PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
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.
PEPFAR funds were initially allocated to Other Prevention. However, the activities listed as Other
Prevention was better located within ARV Services, as the prevention activities were Prevention with
Positives activities. Therefore there is no need to continue funding this activity with FY 2009 COP funds.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.03:
SUMMARY:
The Tshepang Trust (Tshepang), a non-profit organization, recognizes the need for a holistic approach to
HIV management and the need to work in collaboration with other partners to ensure the delivery of a
comprehensive health care package to HIV-infected individuals. To this effect Tshepang has had a long-
standing relationship with the Treatment Action Campaign (TAC) utilizing its counselors at the grassroots
level to bring the required psychosocial care and adherence support in some areas of operation within the
program. It has been Tshepang's experience that some patients might not want to be assigned counselors
due to fear of stigma; however, these services will continue to be made available to them as well as the
telephone line counseling offered by Tshepang Patient Managers on a monthly basis. Tshepang
acknowledges that the program has been, until now, more treatment-focused but it is progressing to be
more comprehensive. A major modification under this program area is to set targets for enrolled individuals
in the FY 2009 COP and to offer a more comprehensive HIV care package for patients enrolled for HIV
management who do not need antiretroviral therapy (ART) yet.
BACKGROUND
Tshepang is the South African Medical Association (SAMA)'s HIV and AIDS program. Its mission is to utilize
private general practitioners (GPs) to increase HIV testing and treatment access to individuals dependent
on the public health care system in a public private partnership model with the South African Government
(SAG). It focuses on providing doctor human resource by mobilizing HIV clinical management trained GPs
using two models of care, a sessional model where GPs are placed on a sessional basis in public ART
clinics and a private GP model where (ideally) the same GPs are utilized to test and treat patients in their
rooms in order to alleviate the burden of care and treatment associated with shortage of infra structure e.g.
consulting rooms, long cues and stigma currently experienced in public healthcare facilities.
The GP model was formulated out of a need by individuals to access treatment services in areas of close
proximity to their places of abode for several important reasons:
Patients can access their treatment and medical care outside of working hours without having to miss work
because they have had to stand in queues for long periods of time in a crowded healthcare setting.
Patients do not have to worry about stigma, e.g. being seen by people they know queueing at an HIV clinic.
The GP model is simply a means to complement government services because it addresses two
fundamental challenges that currently face the department of health: infrastructure and medical human
resources, which are currently lacking in public health facilities. Both the sessional and GP models are an
effective short and immediate way for South Africa to reach its National Strategic Plan (NSP) targets. This is
because 70% of the medical resources, including HIV Clinical Management skills, are in the private sector
in the form of GPs versus 80% of South Africa's population that is dependent on the poorly-resourced public
health care system.
Long-term sustainability depends on all HIV and AIDS patients being cared for by the government, and
when the public health care system is stronger and stable enough with systems in place to take on the
challenges of care and treatment, Tshepang will work with the government to find ways of returning the
patients currently seen at GP's rooms back to government facilities. Looking at the already-mentioned
challenges, this can realistically take place in another three to four years. To take patients back to
government facilities now would create more of a burden for the public health system rather than assist in
ensuring that the country reaches its National Strategic Plan treatment goals of ensuring that 80% of all
individuals needing ART receive it by 2011.
All Tshepang-contracted GPs are skilled professionals who have been trained in HIV clinical management
that acknowledges SAG standards and procedures for HIV care and management. Furthermore, Tshepang
protocols on HIV disease management are based on the SAG national guidelines and the Tshepang model
ideally (although not always possible) has been to utilise GPs who would also assist at local public sites in
order to ensure that they understand clinic procedures and work according to national guidelines.
Tshepang started off as a sub-grantee of American Center for International Labor Solidarity (Solidarity
Center) commissioned as a treatment partner in the Prevention Care and Treatment Access to South
African Teachers (PCTA) program. The partners within the PCTA consisted of four South African teacher
unions, the U.S. Academy for Educational Development (AED), the American Federation of Teachers (AFT)
and the Solidarity Center being the prime recipient of funding from PEPFAR for all these partners. Within
this partnership teacher unions would refer their colleagues for HIV and AIDS treatment to Tshepang and
later as the program evolved also referred them for testing.
In the meantime, a request for proposals was issued by PEPFAR via the CDC for a five-year cooperative
agreement for a workplace intervention program (WIP) to run from FY 2007 until FY 2012 and Tshepang
applied. The organization was awarded the grant and now receives direct funding from PEPFAR through
CDC to provide counseling, care and ART to individuals in the workplace in order to continue with the
treatment of teachers from the PCTA program but also extend the program to include healthcare workers
and workers from the Small Medium Micro Enterprises (SMMEs), their spouses and immediate family
dependents. WIP is based on the GP model. The funding cycle for WIP started in October 2007 but
because Tshepang had been given a no cost extension as mentioned earlier, the organization only started
using its grant funds with effect from January 2008.
In the past when Tshepang was still a sub-grantee of the Solidarity Center, although HIV care enrollment for
HIV-infected individuals was recorded, there were no specific targets for it. Care or wellness management
went as far as monitoring individuals who were pre-ART for repeat GP consultations. At these consultations,
clinical assessments and CD4 counts blood tests would be taken within three months or six months
intervals depending on the baseline CD4 counts and clinical condition of the patients. Cotrimoxazole was
only offered to individuals eligible for ART as part of treatment readiness and those that presented with
minor opportunistic infections (OIs) even though ART was not yet warranted.
Activity Narrative: However, past experience has demonstrated that most pre-ART patients have a tendency to disappear from
the program in cases where follow-up is not regular and linked to service delivery. Thus, starting in FY FY
2008, the major focus will be to retain individuals enrolled for care who are at a pre-ART stage at the time of
enrollment. Retention strategies will include status support through counseling, promotion of limited
disclosure to spouses or partners and trusted family members or friends, couple counseling (especially
because in Tshepang's experience most of the patients seen come without their spouses or partners) for
testing and treatment services.
In FY 2009, Tshepang will be offering a basic care package that includes cotrimoxazole prophylaxis for all
patients at stages 2, 3 and 4 of the disease enrolled in the program. Numbers of individuals under care will
be a target indicator and care will include cotrimoxazole prophylaxis, TB screening, cervical cancer
screening, pathology and clinical assessments e.g. repeat CD4 counts and physical examinations for all pre
ART individuals, status acceptance counseling, couples counseling and testing, encouraging disclosure on
a limited basis, continued counseling on treatment literacy and adherence. This will be facilitated by
Tshepang Patient Managers who are professional nurses trained and experienced in HIV Clinical
Management in collaboration with the GPs seeing the patients on the ground. During the PCTA program,
Tshepang had trained nurses as well to be counselors working with GPs to follow up on patient adherence.
These will be further utilized to facilitate support groups for patients enrolled under WIP.
ACTIVITIES AND EXPECTED RESULTS:
New Activities:
From October 1, 2008, all HIV-infected patients enrolled for HIV palliative care but not eligible for ART will
be seen by GPs more regularly. This will involve patient monthly visits to restore and maintain the
individuals' immune system by offering cotrimoxazole prophylaxis as mentioned above and delaying the
need for ART, TB screening and TB prophylaxis, monitored referrals to local TB clinics for TB active
persons, cervical cancer screening and general patient clinical assessment.
Tshepang anticipates enrolling an additional 1,000 individuals for HIV care, taking the anticipated number of
people enrolled to 2,600. All the 1000 newly enrolled individuals will be screened for TB and when negative
receive TB prophylaxis in the form of Isoniazid, all HIV-infected individuals not TB active but in stages 2, 3
and 4 will receive cotrimoxazole prophylaxis to prevent opportunistic infections. Women will also be
screened for cervical cancer through pap smears.
Modified Activities:
Tshepang's approach has also evolved to include prevention and in-depth adherence counseling for
patients on treatment. Currently, Tshepang is doing voluntary counseling and testing (VCT) for early
detection and positive prevention, encouraging routine family counseling including couples and children.
In the repeat consultations, patients will be counseled on accepting their status, maintaining a lifestyle of
positive prevention, where the principles of ABC will be emphasized, couples and other immediate family
members, counseling and testing will be encouraged as well as disclosure to spouses and trusted
individuals for better adherence.
All these planned activities will ensure that patients on pre-ART are regularly seen by their GPs (at least
once a month), making follow-up monitoring of the enrolled individuals easier so that the program does not
end up with lost to follow up cases but rather maintains a high retention rate of individuals under care.
Emphasis Areas
Workplace Programs
Human Capacity Development
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.08:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
The Tshepang Trust (Tshepang)'s general practitioner (GP) model was formulated out of a need by
individuals to access treatment services in areas of close proximity to their places of abode for several
important reasons:
because they have had to stand in lines for long periods of time in a crowded healthcare setting.
