Integrated HBHC services will be provided to 186,121 PLHIV in Lukhanji, Intsika Yethu, Emalahleni, Engcobo, Inxuba Yethemba and Sakhisizwe, Makana and Nkonkobe sub districts of the EC Province. Services will include; screening, diagnosis and treatment for active TB, STIs, and other OIs; CTX; IPT; NACS, pain assessment and management and linkage to the HBHC community component. Referral networks between the community and the 200 facilities will be established to enhance pre-ART follow-up and timely ART initiation. The I ACT support groups will be established in all the 200 facilities to empower the PLHIV and minimize the LTFU of pre-ART/ART clients as well as to serve as a link between facilities and the community. At home/community level comprehensive, family-centered holistic services will be implemented including integrated prevention services, clinical/physical, psychological, spiritual and social care. Community systems will be strengthened to enable self-sufficiency and self-sustenance among the 48 CBOs. A total of 480 CHWs from the CBOs and 1000 from facilities will be trained and mentored. A minimum package of services will be adapted and implemented for pre-ART and ART patients. Caregiver support programs will be adapted to each community structure to address burn out, retreat and respite issues. Capacity of other local entities will also be built: youth; religious institutions; and traditional leaders and healers - to promote behavior change; increase the demand/uptake of HIV services; address culturally sensitive issues; reduce risky behavior and facilitate social change. For sustainability, the sub district, district and provincial health management teams and leadership will be engaged to advocate for HBHC services and policy issues.

Integrated HBHC services will be provided to 186,121 PLHIV in Lukhanji, Intsika Yethu, Emalahleni, Engcobo, Inxuba Yethemba and Sakhisizwe (Chris Hani District), Makana (Cacadu District) and Nkonkobe (Amathole District) sub districts of the EC Province. Services will include; screening, diagnosis and treatment for active TB, STIs, and other OIs; CTX; IPT; NACS, pain assessment and management and linkage to the HBHC community component. Referral networks between the community and the 200 facilities will be established to enhance pre-ART follow-up and timely ART initiation. The I ACT support groups will be established in all the 200 facilities to empower the PLHIV and minimize the LTFU of pre-ART/ART clients as well as to serve as a link between facilities and the community. At home/community level comprehensive, family-centered holistic services will be implemented including integrated prevention services, clinical/physical, psychological, spiritual and social care. Community systems will be strengthened to enable self-sufficiency and self-sustenance among the 48 CBOs. A total of 480 CHWs from the CBOs and 1000 from facilities will be trained and mentored. A minimum package of services will be adapted and implemented for pre-ART and ART patients. Caregiver support programs will be adapted to each community structure to address burn out, retreat and respite issues. Capacity of other local entities will also be built: youth; religious institutions; and traditional leaders and healers - to promote behavior change; increase the demand/uptake of HIV services; address culturally sensitive issues; reduce risky behavior and facilitate social change. For sustainability, the sub district, district and provincial health management teams and leadership will be engaged to advocate for HBHC services and policy issues.

Technical Assistance (TA) for implementation of care and support programs for 8600 OVCs aged 0-18 years by mitigating the impact of HIV and reducing risk and vulnerability to HIV. Contribute to PEPFAR goal of care for 5 million infected and affected OVCs. Support the South African Government (SAG) National Action Plan for Orphans and Vulnerable Children OVCs. Create a supportive social environment. Help children and adolescents meet their own needs, improve the lives of children and families affected by AIDS. Reduce psychosocial, health and socioeconomic impacts. Strengthen and expand delivery of community-based OVC and HIV prevention, care and support services.

Support every facet of a healthy childs development and family life through formalization/ strengthening identification and registration at all levels. Create, strengthen and mobilize 200 multi-sectoral Child Care Forums (CCFs) - linked to the 200 HF to ensure a coordinated community response and capacity building for 48 CBOs. Engage all relevant community structures including Local AIDS Council,Local AIDS Community Coordinating Council (LACCA), SAG departments: of Social Development , Health and Education. Create a two-way referral system between ART facilities and community structures (48 CBOs and 200 CCFs). Establish peer support groups for children on ART; strengthen advocacy and community mobilization towards protection of childrens rights.Train 60 Social Workers to facilitate the development, maintenance and sustenance of the Community Counseling Forums (CCFs). Revise existing OVC identification and registration tools and align with PEPFAR OVC and SAG indicators implemented through the 48 CBOs. Strengthen the electronic database to strengthen reporting and tracking of OVCs services. Use child Status Index for case management. Select capable and competent CBOs for the management of community based HIV services. Strengthen CBOs to become centers of excellence for provision of TA to mushrooming CBOs. Train Caregivers to provide essential clinical nutritional support, child protection interventions, general healthcare referral, HIV prevention education, psychological care and household economic strengthening. Facilitate formation of 48 support groups for caregivers. Establish a 2-way functional referral system between the 200 HF and the community structures for continuum of care.

Africare will provide support in Chris Hani district in EC province. All PLHIV seen at health facilities (HF) are screened for TB at the initial and follow up visits; at least 90% of TB/HIV co-infected patients who qualify are on cotrimoxazole preventive therapy (CPT), all asymptomatic HIV infected clients are initiated on Isoniazid Preventive Therapy (IPT), All TB patients are offered provider initiated counseling and testing services (PICT); PLHIV with active TB are on treatment, 80% clients on TB treatment complete their treatment, and, TB infection control and prevention is implemented in all the facilities.

Facilitate integration of TB-HIV Services at the community level to improve the coordination of TB management and increase case detection at community level through support groups and partnership with CBOs. Conduct advocacy, community mobilization and sensitization to raise awareness on TB and HIV services. Train CHW on conducting TB symptom screening and on safe sputum collection.

Ensure that all patients found with active TB are started on treatment and at least 80% complete the treatment. Engage the DOH to ensure that TB/HIV co-infected patients are provided services by a single clinician, while utilizing one clinical record in order to facilitate functional linkages/integration between TB diagnosis and HIV and TB treatment programs.

Offer IPT to all TB asymptomatic HIV infected individuals. Ensure regular availability of INH at all HF through appropriate pharmacy technical support.

Promote rapid identification of TB disease, rapid initiation of TB treatment and ensure adherence to treatment. All HF will undergo annual TBIC assessments and environment controls.

Work with ECRTC to train and mentor 400 HCWs on TB/HIV in accordance with NDOH guidelines. Procure, adapt and disseminate TB tools, guidelines, SOPs and manuals. Regular chart and register reviews will be conducted to monitor TB services. Strengthen Surveillance on TB/HIV co-morbidity. Data quality improvement and assessments. Indicator reporting and feedback to monitor and evaluate clinical outcomes, and standard of care.

The program will strenghten PMTCT delivery through early infant diagnosis and follow-up, to robust, adolescent-friendly care. Interventions will focus on HIV-exposed children, HIV-infected children, HIV-affected children, adolescents together with their families. Emphasis will be placed on integration of PMTCT, ART, pediatric outpatients department and primary health care (PHC) as well as TB clinics, to identify children that are HIV exposed, infected or affected. Major interventions will include training, mentorship, technical assistance, supportive supervision, community education and quality assurance. Integration of services as well as step up of counseling of caregivers to bring children to the health facilities will be prioritized. Functional linkages between related programs, including PMTCT, ART, MCH, IMCI, TB and community-based activities (psychological, social, spiritual and prevention services), will be established and strengthened at the health facilities. These linkages will be regularly monitored and their efficacy evaluated by Africare Clinical Advisors.Facility specific systems for early diagnosis (EID) of the HIV exposed and infected infant (HEI) to increase the uptake at 6 weeks and ensure testing using rapid tests at 12-18 months will be assessed and strengthened based on the SAG guidelines. All infants will have their HIV exposure status established and documented at their first contact with the health system. Testing algorithms will include recommendations for repeat testing of children who test HIV-negative but have on-going HIV exposure through breastfeeding, and children who test HIV-positive on antibody tests performed before 18 months of age. Infants who are found PCR positive will be fast tracked to start ART. This will be facilitated by ensuring HEI registers and mentoring of the health care workers on the management of HEI. Africare will train data capturers on the use of the PedTrack software, health care workers will be trained to identify HIV exposed infants and to ensure follow-up. Particular attention will be given to establish functional linkages between the MCH health care workers with the care and treatment sites for follow-up of HIV infected women and HIV-exposed infants.. LTFU cases will be analyzed and interventions planned and implemented for consistency of messages and effectiveness of delivery messages. Health care workers will be trained to provide counseling and support for infant feeding options and to establish functional appointment systems for regular health assessment and promotion visits for the HEI. HIV pregnant women will be encouraged to disclose their status during their ANC visits to promote adherence to infant feeding choices made. Africare will build capacity at the sub district and facility level for assessment of anthropometric status, nutrition-related symptoms and diet. Children whose diets are unlikely to meet vitamin and mineral requirements will be referred for daily multi-micronutrient supplement. Clinically malnourished children will also be referred for therapeutic or supplementary feeding support.Technical assistance and support will be provided to ensure CTX prophylaxis, and linkages to child survival interventions including immunizations; growth and development monitoring; diarrheal disease management, and, TB screening. Health care providers will be trained and mentored to ensure CTX prophylaxis for HEI, growth monitoring, developmental and TB screening.

Africare will provide support in Chris Hani district in EC province, 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 Human Resources for Health (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 Public Health Care 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

Africare will provide support in Chris Hani district in EC province, to support the NDOH scale-up of PMTCT towards the elimination of MTCT (eMTCT) by 2015 through capacity building at all levels of care and provide training/mentorship to 400 health staff. Strengthen community systems to expand PMTCT coverage from three to eight sub districts (79 to 200 health facilities; 12 to 48 CBOs) while at least 6000 eligible women in reproductive age are reached with the four prongs of PMTCT services. PICT to all pregnant women seeking care; access to CD4 testing for HIV+ women; prophylaxis (ARV, CTX, INH); counseling and support for infant feeding. Women living with HIV will receive treatment, care and support services as well as care for their children and families. Activities will ensure identification and early and enrollment into high-quality PMTCT services.

Retention and adherence of mother infant pair PNC will be revitalized through establishment of functional linkages between the MOU with respective PHCs. PedTrack scheduling software and PMTCT spread sheet will be expanded to cover 8 sub districts. Use Customized diaries in all the ANC clinics and track defaulters.Promote use of partners and family members as infant feeding supporters to enable HIV+ pregnant women to disclose their status. This will increase adherence to infant feeding choices. Establish PMTCT support groups throughout the program. PMTCT will be integrated with TB, Integrated Management of Childhood Illnesses, Pediatrics and Maternal Newborn Child Health (MNCH) programs. Staff training and mentoring on appropriate HIV Exposed Infants (HEI) management. Implement a model to improve partner and couples HIV testing counseling services within the MCH platform, early linkage to care improved access to HIV prevention services throughout the continuum of care. Implementation of health facility specific interventions to ensure that PMTCT clinics are men friendly. Establish formal links with 48 CBOs supported by Africare and other community resources to ensure leverage to help women cope with the impact of a HIV diagnosis. The 48 CBOs and the health system in the seven sub districts supported by Africare are complementary and have synergies within their catchment areas. Africare will assess, identify gaps and implement interventions to strengthen specific essential elements within the CBOs. This elements include a) context specific planning and monitoring & evaluation; b) personnel, technical & organizational capacity building; c) financial and material resources such as HCBC/OVC essential commodities; d) home and community based care and OVC services based on evidence & standards, implemented ethically and sustainably; e) community networks, linkages & partnerships; f) management, accountability and leadership; and, g) communication and outreach. These elements will ensure increased access, use and quality of HCBC/OVC interventions, effective use of prevention, care, treatment and support services and improved support for PLHIV their families, community and health workers in the seven sub districts.

Engage DOH and stakeholders, including other PEPFAR partners within the catchment area in PMTCT through regular management and technical meetings, workshops and feedback for monitoring and QA. Institutionalized reqular feedback to promote data use and continual education and motivation of staff.

Africare will provide support in Chris Hani district in EC province, supporting provision of ART services in all health facilities. The goal is to provide technical assistance (TA) to SAG to deliver a comprehensive treatment package including cotrimoxazole and Isoniazid prophylaxis, ART and TB screening, diagnosis and treatment to reduce to at least 80% HIV/AIDS morbidity and mortality among PLHIV. The objective is to provide TA for delivery of ART services to 31,531 PLHIV and ensure regular availability of ARV, TB, STI and other OI Drugs in all facilities.

To ensure local ownership and sustainability, Africare will implement the Clinical Systems Mentorship (CSM) for health system strengthening and capacity development. Facilities will be move from regular external support to implement a model with a higher standard of care and independence. This strategy will improve efficiency and effectiveness and facilitate rapid expansion in the 3 districts.

The program will further support the PHC re-engineering strategy, HF assessments based on the model and standards of care elements, training of 400 professional nurses, follow-up onsite clinical systems mentoring, and to address barriers to NIMART. ART outreach teams from the 16 hospitals will be established in collaboration with the sub district teams. These teams will monitor quality of services and supervision of NIMART through the sub district multidisciplinary teams.

Comprehensive and integrated approach to care and treatment will ensure compliance to the WHO 3-Is approach and the South Africa specific 2-Is: integration of HIV and TB services, and initiation of early treatment. Support will be provided to pharmaceutical management to ensure regular drug availability, training and mentorship on drug supply management, and support to the Pharmacist Assistant training program. The support will also ensure appropriate Pharmacovigilance (PV) reporting and management at the 16 hospitals through training and mentorship and establishment of PV committees at the referral hospitals to ensure compliance with Good Pharmacy Practice.

Program performance measurement will be based on basic program evaluations and routine HMIS in line with the NDOH 3 Tier M&E System.

Africare will provide support in Chris Hani district in EC province, will further support the expansion of Paediatric HIV Treatment to increase the proportion of paediatric clients initiated on ART from 8% to 15%. The program will strengthen case identification and patient management, including linkages between health services and referral mechanisms; improve follow-up of HIV-exposed Infants; enhance Early Infant Diagnosis (EID); and support training in paediatric HIV care and treatment for the current NIMART implementing staff.

Nurse Mentors and Clinical Advisors will train and refresh all providers in HIV Treatment, and will monitor progress of providers in appropriately starting ART in eligible children while focussing on the NIMART nurses. In addition, Africare will regularly review paediatric standards of care tools.

Treatment failure will be monitored among children taking ART. Africare will train healthcare providers to recognize treatment failure, by regular mentoring and in-service trainings. The team will ensure service providers understand that poor adherence is the commonest reason for failure, and adherence strengthening should be explored. Referral and supervisory systems to manage and monitor patients on ART will be developed and or adapted.

Emphasis will also be placed on cross referral between TB and HIV services, and between immunization/well baby clinics and ART clinics. Efforts will be made to include PICT providers and representatives of referral endpoints in multidisciplinary team meeting at the health facilities.

All health facility staff will be trained on PICT, and regular supply of rapid test kits from the government depots will be supported. Facilities will be systematically assessed in each sub district to determine gaps in PICT training and test kit availability.

The expansion of Tier.net ART will be supported for the capturing and collating of paediatric HIV treatment data. These data will facilitate paediatric patient management while identifying gaps in services, tracing and tracking, and targeting intervention efforts for special groups of children.

Africare multidisciplinary teams will provide systematic on-site mentorship to clinicians, pharmacists, and data capturers. These mentorship efforts will focus on competency of on-site staff on paediatric treatment.

Regular refresher in-service trainings in paediatric care and treatment will be coordinated by the Nurse Mentors and Clinical Advisors. Referral hospital clinicians will be facilitated to develop facility-based training programs for their colleagues and other members in the PHC. This type of in-service training, will minimize disruption of service delivery. In areas where local expertise is lacking, Africare will assist in the provision of sessional doctors for service delivery.

Tools to improve adherence to ART will be developed/adapted. Care providers will be trained in the establishment of adherence programs aimed at the patient and the family, drug issues such formulation and toxicity, and healthcare system strengthening which will encourage the establishment of long-term relationships among children, their families, and the clinic staff. All members of the MDT will provide counselling, tracking and follow-up of children. Disclosure of the child's illness will form an essential part of regular follow-up - Africare will assist clinicians to be appropriately trained and sensitized to the process.