The PEPFAR-funded CAPRISA AIDS Treatment (CAT) Program started in 2004 with two innovative approaches; integration of AIDS care with TB treatment at an urban TB clinic in eThekwini and a nurse-driven AIDS care service in a rural community in Vulindlela. Specific objectives include; expanding access to HIV counselling, care and treatment activities by supporting the South African Government health services in the Vulindlela sub-district and in facilities in eThekwini, strengthening the programme of pre-ART care in the facilities we support, maintaining survival or AIDS free events in 85% of the enrolled population for up to 12 months of follow-up in facilities we support, supporting counseling and testing activities, specifically for TB-HIV co-infected patients, adolescents and young women in Vulindlela, expanding MMC and other HIV prevention interventions in an effort to prevent new infections and halt the further spread of HIV, expanding TB HIV integration services, and TB prevention services in the facilities we support, which includes implementing quality improvement strategies in facilities managing drug sensitive and drug resistant tuberculosis, conducting operational research via our PHE award on improving our understanding of recurrent tuberculosis on populations on ART, and improving access to sexual reproductive health services among adolescent girls by facilitating specific counseling among these populations on: know your HIV status, delaying sexual debut, self- reporting of STIs and facilitating referral for contraceptive services. CAPRISA will also conduct research and improve quality of services as they relate to systems strengthening in the response to TB and HIV.

The CAT program will support SAG facilities in prolonging and optimizing quality of life of HIV-infected adults and their families. -Integration of TB-HIV services- CAPRISA has gained years of experience and clinical expertise in TB-HIV co-infection and patient management. The NIMART Mentoring program will serve as the conduit through which this expertise is transmitted to PHC nurses. - Nutrition assessment will be implemented to identify vulnerable patients eg. poor nutritional status, children, pregnant women and TB co-infected. Those identified will be followed up with specific nutrition counseling and support - Provision of peer support groups and psychosocial support will be maintained within CAPRISAs current ART related activities - All HCT patients accessing health services, will have a TB symptom screen. Patients positive for HIV or TB will be rapidly linked to treatment and care services - Field DOT program This community project conducts door to door visits and CCGs offer support and treatment supervision to patients hence reducing patient load and decreasing costs to the patients for accessing care and increasing Treatment adherence -Patient retention and referrals-CAPRISA has well established linkages with DoH facilities to make referrals. The CAPRISA program has a retention rate of >90%. Development of tools, standards for retention and monitoring and evaluation of patient outcomes have served to improve and inform retention strategies. The mentoring program will include training on lessons learned from the CAPRISA Cohort Retention team. Pre-ART registers will be implemented to reduce pre-ART losses to follow-up, morbidity and mortality. -Monitoring and Evaluation- assist the SAG facilities that we support, CAPRISA staff will provide mentorship for analysis of program data , data audits, on site supervision of M&E officers and building technical skills (e.g. computer skills, data capturing skills).-The PWP strategy is ongoing with targeted efforts aimed at reducing transmission of HIV from PLWHA through counseling, education, motivation and monitoring of critical aspects patient high risk behaviour, clinical care and treatment adherence.

The CAPRISA program will provide technical assistance to support the expansion, decentralization and integration of TB and HIV services. - Symptomatic TB screening for contacts of TB patients in health services and linkage to care will be strengthened. TB HIV co-infected patients(including MDR/XDR) who default clinic appointments will be traced after missed visits- Advocacy Communication and Social Mobilisation- Expand current advocacy and social mobilisation activities with respect to increasing awareness of TB, STI's and HIV, aimed at changing and encouraging health seeking behaviour with respect to reducing risk to these diseases among those unaffected and increasing access to diagnosis, care and support for those affected by these diseases

- All pregnant women and children accessing health facilities will have access to HCT and TB screening. Patients that screen positive for TB or HIV will be linked to care and treatment services. Services PLWA not yet eligible for ART include short PMTCT, IPT and cotrimoxazole. - Processes ensuring uninterrupted supply of drugs using iDART technology, will be expanded. This includes ordering procedures, manual stock card management systems with routine inventory checks aimed at effective drug supply chain management to the patients under our care.- Expand coverage of HIV testing in TB patients, and TB screening in HIV infected patients

-Implement a program of treatment literacy and adherence support for TB therapy and ART -Provide technical support and training for expansion of for Nurse initiated management of integrated TB and HIV care-Implement a TB preventive strategy in HIV infected patients by incorporating the 5 principles of TB infection control, IPT rollout in HCWs and HIV infected patients, intensified case finding and contact tracing, integration of HIV and TB services, and early initiation of treatment in HIV TB co-infected patients.-Offer technical capacity to strengthen systems with respect to monitoring and evaluation activities: Ensure high quality data on national registers, and conducting data audits aimed at improving quality of routine patient data.

CAPRISA will support systems strengthening specifically in response to TB and HIV by conducting specific research in aimed at improving our understanding of TB HIV co-infections in order to tailor health and wellness interventions appropriately, improving quality of services offered by ensuring that patients are screened for TB and HIV, receive results promptly and that all patients diagnosed with TB and HIV receive the appropriate care and follow-up, providing training and mentorship to PHC facilities in the geographic area we support to ensure that the community based facilities are capacitated to provide comprehensive package of services for TB and HIV,strengthening patient tracking systems and supporting Monitoring and Evaluation systems by direct supervision and data audit systems.

The CIRC program will prioritise young male learners between 15-20 years to increase access of MC within a context of comprehensive HIV risk reduction and sexual reproductive health services. Increasing coverage of MC in this group will have a substantially higher impact on reducing HIV infection rates in the Vulindlela community through additionally impacting HIV infection rates in young women. A range of activities that will provide safe high quality MC service with a client support system includes: 1. A multi-pronged approach to community outreach that is not limited to:

o Distribution of materials i.e. pamphlets o Meetings with relevant groups i.e. school learners, school leadership, parents, adolescents, men from the communityo Providing information about HIV/AIDS and the role of MC in reducing this risk and where MC services can be accessed. 2. A clinic with multiple surgical bays geared to provide 10 MCs per day and 60 MCs per Saturday as part of a comprehensive HIV prevention package i.e: o MC education and counselling on risk reduction and safer sex with provision of condoms o HCT and appropriate referral if required o Provision and promotion of male and female condoms o Comprehensive medical examination including STI screening and syndromic treatment and TB screening

o Efficient patient schedulin o The use of electrocautery and the forceps guided method o Follow-up post surgery with 24hour emergency support o Post-operative review at 2days, 7 days and 21 days with a non-compulsory visit between 1-6 months post surgery. HIV test will be offered and HIV risk assessed. o Adverse events will be noted and post-surgical recovery will be assessed. 3. Expansion and accessibility of services is facilitated through providing HCT, screening and conducting reviews at the schools and local PHC clinics. 4. Monitoring and evaluation through rigorous record keeping with quality assurance being monitored by a Specialist Surgeon/Urologist.

The CAPRISA program will implement a School-based initiative of Sexual Reproductive Health (SRH) services in Vulindlela. There are 42 secondary schools in the district with 6 high schools that have an estimated enrolment of 1970 adloscent girls who will be targeted to pilot this project. The girls are aged between 12 and 22 years old. CAPRISA monitors, as part of ongoing epidemiological studies, the temporal trends in HIV infection in the Vulindlela sub-district and this research has consistently shown a very high HIV prevalence in the district with young women being most at risk for HIV infection. Description of the intervention: The following activities are therefore planned for this project: A mobile unit will be placed at some of the schools to provide a comprehensive Sexual Reproductive Health (SRH) service to the learners. The services offered will include: STI screening and syndromic management thereof;

Voluntary HIV testing with pre- and post-test counselling; Fertility control counselling and service provision;

Pregnancy testing and referrals where required; Provision of male and female condoms; Linkage to care for those who may test HIV positive;How activities are linked to other services: The provision of SRH is a part of other HIV prevention and health services offered at the CAPRISA Vulindlela Clinic that includes: Medical Male Circumcision Support services for HIV infected individuals and their families Infant, Adolescent and Adult treatment, support and care

The CAT program will implement a range of activities to strengthen the availability of treatment for adult HIV infected patients at PHC facilities.This includes 1. A structured mentorship program - where nurses at PHCs will be offered hands on training on Nurse Initiated Management of ART (NIMART), management of HIV associated complications and implementation of guidelines for chronic care management and treatment of HIV, Guidelines on TB management, and guidelines on TB prevention, among others.2. CAPRISA staff will provide on - site supervision and training on optimizing clinical processes, clinic flow, and integration of HIV into existing health services. This will facilitate continued expansion of services. 3. Targeted activity toward strengthening systems specifically with respect to and monitoring and evaluation activities; implementation of the Tiered M and E system, and data audits aimed improving quality of routinely recorded and reported performance measurement data.4. Tracking of performance measurement data over time, to identify program weaknesses. This information will be used to improve quality and efficiency of service delivery at the SAG facilities where we work.5. CAPRISA has developed both excellent tools to enhance patient adherence to treatment, and tracking patients retention in our programs. These skills and tools will be transferred to sites we support to strengthen existing tracking systems. 6. To expand coverage of HIV services, including the provision of ART, cotrimoxazole prophylaxis, and TB screening to adolescents and young women in rural communities and TB HIV integration services, including ART and cotrimoxazole, to TB HIV co-infected patients.7. To provide health systems strengthening including human resources and ART services including laboratory monitoring where not available, to support the provison of ART to patients.