CDC aims to establish a new five-year cooperative agreement with the National Department of Health (NDoH) to implement evidence-based public health programs, surveillance and disease control, and prevention activities. PEPFAR funds will support the NDOH to incorporate results of program evaluations into operational disease prevention and control programs, ensure the sharing of expertise and lessons learned nationally, regionally and internationally, and use the results to develop science-based health policies and guidelines. Funds will be used to pay for staff to implement the vision of the Partnership Framework Implementation Plan including the transition activities within the NDOH. CDC activities will be integrated within NDOH operational plans for HIV and TB prevention, care, treatment, strategic information, laboratory systems strengthening, and health systems strenthening.

The NDOH Care and Support sub-directorate will coordinate care and support activities across all provinces. This coordination will include PEPFAR partners that are involved in care activities, and coordination will be facilitated through quarterly meetings organized at national level. These meetings will review feedback from the provincial Departments of Health (DoH) and PEPFAR teams, resolve challenges, and chart the way forward for the care and support programs for People Living with HIV (PLHIV), where the Integrated Access to Care and Treatment (I ACT)programme has now been absorbed. The grant will also enable the NDoH to plan and execute activities to minimize HIV/TB related stigma. The ultimate goal of this activity is to improve access to and retention of PLHIV in HIV/TB services, improve their health outcomes, and quality of life.

Funds will be used to support the South African National Strategic Plan (NSP) and TB/HIV strategic planning. This includes supporting the implementation of the five "I"s: (i.e., infection control, intensified case findings, TB/HIV integration, initiation of antiretroviral treatment (ART) and the implementation of isoniazid (INH) prophylaxis); recording and reporting (including monitoring and evaluation); all aspects of drug-resistant TB (including implementation of the multi-drug resistant TB (MDR-TB) decentralization program, the nurse-initiated MDR-TB management training and support to the KuduWave audiometry program); and advocacy, communication and social mobilization (including support for the Kick TB initiative to the schools and mines, national health days such as World TB and AIDS Day). Funds will be used to support training, printing and developing guidelines (including new TB/HIV guidelines, revised infection control guidelines, TB guidelines for Correctional Services and the mines and revised IPT guidelines), policies and tools (including for GeneXpert, other diagnostics, isoniazid preventive therapy (IPT), pediatric and prevention of mother-to-child transmission of HIV (PMTCT) TB. Training will be provided to districts/sub-districts on new guidelines, community-based programs to trace TB defaulters, re-engineering, counseling and testing to TB patients, TB pediatrics and TB management to PMTCT patients.

Support for TB surveillance, assessments (e.g., an evaluation of the Kick TB campaign in the mines), related meetings/workshops/trainings/conferences. For example 100 attendees from rural South Africa will be sent to the annual South African TB Conference eight satellite sessions supported. Support will also be given to the national TB prevalence survey, the four quarterly TB/HIV meetings and funding for two technical assistant posts at NDOH. TB/HIV training through the regional training centers and TB quality assurance will also be supported. The expansion of TB/HIV to the mining and correctional services communities will also be supported. This includes training on TB/HIV guidelines, expansion of the ETR.Net and EDR.Web and GeneXpert to these communities.

The implementing partner will support the national, provincial and district DoHs' overarching goals to scale up the number of pediatric patients in care and on ART according to the Blue Print for Pediatrics. In addition, increase the service delivery to HIV-infected infants, children and adolescents. This will be achieved with the district and regional training centres, and other stake holders. Capacity will be built as follows: (1) Provide continuous training to clinicians (physicians, nurses and clinical associates) on the diagnosis, treatment and management of HIV-infected infants and children. (2) Support the district and facilities to ensure scale up of provider-initiated counseling and testing, and sensitize provider to offer HIV tests to infants, children and adolescents at all levels of care with an unknown HIV status. (3) Provide on-going 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 maternal child health, the Expanded Programme for Immunization and the Integrated Managment of Child Illnesses (IMCI). (6) Support the districts to ensure that all HIV-infected children have access to CD4% and viral load testing. Work with the National Health Laboratory Service and the districts to ensure that results are returned to facilities at a timely manner. Work with the districts to ensure that facility-based staff report and record results.(7) Support the districts and sites in ensuring that there is a quality improvement plan. Ensure that the district and sites use data to affect change at the site and district levels. (8) Support districts and Regional Training Centres to provide 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.

A PEPFAR-supported evaluation of the gaps and challenges with the pre- and post-analytical phases in public health care services was conducted two years ago. Gaps and challenges were identified and recommendations were made to the NDoH. However, the NDoH has not had the capacity to implement many of those recommendations because of limited NDoH staff who focus on laboratory systems strengthening. Laboratory funds will be used to support eight director level positions within the NDoH to develop laboratory policies, support improved laboratory information systems and integration, and address other laboratory systems strengthening such as improving turn-around times. This newly established lab unit within the NDoH will work closely with the National Health Laboratory Service (NHLS) to improve service delivery.

PEPFAR Funds will be used for the following: (1) Conduct an evaluation to determine success of the ART tiered system rollout in facilities where back-capture, data cleaning and implementation have been completed; (2) Finalize implementation of the tiered ART monitoring strategy focusing on tiers 1 and 2; (3) Train provincial and district officials responsible for implementation of the tiered ART monitoring system (i.e. PITs and DITs); (4) Conduct M&E workshops; (5) Recruit new data capturers (graduates from previous training) to be placed at primary health care facilities where NIMART is being implemented; (6) Train data capturers (21 day training); (7) Further develop TIER.Net (* funds for this activity also partially contributed through Global Fund); and (8) ensure includsion of the HIV related components in the Demographic Health Survey.

Funds will be used to for positions within the NDOH to support the vision of the Partnership Framework Implementation Plan including staff that work directly on the transition of care and treatment services. Funds will also be used to support Community Health Care worker training as part of PHC re-engineering. Lastly, funds will enable the NDOH to support staff within each of the provinces to coordinate PHC system strengthening. This will include improving access to HIV and TB care and treatment services within all levels of the public health care system (working closely with the PEPFAR partners within each of the provinces).

The NDoH has set aggressive goals for medical male circumcision (MMC) and is employing a catch up strategy to ensure that 80% of HIV-negative South African men aged 15-49 (approximately 5-6 million) are circumcised as part of a package of HIV prevention and sexual/reproductive health services within the next five years. CDC is working closely with the NDoH on strategic planning and development of guidelines and is currently funding implementing partners to perform technical support services ranging from communications to training, as well as funding service delivery partners at public, private, fixed and mobile facilities. The NDoH is leading the national MMC program and responsible for significant coordination and information gathering and dissemination. Circumcision-related activities to be included in this award are: training community health workers (CHW) on MMC community mobilization; providing technical assistance on strengthening supply chain management systems; supporting national MMC campaigns; printing strategic MMC program documents; and printing strategic materials to guide and advance the MMC program nationally. Materials can include policies, guidelines, standardized quality assurance (QA) tools, educational materials, reports and other publications. Coordination of stakeholder meetings will involve organizing periodic stakeholder consultations to review the MMC strategy; estimate MMC prevalence; identify gaps and synergies across SAG, donors, and implementing partners; plan, coordinate and implement the neonatal MMC and PMTCT integration; validate MMC standardized quality assurance (QA) tools; and share lessons learned across all sites. Additional activities include securing venues, invitating participants, developing relevant meeting materials, and mechanisms for collecting and disseminating meeting minutes and reports.

Finally, monitoring and evaluation with ongoing modification of monthly reporting forms and databases and standard MMC register, and adverse event surveillance system are additional activities.

The funds will support the implementation of evidence-based HIV prevention programs for youth. These will be age appropriate to adolescents aged 10-19 years and youth between 15-24 years. The girl child, who is at high risk for HIV infection, will be targeted. Targeted prevention interventions will be improved and strengthened to integrate HIV, sexually transmitted infections, and family planning. The Integrated School Health Program will be supported by ensuring effective implementation through monitoring and evaluation of the program at the implementation level. Meetings with implementers will be conducted quarterly to address any challenges and to ensure that interventions are responsive to the adolescent and youth epidemic and to reduce new HIV infection.The program aims to reach 16,500 young people.

In the effort to strengthen HIV Counseling and Testing (HCT) services in health facilities, the NDoH plans to: (a) provide provider-initiated counseling and testing (PICT) and couples HIV counseling and testing (CHCT) master and basic trainings to health-care providers and to South African government partners through the Regional Training Centers; and (b) provide basic HCT training to lay counselors through the Regional Training Centers. NDoH will also convene a National PEPFAR Partners Meeting Seminar that will bring together representatives from various US government agencies, PEPFAR supported implementing partners, NDoH, and private health sector involved in the HIV programs to enhance the role of the private sector in the delivery of PICT and to synergize activities. NDoH will host lay counselor HCT and QA consultation meetings to improve the quality of counseling, systems, and data. These efforts should see HIV testing increasing from 3% to 50% of patients being tested in health facilities as a standard of care.

NDoH plans to strengthen the testing of children. Health-care providers will be trained on how to appropriately counsel children and test them for HIV following the guidelines. Lastly, NDoH plans to strengthen the implementation of CHCT and home-based HIV testing together with linkages to care, support and treatment; so these funds will be used to execute these activities.

South Africa has committed itself to accelerate progress towards the elimination of mother-to-child HIV transmission (MTCT) by 2015.Considerable progress has been made towards the national scale-up plans for Prevention of Mother-to-Child HIV Transmission (PMTCT) through the Accelerated Plan. With the renewed scale-up to the elimination initiative for 2015, improved reporting on program coverage is critical. However there is a need for heightened program impact and strengthened linkages and improvements in maternal and child health and survival.

The new initiative aims to reduce MTCT, strengthen the four prongs of the PMTCT and link other initiatives on maternal, reproductive and child health to achieve the Millennium Development Goals (MDGs) 4, 5 and 6.Specifically this includes:

? Supporting the development and implementation of the Action Plans for PMTCT to enable South Africa to achieve their goals;

? Strengthening the continuous quality improvement activities;

? Supporting the implementation of the Campaign on Accelerated Reduction of Maternal and Child Mortality Activities (CARMMA);

? Supporting the development and implementation of the Action Plans for Pediatrics to assist the South African government in scaling up ART services for the children;

? Support the NDoH on implementation new PMTCT guidelines in terms of development and review of the new guidelines;

? Distributing and printing new guidelines;

? Supporting pediatric HIV trainings through the Regional Training Centres;

? Implementating new PMTCT guidelines; and

? Monitoring and evaluation of the PMTCT program.

Continued support for nurse-initiated management of antiretroviral treatment (NIMART) training and developing or stengthening clinical mentorship program activities.

The implementing partner will support the national, provincial and district DoHs' overarching goals to scale up the number of pediatric patients in care and on ART according to the Blue Print for pediatrics. In addition, increase the service delivery to HIV-infected infants, children and adolescents.This will be achieved with the districts, the Regional Training Centres and other stakeholders. Capacity will be built as follows: (1) Provide continuous training to clinicians (physicians, nurses and clinical associates) on the diagnosis, treatment and management of HIV-infected infants and children. (2) Support the district and facilities to ensure scale up of provider-initiated counseling and testing, and sensitize provider to offer HIV tests to infants, children and adolescents at all levels of care with an unknown HIV status. (3) Provide on-going 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 maternal child health, the Expanded Programme for Immunization and the Integrated Managment of Child Illnesses (IMCI). (6) Support the districts to ensure that all HIV-infected children have access to CD4% and viral load testing. Work with the National Health Laboratory Service and the districts to ensure that results are returned to facilities at a timely manner. Work with the districts to ensure that facility-based staff report and record results.(7) Support the districts and sites in ensuring that there is a quality improvement plan. Ensure that the district and sites use data to affect change at the site and district levels. (8) Support districts and Regional Training Centres to provide 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.