1n 2009 ECRTC has been working with provincial facility managers, clinical doctors and nurses reviewing and incorporating preventive therapy regimens such as cotrimoxazole and disseminating the standardized palliative care and HIV Cor-morbidity management protocols to more facilities. ECRTC provides training to community based organizations and PLHIV through collaboration with SA Partners and Masihlanganeni Network of People living with HIV and AIDS. The ECRTC has developed a training program with all the learning materials for the Level 4 CCW curriculum. Also, an HIV advocacy and leadership skills training course has been adapted into SAQA standards, piloted and lessons learned incorporated into the course. Community based organisations have been mobilised in 2 districts (OR Tambo and Ukhahlamba), trained, mentored, and strengthened their capacity as community support service points working with ARV clinics. The ECRTC has appointed and trained wellness mentors that are attached to the three ECRTC satellite mentoring teams with a responsibility of mentoring CCWs in the facilities while directly supporting the initiation of support groups and training of PLHIV within their support groups, as well as improve recording systems by CHWs. There has been an improvement in recording of work done by CCWs as a result of the mentoring of facilities by wellness mentors. ECRTC will be increasing human capacity through demonstration of optimal Adult Care and support protocols through 14 learning network sites throughout the Eastern Cape Province. Each site will be a learning hub for a cluster of health facilities who will meet at least two days every month. For each visit there will be an ECRTC team comprising of a dedicated Doctor, Training Coordinator and Nurse Clinician supported by a Social worker and wellness mentors. During this period the team supports the facility managers to initially evaluate the care support services, patient review, and palliative care evaluation identifying need and providing targeted didactic training, ongoing mentoring support and coaching using case discussions and introducing standardized protocols and procedures based on national guidelines, and application of improvement methodologies. Didactic Training ECRTC will package developed learning on care and support including palliative care and prophylaxis component of the certificate courses offered by Walter Sisulu University. 2. Training materials reproduction and distribution The updated materials will be replicated and distributed to training organizations throughout the province.

3. Training implementation ECRTC has scheduled and will provide 6 direct training sessions each in HIV acute Care, Palliative care, Post exposure prophylaxis. Health care workers on adult HIV care and PLWHIV and Lay counselors will also be trained on the basic care package, per facility in collaboration with MANEPHA. Mentoring sites by ECRTC team and through engagement of 12 part time wellness will provide ongoing support to community workers to implement the basic package of care at community level, through the 14 learning hubs supporting Health promoters and facility managers to empower them to be able to initially evaluate the adult HIV care in their sub-districts and provide targeted didactic training, ongoing mentoring and coaching using standardized care protocols. 4. Performance improvement program Coaching staff of sub- districts, treatment sites and their feeder clinics in improvement approaches and methods and in 3 sub-districts (101 clinics) so doing, creating a "learning" network and demonstrable improvement in care across operation. This will facilitate and support health workers to maintain accurate records and use them to assess and effect improvements in delivery of quality HIV and AIDS palliative care and enhance their capacity to participate effectively in all levels of HIV and AIDS care. The areas of emphasis include the quality of counseling, early diagnosis and ensuring follow up and support for all HIV positive people, nutrition and prophylaxis treatment and referral to initiate ARV treatment and social support. Expected Outcomes Protocols for general HIV care and cor-morbidities including palliative care for inpatient and outpatient will be introduced adapted and monitored during mentoring sessions to provide standardized optimal care services. Demonstration of a Wellness Program Work with Health promoters, social workers and community care workers for psychosocial support including support group activities basic package of care and patient tracking Demonstrate and mentor Family Clinic approach Implement a family centred approach when managing clients infected by HIV through encouraging the other family members to come for HIV testing for early diagnosis, care and support. Nutrition support Participation in wellness and Home care learning activities Implement Home based care programs and community awareness. Implement an individual awareness program, support group activities and deliver basic care package. Improve system for patient follow up tracking and referral. Supervision of community workers maintain accurate records, Regular analysis and review of and participation in Performance improvement meetings for continued learning. Support community based organizations.

During the past three years the ECDOH introduced a comprehensive HIV care and treatment programme. ECRTC effort has been mainly in the preparation of new sites for accreditation. To date, a large number of patients have been started on antiretroviral therapy (ART) at hospital level, but there is a gap in preparing primary health care clinics and district hospitals to continue supporting patients (down- referral). Many eligible patients are started late on ARVs which may result to poor outcomes. Despite the numbers trained and mentored by ECRTC, 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. With the limitation of reliable information system and medical records there are no clear trends on the efficiency of access to appropriate care, how patients are responding or not responding to therapy or emergence of resistance. HIV care has continued to be a vertical program with limited integration in the rest of health care services which has given an impression among managers, clinicians and even clinical consultants that it is someone else's responsibility. There is an urgent need to provide facility- level mentoring and support from managers, clinic supervisors and more experienced clinicians. Objectives: In the coming year ECRTC objective will be support for accredited sites and capacitating of all levels of care to prepare for initiation and follow up patients initiated on ARVs. ECRTC will be increasing human capacity through Demonstration of optimal Adult Antiretroviral (HAART) support and Care through a 14 learning network sites throughout the Eastern Cape Province. Each site will be a learning hub for a cluster of health facilities who will meet at least two days every month. For each visit there will be an ECRTC team comprising of a Doctor, Training Coordinator and Nurse Clinician supported by a pharmacist and laboratory technologist. During this period the team supports the facility managers to initially evaluate the HAART services patient review, and care evaluation identifying need and providing targeted didactic training, ongoing mentoring support and coaching using standardized HAART protocols and application of improvement methodologies. ECRTC will support a demonstration of optimal care within available resources at different levels of care with the objectives of: • Understanding what it takes to get things working • Provide an opportunity for HCW to learn by spending time rotating through a working program to learn and benchmark what could be emulated in their facilities. Activities to be facilitated by ECRTC will be: Monthly Outreach visits to clusters and ongoing Tele-consultation by ECRTC team, ECDOH Clinical support:

Continue preparation of sites for accreditation with scheduled Site Preparation (6 sessions) and Chronic care to initiate ARV (9 sessions) sessions. The more experienced ECRTC doctors and nurses will guide standardized Protocol Development and dissemination, and provide Clinical Consultation and discussion of difficult patients with Clinicians at tertiary level 3: (2 days per week) Provide bedside mentoring through Clinical review of Specialist Complicated admitted or referred cases including PMTCT and Children (e.g. Pneumonia, liver disease, Drug reactions, Kaposi. Non HAART response- Resistance) in Specialist Clinic and Ward Rounds. Facilitate Monthly Pharmacovigilance meetings and Switch committees. Operational Systems such as referrals, project planning, procurement, ordering will be adapted during mentoring sessions to provide optimal services. Information systems including patient records and data quality will be perfected to ensure ongoing monitoring and feed back of clinical care, services uptake rates and program outcomes. Supervisors will be mentored on regular analysis and review of data and participation in level 2 Performance improvement meetings. Performance Improvement (PI) ECRTC PI mentors will work closely to mentor Program managers, Supervisors and operational managers at sub-district and facility level on performance improvement methodologies enhancing their job performance areas of supervision of facility performance and support at all levels. The managers will apply the methodologies to the health facilities to improve the performance of the facilities and programs they are responsible for. Emphasis will be put on: • Accurate records, regular analysis and review of data. • Identifying gaps. • Mobilize teams and resources to close the gaps. • Review the changes effected to see if they are working. • Maintain a continuing learning network.

The NSP seeks to ensure the effective implementation of policies and strategies to mitigate the impact of HIV in particular to orphans and vulnerable children as well as youth headed households while also improving enrolment and retention of children (and adults) on ART (85%) through implementation of facility and community based adherence support strategies and programs (100% sub-districts). In 2009 ECRTC employed a dedicated medical doctor on a 3 year contract, to provide training

development coordination, clinical consultations, training and advice on Pediatric management of HIV and AIDS. She will continue working with provincial facility managers, clinical doctors and nurses reviewing and incorporating Pediatric care management protocols to more facilities and integrating pediatric care into the existing PMTCT services and IMCI training and services. ECRTC will be increasing human capacity through demonstration of optimal Pediatric care and support protocols through 14 learning network sites throughout the Eastern Cape Province. The dedicated TB_HIV doctor will through a learning hub for a cluster of health facilities, support the Clinicians and facility managers to evaluate Pediatric care and support services, identifying need and providing targeted didactic training, ongoing mentoring support and coaching using case discussions and introducing standardized protocols and procedures based on national guidelines, and application of improvement methodologies. In the past year ECRTC has developed and sustained collaborating relationships with Children's HIV Association- South Africa (CHIVA) to take provide support for pediatric care training which has so far received limited attention. Expertise will work with RTC in six one week hands on clinical mentoring sessions for clinicians from a cluster. Three of these mentoring will end with 2 days pediatric HIV management conferences for participants from through the province. Pediatric care training materials will be updated, adapted, reproduced and distributed during Didactic Training implementation and to other training organization throughout the province.

Performance improvement The support areas to improve skills and quality of care through PDSA cycles and monthly improvement meetings incorporating 2 sub districts. Focus will include increasing PMTCT uptake, quality of counseling, maintaining accurate records, ensuring follow up of new born infants, infant feeding, performance of PCR and referral to ARV treatment and social support. The training and mentoring will be targeted to developing care teams that include managers, doctors, nurses and community health workers and will consider and review relevant system issues. Demonstration models are set up to develop practical knowledge of care programs. Lessons learned from such a model will inform the current changes in the development of a pediatric care training module and also provide hands on practical experience in training health workers. A Pediatric 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.

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 HAART. In 2009 ECRTC employed a dedicated medical doctor on a 3 year contract, to provide training development coordination, clinical consultations, training and advice on Initiating and management of HAART in children. She will continue working with provincial facility managers, clinical doctors and nurses reviewing and incorporating Pediatric care management protocols to more facilities and integrating pediatric HAART c are into the existing PMTCT services and IMCI training and services. ECRTC will be increasing human capacity through demonstration of optimal Pediatric care and support protocols through 14 learning network sites throughout the Eastern Cape Province. The dedicated Pediatric HIV doctor will through a learning hub for a cluster of health facilities, support the Clinicians and facility managers to evaluate Pediatric care and support services, identifying need and providing targeted didactic training, ongoing mentoring support and coaching using case discussions and introducing standardized protocols and procedures based on national guidelines, and application of improvement methodologies. ECRTC will continue drawing on and coordinating of visiting expertise from Children's HIV Association- South Africa (CHIVA) to take provide support for training on initiating and management of HAART in children which has so far received limited attention. Expertise will work with RTC in six one week hands on clinical mentoring sessions for clinicians from a cluster. Three of these mentoring will end with 2 days pediatric HIV management conferences for participants from through the province. Ongoing Support ECRTC will continue to provide ongoing support for clinical teams at district level to improve quality of and confidence of clinicians in providing pediatric ART through telephonic support to clinicians in rural areas. ECRTC will also facilitate regular mentoring visits by pediatricians experienced in pediatric ART to district hospitals and community health centers to strengthen their capacity and improve quality of pediatric ART in these areas.

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. A Pediatric 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. 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.

1n 2009 the ECRTC has been working with provincial PMTC managers reviewing and incorporating dual therapy regimens and disseminating the standardized PMTC procedures manual to more facilities. ECRTC will be increasing human capacity through Demonstration of optimal PMTCT Care through 14 learning network sites throughout the Eastern Cape Province. Each site will be a learning hub for a cluster of health facilities who will meet at least two days every month. For each visit there will be an ECRTC team comprising of a dedicated PMTCT -Pediatric Doctor, Training Coordinator and Nurse Clinician supported by a pharmacist and laboratory technologist. During this period the team supports the facility managers to initially evaluate the PMTCT services patient review, and care evaluation identifying need and providing targeted didactic training, ongoing mentoring support and coaching using standardized PMTCT procedures manual and application of improvement methodologies. Integration will be explored through a Family care approach to the management of clients including PMTCT and Children.

Training development ECRTC will continue to ensure that the current PMTCT training materials and procedures manual is updated to include any new province specific adaptations to the national guidelines 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 accredited course. New courses: ECRTC will package developed PMTCT and Health Information system modules component of Postgraduate certificate course offered by Walter Sisulu University. 2. Training material reproduction and distribution The updated materials will be replicated and distributed to training organizations throughout the province. 3. Training implementation ECRT will organize scheduled didactic PMTCT trainings for those individuals who have not been trained in PMTCT or who need update; Conduct a brief skills audit assessment and recommend to attend ECRTC scheduled PMTCT training sessions providing direct 'top-up' training for Doctors, nurses and lay

counselors that have already been trained on PMTCT Mentoring Performance improvement The ECRTC supports areas to improve skills and quality of care through care reviews and monthly improvement meetings implementing and evaluating PDSA cycles. This will be done monthly in all 14 learning hubs and continuously in 3 sub districts. Focus will include increasing PMTCT uptake, quality of counseling, maintaining accurate records, ensuring follow up of new born infants, infant feeding, performance of PCR and referral to ARV treatment and social support. The training and mentoring will be targeted to developing a care team including managers, doctors, nurses and community health workers and will be considering and reviewing relevant system issues.

EXPECTED RESULTS: PEPFAR funding will be used to continue employment of a PMTCT dedicated team of 1 Doctor, 1 trainer, 1 laboratory technologist 1, nurse clinician and supporting administration and logistics of the team to accomplish the above tasks. This will support the National Strategic Plan (NSP) for HIV and AIDS and Sexually Transmitted Infection (STI) for 2007-2011, adopted by Cabinet in 2007, which has made allowance for the introduction of dual therapy to reduce mother-to-child-transmission of HIV. The reported indicators are a projection of number of people to be trained in scheduled sessions and mentored at the 14 learning hubs throughout province and pregnant women and babies at all service outlets the minimum PMTCT package: counselling and testing of babies at sites visited by the ECRTC. The service outlets include Nyandeni, Mhlontlo and KSD sub-districts. These are sites visited throughout the year either during the performance improvement programme or mentoring by ECRTC teams.

Tuberculosis associated with HIV still the biggest Cor-morbidity in the Province. There is a need to integrate TB_HIV care into one program. The Eastern Cape Regional Training Center (RTC) will use FY 2010 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. RTC will continue to employ a dedicated medical doctor, to provide training development coordination, clinical consultations, training and advice on HIV and AIDS in the field of TB/HIV.

In 2009 ECRTC has been working with provincial facility managers, clinical doctors and nurses reviewing and incorporating preventive therapy regimens such as INH prophylaxis and disseminating the

standardized TB_ HIV Cor-morbidity management protocols to more facilities. ECRTC will be increasing human capacity through demonstration of optimal TB/HIV care and support protocols through 14 learning network sites throughout the Eastern Cape Province. The dedicated TB_HIV doctor will through a learning hub for a cluster of health facilities, support the Clinicians and facility managers to evaluate TB-HIV patient care, Infection Control and support services, identifying need and providing targeted didactic training, ongoing mentoring support and coaching using case discussions and introducing standardized protocols and procedures based on national guidelines, and application of improvement methodologies. Didactic Training Training materials reproduction and distribution The updated TB-HIV training materials will be replicated and distributed to training organizations throughout the province. Training implementation ECRTC has scheduled and will provide 6 direct training sessions each in TB-HIV expecting 40 participants each Performance improvement program Coaching staff of sub- districts, treatment sites and their feeder clinics in improvement approaches and methods and in 3 sub-districts (101 clinics) so doing, creating a "learning" network and demonstrable improvement in care across operation. This will facilitate and support health workers to maintain accurate records and use them to assess and effect improvements in delivery of quality HIV and AIDS TB, palliative care and enhance their capacity to participate effectively in all levels of HIV and AIDS and TB care. The areas of emphasis include the quality of early diagnosis and ensuring follow up and support for all TB-HIV positive people, nutrition and prophylaxis treatment and referral to initiate ARV treatment and social support. Expected Outcomes Protocols for general HIV -TB care and infection control for inpatient and outpatient will be introduced adapted and monitored during mentoring sessions to provide standardized optimal care services.

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.