Patients do not have to worry about stigma, e.g. being seen by people they know queuing at an HIV clinic.
fundamental challenges that currently face the department of health, infrastructure and medical human
resources which are currently lacking in public health facilities. Both the sessional and GP models are an
because 70% of the medical resources including HIV Clinical Management skills are in the private sector in
the form of GPs versus 80% of South Africa's population that is dependent on the poorly-resourced public
Long-term sustainability depends on all HIV and AIDS patients being cared for by the state and when the
public health care system is stronger and stable enough with systems in place to take on the challenges of
care and treatment, Tshepang will, in cooperation with government, find ways of returning the patients
currently seen at GP's rooms back to state facilities. Taking the challenges mentioned above into account,
this can realistically take place in another three to four years. To take patients back to state facilities now
would create more of a burden for the public health system rather than assist in ensuring that the country
reaches its NSP treatment goals of ensuring that 80% of all individuals needing ART receive it by 2011.
that acknowledges South African Government (SAG) standards and procedures for HIV care and
management. Furthermore, Tshepang protocols on HIV disease management are based on the SAG
national guidelines and the Tshepang model ideally (although not always possible) has been to utilize GPs
who would also assist at local public sites in order to ensure that they understand clinic procedures and
work according to national guidelines.
unions, the Academy for Education Development (AED), the Federation of American Teachers (AFT) and
the Solidarity Center being the prime recipient of funding from PEPFAR for all these partners. Within this
partnership teacher unions would refer their colleagues for HIV and AIDS treatment to Tshepang and later
as the program evolved also referred them for testing. The funding cycle for the Solidarity Center grant
came to and end in March 2007, but the Center gave Tshepang a no-cost extension to continue with testing
and treatment services until December 2007.
agreement for a workplace intervention program (WIP) to run from FY 2007 until FY2012 and Tshepang
applied. The organization was awarded the grant and could now receive direct funding from PEPFAR
through CDC to provide counseling, care and antiretroviral therapy (ART) treatment to individuals in the
workplace in order to continue with the treatment of teachers from the PCTA program but also extend the
program to include Health Care workers and workers from the Small Medium Micro Enterprises (SMMEs),
their spouses and immediate family dependents. WIP is based on the GP model. The funding cycle for WIP
started in October 2007 but because of the no-cost extension mentioned earlier, the organization only
started using its grant funds with effect from January 2008.
Tshepang is now moving towards a holistic approach to care and treatment with the cycle starting from
routine counseling and testing as part of prevention and early detection as per national guidelines and the
NSP, then care (which includes cotrimoxazole prophylaxis, TB screening and cervical cancer prevention)
and ultimately ART. Adult treatment at Tshepang has always been family-orientated with primary members
including their spouses and immediate dependents being enrolled into the program, however there have not
been many dependents joining, since the program is a workplace program, not many individuals enrolling
come with children into the program although they are catered for. For example between January and June
2008, only 41 dependents, 33 adults and 8 children have been enrolled onto the program versus the 654
that were enrolled as primary recipients. Tshepang aims to focus more on couple counseling and being
more aggressive in enrolling the partners of recipients into treatment particularly men and children. This will
be done through GPs as part of ongoing counseling during consultations and also through Patient
Managers as they continue with adherence counseling on a monthly basis.
In the FY 2009 COP, 1,350 individuals will be maintained on treatment plus additional 200 new initiations to
offset individuals that might fall off the program. Tshepang believes that this will allow it to focus on
incorporating the new activities and stringently monitoring adherence, treatment success and following up
on pre ART enrolled people.
In terms of monitoring outcomes, the Trust will be increasing its efforts on monitoring 6, 12 and 24 monthly
cohorts, ensuring that individuals timeously do their repeat blood tests for CD4 counts and viral loads. The
Trust will also be focusing on recording major side effects and adverse events. Tshepang recognizes the
need to focus more on monitoring and evaluation (M&E) and will endeavor to allocate at least 4% of its
treatment budget towards M&E.
Activity Narrative: New Activities:
The Trust will also offer nutritional supplements in the form of multivitamins to its patients as a new activity
that enhances current services.
------------------------------
INTEGRATED ACTIVITY FLAG:
This activity is on services rended in order to make the provision and access to ARVS possible for the 1,000
individuals targeted for FY 2007. This activity includes doctor consultations for existing and new patients on
ARVs, patient on a wellness program and laboratory services.
This activity is a follow-on to the partnership with the American Center for International Labor Solidarity.
With FY 2007 PEPFAR funding, the USG issued an Annual Program Statement to solicit partners to provide
comprehensive prevention, care and treatment services in a workplace setting. Tshepang Trust was
selected as one of the partners to continue implementing HIV and AIDS workplace intervention. Treatment
will continue to be provided to workers and their dependents living with HIV in selected small to medium
enterprises (SMEs) in the health and education sector. Care and support for HIV-infected workers will be
provided through wellness programs in workplaces and through referrals to community-based
organizations.
BACKGROUND:
Whilst business has become somewhat more responsive to the needs of its employees to encourage
testing for early detection and treatment of its employees to encourage testing for early detection and
treatment of its employees in larger corporations, the reality is that there are still very low levels of
counseling and testing in the workplace. Employees still do not trust that by enrolling in workplace HIV
programs, they will not be discriminated against. The situation is worse in the small medium enterprises
(SMEs) because unlike big corporations, SMEs are failing to follow the lead of their counterparts in
providing counseling and testing services to their work force. As a result, SMEs need assistance in
providing and developing a workplace response to HIV and AIDS.
