HSTs goal is to improve the effectiveness of the District Health System to decrease the burden of HIV, AIDS, STIs, and TB, and reduce child and maternal deaths.This five-year project will contribute to achieving the prevention; care, support, and treatment; and sustainability goals of the PEPFAR 5-year strategy and the approach will align to Global Health Initiative (GHI) principles. The approach of this proposal is largely developmental and geared towards health systems strengthening. In leveraging proven strategies and methodologies to minimize risk and maximize efficiency and effectiveness, this project will seek to develop local indigenous capacity both within government and the NGO sector to: 1. Do population-based planning, target setting, and monitoring and evaluation; 2. Deliver integrated HIV services including pediatric, PMTCT, and TB services; 3. Develop, implement, and maintain referral networks that will contribute to improved quality of service delivery; and 4. Use information as a key driver to decision making to improve health outcomes through implementation of the three tier health information system. The interventions will combine health systems strengthening and community-based and facility-based strategies to deliver HIV/AIDS and TB services. The approach is to build capacity of managers and technical staff through mentoring and technical assistance to ensure local ownership and sustainability. Herewith a summary of the vehicle request: 16 x VW Polo (one per SA SURE district); $ 320,384; vehicles will be used for traveling to perform activities related to project implementation. This vehicle will be shared by the project team in the districts.

HST will work closely with National, Provincial, and District DOH and other PEPFAR partners in ensuring a continuum of care and support, through both community- and facility-based services, for PLHIV starting from the time of diagnosis. Priority will be given to the early identification of PLHIV, linking and retaining them within care and support services to minimize loss to follow-up, and to reduce early morbidity and mortality. Upon diagnosis of HIV, HST will advocate for immediate CD4 testing (POC testing technology will be considered) and counsel clients to return for results. The partner will also ensure that patients are immediately linked to psycho-social counselling and support groups (e.g. I ACT). HST will implement and maintain pre-ART registers to follow-up patients and track-down early defaulters. To maintain the quality of life of PLHIV, HST will provide cotrimoxazole prophylaxis and Isoniazid preventive therapy (IPT) to all eligible patients and will ensure that PLHIV are provided with routine screening and management of Tuberculosis, other opportunistic infections (i.e. Cryptococcal disease, cervical cancer), and sexually transmitted infections. PLHIV will further be supported through routine nutritional assessments, counselling and support (NACS), and the assessment and management of pain. In order to reduce the transmission of HIV to uninfected individuals, HST will implement prevention with Positives (PwP) programming that may include condom distribution, reduction in high risk behaviour, and reduction in risks imposed by alcohol and use of illegal drugs. The partner will also conduct activities related to care and support program monitoring and evaluation according to appropriate guidelines of the DOH or as advised by PEPFAR.

HST provides comprehensive care and treatment support in 12 districts across RSA in cooperation with another PEPFAR partner, Aurum. In this program model, HST provides program capacity and TA support while Aurum fills key gap HR needs in the public health workforce, in the target districts.

HST will work close together with the national, provincial, district and sub-district departments of health, other PEPFAR funded partners and stakeholders to ensure that no duplication of services will take place and that the NDOH/PDOH policies are adhered to. Facility TB/HIV assessments will be done to identify needs to be addressed. No new tools or training materials/guidelines will be developed without the approval of the national, provincial, district and sub-district departments of health. Only approved NDOH TB/HIV training will be supported. The partner will focus on the 5 Is: infection control (in collaboration with CSIR and NDOH), implementation of INH prophylaxis to all legible clients; intensified case finding (supporting the NDOH household/outreach case finding initiative, through close collaboration with NDOH and provincial DOH); integration of TB/HIV (all HIV patients will have a known TB result and all HIV patients been symptom screened for TB and referred for TB management or IPT ); initiation of ARVs to eligible TB patients (including CD4 counts to all TB patients). Community TB contact and default tracing will be supported by the partner as well as the NDOH MDR/XDR decentralized (program by means of injection teams to deliver treatment). Support will also be given to strengthen TB and TB/HIV recording and reporting (monitoring and evaluation) and the partner will work close with NHLS to ensure short turnaround times of results (including support to the GeneXpert diagnostics). The partner will also support the essential drug management (EDL) program to ensure that no interruption of treatment will occur. The partner will ensure that PMTCT, ANC, and pediatric services be part of all TB/HIV activities. Support will be given to advocating, monitoring and social mobilization (ACSM) activities on district, sub-district and facility level, TB and HIV days and the Kick TB initiative.

HST provides comprehensive care and treatment support in 12 districts across RSA in cooperation with another PEPFAR partner, Aurum. In this program model, HST provides program capacity and TA support while Aurum fills key gap HR needs in the public health workforce, in the target districts.

Activities will target children and adolescents from newborn to 21 years of age. The partner will do needs assessments and work with the District health management (DHMT) team to identify gaps in care. HST will support and strengthen integration of MCH, IMCI, IMAI, nutrition, growth monitoring and HIV services. Identification of HIV exposed (HEI) and infected babies at 6 weeks will be strengthened through optimal use and the recording of the mothers HIV status on the Road to health card. HST will strengthen referral systems between maternity (labor and delivery) and Primary health care clinics to improve follow up and tracking and tracing of mother infant pairs. The partner will support and strengthen the recording and reporting and improve systems to ensure that commodities for DBS PCR testing and drugs (ARVs, cotrimozaxole and Nevirapine syrup) are available at health facilities. HST will strengthen the provision of a minimum package of care for HIV infected children which includes, cotrimoxazole prophylaxis, TB screening at every visit, provision of IPT for children, growth monitoring and nutritional assessment, immunizations, and psychosocial support. HST will support the strengthening of adolescent services including PICT, and psychosocial support especially around issues of disclosure, prevention with positives, and adherence.HST will assist the district and facilities with the implementation of a quality improvement program that will include the following: improved recording and reporting, and monitoring and evaluation. Moreover, the partner will also support the facility, district and province to develop strategies to improve uptake in PCR testing, cotrimoxazole, retesting post weaning and retesting at 18 months.

Partner will provide support in O R Thambo (EC), Fezile Dabi (FS), Lejwelaputswa (FS), Mangaung (FS), Xarieb (FS), Umgungungdlovu (KZN), Uthukela (KZN, Zululand (KZN) Umzinyati (KZN), Waterberg (LP), Frances Baard (NC) and Pixley Ka Seme (NC) districts towards the implementation of key national programs and health initiatives specifically focusing on:

1. Provide support towards the development of district health plans

2. Provided assistance in strengthening leadership and management capacity

3. Support new or existing management systems and tools specifically aimed at HRH management (recruitment, retention, decreasing vacancy rates) as well as the implementation of the NDOH/PEPFAR HRH transition plan at district, sub-district and facility levels

4. Support capacity development through the coordination, planning, training for and implementation of priority programs (i.e. NIMART, I-ACT) as designed by the National Department of Health

5. Strengthen supply chain management systems

6. Strengthen information management systems (including M&E, disease surveillance and outbreak monitoring, management reporting),

7. Strengthen laboratory processes / systems

8. Support the implementation of quality improvement initiatives within the district

9. Support the implementation of the PCH re-engineering strategy, working with the District Health Team to establish/roll-out the specialist support teams, school health programs and community outreach teams as specified in the PCH re-engineering strategy for the country

10. Support in the planning for the National Health Insurance (NHI) in identified districts

HST provides comprehensive care and treatment support in 12 districts across RSA in cooperation with another PEPFAR partner, Aurum. In this program model, HST provides program capacity and TA support while Aurum fills key gap HR needs in the public health workforce, in the target districts.

HST will provide support to the District and province in improving the quality and coverage of the PMTCT services in women from age 15-49 years, to achieve Mother to Child transmission rate < 2% at 6 weeks and < 5% at 18 months by 2015 in line with National Service Delivery agreement. HST will continue to support the national PMTCT program by addressing some of the inherent programmatic gaps through technical assistance including ongoing support thru on-site mentorship of NIMART trained nurses; and health care workers trained in family planning, TB/HIV/STI management, couple counseling, Basic Antenatal Care services and infant feeding practices. HST will ensure that all women seen at ANC will have access to family planning counseling services, safer pregnancy counseling, and nutritional counseling and support services. HST will work with South African government to improve linkages and integration of services between PMTCT, MCH, sexual and reproductive health, youth services and family planning services. Activities will include promotion of PICT, TB screening of all pregnant women irrespective of their HIV status, promote early booking and the retesting at 32 weeks. HST will develop effective strategies to follow-up mother-baby pair post delivery. The program will prioritize early infant diagnosis by strengthening the referral systems between hospitals, clinics and community outreach programs. Furthermore, activities addressing cultural attitudes to infant feeding practices, male involvement in PMTCT and antenatal care, and increased uptake of services will also be supported. HST will also work with the laboratory department to ensure improved turnaround time for CD4 counts, PCR and other laboratory results. HST will conduct quality improvement activities in order to identify areas of and need and will work with the district to innovate solutions for better program outcomes. HST will provide support to District health information system to enable tracking of progress by using Maternal and PMTCT indicators according to SAG.

HST provides comprehensive care and treatment support in 12 districts across RSA in cooperation with another PEPFAR partner, Aurum. In this program model, HST provides program capacity and TA support while Aurum fills key gap HR needs in the public health workforce, in the target districts.

HST will work with the National, Provincial and District DOH to identify priorities and needs for adult HIV treatment. HST will also work with other stakeholders to ensure that there is no duplication of services provided within their supported sub-district and/or district. HST will overall support the following: 1. Collaborate with the District to support PHC re-engineering initiatives.2. Provide supportive supervision and mentoring to all the nurses trained on NIMART to be confident about their skills. 3. HST will support the Department of Health (DoH) in its efforts to improve access to ARV treatment by assessing jointly with DoH, the readiness of facilities for initiation of patients on ART. 4. Support the District to ensure that all facilities have updated treatment guidelines on site and that staff at sites are familiar with their content.5. Ensure that all patients with CD4<350 are initiatated on ART.6. HST will also work with the DoH to strengthen quality improvement of treatment programs. These efforts will include strengthening and supporting the implementation of the DoH 3-tiered system of M&E for ART; improving adherence to treatment by increasing the proportion of adults and children who remain on ART after initiation; and conducting cohort studies and ensuring integration of TB and HIV services. Moreover, HST will ensure that data is owned by the site staff and will support sites to use data by identifying gaps in care and problem solving to develop a plan to address these gaps.7. Through all activities, HST will strive to build local capacity at the facility and district level s with the goal that these activities will be transitioned to the local government in the next 5 years.

HST provides comprehensive care and treatment support in 12 districts across RSA in cooperation with another PEPFAR partner, Aurum. In this program model, HST provides program capacity and TA support while Aurum fills key gap HR needs in the public health workforce, in the target districts.

HST will support District and SAGs overall arching goals to scale up the number of Pediatric patients on ART to 15% the total on ART for the sub-district or district, and increase service delivery to HIV-infected infants, children and adolescents. This will be achieved with the District and the Regional Training centers, and other stake holders. Capacity will be built in the following manner:1. Provide continuous training to Clinicians (physicians, nurses and clinical associates) on the diagnosis, treatment and management of HIV-infected infants and children. 2. Provide support to the District and facilities to ensure scale up of PICT. Sensitize provider to offer HIV tests to infants, children and adolescents that are encountered at all levels of care with an unknown HIV status. 3. Provide ongoing support for NIMART. The partner will provide onsite mentorship and regular onsite follow up to ensure that nurses are capacitated to initiate and provide care and treatment services to HIV-infected infants and children.4. Support and ensure linkages to programs providing nutritional support, adherence, and psychosocial support.5. Support and ensure that Pediatric ART services are integrated with MCH, EPI and IMCI.6. Support the District to ensure that all HIV-infected children have access to CD4% and viral load testing. Work with the NHLS and District to ensure that results are returned to facilities at a timely manner. Work with District to ensure that staff at facility reports and records results.7. Support the District and sites in ensuring that there is a quality improvement plan in place. Ensure that District and sites use data to affect change at the site and District levels. 8. Support District and RTC in providing training and onsite support for improving data collection, recording and reporting. 9. Support the District to ensure that there are adolescent friendly spaces to address the unique issues and challenges that HIV-infected adolescents encounter, particularly issues related to disclosure, and sexual and reproductive health.