IntraHealth International implements comprehensive HIV prevention and care programs focused on service provision in high prevalence areas of Central, Western and Eastern Equatoria States. During the first 3 years of the 5 year cooperative agreement with CDC, IHI also targeted the military population. In FY 2012 IntraHealths activities will no longer include this target population as the USG is transitioning all military related programs to the DoD. IHI works with MOH and SSAC to strengthen health systems and provide technical support for policy development. In FY 12, prevention services will focus on PMTCT, Care including prevention with positives, sexual and other behavioral risk prevention. HIV testing and counseling (HTC) will be scaled-up using different models. Health systems strengthening activities will include training in HTC, PMTCT, PITC, and in strategic information. Technical support and assistance will be provided to the MOH for policy and guidelines development which may include PwP curricula, PITC Guidelines, Alcohol and HIV prevention.

IHI will focus sexual prevention programs at the most-at-risk or vulnerable populations. Assessments will be conducted in communities to determine cultural or social factors that may contribute to risk for HIV and this will inform the sexual prevention messages and focus.

M&E activities using a newly developed data base will be implemented. IntraHealth will continue to strengthen MOH M&E capacity to improve the quality of reporting and planning by 1) on-the-job training for VCT counselors, PMTCT providers and data clerks, reporting and analysis staff, and 2) quarterly supervision visits and data review meetings, and monthly phone calls to field-based staff to address questions and concerns

At the national level, technical support will continue to be provided by IntraHealth to the HIV/AIDS Directorate at the MOH and SSAC in development of appropriate guidelines and strategies with specific support for the development and adoption of national PwP or other care guidelines and curriculum.

Adult care and support services will be provided at all health facilities supported by IntraHealth including testing and counseling services and PMTCT. At health care facilities, all age groups will be provided with care services. The PEPFAR Basic Care Package will be offered to all HIV positive individuals receiving services at PEPFAR sites (e.g., TB screening, condoms, Cotrimoxazole, staging and referral for ART, and linkages to people living with HIV (PLHIV) or other community support groups). Persons infected with HIV will continue to be referred to the closest MOH Comprehensive Care Center; these centers will provide treatment and other care services. Persons detected with HIV through counseling and testing will also be referred to the nearest support groups.

Support services at the community level will include social, psychosocial and spiritual support; this will be offered to HIV-positive individuals and their families through home visits by volunteers drawn from post-test support groups. Treatment retention will be supported by use of volunteers who will work as treatment supporters. Loss to follow up to care will be minimized by strengthening counseling both at the facility and in community through support group educators. IntraHealth will work with other agencies to acquire and deliver home based care kits for bed ridden and extremely ill clients.

PLHIVs who have been trained as support group educators will promote HIV/AIDS prevention among their peers. The intervention was piloted in Juba and will be expanded to Yambio and Yei. These educators will conduct group education sessions at health facilities especially in OPD and ANC/PMTCT and will also be used for outreaches by local partners in CES and WES.

One method that will be used to strengthen the referral system will be to confirm the clients telephone number at the point of entry. Positive clients will be called within 48 hours to determine which facility they used and confirmation will be made by calling that facility.

Retention of HIV positive clients will be a primary focus in FY12. The use of volunteers has been one method to provide retention and the same method will be assessed for retention in care. IQ charts will be used to access clients condition, CD 4 levels and to follow up on clients missing their appointments for Cotrimoxazole refill.

Supportive supervision and on the job training will be provided by IntraHealths staff to health care workers to ensure high quality care and support services. Client exit interviews will be used to access client satisfaction with the services provided.

IntraHealth will continue with TB/HIV/AIDS collaborative activities at the national level by providing technical assistance and support to MOH TB/HIV initiatives. TB screening will be done at all VCTs and clients referred to TB diagnostic centers for treatment. Health care workers at TB wards will be trained in PITC. Methods will be assessed to strengthen the referral system at both point of entry and the TB diagnostic and treatment centers and the use of cell phones to track clients will be considered. With support from the MOH TB/HIV section, health care workers at the facilities will be encouraged to identify clinical signs of TB patients. TB screening will be part of basic care package provided during home based care visits. Children with any sign or symptoms coming to pediatric wards/OPD will also be offered TB/HIV services.

The GoSS continues the reconstruction of its health care infrastructure including laboratory services. PEPFAR is working with the MOH at the national level to develop and implement a quality management system that will lead to the ability of laboratories to develop the level and quality of services that lead to accreditation. However there is a need to ensure that laboratory staff has the opportunity to have refresher training on basic laboratory skills as well as specific skills for HIV or opportunistic disease diagnosis. Intrahealth will support in-service trainings for Laboratory staff in the geographic regions where they operate in order to improve the quality of laboratory services for HIV clients. The training curricula will be reviewed by the PEPFAR Laboratory Advisor to ensure the training is appropriate.

IntraHealth will work with partners to develop their capacity to collect and use strategic information by strengthening monitoring and evaluation skills, HMIS and sentinel surveillance through training, supervision and mentoring. IntraHealth will conduct semi-annual data quality assessments for partner sites to ensure data quality by identifying strengths and weaknesses in data collection and reporting, and providing feedback and support. The first one is a mini data quality assurance (DQA) and entails a quick review of partners data collection and reporting tools for consistency (reliability) and accuracy (validity). The second is the real DQA exercise and this entails a comprehensive review of our partners data systems. The objectives of the DQA exercise are to: Assess validity and reliability of the data collected and reported by partners, assess the data collection tools, data storage methods, data flow, and data analysis methods used by partners, assess M&E strengths and gaps within partners, especially on data collection and reporting along with providing supportive supervision and mentoring to partners. A data use plan for the project will be developed to ensure utilization-focused monitoring and evaluation approach.

The MOH HIV Directorate and the SSAC have a limited number of personnel at all levels; this hinders their ability to develop policies, frameworks and guidelines. Technical assistance will continue to the MOH and SSAC in the development of HIV/AIDS policies, frameworks and guidelines. IntraHealth will continue to participate on the SSAC and MOH technical working groups which are responsible for development and/or review of Global Fund applications, other documents, and national initiatives such as activities related to World AIDS Day. The participation by IntraHealth fills a gap in both technical skills and general manpower to ensure all tasks are accomplished.

IntraHealth has used a comprehensive HIV/AIDS prevention approach that includes abstinence and being faithful (AB). The communication strategies are simple and clear and reflect an integrated behavior change communication strategy of promoting AB as well as linking partner reduction to couple-centered HTC. The program will continue to raise awareness on HIV/AIDS to reduce stigma and use HIV/AIDS awareness activities as an entry to HTC, PMTCT, care and treatment programs. Both small and large group events will be used to effectively reach as many people as possible with HIV/AIDS prevention messages and provision of HTC services at the same outreach session. Training remains a key component for effective implementation of HIV/AIDS sexual prevention activities. IntraHealth will work with its partners to implement services that are aimed at reducing multiple concurrent partners through raising awareness. Religious leaders from 15 churches and 5 mosques in Juba (CE) and Tambura (WE) will be sensitized on HIV awareness and HIV prevention knowledge will be provided, so as to incorporate AB messages in their sermons for church services. The message is expected to reach large groups per service. AB, IEC material will be adapted/developed and printed for wide circulation. Sexually-active youth will be encouraged to learn their HIV status. In Yei, St. Bakhita will continue radio talk shows and work through the Catholic Churches network on AB messages. Similar radio messages will be aired to raise HIV awareness in other parts of Central and Western Equatoria.

The Global Fund (GF) was the largest donor for HTC services in South Sudan. With the end of resources from Global Fund Round 4 for HIV/AIDS and the cancelation of Round 11, there are no identified resources to continue HTC at GF supported sites. PEPFAR South Sudan and the MOH are identifying high priority HTC sites to be considered for services under PEPFAR; as sites are identified, IntraHealth will work with the MOH at the new PEPFAR sites to implement testing and counseling services. The sites for implementation of HTC services are expected to be in Central Equatoria and/or Lakes states with some possibility in Eastern or Western Equatoria.

PEPFAR South Sudan is focusing on transitioning and using PITC as the primary testing and counseling method. IntraHealth is providing technical assistance and working with the MOH to develop national guidelines and training curriculum for PITC services; once developed the national curriculum will be used to train health care workers involved with PITC. Participatory planning techniques will be used to engage State Ministries of Health, SSAC, MOH and stakeholders.

To implement PITC at the facility level, IntraHealth will make an assessment in coordination with the local authorities of each facility and develop a plan specific to the facility for PITC. The primary target departments for PITC include: ANC; Tuberculosis clinics; STI and/or Family Planning Clinics; OPDs; Inpatient Medical/Surgical; Laboratory; and to attendants of patients in medical, surgical and pediatric wards. Current sub-contractors will begin to transition to PITC; IMC will introduce PITC services at its current static sites (Tambura Hospital and Source Yubu PHCC). St. Bakhitas staff is already trained on PITC and PITC services will be initiated at their OPD and inpatient department.

Outreaches and mobile counseling and testing will continue to be used to provide testing and counseling services to increase access to hard to reach areas, and where there are no functional health facilities. At new sites, the focus will be on using PITC to implement testing and counseling services.

All HIV positive clients from CDC-funded IntraHealth sites are linked by use of referral cards to the nearest treatment center where counselors from these sites follow the progress of the referred clients. IntraHealth will continue to strengthen its referral linkages through support groups, use of referral cards and client tracing using telephone.

Regular supportive supervision will be provided to all HTC sites to ensure the quality of service is maintained and the appropriate services are being conducted. VCT and PMTCT sites will continue collecting dried blood spot (DBS) samples for external quality assurance. The HTC sites will also be enrolled onto a dry tube specimen proficiency testing program.

Refresher trainings that follow the national guidelines will be provided to already trained counselors. Counselors will be trained on universal precautionary measures, and post exposure prophylaxis services will be provided at all sites. As needed any new counselors will be trained following the national guidelines. As the MOH develops and provides guidelines for PITC, PITC trainings will be conducted for each site following the guidelines.

During FY12 a greater focus will be placed on detecting as many cases of HIV as possible with a focus on more at risk populations. In an effort to reach more persons with HIV and direct them to prevention programs, IntraHealth will focus sexual prevention programs in the communities and target populations identified or thought to be most at risk in the service areas of the other prevention programs.

The mobile and most at risk populations include transport workers, sexually active youth, transactional sex workers, discordant couples, and those who use drugs and misuse alcohol. These populations will continue to be targeted through HIV awareness outreaches and workshops, and condom distribution. IH will work with bar and hotel managers where commercial sex is taking place in order to sensitize them on HIV risks, and to encourage use of condoms by the sex workers and their clients. As per the rapid assessment report of Alliance International, there are around 6000 female sex workers (FSWs) in Central and Eastern Equatoria. IH plans to reach 1000 FSW and carry out HIV awareness workshops for FSW in Central and Western Equatoria states through its partners.

IH will also work in close collaboration with Association of boda boda drivers (motorcycle taxi drivers) in Juba and Tambura, to identify boda boda drivers who will work as peer educators for HIV awareness. IH will revise its peer educators manual to add topics on reducing alcohol use, MCP, safer sex practices, etc. Peer educators will conduct awareness sessions, condoms promotion along with provision of IEC material to their peers. MCT will be carried out in collaboration with local partners. Few peer educators will be trained as peer educators supervisors, who will then supervise the work of the educators. Norms and cultural practices that lead to high risk behavior will also be identified for focused interventions for a larger impact. Condom dispensers will be placed at specific sites (e.g., bars and brothels) and refilled regularly. Where feasible, condom distribution will be linked to mobile HTC services and HIV/AIDS awareness outreach sessions where condoms are distributed at the end of the outreach sessions. Both penile and vaginal models will be used to demonstrate correct usage of male and female condoms, respectively. HIV/AIDS educators and peer educators will distribute condoms during small and large group events to more effectively reach as many people as possible. Condoms will also be available at all VCT and PMTCT sites. The prevention program will also promote and synergize with HTC and PMTCT programs, as well as care and treatment programs. The communication strategies will reflect an integrated behavior change communication strategy of promoting use of condoms where couple status is unknown.

Target Population

Approx Dollar Amount

Coverage number to be reached by each intervention component

Activity

CSW

$69,280

1000

HIV awareness workshops

Condoms

C&T

Boda boda drivers

$100,000

1500

Peer educators will conduct awareness sessions, condoms promotion along with provision of IEC material to their peers. MCT will be carried out in collaboration with local partners.

In FY12, IntraHealth will continue to implement the WHOs 4 pronged approach strategies from FY11, namely:

Prevention of primary HIV infections through ABC (Abstinence, Being Faithful and Condom use) messages and integration of HIV/AIDS education;

Family planning services for prevention of unintended pregnancies among HIV-infected women;

Rapid provider-initiated HIV counseling and testing for pregnant women at the antenatal and maternity settings;

Combination short-course ARV prophylaxis for mother and infant, and referral for ART for mothers and infants;

Provision of care and support to the mother and infant, including counseling and support for infant feeding, links to nutrition services and support during immunization visits;

Improved record keeping for patient management

These strategies will continue to be implemented at the existing PMTCT sites in Western and Central Equatoria states. These existing sites have easy access to CD4 testing facilities provided at Tambura Hospital and Yei Civil Hospital. GoSS resources for PMTCT are limited in FY12 due to the continuation of services which support sites that were operational during FY11. IntraHealth will further focus on using existing ANCs and related MNCH and FP services as the primary platform for PMTCT with the goal of an integrated ANC program that includes PMTCT.

In collaboration with the PEPFAR South Sudan & the GoSS, IntraHealth will identify other sites to strengthen PMTCT programs and outreaches which may have less support now due to the CoS. Appropriate methods will be identified for these sites such as PMTCT outreach campaigns.

Teams from St. Bakhita Health Center plan to offer outreach PMTCT services to nearby primary health care centers (PHCCs) and primary health care units (PHCUs) on pre-arranged dates and times as per schedule. Community mobilization for outreach activities will be carried out by radio messages and through the network of Catholic Churches.

To improve the quality of PMTCT services, including the roll-out of WHOs new strategy for 3-dose combination short-course ARV prophylaxis, IntraHealth will conduct trainings and refresher courses for PMTCT providers. Midwives and traditional birth attendants will be trained and linked closely with the facility to bring pregnant HIV-infected mothers to the hospital for delivery, bring prophylaxis to their homes and follow up on mother-infant pairs. IntraHealth will continue to use the MOH registers for data collection at all sites. This will not only improve data quality but also follow-up of mothers needing additional health services. Other PMTCT support activities for FY12 will include:

Encourage formation of mother to mother support groups where positive pregnant mothers will be linked to the groups through mentor mothers.

Testing for syphilis, referral and/or treatment when necessary.

Provision of mosquito nets to pregnant women through support from PSI and other donors.