The Tshepang Trust (also known as Tshepang) is the South African Medical Association (SAMA)'s HIV and
AIDS program initiated to bridge the gap in medical resources using private general practitioners (GPs) in
the public private partnership model in order to assist the South African government fight against HIV and
AIDS. SAMA has more than 5000 private medical practitioners in the private practice trained in HIV clinical
management. Tshepang has been in existence since June 2003 and is a registered local non governmental
organization (ngo) operating as a trust under Section 21 of the South African Companies Act. This is a
workplace program targeting small medium enterprises (SMEs) employees, their partners and dependents
using general practitioners and their consulting rooms as sites. For this initiative Tshepang trust is in the
process of forming collaborative relationships with two South African corporate companies to establish a
HIV and AIDS workplace program. In addition to this initiative, Tshepang will work with the healthcare
sector, targeting personnel in hospitals and clinics within the Gauteng area. Tshepang Trust currently has
strong evidence of leadership support from the South African Government through a public private
partnership with the Gauteng provincial department of health to enhance the scale up of HIV counseling and
testing (CT) and treatment in Gauteng's ARV sites. Tshepang currently serves under serviced rural areas in
South Africa utilizing general practitioners who are located mostly in rural areas. Using this model,
Tshepang has developed a public-private partnership between SMEs where employees and their
dependents can access private GPs in areas close to where they are employed without fear of
discrimination of being absent from work. In addition all of the general practitioners are within reach of the
targeted audiences and are local and indigenous and therefore able to relate to the target population
according to their culture and in local languages. The geographical coverage area for this project is
KwaZulu-Natal, Mpumalanga, and Eastern Cape province. The emphasis area for this workplace activity is
development of networks, linkages, referral systems. The target population for this initiative is men and
women of reproductive age working in SMEs, their partners and dependents. This includes factory workers,
teachers working in the education sector and healthcare workers working in the public healthcare sector.
The emphasis areas for this activity will be information, education, communication and development of
network/linkages/referral systems.
ACTIVITY 1: GP Network Model
Through a public-private partnership among workplaces, NGOs and government, participating workplace
programs will employ the services of doctors to provide antiretroviral therapy (ART) to workers who qualify
for treatment. The doctors will continue with refresher course training in HIV and AIDS clinical management
and will have experience in drug purchasing, ART and PMTCT treatment and surveillance. The doctors will
perform a clinical examination and staging, including taking blood for CD4 testing of patients. A viral load
test will be done before the start of treatment. The treatment services will utilize South African Department
of Health standards and guidelines. All patients will receive their drugs from the doctors' rooms. The
Tshepang Trust will through its contracted dispensing and delivery service provider ensure that the delivery
system keeps stock of and is able to deliver antiretroviral therapy medications to any physical address.
Special care will be taken to ensure that patient confidentiality is not compromised.
By providing comprehensive ARV services, including patient eligibility testing and drug procurement,
workplace HIV prevention programs will provide HIV-infected workers in small and medium enterprises in
the health and education sector with care and treatment.
Activity Narrative: ACTIVITY 2: Treatment advocacy campaign
FY 2007 funding will be utilised to provide treatment literacy materials and information on treatment services
available in the respective targeted areas. This may include links for patients to a toll free support line.
Information on how to access testing and treatment services will be disseminated through SMEs, hospitals
and the teachers' and healthcare workers' unions.
ACTIVITY 3: Providing ART services
Workers who are HIV-infected and require ART will be able to access these services through the Tshepang
Trust. All workers will receive a unique identifier which will be used for tracking and monitoring the treatment
services and protect the identity of the patient. The Tshepang Trust contracted GPs will provide the range of
ART initiation services, including all relevant laboratory testing, and adherence counseling. The identified
treatment partners will use South African Government treatment guidelines and protocols. About 150
individuals who are not working from the Orange Farm community will be included as part of the 500
existing patients on treatment.
ACTIVITY 4: Monitoring and reporting
The treatment partner will track all relevant patient data for monitoring and reporting purposes.
Providing comprehensive treatment services in a workplace setting will contribute to the PEPFAR 2-7-10
goals. These activities will also support the care and treatment objectives laid out in the USG Five-Year
Plan for South Africa.
New/Continuing Activity: Continuing Activity
Continuing Activity: 19526
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
19526 19526.08 HHS/Centers for Tshepang Trust 8711 8711.08 $986,000
Disease Control &
Prevention
Estimated amount of funding that is planned for Food and Nutrition: Commodities $25,876
Table 3.3.09:
The TB/HIV program area is a new activity for Tshepang in FY 2009. Although the organization has always
taken care of HIV-infected individuals, it has not screened patients for TB nor has it offered preventative
therapy or treatment for TB patients, instead referring patients to access these services in public sector TB
clinics. In FY 2009 Tshepang will be providing TB screening to a thousand individuals, providing Isoniazid
Preventive Therapy (IPT) and referring TB cases for treatment at nearby public TB treatment sites with
follow-up mechanisms through Tshepang Patient Managers and utilization trained nurses as adherence
counselors.
The Tshepang Trust (Tshepang), a non-profit organization, is the South African Medical Association's HIV
and AIDS program. Its mission is to utilize private general practitioners (GPs) to increase HIV testing and
treatment access to individuals dependent on the public health-care system, using a public private
partnership model with the South African government. It provides medical human resources by mobilizing
HIV clinical management trained GPs using two models of care, a sessional model where GPs are placed
on a sessional basis in public antiretroviral treatment (ART) clinics, and a private GP model where (ideally)
the same GPs are utilized to test and treat patients in their private consulting rooms in order to alleviate the
burden of care and treatment associated with shortage of infrastructure (e.g., consulting rooms, long
queues, and stigmatization experienced in public health-care facilities.
The GP model was formulated out of a need by individuals to access treatment services close to their
homes and workplaces. This is important because (a) patients can access their treatment and medical care
outside working hours without having to miss work (public health-care facilities are characterized by long
queues and lengthy waiting times, and crowded settings), and (b) patients need not be concerned about
stigmatization, by for example, being seen by people they know at an HIV clinic.
The GP model complements government services because it addresses two fundamental challenges that
currently face the Department of Health's public facilities: infrastructure and medical human resources. Both
the sessional and GP models are an effective short and immediate way for South Africa to reach its HIV &
AIDS and STI Strategic Plan for South Africa, 2007-2011 (NSP) targets. Approximately 70% of the medical
resources including HIV Clinical Management skills and GPs operate in the private sector. This is in stark
contrast to 80% of South Africa's population that is dependent on the poorly resourced public health-care
system.
Long-term sustainability depends on all HIV patients being cared for by the state and once the public health-
care system has stabilized, Tshepang will, in cooperation with the government, find ways to return GP's
patients to state facilities. This may take place within three to four years. All Tshepang-contracted GPs are
skilled professionals who have been trained in HIV clinical management aligned with South African
government standards and procedures. Furthermore, Tshepang protocols on HIV disease management are
based on the national guidelines and the Tshepang model ideally (although not always possible) has been
able to utilize GPs work at public sites in addition to private practice to ensure that they understand clinic
procedures and work according to national guidelines.
Tshepang has received PEPFAR funding through the American Center for International Labor Solidarity
commissioned as a treatment partner in the Prevention Care and Treatment Access to South African
Teachers program. This funding ended in March 2007, but Tshepang was given a no cost extension to
continue with testing and treatment services until December 2007. A five-year cooperative agreement for a
workplace intervention program was granted in FY 2007 and activities included counseling, care and ART
treatment to individuals in the workplace.
The Tshepang Trust recognizes the need for a comprehensive approach to HIV management and the need
to work in collaboration with other partners to ensure the delivery of a comprehensive health-care package
to HIV-infected individuals. To this effect, Tshepang has had a long-standing relationship with the Treatment
Action Campaign utilizing its counselors at grassroots level to bring the required psychosocial care and
adherence support in some areas of operation within the program. Tshepang has trained nurses in
voluntary counseling testing and adherence counseling with the purpose of aligning them with the GPs to
take care of the psychosocial needs of patients and their families within the program. It has been
Tshepang's experience that some patients, (particularly the relatively elite ones) like teachers and nurses
might not want assigned counselors due to fear of stigma; however, these services will continue to be made
available to them. In addition, a telephone line for counseling offered by Tshepang Patient Managers on a
monthly basis will be maintained.
The Tshepang Trust acknowledges that the program has been up till now more treatment focused but it is
progressing to be more comprehensive. With effect from October 1, 2008, all HIV-infected patients enrolled
for HIV palliative care but not legible for ART will be seen by GPs more regularly. This will involve patient
monthly visits for cotrimoxazole prophylaxis to restore and maintain the individuals' immune system and
delay the need for ART, TB screening and TB prophylaxis, cervical cancer screening and general patient
clinical assessment. Tshepang's approach has also evolved to include prevention and in-depth adherence
counseling for patients on treatment. Currently Tshepang is providing voluntary counseling and testing for
early detection and positive prevention, encouraging routine family counseling including couples and
children, prevention education that incorporates abstinence, being faithful and correct and consistant
condom use messages (i.e., abstinence including delaying sexual debut, being faithful, female
empowerment, male reaffirmation and condomising (as a last resort)) through the "stick to one partner"
campaign to be launched at the beginning of 2009.
Table 3.3.12:
This is a follow-on activity to year one of the Workplace Intervention Program.
The Tshepang Trust (Tshepang), a non -profit organisation, is the South African Medical Association
(SAMA)'s HIV/AIDS program. Its mission is to utilize private general practitioners (GPs) to increase HIV
testing and treatment access to individuals dependent on the public health care system in a public private
partnership model with the SA government. It focuses on providing doctor human resource by mobilizing
on a sessional basis in public antiretroviral treatment (ART) clinics and a private GP model where (ideally)
the same GPs are utilized to test and treat patients in their rooms in order to alleviate the burden of care
and treatment associated with shortage of infra structure e.g. consulting rooms, long cues and stigma
currently experienced in public healthcare facilities.
because they have had to stand in cues for long periods of time in a crowded healthcare setting.
fundamental challenges that currently face the Department of Health, infrastructure and medical human
effective short and immediate way for South Africa to reach its HIV & AIDS and STI National Strategic Plan,
2007-2011 targets. This is because 70% of the medical resources including HIV Clinical Management skills
are in the private sector in the form of GPs versus 80% of South Africa's population that is dependent on the
poorly resourced public health care system.
Long term sustainability depends on all HIV/AIDS patients being cared for by the state and when the public
health care system is stronger and stable enough with systems in place to take on the challenges of care
and treatment, Tshepang will in coorperation with government find ways of returning the patients currently
seen at GPs rooms back to state facilities. Looking at the already mentioned challenges, this can
realistically take place in another three to four years. To take patients back to state facilities now would
create more of a burden for the public health system rather than assist in ensuring that the country reaches
its NPS treatment goals of ensuring that 80% of all individuals needing ART receive it by 2011.
All Tshepang contracted GPs are skilled professionals who have been trained in HIV clinical management
that acknowledges SA government standards and procedures for HIV care and management. Further more
Tshepang protocols on HIV disease management are based on the SA national guidelines and the
Tshepang model ideally (although not always possible) has been to utilise GPs who would also assist at
local public sites in order to ensure that they understand clinic procedures and work according to national
guidelines.
unions, the United States-based Academy for Educational Development (AED), the Federation of American
Teachers (AFT) and the Solidarity Center being the prime recipient of funding from PEPFAR for all these
partners. Within this partnership teacher unions would refer their colleagues for HIV/AIDS treatment to
Tshepang and later as the program evolved also referred them for testing. The funding cycle for the
Solidarity Center grant came to and end in March 2007 but the Center gave Tshepang a no cost extension
to continue with testing and treatment services until December 2007.
In the meantime a request for proposals was issued by PEPFAR via the Centers for Disease Control and
Prevention (CDC) for a five-year cooperative agreement for a workplace intervention program (WIP) to run
from FY 2007 until FY 2012 and Tshepang applied. The organization was awarded the grant and can now
receive direct funding from PEPFAR through CDC to provide counseling, care and ART treatment to
individuals in the workplace in order to continue with the treatment of teachers from the PCTA program but
also extend the program to include healthcare workers and workers from the Small Medium Micro
Enterprises (SMMEs), their spouses and immediate family dependents. WIP is based on the GP model.
The funding cycle for WIP started in October 2007 but because Tshepang had been given a no cost
extension, as mentioned earlier, the organization only started using its grant funds with effect from January
2008.
In the past when Tshepang conducted counseling and testing services for teachers through the PCTA
program under the Solidarity Center, Enzyme-Linked Immunoadsorbent Assay (ELISA) tests were used
because people receiving results in an environment where their colleagues are would have been
counterproductive. However this model did not work because even though the people that had gone forward
for testing had given their contact details for follow-up and referral where they could receive their results in
GP rooms and then get enrolled into HIV care, most of them never got their results. There were various
factors why this was the case: cell phone numbers were wrong or not working, those that were reached and
asked to go and get their results refused and did not want to be contacted again or said they would go but
never went etc.
Activity Narrative: Tshepang recognises the need for a holistic approach to HIV management and the need to work in
collaboration with other partners to ensure the delivery of a comprehensive healthcare package to HIV-
infected individuals. To this effect the Tshepang has had a long standing relationship with the Treatment
Action Campaign (TAC) utilising its counselors at grassroots level to bring the required psychosocial care
and adherence support in some areas of operation within the program. In other areas the Trust has trained
nurses for voluntary counseling testing (VCT) and adherence counseling with the purpose of aligning them
with the GPs to further take care of the psychosocial needs of patients and their loved ones within the
program. It has been Tshepang's experience that some patients, (particularly the relatively elite ones) like
teachers and nurses might not want to be assigned counselors due to fear of stigma, however these
services will continue to be made available to them as well as the telephone line counseling offered by
Tshepang patient managers on a monthly basis.
Tshepang acknowledges that the program has been heavily treatment focused up to now, but it is
progressing to be more comprehensive. With effect from October 1, 2008, all HIV infected patients enrolled
for HIV palliative care but not elegible for ART will be seen by GPs more regularly. This will involve patient
clinical assessment. Tshepang's approach has also evolved to include prevention and in depth adherence
counseling for patients on treatment. Currently Tshepang is doing VCT for early detection and positive
prevention, encouraging routine family counseling including couples and children, prevention education that
incorporates abstinence, being faithful and condom use (ABC) messages i.e. abstinence including delaying
sexual debut, being faithful, female empowerment, male reaffirmation and condomising (as a last resort)
through the "stick to one partner" campaign to be launched at the beginning of 2009.
Tshepang has done well in providing CT services even in the light of a late start and the initial start up
challenges, because GPs rose to the occasion and encouraged routine testing in their rooms. The
partnership with Eskom, South Africa's energy supplier, has also done very well now that it is building up
power stations to increase the nations' electricity capacity and there are a lot of sub-contractors that are
receiving counseling and testing services through Tshepang.
The need for CT services is huge and Tshepang realizes that CT cannot only be limited to GPs rooms and
a couple of workplace events here and there, particularly because South Africa is a vast country with vast
needs in the remotest of areas where sometimes GPs cannot reach. As an enhancement to FY 2008 and
an ongoing activity in FY 2009, Tshepang has forged partnerships with various VCT organizations and
pathology laboratories as sub-contractors who are assisting Tshepang to increase counseling and testing
access. The main emphasis in these partnerships is that HIV infected individuals must translate to HIV care
enrollments through Tshepang GPs. All HIV-infected individuals from campaigns are immediately contacted
and referred to GPs in areas where they live and enrolled into the workplace intervention program (WIP).
The Trust has maintained its partnership with the PCTA Education Labour Relations Council teacher union
group. It is important to note that the numbers of testing done for this group are part of Tshepang's overall
testing figures although the unions may have them as targets for their CT program area.
In FY 2008 a revision of testing target was made where 10,000 individuals will be tested versus the 15,000
that was originally targeted, the numbers will be maintained at 10,000 in the FY 2009 COP. The reason for
decreasing the target is for the Trust to be able to effectively cater for care and treatment services. If targets
were kept at 15,000, presumably 1,500 individuals who need to be enrolled for care if one considers that
10% of all individuals tested are likely to be HIV infected, however the target for new HIV enrollments is a
1,000. If the target was not reduced to 10,000, the funds allocated for care and treatment would not be able
to cater for the 500 extra individuals that would need it.
GPs will be trained and equipped through the Foundation for Professional Development (FPD) on routine
counseling and testing in order for them to make this activity an integral part of routine medical care.
--------------------------
Activities are linked to others described in ARV Drugs, ARV Services, and Other Prevention. This is a
follow-on activity to the American Center for International Labor Solidarity.
the FY 2007 PEPFAR funding corporative agreement has enabled the Tshepang Trust to start testing
workplace employees together with their immediate dependents. In the FY 2007 period and going into the
FY 2008, the Trust is focusing on utilizing general practitioners (GPs) to do routine counseling and testing in
their consulting rooms. The Trust although it had a slow start for the FY 2007 period, is gaining momentum
with testing both in GPs rooms and in workplaces through partnerships with other VCT entities, is currently
testing on average 500 individuals per month and the number is rising as the program becomes known with
the assistance of the SA Medical Association in alerting its members on the program.
The emphasis area for this workplace activity is testing for early detection. The target population for this
initiative is men and women of reproductive age working in SMEs, the healthcare and education sector
including their partners and dependents. This includes managers, worker representatives and workers,
educators and other individuals working in the education sector and healthcare workers working in the
public healthcare sector particularly in areas where Tshepang currently has public private partnerships with
some of Gauteng's public ARV sites.
With funding from PEPFAR, these workplace programs will conduct HIV awareness and testing sessions for
Activity Narrative: both employers and employees on the basic facts of HIV transmission, prevention, and impact of HIV and
AIDS on the industry.
This activity will directly contribute to PEPFAR's goal of preventing 7 million new infections and treating
more than 10 million infected persons. These activities support the USG Five-Year Strategy for South Africa
by expanding and improving quality workplace HIV and AIDS prevention programs and are also in line with
the SA National Strategic Plan.
This activity will provide access to VCT services for employees, their partners and their dependents through
referrals to general practitioner (GP) sites and aso workplace wellness facilities. These GPs will provide
counseling and testing and initiation into treatment.
These accomplishments will directly contribute to the realization of PEPFAR's goal to prevent 7 million new
infections and provide care for 10 million people infected with HIV. These accomplishments also support
the prevention, care and treatment goals laid out in the USG Five-Year Strategy for South Africa.
Continuing Activity: 19515
19515 19515.08 HHS/Centers for Tshepang Trust 8711 8711.08 $386,000
Table 3.3.14:
Under the PEPFAR-funded Workplace Intervention Program, the Tshepang Trust will continue to offer
teachers, health care workers and people from the small medium and micro enterprises (SMMEs), together
with their spouses and immediate dependents, life saving antiretroviral drugs (ARVs) in a safe, confidential,
private and patient-friendly environment that promotes destigmatization through private general practitioners
(GPs) in their consulting rooms.
The mode of delivery of ARVs is that they are couriered into GPs rooms already dispensed, labeled and
patient-ready on a monthly basis through a reputable pharmaceutical distributing and dispensing company
within a 48-hour turnaround period. Every time the drugs are delivered, the patients receive text messages
on their cell phones from this company to alert them that their medication has arrived and is ready for
collection at the GP's office. The same company uses text messages to alert the patients for repeat blood
tests a month before they are due and to alert GPs to write repeat prescriptions for active patients a month
before prescriptions are about to expire.
When the Trust started, it was using ethical drugs as it had negotiated preferential access prices with all the
major pharmaceutical companies providing ARVs. However, it now accepts generic ARVs that are Food
and Drug Administration and Medical Control Council-approved in order to bring the costs of medication
down and increase its chances of putting more individuals on treatment.
--------------------------------------
Activities are linked to others described in Counseling and Testing, and ARV Services. This is a follow-on
activity to the American Center for International Labor Solidarity.
This activity is a follow-on to the partnership with the American Center for International Labor Solidarity to
treat South African educators and their spouses and dependents through the Prevention, Care and
Treatment Access Program. This activity as part of the COP between PEPFAR and Tshepang has been
expanded to include individuals in the SMME and Healthcare Sector. With FY 2007 PEPFAR funding, the
USG issued an Annual Program Statement to solicit partners to provide comprehensive testing, care and
treatment services in a workplace setting. The HIV and AIDS TREATMENT activity includes, doctor
consultations, ARVs, related medications e.g. for minor opportunistic infections for a 1,000 patients.
workplace program targeting small medium enterprises (SMMEs) employees, their partners and
dependents using general practitioners and their consulting rooms as sites. For this initiative Tshepang
trust is in the process of forming collaborative relationships with two South African corporate companies to
establish a HIV and AIDS workplace program. In addition to this initiative, Tshepang will work with the
healthcare sector, targeting personnel in hospitals and clinics within the Gauteng area. Lastly, Tshepang
will continue to provide services to educators who received services under the Solidarity Center program
which is ending in December 2007. Tshepang Trust currently has strong evidence of leadership support
from the South African Government through a public private partnership with the Gauteng provincial
department of health to enhance the scale up of HIV counseling and testing (CT) and treatment in
Gauteng's ARV sites. Tshepang currently serves under serviced rural areas in South Africa utilizing general
practitioners who are located mostly in rural areas. Using this model, Tshepang has developed a public-
private partnership between SMEs where employees and their dependents can access private general
practitioners in areas close to where they are employed without fear of discrimination of being absent from
work. In addition all of the general practitioners are within reach of the targeted audiences and are local
and indigenous and therefore able to relate to the target population according to their culture and in local
languages. The geographical coverage area for this project is national. The emphasis area for this
workplace activity is development of networks, linkages, referral systems. The target population for this
initiative is men and women of reproductive age working in SMEs, healthcare and education sectors, their
partners and dependents. This includes factory workers, teachers working in the education sector and
healthcare workers working in the public healthcare sector. The major emphasis area for this activity will be
commodity procurement as is ARVs and medication for minor opportunistic infections and side effects, with
minor emphasis placed on development of network/linkages/referral systems.
Activity Narrative: programs will employ the services of doctors to provide antiretroviral therapy (ART) to workers who qualify
for treatment. The doctors will be trained in HIV and AIDS clinical management and will have experience in
drug purchasing, ART and PMTCT treatment and surveillance. The doctors will perform a clinical
examination and staging, including taking blood for CD4 testing. A viral load test will be done before the
start of treatment. An adherence counselor will be assigned to each patient and will be responsible for the
continued home-based support and monitoring of the patient's condition. The counselor will also liaise with
the doctor. The treatment services will utilize South African Department of Health standards and guidelines.
All patients will receive their drugs from the doctors' offices. The doctor will ensure that the delivery system
keeps stock of and is able to deliver antiretroviral therapy medications to any physical address. Special
care will be taken to ensure that patient confidentiality is not compromised.
These activities will directly contribute to the PEPFAR goal of providing comprehensive HIV and AIDS care
to ten million people and ARV treatment to two million people. These activities will also support the care
and treatment objectives laid out in the USG Five-Year Plan for South Africa.
Continuing Activity: 19520
19520 19520.08 HHS/Centers for Tshepang Trust 8711 8711.08 $1,105,000
Table 3.3.15:
