The goal of the Institute for Youth Development (IYDSA) program is to provide and support comprehensive TB/HIV care and treatment services in the allocated 5 districts (Cacadu, Nelson Mandela District A, Peddie S, Amatlhati and Great Kei) as set out by the PEPFAR realignment process. In Amathole district there are 63 facilities, 32 in Cacadu and 7 from the Nelson Mandela Metro sub district A. The care and treatment services are provided primarily through the nurse-initiated management of ART (NIMART) mentorship program which increases access and strengthens the health system. These facilities will together serve a total of 18600 patients in care and 11600 will receive ART. In accordance with the national policies, IYDSA is moving towards elimination of MTCT. The program focus of youth and adolescent will be preventing new infections, and care and treatment to infected patients. IYDSA has a complete and well defined M&E plan, which includes the monitoring of the comprehensive care program, as well as an SMS mentoring monitoring system. Quality assurance teams monitor and validate data from the clinics on a monthly basis, identifying gaps and taking corrective action.7 Vehicles were purchased through COP FY2011; none for COP FY 2012; 7 Total.

IYDSA's goal is to provide holistic care of HIV + adults and their families. This includes clinical care, psychosocial services and nutritional support. Adult care and support services are offered by roving technical teams which include a doctor, social worker and dieticians. These teams support the 102 IYDSA government facilities and home based care services. Primary Health Care nurses are trained in nutritional support, HIV care, psychosocial assessment and family support. Training of adherence monitors includes food security, counseling and defaulter tracing. The adult care and support services are offered at the allocated districts as set out by the PEPFAR realignment process. In Amathole district, 63 facilities are supported by IYDSA, 32 in Cacadu district and 7 from Nelson Mandela Metro sub district A.Client retention & referral system is key to successful management in HIV. A thorough assessment and preparation of clients is conducted prior to initiation of ART. This includes counseling, assessment of family support and assignment of an adherence monitor. In addition to psychosocial needs, physical needs of clients through facilitation of government grants and food parcels take place. During the pre-ART clients receive cotrimoxazole and INH as prophylaxis. Intensive TB, cervical cancer screening and management is also carried out at PHC facilities. All patients on pre-ART are encouraged to join support groups which are facility based. Complicated cases are referred up from PHC facilities to tertiary levels of care. Finally, Counseling and behavioral modification of PLWHA (PwP) is includedas part of the comprehensive care of the infected, and emphasis will be put on preventing the transmission of HIV through promotion of condom use, effective treatment of sexually transmitted diseases, encouraging the avoidance of high risk behavior, and constant education on dangers posed by alcohol and drug abuse. Post Test Clubs (support groups) are used as a means of engaging program entrants to maintain their health as well as that of their communities.

IYDSA shall target 102 allocated public facilities in Amathole, Cacadu and Nelson Mandela District in which a comprehensive care and treatment package including ART provision, cotrimoxazole prophylaxis and TB screening will be implemented. TB care and treatment continues to be the prerogative of the PHC system, and all efforts will focus on enhancing the delivery of TB care and TB prevention. In addition, Quality control and performance assessments will be completed by a QA team that will monitor the TB data from the clinic registers and patient folders on a monthly basis, validate, identify gaps and take corrective action. Quarterly performance assessments will also be conducted and reported to district, enhancing the monitoring and implementation of the clinical program. Finally, ; IYDSA will support TB care and prevention through training, with a focus on implementation of on-going IPT provision, through ongoing clinical mentoring. The mentoring will focus on differentiating TB screening and symptom screening and HIV/TB integration using both as entry points to care. MDT meetings and nerve centers will ensure that patients are fast tracked even where clinical support is minimal. HCW will be trained to support the IPT program.

Each school will be assigned a nurse in the revitalization of PHC systems. Each clustered facility will have a mentor assigned to keep nurses updated about prevention messaging. Gender empowerment programs will be promoted for early adolescents. To be included in school health and life skill programs as well as messaging to include delaying sexual activity, family planning, and decreasing risky behavior. The emergence of substance abuse also needs attention as it is a secondary driver of the epidemic. The post-test clubs will be used in the communities to provide parents and caregivers information on disclosing their status to their children and assisting them to de-stigmatize the disease.. The increasing tendency to defaulting and non-adherence in this age group has prompted IYDSA to create adolescent centers in the districts we support, and to model care to this group, addressing the special needs. A transition plan into adult care will also be evaluated and best practices sought for other organizations to benchmark. Community education on exclusive breast feeding and weaning practices will be intensified. A strong social compact is needed to decrease the pressure that young mothers feel to bottle feed. This will directly decrease the number of children testing positive at 18months PCR. IYDSA promote the concept of family health within the PHC system and seeing patients in isolation limits the effectiveness of prevention. This requires support for the IMCI and EPI programs. IYDSA will ensure that all the clinics offer this integrated package of care for the youth. Plans exists to expand the HCT campaign to include all children who present at the clinic using the current consent and assent guidelines of the NDOH. Efforts will be made to intensify the identify children who may have been missed at the 6 week PCR. Attention will be paid to retesting infants post weaning to ensure no children are missed. The new cadre of clinical assistants will be mentored on correct pediatric counseling by the social workers. All mentees will become competent and able to counsel youth, particular adolescents.

IYDSA's partnership with the government includes receiving all required drugs for the program. In order to receive the government supply of drugs in our program, IYDSA has agreed to provide the government with additional support in the form of 2 Pharmacists and 12 Pharmacy assistants to pack and manage the supply of these drugs. IYDSA also assists with training of DOH staff in supply, recording and management of pharmaceutical drugs. In addition, IYDSA provides transport, communication, laptops, data recording, labels, software and printing. IYDSA maintains a buffer Stock of 600 scripts (provide by SCMS), in order to meet drug requirements in the event of stock outs, or other supply problems which may compromise the provision of drugs in the program.

SAG is committed to total elimination of MTCT of HIV by 2015. IYDSA is committed to seeing this goal achieved. The aim is to treat and manage the mother and baby pair as an effective preventive strategy. This includes the integration of PHC services withPMTCT as an entry point into prevention, care and treatment of women and children. HCT, family planning, ART and nutritional support, STI and TB management will also be provided. The strategy is to continue integrating all services within the PHC system with the main focus being partner testing; Re-testing of HIV negative women at 32 weeks of pregnancy; to Conduct PCR on babies at 6 weeks and retesting at 18 Months;and to promote exclusive breast feeding; and finally to enforce retesting post weaning. IYDSA will also support capacity building and training through NIMART mentoring support for PHC nurses with PMTCT guidelines as well as supervisory support on eligible women. The key focus is preventing transmission early in pregnancy; during delivery and postnataly. Facilities receive support which enables them to roll out ART, thereby decentralizing the services to the PHC level. IYDSA will scale up PMTCT to between 20% - 50% in FY2012.Finally, IYDSA will ensure support at all levels of care, as well as M&E of the program. IYDSA will assist in the development of the District and Sub-District PMTCT plans. These will be reviewed throughout the different stages. Roving quality control units are responsible for auditing files and registers, carrying out periodic quality control measures ensuring consistent evaluation of the MTCT program. QA teams will monitor the PMTCT data from the clinic registers and patient folders on a monthly basis, validate, identifygaps and take corrective action. Quarterly performance assessments will continue to be conducted and reported to district, enhancing the monitoring and implementation of the program. PMTCT reports generated on a quarterly basis will continue to be shared with ECDOH to improve SAG intervention strategies.

In accordance with national guidelines, IYDSA shall continue with NIMART mentoring to scale up access to treatment. Integration of treatment with TB, Maternal and Child health, PICT, Prevention and Prophylactic treatment strategies, Laboratory services, drug management, and data management will be ensured. In regards to adherence and retention of patients in care,IYDSA shall develop plans for routine assessment and evaluation of patients lost to follow up and have standard operating procedures to guide teams in addressing the loss. Plans will also include tracing of patients that have been down referred and up referred to other facilities. The target population of IYDSA will be 102 allocated public facilities in Amathole, Cacadu and Nelson Mandela Districts. Where a comprehensive care and treatment package including ART provision, cotrimoxazole prophylaxis and TB screening will be implemented. Mentoring of PHC nurses shall ensure continued expansion of ART services and sustainability of ART service delivery. In addition, quality control and performance assessments will be performed and all patients on treatment will be closely monitored for virological treatment failure. Clients with suspected drug resistance will be tested in accordance with set guidelines. Performance assessments will include pharmacovigilance through close monitoring of laboratory tests as per treatment guidelines. Technical teams will support the tracing and monitoring of patients that are lost to follow up. Quality control units will be responsible for the periodic and randomly selected quality control audits. The findings from the quality audits and performance assessments shall be shared with the sub district and the district to help in the improvement of ART services at facilities. Finally, in regards to the transition of services to Government,IYDSA continues to provide care at four private sites, with 14 sites already having transferred all their patients to PHC facilities. IYDSA will seek to pilot a model of private clinics which will be supported and funded through the National Health Insurance system (NHI).

NIMART training ensures that all the sites are initiating children on ART. There is no differentiation between adult and pediatric NIMART, both are implemented at all facilities. IYDSA will ensure that the basic integrated package of care is adopted, including HIV/TB integration. In addition, IYDSA will ensure that early infant diagnosis is enhanced with thorough repeat testing at 18 months. Linkages with the IMCI programs need to be reinforced, and ensure that the NDOH guidelines for ART are implemented. Mentoring teams will ensure that children under 2 are initiated on ART irrespective of CD4 count. The Continued promotion of exclusive breast feeding in HIV-infected mothers will continue to be an integral part of the program and. all supported PHCs will provide pediatric PICT. In addition, IYDSA will provide Technical Assistance to ensure that carefully-written CTX policy and guidelines for HIV-exposed/infected children are available in all clinics. IYDSA will scale up CTX prophylaxis so that 80% of children receive CTX according to the guidelines and this will be achieved through enhancing the pediatric NIMART program with focused mentoring on pediatrics. Through mentoring and performance improvement cycles IYDSA will ensure that all children eligible receive CTX prophylaxis. IYDSA will also strengthen the monitoring of the pediatric program to ensure retention in care. Many children are not followed up and many pediatric patients are lost and therefore,TA will be given to allow for continuous tracing of this cohort. M & E improvements in the pediatric cohort need to be addressed as currently the data is not disaggregated into age groups. Effective collection tools will be developed to address this issue and specialized TA will be given to establish adolescent centers for treatment as the requirements for this cohort of patients and TA teams will ensure that a protocol is devised for this cohort to transition into adult care. IYDSA will seek to develop 4 specialized Mother, Child and Adolescent health facilities which will have all levels of clinical support from PHC nurses to pediatricians. This will ensure that all districts are able to initiate children and manage complications.