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
SUMMARY:
The Eastern Cape Regional Training Center (RTC) was established in 2003 by the Eastern Cape
Department of Health (ECDOH) to create a center of excellence for HIV care, management and treatment.
The initial focus of the RTC was to coordinate HIV and AIDS training for health workers across the province,
but has since expanded (with PEPFAR funding) to develop model HIV care and treatment programs in
facilities around Mthatha. RTC is located at the Walter Sisulu University in Mthatha. RTC will focus on the
provision of training health-care workers on PMTCT guidelines in this program area.
BACKGROUND:
The Minister of Health approved the revised national prevention of mother-to-child transmission (PMTCT)
Policy and Guidelines on 12 February 2008. These new national guidelines include dual therapy for
pregnant HIV-infected women. All public health facilities are required to implement these new guidelines.
RTC will use FY 2009 PMTCT funds to assist the Eastern Cape in the training of health-care providers on
these new national guidelines. The implementation of the revised national PMTCT policies and guidelines
will be one of the most important interventions during this financial year.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Updating Training Module and Procedures Manual
The ECDOH has asked RTC to ensure that the current PMTCT training module and procedures manual is
updated to include the dual therapy, infant feeding, and the data management aspects of the program.
Sections relevant to nutrition, laboratory services, counseling and testing, drug stock management, etc. will
be covered in the curriculum.
ACTIVITY 2: Training
RTC will conduct a brief skills audit of nurses already trained in PMTCT, per facility. This will also inform site
selection, as well as prioritization for 'top-up' training. RTC will facilitate the 'top-up' training for 1,600 nurses
that have already been trained on PMTCT.
RTC will also facilitate the cascading of the train-the-trainer program that was initially facilitated by the
National Department of Health, and that aimed at reaching non-governmental organizations, including the
AIDS Training Information and Counselling Centres (ATICCs) in the province.
RTC will package PMTCT and Health Information system modules (already developed) to form part of
certificate courses offered by the Walter Sisulu University.
ACTIVITY 3: Reporting
RTC will facilitate the review of registers currently used to monitor the PMTCT program in the province.
These registers include voluntary counseling and testing, PMTCT, antenatal care and Milk registers.
RTC will use PEPFAR funds to continue to employ members of a PMTCT dedicated team, consisting of one
medical doctor, one trainer, one laboratory technologist, and one nurse clinician. Funds will also be used to
support the administration of and logistics of the team to accomplish the above tasks.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Child Survival Activities
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $250,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
The Eastern Cape Regional Training Center (RTC) will be scaling down direct patient care in future to
concentrate on training. As advised by the province, RTC will be setting up Centers of Excellence. RTC will
work closely with the HIV Directorate and other relevant departments in the Department of Health (DOH) to
increase the current RTC onsite mentoring approach to cover more sites for longer periods and other
aspects of care, including TB infection control, and integrated management of childhood illness (IMCI).
RTC will establish district-based Performance Improvement projects and Specialist Clinics with a wellness
program as Centers of Excellence where clinicians can rotate for specified periods to acquire skills.
RTC will offer training on care and support on subjects including: Basic HIV/ AIDS, Palliative Care and
Acute Care and Prophylaxis.
RTC will work on development and accreditation of the Basic Care Package training program for people
living with HIV (PLHIV), including their training in the 27 RTC-mentored sites.
RTC will introduce a family-centered approach to care and support at community and household level to
reduce stigma and discrimination and provide a supportive environment for the PLHIV.
-------------------------
The Eastern Cape Regional Training Center (RTC) will use FY 2008 funds in the Eastern Cape for
sustainable human capacity development for all health workers through provision of support and training for
improvement of health systems of HIV and AIDS care in the Eastern Cape. RTC staff will also continue to
improve their knowledge and skills by having weekly academic clinical discussions, internal workshops, and
ongoing mentoring and Performance improvement meetings with staff of partner facilities and their feeder
clinics and in so doing, creating a "learning" network across all the LSAs of operation. This will facilitate
health workers to deliver quality HIV and AIDS palliative care and enhance their capacity to participate
effectively in all levels of HIV and AIDS care. Three teams from RTC will each support a facility and its
feeder clinics for a period of four months to initially evaluate the HIV and AIDS palliative care training needs
and provide targeted didactic training, ongoing mentoring and coaching using standardized procedures
manuals and tools that are in line with the national guidelines. A performance Improvement officer will
continuously mentor and improve performance of the trained personnel while the teams move on to cover
other clinics. Community support groups will be supported and trained in delivering the basic Care package
to PLHIV and their families in their respective communities. The primary emphasis will be given to core
activity of training, with minor emphasis to quality assurance and supportive supervision for health systems
improvement in HIV and AIDS care, information, education and communication (IEC). The primary target
groups are public and private health care workers. FY 2008 activities will be expanded to include continuous
performance improvement of facilities and feeder clinics There will also be a central information officer
supporting the three teams, information systems strengthening at facility and feeder clinic levels, thus
building information management and reporting capacity of these clinics. Teams will ensure all team data
collection is captured into the main RTC M&E systems.
RTC will also train local PLHIV groups on the Basic Care Package and mentor these in the areas of support
to implement the Basic Care Package. RTC will be responsible for the accreditation and production of the
training material for this purpose. The Basic Care Package will include: Acceptance of status, disclosure,
prevention with positives, nutrition assessment and counseling, What is HIV, progression of illness,
treatment literacy and adherence counseling.
Since 2004 RTC has developed two care support centers in two hospitals and nine clinics and generated a
model and protocols which will be introduced at new sites in FY 2007. A system of improvement cycles
have been introduced in one sub-district.
RTC has been working with ECDOH managers in developing and disseminating care protocols and will be
providing support and working closely with the district and facility managers to increase skills capacity to
improve the quality of HIV treatment and support services at facilities and community level.
In FY 2008 RTC activities will continue to address activities related to training; local organization capacity
development; quality assurance; and supportive supervision. Funding will be used to train and mentor
health care providers on HIV and AIDS related palliative care and support programs. This will include the
preventive package of care including prevention with positives, screening for opportunistic infections
according to national guideline for management of HIV; WHO clinical staging and provision of cotrimoxazole
prophylaxis, screening for and treating TB in PLHIV and provision of INH prophylaxis. RTC will also seed
accreditation of training curriculum for the Basic Care Package for PLHIV in conjunction with NASTAD and
train PLHIV in implementing the basic care package. Target personnel will include physicians, nurses and
nurse practitioners and other hospital and clinic staff.
ACTIVITY 1:
RTC will through the 4 clinical teams assess the palliative care training needs of health care providers at
selected hospital and feeder clinics sites in the Eastern Cape province. Palliative care training will be
designed according to the needs of the care providers. The areas to be covered are: basic prevention
including prevention with positives, clinical screening and monitoring of the PLHIV, treatment of
opportunistic infections, cotrimoxazole and INH prophylaxis and pain and symptom management. These
Activity Narrative: training will be in the form of case discussions, ward rounds, targeted didactic training, mentoring and
coaching. This will be followed up with quality assurance interventions by the QA team to ensure transfer of
skills into practice.
ACTIVITY 2:
RTC will in conjunction with NASTAD's sub-partners (JRI and SA Partners) seek accreditation for the
training curricula for the Basic Care Package for PLHIV. RTC will also produce the training material for this
training and train PLHIV to form and facilitate support groups to deliver the Basic Care Package. This
package will cover the following: acceptance of HIV status, disclosure, prevention with positives, and
treatment of opportunistic infections (with a special focus on TB/HIV co infection and the provision of
cotrimoxazole), ARV and adherence and nutrition assessment and counseling. RTC will form support
groups for PLHIV and their families in each of the sites they support to deliver the basic care package.
These activities will contribute to the PEPFAR goal of reaching 10 million HIV-infected and affected
individuals with care.
New/Continuing Activity: Continuing Activity
Continuing Activity: 14050
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
14050 7961.08 HHS/Centers for Walter Sisulu 9626 9626.08 $679,000
Disease Control & University
Prevention
7961 7961.07 HHS/Centers for National 4397 492.07 $250,000
Disease Control & Department of
Prevention Health, South
Africa
* TB
Estimated amount of funding that is planned for Human Capacity Development $400,000
Table 3.3.08:
One main Regional Training Centre (RTC) mandate is to ensure training accreditation. The current training
module and materials based on national guidelines will be formalized into a certificate and diploma
qualification with technical support of partners such as ITECH, and will be offered by Walter Sisulu
University. This will give recognition to the current training and develop career path for health workers RTC
is training.
RTC will be scaling down direct patient care in future to concentrate on training. As advised by province,
RTC will be setting up Centers of Excellence. RTC will work closely with the HIV Directorate and other
relevant departments in the department of health to increase the current RTC onsite mentoring approach, to
cover more sites for longer periods, and to improve other aspects of care, such as TB, infection control,
integrated management of childhood illness (IMCI). RTC will work to establish district-based performance
improvement projects, specialist clinics with wellness programs as centers of excellence, where clinicians
can rotate for specified periods to acquire specific skills.
-----------------------------------
The Eastern Cape Regional Training Center (ECRTC) will use FY 2008 funds in the Eastern Cape to
strengthen the capacity of healthcare workers (HCW), facility managers, social workers, doctors, nurses, lay
counselors and community health workers (CHW); prepare new sites for accreditation; and provide
mentoring to strengthen the provision of quality antiretroviral treatment (ART). Activities in this program area
will expand by recruiting an extra centrally based physician and pharmacist to strengthen the existing teams
and continue supporting the original 2 hospitals and 11 clinics in Mthatha. Three training, mentoring and
support teams from ECRTC will be strengthened by recruiting an additional 2 clinical training officers, and
will each continue to support a facility and its referral clinics for a period of four months to initially evaluate
the treatment services training needs and provide targeted didactic training, ongoing mentoring and
coaching by performance improvement officers on a continuous basis using standardized procedures
manual and tools, when the lead training teams have moved on. The creation of a learning network will
expand community support groups where PWAs will be trained to implement a basic HIV and AIDS care
package including ART. The emphasis areas are human capacity development and local organization
capacity building.
The ECRTC was established through a service agreement between the prime partner Eastern Cape
Department of Health (ECDOH) and Walter Sisulu University (WSU) to provide ongoing training for quality
improvement in HIV care and treatment programs.
The function of the ECRTC has been to develop accredited training modules and care protocols for different
categories of health workers based on National Department of Health guidelines. ECRTC has demonstrated
and evaluated the HIV, TB and STI best practices continuum of prevention, care and treatment model in
selected facilities, providing direct patient care and the opportunity for HCW to receive practical training.
ECRTC provides technical assistance to the ECDOH regarding the expansion of its HIV intervention
programs, and supports hospital and clinic site readiness for accreditation to provide comprehensive HIV
care and treatment.
The primary target populations are the facility managers, doctors, nurses, social workers, lay counselors,
CBO staff and community health workers.
During the past three years ECDOH has introduced a comprehensive HIV care and treatment program.
After workshops alone HCW were unable to implement programs. A number of patients have been started
on ART at hospital level, but there is a gap in preparing primary clinics to continue supporting patients
(down referral). Many eligible patients are started late on ARVs which results in poor outcomes. There is
limited awareness and skill among clinics to enable early diagnosis and entry into the care system. There
are known drug-drug interactions in patients with co-treatment of ARVs and other drugs and a number of
side-effects and complications are beginning to emerge. There is a need to provide facility-level mentoring
support from more experienced clinicians.
The ECRTC has been working with provincial ART managers in developing and disseminating care
protocols and will be providing support and working closely with the district and facility managers in
introducing the process to increase skills capacity to improve the quality of HIV treatment.
In FY 2008 ECRTC activities will continue to address the following activities: training; local organization
capacity development; quality assurance; and supportive performance improvement supervision. Funding
will be used to enhance the ECRTC strategy of training, preparation of new facilities for accreditation as
ARV sites, and providing clinical mentoring to selected sites but also building patient Information
management and training. ECRTC will use funds to employ and support administration and logistics of a
comprehensive care training team consisting of a clinical director, three doctors, three nurse clinicians and
three administrative assistants (for three teams), one each placed at the three satellite sites (Mthatha, Port
Elizabeth, and East London). Each team will provide dedicated support to three district hospital sites and
their referral clinics for a period of four months, and then move to the next three sites for the next four
months, completing three cycles a year.
ECRTC will use funds to employ a research and M&E manager, information systems officer and a central
information officer supporting the 3 teams and continued facility/clinics records management and reporting
capacity building. The M&E team be responsible for monitoring and evaluation of all ECRTC activities,
Activity Narrative: through accurate measurement of results, designing M&E tools for the teams/clinics and knowledge
database maintenance The activity will address the priority areas of human capacity development,
improving skills of a care team at facilities (doctors, nurses, managers, social workers, health promoters and
CHW) through targeted didactic training, case discussions and mentoring in assessing, initiation, follow-up
and monitoring of patients on ARVs while considering and reviewing relevant local system issues. Ongoing
support will continue with telephone consultations after the four months. ECRTC will train and mentor 35
facilitators from 7 NGOs who will cascade the training of a comprehensive curriculum for community health
workers to include ART.
ECRTC training and mentoring will address data collection, maintaining accurate records, feedback and
usage through quality improvement cycles to address early presentation, follow-up of patients for
adherence, complications and pharmacovigilance.
Training of facility staff, a CBO and community health workers will emphasize follow-up and tracking
mothers from the PMTCT program to enable PCR screening, early detection and referral of children into the
care and treatment programs.
The primary objective of the project is sustainable, targeted human capacity development for the HCWs.
ECRTC staff will also continue to develop and improve their knowledge and skills by having weekly
academic discussions, attending relevant conferences and ongoing mentoring from local experts and
visiting experts through collaboration with partners I-TECH and the Owen Clinic.
In the past twelve months with PEPFAR funds, ECRTC has developed protocols and models which have
been introduced in the province as new sites are supported for accreditation. More than 27 treatment sites
have been supported for accreditation and the ECRTC will continue to support accreditation of new sites in
FY 2008. A system of improvement cycles has been introduced. A pharmacovigilance program has been
piloted in two hospitals and nine clinics, which highlighted a number of complications as well as drug-related
problems, which will be addressed through the training and mentoring program.
This activity contributes to the PEPFAR objective 2-7-10 by increasing the capacity of the public sector to
effectively provide HIV care and treatment services. These activities are not at the site level but are more
system strengthening activities and constitute what is considered 'indirect' support in the Eastern Cape
province. Therefore there are no direct targets for numbers of people reached.
Continuing Activity: 14052
14052 7963.08 HHS/Centers for Walter Sisulu 9626 9626.08 $1,164,000
7963 7963.07 HHS/Centers for National 4397 492.07 $450,000
Estimated amount of funding that is planned for Human Capacity Development $984,000
Program Budget Code: 10 - PDCS Care: Pediatric Care and Support
Total Planned Funding for Program Budget Code: $7,192,004
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
The vision for the PEPFAR South Africa team for Pediatric Care and Treatment is to support the South African Government (SAG)
policies and programs to provide comprehensive HIV care and treatment services to all those in need. It is estimated that currently
5.7 million people in South Africa are HIV-infected, and that ~1.7 million are in need of treatment. A significant number of the HIV-
infected are children living with HIV. According to the Human Sciences Research Council survey in 2005, there are an estimated
129,621 children aged 2-4 years and 214,102 children aged 5-9 living with HIV.
The 2003 Comprehensive Plan for HIV and AIDS Care, Management and Treatment (Comprehensive Plan) states that its primary
aim is comprehensive prevention, care, and treatment for all in need with the target of universal access to antiretroviral treatment
(ART) over a five-year implementation period (2004 - 2009). The goals of this plan are reiterated in the new South Africa National
Strategic Plan for HIV & AIDS and STI, 2007-2011 (NSP). The plan emphasizes that children under 18 constitute 40% of the
population of South Africa, making this a key target group for HIV prevention, care, and treatment services. The NSP aim for 2009
is to start 33,000 children on treatment and to provide care for 250,000 children.
The USG has contributed significantly to these goals and targets, and with the support of the PEPFAR program, 550,000 people
are currently on ART in South Africa, of which 50,000 (10%) are children 15 and younger (30% of children on ART are under 5
years), and more than 1.4 million people receive appropriate care and support (C&S) including palliative care. South Africa has
exceeded its PEPFAR treatment target set for September 2009 one year early and continues progress to meeting the care and
support targets. The PEPFAR-funded treatment programs have maintained excellent retention in program since implementation in
2004. Cumulatively, only 15% of patients started on treatment have died, stopped ART, or were lost to follow-up. Treatment and
care partners are progressively improving their capacity to measure outcomes.
Only 13.7% of South Africans have access to medical insurance. The estimated 1.2 million adults and children still in need of ART
are primarily dependent on the public sector for care and treatment services. The number in need will continue to rise, especially
in light of revised national guidelines raising the threshold for ART eligibility from a CD4 of 200 to 250.
Much more needs to be done to ensure that the ART coverage (currently estimated at 30%) comes closer to the targets set by the
SAG. Maintaining the estimated 500,000 adults and children on treatment, and reaching the additional 1.2 million who need ART
requires continuous investment in treatment services in South Africa.
The National Department of Health (NDOH) has allocated approximately $410 million USD for the implementation of the
Comprehensive Plan in FY 2009 (prevention, care, and treatment), mainly through conditional grants to the nine provinces.
According to the NSP Costing Plan, the total need for funding for ART alone in 2009 is $710 million for adults and an additional
$128 million for children (a total of $838 million), clearly indicating the need for additional funding and support to the SAG and civil
society. Much of this funding is directed to the purchase of antiretroviral (ARV) drugs since all drugs for the public sector ART
program are procured and supplied by the SAG. The SAG also provides, in some instances, the ARV drugs for non-governmental
organizations (NGOs) and private sector programs with PEPFAR funding other service components. The USG is ideally
positioned to support the implementation of the NSP by ensuring equitable access to quality HIV care and treatment through
support to the SAG by PEPFAR-funded partners. Major donors (Ireland, DFID/United Kingdom, European Union and the
Netherlands) contribute to care and treatment-related services, such as mass media communication campaigns, home-based
care programs, and policy development in the National Department of Health, but the USG is the only donor funding direct ART
services. Other contributing donors to the care and treatment program include Canadian International Development Agency, The
Global Fund, The Elton John Foundation, and several public-private partnerships. The USG meets with the major donors several
times per year in various fora to discuss activities, explore collaborations, and minimize duplication of effort.
The capacity to deliver pediatric care and ART services varies significantly within the country, although additional funding in FY
2008 has been devoted to improving access to pediatric care and ART, especially through training activities and technical
assistance. These efforts will continue in FY 2009 where despite a budgetary reduction for PEPFAR in South Africa, services for
mothers and children (prevention of mother-to-child transmission (PMTCT), orphans and vulnerable children (OVC), pediatric care
and treatment) have been prioritized and in some cases funding has even increased.
PEPFAR partners continue their efforts to reach a pediatric target of 15% of the total treatment population by the end of FY 2009.
By September 2010, PEPFAR South Africa is targeting 13% of pediatrics on treatment.
In addition to the human capacity development activities, emphasis in FY 2009 is placed on early diagnosis for infants and
children, the referral of children from PMTCT programs to treatment services to integrate HIV and AIDS services more efficiently,
onsite mentorship, and linkages between OVC programs and pediatric treatment programs. Based on OGAC guidance, partners
are also incorporating nutrition support, especially for children. The NDOH has requested that community integrated management
of childhood illnesses (IMCI) activities be integrated into the community component of care and treatment and this is reflected in
the activities of care and treatment partners in FY 2009.
The key pediatric care and treatment priorities for the USG in FY 2009 are: 1) developing human capacity, especially at primary
healthcare level; 2) strengthening decentralization of HIV care and treatment, including building capacity for nurse-initiated ART;
3) encouraging early identification of children in need for HIV care and treatment services (e.g., provider-initiated counseling and
testing (CT)); 4) CD4 testing for those that test HIV positive and dried blood spot PCR at six weeks; 5) strengthening the capacity
to diagnose and treat TB in children; 6) continuing to strengthen the integration of treatment programs within other health
interventions (e.g., PMTCT, cervical cancer screening, and reproductive health); 7) providing cotrimoxazole prophylaxis to all HIV-
exposed children from 6 weeks of age; 8) fast-tracking children eligible for ART; and 9) reducing loss to initiation of treatment of
children that test HIV positive, and loss-to-follow-up once on treatment.
The key PEPFAR C&S priorities focusing on pediatrics in FY 2009 are to strengthen quality HIV and AIDS palliative care service
delivery and to implement standards of care. PEPFAR will support this effort by: 1) strengthening the integration of the basic care
package and family-centered services across all care and treatment programs for adults and children living with HIV; 2) increasing
the number of trained formal and informal healthcare providers, building multidisciplinary teams to deliver quality care with pain
and symptom control and improving human resource strategies; 3) building active referral systems between community home-
based caregivers (CHBCs) and facility services; 4) developing quality assurance mechanisms, including integration of supervision
systems and standardization of services and training; and 5) translating national policy, quality standards, and guidelines into
action, particularly national adoption of the basic care package. PEPFAR partners will advocate for new national guidelines to
improve access to pain management including the authority for nurse prescription. In collaboration with SAG, FY 2009 funds will
scale-up direct delivery of quality palliative care services.
All PEPFAR-funded care and treatment partners (the majority of whom are local entities) follow SAG standards, policies and
guidelines. The USG program continues to strengthen comprehensive high quality care for HIV-infected and affected people by:
1) scaling-up existing effective programs and best practice models in approximately 900 public, private, and NGO sites in all 9
provinces; 2) providing direct care and treatment services through prime partners and their sub-partners; 3) increasing the
capacity of the SAG to develop, manage, and evaluate care and/or treatment programs, including recruiting additional health staff,
training and mentoring health workers, improving information systems, conducting public health evaluations, and providing service
infrastructure assistance; 4) increasing demand for and acceptance of ART through community mobilization; 5) ensuring
integration of ART programs within palliative care, TB, reproductive health, STI, and PMTCT services; and 6) assisting in the
accreditation of facilities for ART initiation.
The USG supports a holistic, family-centered approach to HIV and AIDS care that begins at the onset of HIV diagnosis,
throughout the course of chronic illness, to end-of-life care. This is of particular importance when working with HIV-infected
pediatric individuals. In order to ensure that all HIV-infected clients have access to basic care services and to minimize loss to
initiation (currently at about 70%), PEPFAR partners will provide a basic package of services for all HIV-infected individuals. This
package will include acceptance of status, disclosure, prevention with positives (PwP), psychosocial support, nutrition assessment
and counseling, pain assessment and referral, treatment literacy and adherence counseling, and outreach services to trace clients
who have defaulted from the program. Emphasis will be placed on ensuring that HIV-infected individuals who are eligible receive
cotrimoxazole as per national guidelines. This package of services will be offered at community level through support groups for
individuals and care givers. These support groups (primarily run by people living with HIV (PLHIV)) will serve as a link between
the health facilities and the community to ensure a continuum of care. Counseling and testing sites will refer all clients (or their
caregivers) testing positive for HIV to the support group in their area.
Human capacity in the health care system is under strain, and coordination between public and private sectors and facility and
community-based care remains fragmented. FY 2009 investments will result in an improved continuum of clinical, psychological,
spiritual and social care, and prevention services for PLHIV. The NDOH leads and coordinates national efforts to advance
palliative care. Partnering with the NDOH at all levels, PEPFAR partners will continue to support the integration of standardized
quality palliative care services into primary health care as well as build HIV-related care services into CT, TB, ART, PMTCT, and
prevention programs and reproductive health services, STI sites, workplaces, and CHBC sites, including for OVC. This will build
on previous investments in supportive care to improve access to preventive care and basic clinical care services for PLHIV at the
community level.
The minimum care standard for facilities includes the following elements of the preventive care package and other essential care
interventions, including: 1) prophylaxis and treatment for opportunistic infections (OIs), per national guidelines - cotrimoxazole
prophylaxis for stage III-IV disease, CD4<200 or HIV-exposed/infected children; TB screening and management, isoniazid
preventive therapy in selected sites, and candidiasis screening and management where the Diflucan/Flucanozale partnership
exists; 2) CT to partners and family members; 3) nutrition counseling, clinical measurement and monitoring, micronutrient support
according to WHO guidelines, and wrap-around support; 4) STI care; 5) routine screening and management of pain and
symptoms; 6) child survival interventions for HIV-infected children (e.g., immunizations, growth monitoring, and safe infant/young
child nutrition); 7) integrated PwP strategies including messaging, condoms, support for disclosure of status, referral for family
planning and PMTCT services, ART adherence education, leading healthy lives, reduction of risk behaviors, and reduced rates of
HIV transmission; 8) provision of at least one element of psychological, social, or spiritual care, or prevention services
(emphasizing the holistic approach); and 9) referrals to other services.
The minimum standard for services at CHBC levels includes messaging, mobilization, and referral (with follow-up) for the above
mentioned services plus routine screening of all PLHIV and their family members (including OVC) for OIs, TB, symptoms and
pain; prevention messaging and condom provision; personal hygiene strategies to reduce diarrheal disease, and distribution of
insecticide-treated nets where appropriate. Home and community settings often facilitate delivery of a more comprehensive
response including the provision of bereavement care, household support, and community support meetings. PEPFAR partners
will continue to strengthen adherence to national standards with emphasis on relief of pain and symptoms and the provision of
culturally appropriate end-of-life care. The package of services at facility and community levels also includes medication
adherence support for ART, TB, and OI. At all levels, attention will be given to increasing gender equity in accessing HIV and
AIDS programs, increasing male involvement in community programs, reaching pediatric patients, addressing stigma and
discrimination, and building partnerships with local NGOs and faith and community-based organizations.
In FY 2009, the USG will continue to use a minimum requirement for someone having received C&S, including palliative care,
which reflects a minimum standard of HIV-related services, aligning the program more closely to WHO standards. An HIV-infected
individual must have received at least one form of clinical and one other type of non-clinical care. For HIV-affected family
members, the minimum requirement would be that the individual receive services in at least two of the five categories of clinical,
psychological, social and spiritual care, and prevention services. While quality is very difficult to measure through routine
indicators, this reinforces the message that PEPFAR is not simply interested in counting the number of people reached, but trying
to reach individuals with appropriate and quality care.
Table 3.3.10:
FY 2008 COP activities will be expanded to include:
-Coordinate adaptation of an advanced training module to ensure delivery of quality pediatric HIV and AIDS
care services; and
-Water and sanitation will be integrated into the pediatric care model.
Comprehensive care for HIV in children has lagged behind in the Eastern Cape province. FY 2009 funds
will be used to address these deficits.
The Eastern Cape Regional Training Center (RTC) will use FY 2009 funds in the Eastern Cape to employ a
person and support travel to focus coordinate and follow through on development of sustainable skills
capacity for health workers to provide holistic care for children, through provision of support and training for
improvement of health systems of pediatric care in the Eastern Cape.
RTC staff will coordinate adaptation of an advanced training module which will be delivered through didactic
training, clinical discussions, internal workshops, ongoing mentoring and performance improvement
meetings with staff of facilities and their feeder clinics and in so doing, creating a learning network across
the local service areas (LSAs) of operation. This will facilitate health workers to deliver quality pediatric HIV
and AIDS care and enhance their capacity to participate effectively in all levels of HIV and AIDS care. The
emphasis areas include the quality of counseling, cotrimoxazole prophylaxis, infant feeding, immunizations,
early diagnosis and maintaining accurate records, ensuring follow up of PMTCT infants, performance of
PCR and referral to initiate ARV treatment and social support.
Water and sanitation (hand washing, proper storage of water, safe preparation of infant feed) will also be
integrated into the pediatric care model. Diarrheal disease is a major concern in the Eastern Cape Province
especially among pediatrics. Water and sanitation will be a focal point of all training and quality
improvement activities at facility, community and district level. Practical demonstration will be necessary
during support group and wellness mentoring in some home visits.
This training module will be formalized into a certificate and diploma qualification with technical support of
partners such as the University of Washington's I-TECH and be offered by Walter Sisulu University.
The primary target populations are families, doctors, nurses and community health workers.
Estimated amount of funding that is planned for Human Capacity Development $55,000
Estimated amount of funding that is planned for Water $5,000
SUMMARY AND BACKGROUND:
The Eastern Cape Regional Training Center (ECRTC) was established through a service agreement
between the prime partner Eastern Cape Department of Health (ECDOH) and Walter Sisulu University
(WSU) to provide ongoing training for quality improvement in HIV care and treatment programs.
ACTIVITY 1: Training
Pediatric treatment has been issue in the Eastern Cape Province since the launch of the National Strategic
Plan in 2003. Clinicians are hesitant in initiating pediatrics on to ART. ECRTC will train clinicians at district
level (doctors and nurses) on pediatric ART with the aim to improve access at district level to pediatric ART.
ECRTC will develop and package a module on pediatric diagnosis, initiation and monitoring of ARV
treatment, to form part of certificate courses offered by Walter Sisulu University. Sections relevant to
nutrition, integrated management of childhood illnesses, laboratory services, counseling and testing, drug
stock management, etc. will be covered in the curriculum.
Other PEPFAR-funded partners including I-TECH will be requested to provide technical support. The
training package will include mentorship and support from the Nelson Mandela Hospital Infectious Disease
unit.
ACTIVITY 2: Ongoing Support
ECRTC will establish ongoing support for clinical teams at district level to improve quality of and confidence
of clinicians in providing pediatric ART. This support will be in the form of monthly case presentations and
discussions and online (telephonic support) to clinicians in rural areas. ECRTC will also facilitate regular
mentoring visits by pediatricians experienced in pediatric ART from the Nelson Mandela Hospital and the
ECRTC mentoring staff to district hospitals and community health centers to strengthen their capacity and
improve quality of pediatric ART in these areas.
ECRTC will employ a dedicated doctor and pharmacist to provide training development coordination, clinical
consultations, training and advice on HIV and AIDS, with particular emphasis on pediatric ARV treatment.
ACTIVITY 3: ART Monitoring
ECRTC will interface the currently developed electronic medical record with the IDART pharmacy
dispensing software from Cell Life. The combined software will be deployed in 6 current facilities, including
putting equipment in facilities/ sites supported by a dedicated data capturer. This will enable great
improvements in the current record system with information that will highlight the trends in pediatric care.
ACTIVITY 4: Performance Improvement
The ECRTC will provide support to improve skills and quality of care through Plan-Do-See-Act (PDSA)
cycles and monthly improvement meetings incorporating two sub-districts. Focus will include increasing
PMTCT uptake, quality of counseling, maintaining accurate records, ensuring follow-up of newborn infants,
infant feeding, performance of PCR and referral to ARV treatment and social support. The training and
mentoring will be targeted at care teams including managers, doctors, nurses and community health
workers and will consider and review relevant system issues. Demonstration models are set up develop
practical knowledge of care programs. Lessons learned from such a model will inform the current changes
in the development of a pediatric care and treatment training model and also provide hands-on practical
experience in training health workers.
Some elements of pediatric treatment are also addressed in more details in other linked areas of the COP,
including Pediatric Care and Support, Counseling and Testing, ARV Drugs, and Adult Treatment.
Estimated amount of funding that is planned for Human Capacity Development $200,000
Table 3.3.11:
The Eastern Cape Regional Training Center (RTC) will expand COP 2008 activities to include:
- RTC will employ a dedicated medical doctor, nurse preceptor and trainer to provide training development
coordination, clinical consultations, training and advice on HIV and AIDS in the field of TB/HIV.
- RTC will develop and package a module on TB/HIV diagnosis and treatment, and infection control to form
part of certificate courses offered by Walter Sisulu University.
----------------------------------
The Eastern Cape Regional Training Center (RTC) will use FY 2008 funds in the Eastern Cape to
strengthen the capacity of health care workers (HCW), facility managers, social workers, doctors, nurses,
lay counselors and community health workers (CHW), including DOT supporters, to deliver quality TB/HIV
services. Three teams from RTC will each support a facility and its feeder clinics for a period of four months
to initially evaluate the TB/HIV training needs and provide targeted didactic training according to the NTP
policies and guidelines, ongoing mentoring and coaching using standardized procedure manuals and tools.
NGO facilitators will be trained to implement a level four comprehensive community health worker
curriculum incorporating HIV and TB. Primary emphasis will be given to training, quality assurance and
supportive performance improvement supervision, and information and reporting systems strengthening at
facility level.
RTC was established through a service agreement between the prime partner Eastern Cape Department of
Health (ECDOH) and the Walter Sisulu University (WSU) to provide ongoing training for quality
improvement in HIV and TB care programs.
The function of RTC has been to develop accredited training modules and care protocols for different
categories of health workers based on National Department of Health guidelines. RTC has demonstrated
RTC provides technical assistance to the ECDOH regarding the expansion of its HIV intervention programs
supporting Eastern Cape hospital/clinic site readiness for accreditation to provide comprehensive HIV care
and treatment.
During the past three years ECDOH has introduced a comprehensive program for HIV care. From
observations during RTC activities in clinics and communities, more than 70 percent of TB patients are HIV-
infected and there seems to be a gap in screening all TB patients for HIV and early identification of TB in
HIV patients who are presenting in facilities. Patients present late for care, already with severe
complications. No clinical prophylaxis of TB is currently provided. There is limited awareness and skill
among the communities to enable early entry into the care system. There are known drug-drug interactions
in patients with co-treatment of ARV and TB drugs. There is an opportunity to combine follow-up of TB
patients with patients on ARVs at community level.
improve the quality of TB/HIV treatment and support services at facilities and community level.
In FY 2008 RTC will continue to address the following areas: training; local organization capacity
development; quality assurance; and supportive Supervision and performance improvement. Funding will
be used to enhance the RTC strategy of training preparation of new provincial sites for accreditation as ARV
sites and providing clinical mentoring to increased sites. RTC will continue supporting training administration
and logistics of a comprehensive care training team allocated to provide dedicated support to three district
hospital sites and at least five feeder clinics, for a period of four months, which will then move to the next
three sites for the next four months, completing three cycles a year. The intensity of support and
Performance Improvement supervision will Increase with introduction of a performance improvement officer,
a critical efficiency improvement position in the teams. Information and reporting improvement will be
achieved by appointing an information officer, whose primary responsibility will be facility information and
reporting systems improvement.
During this period the team will work with and support the facility managers to initially evaluate the TB/HIV
palliative care services training needs, adapt standardized protocols and procedures for local facilities, and
provide targeted didactic training, ongoing mentoring and coaching using standardized protocols and
operating procedure manuals. The activity will address the priority areas of human capacity development,
improving skills of a care team including managers, doctors, social workers, health promoters, CHW, DOT
supporters and nurses at a facility and its feeder clinics through targeted didactic, case discussions,
mentoring and community follow-up of patients with facility staff while considering and reviewing relevant
local system issues. Focus will also be given to building patient information and reporting capacity at
facilities. This activity is aimed at strengthening the recording and reporting system for TB and TB/HIV at
facility level; coaching clinic staff on correct data entry and reporting. Ongoing support will continue through
telephone consultations and special need visits after 4 months. RTC will train and mentor 35 facilitators
from 7 NGOs who will cascade the training of a comprehensive level four curriculum for community health
workers who will be providing community awareness for TB/HIV symptoms and follow-up of both patients
for HIV and TB treatment adherence.
Activity Narrative: RTC will hold three-monthly sessions with three local CBOs at each facility to articulate their role and
function in TB treatment services and enhance their knowledge and skills required to function in that role.
The RTC team will develop simplified TB screening algorithms for HIV patients at clinics and support the
improved provision of INH prophylaxis, early detection and better management of TB/HIV in clinics. RTC
training and mentoring will address the establishment of wellness programs at each facility to encourage
community follow-up, nutrition advice, infection control, referrals to clinics and social support at community
level. RTC through its M&E function will strengthen records management and reporting in TB/HIV clinics,
RTC will continue to piloting the Patient information database management systems at IDC -Mthatha with a
view of rolling it out to other partner hospitals and clinics to Improve patient tracking and records
management.
RTC training and mentoring will address data collection, maintaining accurate records, feedback and usage
through quality improvement cycles to address early presentation, and follow-up and referral of patients on
TB treatment.
RTC is an ECDOH initiative based at the Walter Sisulu University and conducts training at public facilities.
RTC has and will continue to provide technical assistance to the province through regular meetings and
assignments from province managers as well as training for managers.
The PEPFAR funding is helping to establish the program on a firm footing where it can continue with
ECDOH funding.
The primary objective of the project is sustainable targeted human capacity development for all health
workers. RTC staff will also continue to improve their knowledge and skills by having weekly academic
discussions, two internal workshops, attending relevant conferences and ongoing mentoring from another
PEPFAR partner, I-TECH.
This activity contributes to the PEPFAR objective of 2-7-10 by increasing the number of people in care and
strengthening the linkages between HIV and TB programs.
Continuing Activity: 14051
14051 7962.08 HHS/Centers for Walter Sisulu 9626 9626.08 $291,000
7962 7962.07 HHS/Centers for National 4397 492.07 $50,000
Table 3.3.12:
