community, or directly by TBCA. TBCA trains the
of the CHWs is to promote information, education, communication (IEC) in the communities they serve. IEC
activities aim to increase awareness of the availability of comprehensive HIV services; to promote HIV
encourage patients to seek routine care. The team leaders and TBCA-employed nurse mentors facilitate
TBCA assists with monitoring and evaluation activities of the national comprehensive HIV care and
treatment program at supported sites. The above mentioned facility-based CTL assists with TB/HIV
reporting. Coordination of M&E with clinical services will ensure prompt follow-up of children enrolled in care
and treatment and who do not return to clinic. Data collection is facilitated through provision of computers to
each clinic. Training needs related to capturing quality data will be identified and addressed. Gender equity
in the HIV program will be revealed through collection of data showing breakdown of males and females
receiving prevention, care and treatment services. The CTLs have direct communication with CHWs to
ensure follow-up of children referred for services.
ACTIVITY 4: Provision of South African Qualifications Authority (SAQA) accredited training
In FY 2007/08, TBCA began the process of seeking formal accreditation as a training provider with the
Health and Welfare Sector Education and Training Authority (HWSETA). It is anticipated that in FY
2008/09, approval will be granted and provision of accredited trainings at National Qualifications Framework
(NQF) level four and five will be offered to community health workers, non-governmental organizations, and
provincial governments as needs are identified. The goal of training will be to improve pediatric TB and HIV
case finding and adherence.
ACTIVITY 5: Support to Brooklyn Chest Hospital for Management of Multi-Drug Resistant (MDR)/Extensive
Activity Narrative: Drug Resistant (XDR) TB and HIV
auxiliary workers who will counsel MDR/XDRTB patients and run group sessions in the hospital wards. We
will employ two lay counselors who will counsel MDRTB patients attending the outpatients department.
hospitalized children. TB Care employs three edu-care teachers to provide early childhood development
and stimulation to hospitalized pediatric TB and TB/HIV patients. There are currently 48 children
hospitalized, 70% of whom are between three months and five years old. Many have TB and meningitis with
mental disabilities due to late presentation and diagnosis. Funds will be used to improve the physical
environment of the hospital to be more pleasant for patients who are hospitalized for long periods of time.
Referral systems will be put in place to ensure that discharged pediatric patients complete their treatment,
attend follow up visits and receive community-based adherence support.
New/Continuing Activity: New Activity
Continuing Activity:
Estimated amount of funding that is planned for Human Capacity Development $10,000
Table 3.3.11:
Project Integrate will expand to Sisonke district, KwaZulu-Natal (KZN) in FY 2008 and Ehlanzeni district,
Mpumalanga in FY 2009.
ACTIVITY 1: A tracking system is used to ensure that referred clients visit health facilities. Clients receive
referral cards that are left at the clinic, reviewed by community team leaders (CTLs) who meet with
community health workers (CHWs) weekly to check if all referred clients attended the clinic. CHWs trace
clients and encourage them to attend.
The collection of sputa at non-clinical VCT sites in collaboration with the Cape Town and Metro health
services will be piloted. Two sputum samples will be collected from TB suspects and sent for smear
microscopy (TB culture for HIV-infected clients). Clients will be asked to return for their results in 3 days and
sign an informed consent to allow a CHW to visit at home. Clients with positive sputum smears or who
remain symptomatic with negative sputum smears will be referred to a clinic. Tuberculosis Care Association
(TBCA) data capturers and CTLs will track referrals to ensure continuity of care. Due to limited space in
facilities, TBCA will hire one CTL per facility who will work as a data capturer as well. TBCA will ensure the
implementation of CT quality assurance programs aligned with national standards.
ACTIVITY 2: TBCA will assist the Department of Health (DOH) in accrediting TB clinical and primary care
facilities to provide antiretroviral treatment (ART). The nurse mentors will be trained as trainers for PALSA
Plus and STRETCH, approved by the DOH.
ACTIVITY 3: Continuity of care for co-infected patients will be ensured by improving referral systems.
CHWs provide adherence support for patients on TB and ART, and will promote VCT, screen for TB, refer
TB suspects and recall patients who miss appointments for care and treatment. CTLs provide adherence
counseling for TB and ART and refer patients to CHWs for adherence support.
ACTIVITY 4: TBCA will support the DOH to conduct TB/HIV/STI audits. If requested by the DOH, the
School of Public Health, UWC will be subcontracted. The audit tool will be modified for rural areas and be
used at baseline, and after a year, in KZN.
ACTIVITY 5: TBCA will sub-contract the Health Systems Research Unit, MRC to monitor and evaluate
integrated TB/HIV adherence support. The Health Economics Unit of the University of Cape Town will be
sub-contracted to measure the cost-effectiveness of integrated adherence support.
NEW ACTIVITIES:
An infection control nurse will coordinate home assessments and counseling of MDR/XDR-TB patients and
their families. Under direction of the DOH, the nurse will assist facilities to conduct risk assessments and
develop infection control plans based on national and Global TB/HIV Working Group guidelines. These
include advocacy campaigns, infection control, safe sputum collection, cough hygiene, triaging TB suspects,
assuring rapid diagnosis and initiation of treatment, improving room air ventilation, protecting health
workers, building capacity, and monitoring infection control. Community-based infection control plans
include educational materials promoting cough hygiene; open windows; early identification of TB suspects;
early diagnosis and treatment; and completing treatment. TBCA is developing a workplace policy for its
health workers who will be offered VCT and TB screening. Eligible HIV-infected workers will be offered IPT.
TBCA will support Brooklyn Chest Hospital with two auxiliary social workers who will counsel MDR/XDR-TB
patients and run group sessions in the wards, and two lay counselors who will provide adherence
counseling to MDR-TB patients. Clinicians will be trained and mentored to improve HIV care and treatment
for hospitalized TB patients. Three educare teachers will provide early childhood development to
hospitalized pediatric TB patients. Many have TB meningitis and mental disabilities due to late presentation.
The hospital will be upgraded to accommodate long-term patients. Referral systems will ensure that
discharged MDR/XDR-TB patients complete their treatment, attend follow up visits and receive community-
based adherence support. TBCA will support Cape Town in piloting community-based MDR-TB treatment.
TBCA will provide TB/HIV education, VCT, TB screening linked to VCT, clinical mentorship, adherence
support and referral to offenders who are discharged on TB treatment or ART. An application has been
submitted to the Western Cape Correctional Services for quality assurance approval.
TB patients identify a support person in the workplace and TBCA's Health Promotion Coordinator provides
on-site training and education on TB and HIV to the supporters and colleagues.
TBCA hopes to receive accreditation as a training provider with Health and Welfare Sector Education and
Training Authority in FY 2009. Trainings at will be offered to CHWs, NGOs, and provincial governments on
TB and HIV prevention and adherence support.
----------
Activities will be carried out to screen people for TB in non-clinical counseling and testing (CT) and in
clinical sites and to ensure referral for care. The project will support care and treatment services at three
hospital-based clinics and eight primary health clinics (PHC). Clinical training and mentorship will be
provided to screen HIV-infected people for TB, provide appropriate TB treatment, and to screen for isoniazid
preventive therapy (IPT) to prevent TB. CHWs will educate community members about the symptoms of TB
and the importance of seeking care and completing TB treatment. They will screen community members for
TB symptoms of TB and STIs and refer symptomatic people to health services. Community adherence
support will be provided by CHWs for TB treatment, for prophylaxis (IPT and cotrimoxazole) and for ART.
The adherence support model used for ART will be piloted with TB patients. BACKGROUND: TB Care
Activity Narrative: Association (TBCA) will implement this activity in collaboration with provincial and district departments of
health. TBCA has been providing community-based counseling, emergency material relief and TB treatment
support in the Western Cape since 1992. The Western Cape province has requested support from TBCA for
the West Coast Winelands district because the burden of TB with HIV coinfection is high. TBCA is exploring
the possibility of expanding activities to the Northern Cape province as well.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: TB and STI Case Finding Linked to VCT.
VCT will be provided in non-clinical sites including workplaces. During CT, counselors will routinely screen
for TB and STIs, utilizing a questionnaire. Clients who have TB symptoms will be given 2 sputum containers
by the nurse counselor and a referral letter to go immediately to their nearest health facility. Clients with STI
symptoms will also be given a referral letter to their nearest health facility. The CT register will have
additional columns to indicate if clients have TB or STI symptoms as well as a column to determine if the
patient presents at the health facility to which they are referred. PEPFAR funds will be used to employ one
data capturer for each supported health facility to assist with recording laboratory results and to trace
people with positive TB smears to ensure that they are initiated on treatment. The data capturer will also be
responsible for informing the CT teams and community health workers (CHWs) if referred patients attend
the facilities to which they have been referred.
ACTIVITY 2: Improve the Quality of TB/HIV Care and Treatment.
TB/HIV clinical training & mentoring will be provided for all relevant health care workers, in accordance with
the South African National TB Control Program guidelines and national guidelines for HIV care, utilizing
materials adopted by the Western Cape Department of Health (i.e. PALSA plus). Training will focus on the
co-management of TB, HIV and STIs. Health care providers will also be trained to routinely counsel TB
patients about the benefits of knowing their HIV status and to give patients the opportunity to test or to opt
out of testing. HIV-infected TB patients will be offered cotrimoxazole prophylaxis and will have a CD4 count
done as part of screening for antiretroviral therapy (ART). The new NTCP TB register will be introduced to
register all TB patients, to document their HIV status, and to record which TB patients are started on
cotrimoxazole and screened for ART. Health workers who provide care for TB patients will be trained on the
prevention and management of opportunistic infections, on ART and on the new TB register. Health
workers, who provide HIV care, including pediatric services, will be trained to screen all HIV-infected clients
for TB and to screen asymptomatic patients for IPT. HIV-infected individuals with symptoms of TB will be
provided with diagnostic services at the level of care where screened (i.e. ART clinic), including TB culture.
Recording and reporting of TB status will occur at the closest TB treatment clinic. TBCA will work closely
with DOH to integrate services, to allow co-infected patients to seek care at one point of service. Under the
guidance of the clinical coordinator, two nurse mentors will visit health facilities on a regular basis to provide
supervisory support to ensure optimal co-management of HIV, TB and STIs. These visits will reinforce
didactic training and will assist health staff in facilities to solve clinical problems they encounter through
case studies. Nurse mentors will also liaise with the in each facility to assist with monitoring referrals to
ensure a continuum of care between communities, clinics and hospitals. Training and mentoring initiatives
will address clinical issues identified through quality assurance reviews.
ACTIVITY 3: Improve TB and ART Case Holding through Community-based Adherence Support.
The policy of the Western Cape Department of Health is to provide funding for multi-skilled community
health workers (CHWs) rather than community workers that focus on vertical program. CHWs will be trained
on priority health issues to provide integrated community care. They will be responsible for the following
activities: HIV prevention and condom distribution; Education on STI symptoms and the importance of
seeking treatment for STIs; Promotion of HIV voluntary counseling and testing, particularly for pregnant
women; Infant feeding counseling; Education on TB symptoms and the importance of seeking treatment for
TB; Screening community members for TB and STI symptoms and referring suspects to health facilities;
Education on the importance of adhering to prophylaxis (isoniazid and cotrimoxazole), antiretroviral
treatment and TB treatment; Monitoring and providing adherence support to TB patients and HIV-infected
clients taking prophylaxis or ARVs with modified directly observed treatment (DOT); Home-based care;
Identification of malnourished children and referral to health facilities; Assistance in obtaining social support
grants; Referral to support services to address substance abuse and domestic violence; Stigma and
discrimination towards people living with HIV will be addressed through the efforts of community mobilizers
and CHWs who will increase awareness of HIV in their communities utilizing IEC strategies. The TB
Alliance DOTS Support Association (TADSA) will be a partner in the formative assessment of adherence
support services. The first step will be to identify existing organizations that are providing home-based care
services in the area. Where possible, existing home-based carers will be recruited and trained to provide
more comprehensive care as CHWs. Carers who are already engaged in home-based care and who
receive a stipend from the provincial government will integrate the new activities into their existing functions.
In areas where there are no home-based care organizations, CHWs will be recruited from the communities
in the catchment areas of the facilities. Stipends for CHWs will be funded from the PEPFAR budget, at a
similar rate to what the Provincial Government pays. This will ensure sustainability for when the program is
taken over by the government. TBCA has a well developed system of financial controls for managing the
payment of stipends. Approximately ten CHWs and one community team leader will be employed per health
facility, depending on the estimated burden of TB & HIV in the community (see Activity 4). Health facilities
will inform TBCA community team leaders of all patients who are initiated on prophylaxis, ART or TB
treatment. Community team leaders will identify a CHW who lives close to the patient and arrange for the
CHW to meet the patient. Patients on treatment will be visited by a CHW daily for the first two weeks of
treatment, then weekly up to eight weeks of treatment, then every two weeks (modified DOT). CHWs will
identify any potential adherence problems, try to address them with the patient and inform the health
professionals of issues that need to be addressed (e.g., side effects).
ACTIVITY 4: Assessment of Quality of Services.
Activity Narrative: The University of the Western Cape, School of Public Health, will be sub-contracted to evaluate the quality
of TB/HIV/STI services. This will be done by conducting facility audits using an integrated TB/HIV/STI
evaluation tool at the beginning of the project, at one year and at the end of the project. The quality of
services will also be assessed through routine TB and HIV monitoring and evaluation. Existing forms and
registers will be reviewed and, if necessary, be revised, piloted and implemented to collect information for
key indicators. District and facility managers will be assisted in monitoring progress in achieving agreed
upon targets. A baseline survey will be done to assess demographics, TB and HIV education and stigma as
well as health seeking behaviors and uptake of VCT. This survey will be repeated at the end of the project
to assess the impact of the services provided.
ACTIVITY 5: Improving HIV and TB treatment Adherence and Outcomes.
Drawing on ART adherence promotion models this project evaluates a pilot program using lay health
workers to support adherence to TB treatment in Cape Town. The pilot replicates what are seen as the key
elements of the ART adherence model: intensive treatment counseling and preparation sessions by trained
lay adherence counselors; the use of a 'buddy' to support patients; and frequent lay treatment supporters
visits to help patients manage problems that arise during treatment. A qualitative assessment will be done
of the feasibility and acceptability of the adherence model. TB treatment outcomes using the adherence
model will be compared with treatment outcomes with the standard of care (directly observed treatment).
Workplace Programs
Estimated amount of funding that is planned for Human Capacity Development $80,000
Table 3.3.12:
SUMMARY AND BACKGROUND:
All of the above activities will continue in FY 2008 and FY 2009. Activities are planned and implemented in
partnership with Department of Health coordinators for HIV/AIDS, sexually transmitted infections (STIs) and
tuberculosis (TB) (HAST) at all levels of government. Activities will be in line with the new World Health
Organizatino (WHO) guidelines for counseling and testing (CT).
ACTIVITY 1: Non-clinical CT
The Tuberculosis Care Association (TBCA) had originally planned to hire a community team leader and a
data capturer for each supported health facility. Due to limited space in most health facilities, TBCA will hire
only one community team leader per health facility who will perform the functions of a data capturer as well.
In FY 2008 and FY 2009, TBCA will hire five voluntary counseling and testing (VCT) teams in Sisonke
district, KwaZulu-Natal. These teams will form part of a community outreach team that the district has asked
TBCA to pilot. Community outreach teams were proposed in the provincial community-based services plan
that has been approved but has not been funded this financial year. Should the pilot be successful, it is
likely that the province will create posts for these teams which would ensure sustainability.
TBCA, in collaboration with the Department of Health (DOH) and other NGOs will ensure the
implementation of quality assurance (QA) programs for HIV CT in accordance with national QA standards in
clinical and non-clinical settings. This will include a program of rapid test QA in which 10% of patients will
have blood collected for laboratory-based ELISA for a period of one month biannually. Additionally it will
include proficiency testing for those conducting rapid tests and regular on-site monitoring.
TBCA will provide VCT linked with TB and STI screening for officials and offenders in correctional services.
Clients who test HIV-infected will be referred for HIV care, TB suspects will be referred for TB investigation
and clients with STI symptoms will be referred for STI syndromic management.
ACTIVITY 2: Training and Supervision of Counselors
In collaboration with the Department of Health, TBCA will offer to train health care providers in clinics to
provide 'routine offer of HIV CT to TB patients, pregnant women, family planning clients and STI clients.
Given that South Africa has a generalised HIV epidemic, TBCA will consult with the Department of Health to
consider recommending HIV CT to all patients attending health facilities. The emphasis will be on training
health care workers to make HIV testing an integral part of routine medical care, without diverting clinical
staff from their other medical duties.
Refresher training will be provided to counselors regarding acute HIV infection and the window period so
that they can appropriately advise patients whether a repeat test is required in three months. Advanced
counseling training will be provided to counsel couples, families, youth and children as well as clients
affected by substance abuse and domestic violence. Advanced training on adherence counseling for TB
and antiretroviral treatment (ART) will also be provided. All counseling staff will be trained to complete CT
registers.
Professional nurse counselors will be trained to complete monthly reports of key indicators, including the
proportion of clients successfully referred for HIV care, TB investigation and treatment and STI syndromic
management. They will also be trained to properly perform and interpret rapid HIV testing and to implement
quality assurance protocols.
ACTIVITY 3: Measuring Costs and Assessing Cost-effectiveness of Non-Clinical HIV Counseling and
Testing
The economic analysis will be informed by technical assistance from the Centers for Disease Control and
Prevention (CDC) (eg, Uganda study). This activity will be completed in FY 2008.
--------------------------------
This project will increase access to HIV voluntary counseling and testing (CT)
in non-clinical sites and in facilities with a large number of TB cases. Two
mobile services and fixed non-clinical sites in easily accessible areas such as
taxi ranks and shopping areas will provide CT services. TBCA will also assist
the district in training and supervising counselors in clinical sites. Target
populations include the general population, at risk populations, the business
community, discordant couples, pregnant women and orphans and vulnerable
children.
TB Care Association (TBCA) has been providing community-based counseling,
emergency material relief, and support, and TB treatment support in the Western Cape since 1992.
Provision of non-clinical CT and counseling mentorship are new initiatives that
will be conducted in collaboration with the Department of Health. Women are at
higher risk for HIV infection. The provision of CT will therefore benefit women
who test HIV-infected and will access care and support. Men utilize health
Activity Narrative: services less than women and will therefore benefit from the provision of CT in
non-clinical CT sites. TBCA is exploring the possibility of expanding
ACTIVITY 1: Non-clinical Counseling and Testing
TBCA will hold consultations will be held with key stakeholders from government,
non-governmental organizations, community-based organizations and the private
sector, to identify sites in which to establish new services or strengthen
existing services for HIV counseling and testing. The West Coast Winelands
District has suggested that non-clinical CT sites should be established in the
taxi ranks in Malmesbury, Saldanha and Vredenburg. Additionally, two mobile CT
teams will provide services in underserved rural and peri-urban areas and in
private sector workplaces such as farms and factories. In small towns, mobile CT
teams will conduct door-to-door community-based CT. A "100% cover"
campaign will be piloted. This campaign aims to counsel and test all the
population over 14 years and to promote 100% condom use. PEPFAR funds will be
used to purchase two vehicles for the mobile CT teams.
Counseling and testing teams will be recruited, hired and trained in
collaboration with NGOs that are already providing CT services in the area.
Each team will include two lay counselors, one nurse counselor (who will also
do the HIV testing) and a community mobilizer funded by PEPFAR. Five CT teams
will be hired and trained in the first year of the project.
Gender equity in HIV and AIDS programs will be addressed through the provision
of non-clinical CT that will increase access to men. The education provided by
the community mobilizer and the risk reduction counseling will help to change
male norms and behaviors and reduce violence and coercion. As more people
access CT, it is hoped that there will be more discussion of HIV in communities
and that stigma and discrimination towards people living with HIV will
decrease.
The community mobilizer will provide education on HIV prevention (abstinence,
being faithful, using condoms), the benefits of knowing your HIV status, TB and
STI symptoms and the importance of being treated for TB and STIs. Couples will
be encouraged to go for counseling together. The community mobilizer will also
distribute condoms.
Counseling and testing will be provided according to
national and international standards. Counseling will focus on personalized
risk assessment and risk reduction. Correct condom use will be demonstrated and
condoms, procured by the Department of Health will be dispensed. HIV testing
will be informed, voluntary and consented. Rapid test kits will be provided by
the National Department of Health (NDOH).
Any individual who agrees to HIV counseling and testing will also be screened
for tuberculosis and sexually transmitted infections (see TB/HIV Program
Area). If symptoms are present, they will
be referred to the nearest clinic/hospital where further investigations and/or
treatment will be available. All
HIV-infected clients will be referred for HIV clinical care and support
services and will be counseled on preventing transmission with a specific
focus on discordant couples. The CT register will have additional columns to
indicate if clients have TB or STI symptoms as well as a column to determine if
the patient presents at the health facility to which they are referred.
PEPFAR funds will be used to employ one data capturer for
each supported health facility to assist with recording laboratory results and
to trace people with positive TB smears to ensure that they are initiated on
treatment. The data capturer will also be responsible for informing the CT
teams and community health workers if referred patients attend the facilities
to which they have been referred.
PEPFAR funds will be used to hire a CT Coordinator to train, mentor and supervise
the CT teams. Training will comply with national guidelines and will be
conducted in collaboration with National Department of Health and the AIDS
Training Information and Counseling Centre (ATICC). Additional training will be
provided on couple counseling for concordant and discordant couples, counseling
for youth, and counseling to address substance abuse and domestic violence. The
CT Coordinator will also visit clinical CT sites to provide mentorship and
technical support, focusing on TB treatment facilities. The five CT teams,
consisting of five nurse counselors, ten lay counselors and five community mobilizers,
will be trained. Additionally, one counselor in each of the 11 facilities will
be trained, mentored and supervized. In health facilities, routine counseling
and testing will be offered to pregnant women and patients with TB or sexually
Activity Narrative: transmitted infections.
ACTIVITY 3: Measuring Costs and Assessing Cost-effectiveness of Non-Clinical HIV Counseling
and Testing
To assess the affordability of the interventions, a cost-effectiveness analysis
will be done through a sub-contract with the Health Economics Unit of the University of Cape Town. The
cost per person post-test
counseled will be measured and the cost per HIV infection averted will be estimated
for non-clinical HIV counseling and testing compared to standard HIV counseling
and testing. The opportunity costs of adding TB and STI screening during
pre-test counseling will be measured.
The project aims to counsel and test 10,000 people the first year. These
results contribute to the PEPFAR 2-7-10 goals by improving access to and
quality of CT services in order to identify HIV-infected persons and increase
the number of persons receiving ARV services.
Continuing Activity: 13838
13838 13838.08 HHS/Centers for Tuberculosis Care 6628 6183.08 $500,000
Estimated amount of funding that is planned for Human Capacity Development $25,000
Table 3.3.14:
