PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
This University of KwaZulu-Natal project is committed to reducing all components of mother-to-child
transmission, including in utero, intra partum and postnatal transmission. The activities described in COP
2008 focus principally on reducing in utero and intrapartum (i.e., peripartum) transmission via a process of
system strengthening and resolving obstacles to service delivery in the antepartum period. These are the
most accessible aspects of the prevention of mother-to-child transmission program and most likely to yield
immediate benefits. Furthermore, the interventions to reduce peripartum transmission are very well
described and currently available for intervention at scale.
In 2009, the project will aim to consolidate gains in system performance and the monitoring of outcomes
and then, depending on progress in 2008, shift emphasis to postnatal transmission (i.e., optimizing infant
feeding practices in order to reduce postnatal transmission of HIV and promote child survival). This will
involve activities in the health system as well as in the communities that the facilities serve. The team is
already starting to engage on the components of such interventions and to identify what formative work may
be needed.
The project also aims to complete data collection in 2009 for a costing analysis of the main systems
intervention over 2008-2009 to permit a cost effectiveness analysis in 2009-2010.
-----------------------------------
SUMMARY:
The KZN 20,000 project aims to significantly reduce perinatal HIV transmission within 2 years and improve
overall child survival within 5 years in three districts of KwaZulu Natal (KZN) through health system support
interventions that would increase the effectiveness of current Prevention of mother-to-child transmission
(PMTCT) services;
BACKGROUND:
HIV infection in children is preventable. In Europe and the United States mother-to-child transmission rates
have been reduced to less than 2% and few HIV-infected babies are born in these countries. This has been
achieved through active screening and thereby identification of HIV-infected women attending antenatal
clinics, the early initiation of highly active antiretroviral treatment (HAART) whilst women are pregnant,
delivery of infants by cesarean section and the avoidance of all breast milk.
Implementing the same interventions and achieving the same low transmission rates has not been realized
in most resource-poor settings. Whilst the relatively restricted PMTCT protocols that have been applied in
most South African provinces cannot be expected to produce the results seen in developed nations (where
perinatal HIV transmission is the exception) there is an unacceptable gap in performance of the existing
PMTCT programs. Numerous obstacles have contributed to the failure of national and district health
systems to successfully operationalize international PMTCT recommendations. While in some cases there
are genuine deficiencies in human and physical resources, as well as incomplete training, experience in
rural and urban South African PMTCT program points to a widespread failure to reliably deliver the
sequence of simple processes of care (e.g. determining a mother's HIV status, reliable dispensing of
prophylactic drugs). Additional transmissions occur due to inappropriate infant feeding choices by HIV-
infected mothers either because of poor antenatal counseling or/or lack of support from health workers.
Target population for the project includes pregnant women, their infants, and health care workers at the
district health facilities. The emphasis areas are training, strategic information and local organization
capacity building.
ACTIVITIES AND EXPECTED RESULTS:
The KZN Department of Health (DOH) and University of KwaZulu Natal agreed that the project, now known
as KZN 20,000 , would proceed in three phases. Phase I comprises of a situational analysis and planning
exercise (currently underway) to determine the level of health system intervention required to effect large
scale improvement of the PMTCT program. Phase II will focus on rapid scale up of system strengthening
and priority activities to improve effectiveness of PMTCT. Phase III will focus on infant feeding strategies
and community mobilization. FY 2008 funding will be used to implement phase II activities. Subsequent
years of funding will ensure the implementation of Phase III.
Activity 1: Implementation of KZN 20,000
KZN 20,000 will operate across three districts that were chosen by the KZN DoH, namely Ethekwini
(Durban and immediate surroundings), Ugu and Umgungundlovu. Ugu district is a Presidential nodal site,
meaning that it has been designated as a district that is exceptionally poor and under-resourced.
Umgungundlovu contains Pietermaritzburg, the second largest city in KZN. Durban and Pietermaritzburg
both have large areas of informal housing and peri-urban areas with extremely poor communities. The 3
districts contain more than half (~5m) of the entire population of KZN (~9m) and suffer high antenatal HIV
prevalence rates - Ethekwini 41.6%, Ugu 38.9% and Umgungundlovu 44.4%. Between the three districts
there are over 260 PHC clinics and 16 state hospitals delivering 82,000 babies per year. The project is
designed to reduce the number of infant infections in the three districts by 4,800 per year and improve the
health of HIV-infected mothers through strengthening of the existing health system and capacity
development at district and local level. Emphasis will be given to careful documentation of process and
monitoring of outcomes so that best practices and lessons can be rapidly extended to the other 8 districts
within the Province. The KZN DoH is committed to the project and is using it as a way of improving overall
health care management and service delivery. The health system support intervention (Phase II) will also
create a platform from which to introduce interventions to improve infant feeding practices that are critical
for preventing infant HIV infection and reducing infant mortality.
Activity 2: Health System Improvement Intervention:
KZN 20,000 will introduce health systems improvement intervention designed to improve the quality of
PMTCT services across 3 districts. The project team will train and mentor mid-level Primary Health Care
(PHC) supervisors in quality improvement methodologies and management skills that will be supported
through a data collection and monitoring system specifically designed and supported by the project.
Activity Narrative: Implementation of PMTCT services will remain the primary responsibility of health staff in clinics and
hospitals. Routine PMTCT performance indicators will be tracked as well as 3 outcome indicators namely a)
infant HIV prevalence rates at immunization clinics, b) population-based infant mortality rates and c) in-
patient child mortality.
Activity 3: Development of a Data System:
A robust system that allows for timely and accurate collection, transmission (to central data assembly
points), collation, translation and feedback of data is a critical component of an effective improvement
intervention. An IT system is in development that will install a local MS Access database on computers that
will be placed in each District Information Office. All applications will work independently but data will be
automatically uploaded to an SQL database on a remote server each day. Data security can be assured by
use of digital certificates such that data is only accepted from pre-specified machines which have valid
certificates installed. A dedicated data assistant will be located in each district office to capture and manage
data from each clinic and to produce reports for the PHC supervisors. This will initially be a system that runs
parallel to, and will derive data from the current provincial data collection system. There will be no
duplication of data collection since all data will flow to the provincial office. It is anticipated that the systems
will be merged at the end of the funding period if the potential benefits of the proposed system are realized.
The main output of the data system will be to run system performance data reports for program leadership
and site specific process performance reports (line charts and histograms) to guide activities of the nursing
supervisors and clinics staff.
Activity 4: Development of Learning Networks:
Prior experience with large scale improvement interventions indicates that change is accelerated when
successful ideas are transmitted from peer-to-peer, and when a culture of peer support can be developed.
In a traditional quality assurance environment, the front-line staff receive instructions to improve across a
broad array of indicators in what is often a pejorative context. The purpose of the learning network is to
bring together small teams (e.g. facility manager, nurse, counselor) from each health care site to set
common project aims, learn together how to map care processes, identify obstacles and solutions, learn
how to test innovations and how to collect data to track improvement. Additional support will be given to
poor performing clinics. At Learning Sessions, sites that are struggling will also be exposed to participants
from high performing sites who will share their experience and strategies for success. Between these
Learning Sessions, quality mentors will visit the hospitals and together with PHC supervisors will visit the
clinics regularly (1-2 times/month) to support the teams, and sustain the improvement process through
planning new tests of change. The concept of learning networks will apply also to the mentoring of the PHC
supervisors themselves who will be brought together each month for training, transparent review of team
progress, and peer support for successes and challenges in the field.
Activity 5: Monitoring of Infant HIV transmission rates, Infant and Child Mortality:
Perinatal transmission rates will be routinely monitored at sentinel sites in each district through surveillance
of all infants attending 6 week immunisation clinics. Dried blood samples will be collected from all infants
following informed consent from the mother or legal guardian regardless of whether the mother was part of
the PMTCT programme or not. Maternal, infant HIV prevalence rates can be determined as well as vertical
transmission rates.
The goals of project 20,000 are directly aligned with the goals and objectives of the US President's
Emergency Plan for AIDS Relief (PEPFAR). These goals include achieving primary prevention of new HIV
infections through expanding VCT programs and building programs to reduce mother-to-child transmission.
KZN 20 000 aims to improve the overall performance of PMTCT and thus reduce the incidence of new
perinatal HIV infections. Improvement of PMTCT has other desirable indirect outcomes which include early
diagnosis of HIV that leads to increased access to HAART, decrease in infant mortality rates and overall
improvement in child survival.
New/Continuing Activity: Continuing Activity
Continuing Activity: 22374
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
22374 22374.08 HHS/Centers for University of 9649 9649.08 $600,000
Disease Control & Kwazulu-Natal,
Prevention Natal University
for Health
Emphasis Areas
Health-related Wraparound Programs
* Child Survival Activities
* Safe Motherhood
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $359,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01: