INTEGRATED ACTIVITY FLAG: This Centers for Disease Control and Prevention (CDC), PMTCT activity relates to CT (#8215) and Other Prevention (#8216).

SUMMARY: In FY 2006, an evaluation of existing program data is being conducted to understand barriers to effective implementation of maternal syphilis screening and treatment in existing antenatal care (ANC) programs, including links between syphilis and HIV screening. Based on the evaluation results, a new activity is planned to promote integrated prevention of mother-to-child transmission (PMTCT) and syphilis screening in government-run primary healthcare facilities providing ANC services in two provinces, Gauteng and Northern Cape. These provinces were identified in consultation with the National Department of Health (NDOH). The major emphasis area addressed by this project is policy and guidelines, with minor emphasis on human resources, quality assurance and supportive supervision, strategic information and training. Target populations are pregnant women, HIV-infected pregnant women and healthcare workers, including nurses, traditional birth attendants and pharmacists, working in antenatal care facilities.

BACKGROUND: The evaluation described above is expected to be completed in April 2007, with summary results and a report provided shortly thereafter. FY 2007 funds will be used to implement improved service delivery activities based on the findings. The activity is planned to be conducted within existing primary care settings providing ANC to women in their locality, and thus is directly coordinated with and supported by both the South African national and provincial sexually transmitted infections (STI) program. The prime partner, CDC's Division of STD Prevention (DSTDP), provides technical expertise and oversight for the project. DSTDP works directly with the provinces of Northern Cape and Gauteng to conduct activities. DSTDP also sub-contracts with the National Institute of Communicable Diseases (NICD)/STI Reference Centre (STIRC), a South African parastatal, for hiring additional staff, laboratory quality assurance testing and other needed preventive services. Gender issues will be addressed indirectly (e.g., training will cover concerns about partner violence associated with HIV testing; pregnant women's access to ANC/PMTCT services will be encouraged and covered in training).

ACTIVITIES AND EXPECTED RESULTS:

PEPFAR funding will be used to conduct four activities.

ACTIVITY 1: Dissemination of FY 2006 findings A meeting of local/provincial health departments will be held to review results of the 2006 evaluation and develop a plan of action that (1) integrates HIV testing along with syphilis screening in ANC clinics; (2) integrates rapid identification and treatment of women who test positive for syphilis and/or HIV through support of lab capacity; (3) supports pregnant women who are not currently accessing ANC services to do so; and (4) considers uses of alternative models of integrating service and providing PMTCT.

ACTIVITY 2: Capacity building In collaboration with provincial training coordinators, the current approved PMTCT/ANC training curricula will be enhanced to include STI screening algorithms and treatment strategies, with training provided to primary healthcare nurses, pharmacists and others (e.g., traditional birth attendants) providing ANC services in Gauteng and Northern Cape.

ACTIVITY 3: Human resources and technical assistance One in-country coordinator will be hired or retained to oversee program activities based on the findings of the FY 2006 evaluation. In addition, two nurses will provide technical assistance, training and support to provincial ANC and PMTCT programs in the activities, and conduct data collection, etc.

ACTIVITY 4: Recommendations A report will be developed for the NDOH that outlines enhanced program results and recommends next steps. Sustainability will be addressed through the provision of training and additional technical support and to government nurses already providing ANC

services. Human capacity will be developed through the training course and ongoing support to nurses providing ANC services for a high quality program.

These activities will involve the revision of currently approved government training curricula (manuals, etc.) and training of primary healthcare nurses providing ANC services that focus on enhancing antenatal HIV and syphilis testing, treatment and services, and encouraging access to care for pregnant women. This project aims to improve access and quality of PMTCT services, to identify HIV-infected or syphilis serology positive pregnant women, and to increase the number of women receiving treatment for syphilis and antiretroviral (ARV) prophylaxis to prevent STI and HIV transmission to infants. By addressing enhanced PMTCT through improving ANC systems for HIV and syphilis screening, it contributes to the PEPFAR prevention objective of 7 million infections averted. Achievements of the past 12 months of the targeted evaluation include: (1) an initial technical trip to assess local capacity and situation; (2) identification of government sites to participate in the targeted evaluation; (3) submission of evaluation protocols to Gauteng and Northern Cape Provincial officials and to the CDC institutional review board for scientific and ethical review; (4) hiring program staff involved in the targeted evaluation; and (5) the anticipated October 2006 initiation of the evaluation in Northern Cape and Gauteng. The evaluation is expected to be completed in April 2007, with summary results and the report provided shortly after. This is a new activity for the organization, but is based on anticipated results of a 2006 targeted evaluation of PMTCT and ANC services.

This project contribute to PEPFAR 2-7-10 goals by improving access to and quality of PMTCT services to identify HIV-infected pregnant women and increase the number of women receiving ARV prophylaxis to prevent HIV transmission to infants.

INTEGRATED ACTIVITY FLAG:

This activity also relates to activities described in CT (#8215) and PMTCT (#8218).

SUMMARY:

There are two separate activities described in this entry:

The first activity focuses on educating sexually transmitted infection (STI) patients to recognize genital herpes symptoms. Genital herpes (HSV) is the primary cause of genital ulcer disease in South Africa, and has been linked with enhanced HIV transmission and acquisition. Most patients with HSV are unaware of their infections but can be taught to recognize symptoms. The activity will support development of educational materials and provision of training allowing HSV-infected patients visiting primary care clinics providing STI services to recognize herpetic lesions and to take action to reduce their markedly increased risk of HIV acquisition and transmission related to HSV. An increase in local capacity will occur with the hiring and training of local staff while CDC provides supportive supervision and quality assurance measures.

The second activity involves producing and disseminating a condom skills-building video targeting high risk youth. The development of a brief, animated video aimed at a young, sexually active audience will provide critical HIV/STI prevention information and skills, and will predominantly focus on consistent and correct condom use and the importance of STI treatment for partners exposed to STIs. Additional information such as the roles of abstinence, mutually monogamous partnerships, and knowledge of HIV serostatus in preventing HIV acquisition will also be discussed in the video.

The major emphasis area addressed by these two activities is information, education and communication. The minor emphasis areas addressed include linkages with other sector initiatives, local organization capacity development, policy and guidelines, quality assurance and supportive supervision, and training. The target populations include men and women, girls and boys, people living with HIV and AIDS, special populations, National Department of Health (NDOH) staff, and healthcare providers, community-based organizations and non-governmental/private voluntary organizations.

BACKGROUND:

The first activity is new, and has not been previously funded by PEPFAR. The new educational program on herpes symptom recognition is planned to be conducted within existing, government-run primary care settings where STI patients seek services, and will coordinate directly with services provided by the South African provincial government. The prime partner, CDC's Division of STD Prevention (DSTDP), will provide technical expertise and oversight for the project and will work directly with collaborators in the Gauteng Department of Health to conduct activities. DSTDP will also sub-contract with the National Institute of Communicable Diseases (NICD), STI Reference Centre (STIRC), (a South African parastatal organization), for hiring of additional staff, commodities, and other needed services to conduct the activity.

The second activity allows for production, translation and dissemination of a culturally-appropriate educational video for high risk youth. The video is currently under development as part of a PEPFAR 2006 Plus-Up funding: scripts for a brief, high-tech and youth-focused animated message are being developed, and production work will be initiated. Past 12 months achievements include meetings with technical experts outlining key areas to include in video scripts and identification of professional scriptwriters and potential production companies. The current funding will allow video production to be completed, dubbing into multiple languages and dissemination into prevention programs targeting high-risk youth. The prime partner, DSTDP, will provide technical expertise and oversight for the project. DSTDP will sub-contract with a video-production team and work directly with in-country collaborators to be determined, ideally local NGOs serving youth as well as health facilities serving patients with STIs. Gender issues will be addressed indirectly (e.g., negotiation of condoms with partners).

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1:

The herpes education program does not address areas of legislative interest. The target population is STI patients infected with genital herpes viruses, often including most-at-risk-populations. PEPFAR funding will be used to: (1) formulate culturally-appropriate messages about genital herpes and HIV, recognizing herpes symptoms, and means of preventing genital herpes-related HIV acquisition and transmission; (2) develop appropriate educational materials, brochures and posters, about genital herpes and its symptoms to use in primary healthcare settings; (3) translate materials into local languages; (4) assess the use of new educational materials among men and women seeking STI care at primary care settings, and modify materials accordingly; (5) hire local staff (one nurse and one trainer) to support activities (i.e., materials development, training); and (6) provide in-depth training to clinical staff about herpes infection, its links to HIV, and how to use educational materials to teach STI patients.

The condom skills-building video does not address areas of legislative interest. The target population is high-risk (i.e., already sexually active) youth. PEPFAR funding will be used to: (1) complete the production of an educational video; (2) dub the animated video (English) into additional local languages; (3) disseminate the video into healthcare or prevention settings serving high risk youth; and (4) hire one in-country coordinator to oversee dissemination activities, including education to participating sites. Sustainability will be addressed through providing the video and educational materials to health care providers or other prevention specialists at existing programs serving high risk youth. Human capacity will be developed primarily through condom skills building and information provided on the video.

The first activity is anticipated to contribute directly to 2-7-10 goals by preventing transmission of HIV among HSV-HIV co-infected persons, and by preventing acquisition of HIV among HIV-negative patients with STIs. The second activity is anticipated to contribute directly to 2-7-10 goals by reducing acquisition and transmission of HIV through consistent and correct condom use.

INTEGRATED ACTIVITY FLAG:

The CDC's Division of STD prevention activities also relates to Condoms and Other Prevention (#8216) and PMTCT (#8218).

SUMMARY:

This project aims to initiate high quality HIV counseling and testing (CT) services into existing sexually transmitted infections (STI) clinical services. The major emphasis area is information, education and communication; minor emphasis areas are development of referral systems, training healthcare providers, and quality assurance and supervision to support high quality services. This activity falls under one area of legislative interest: stigma and discrimination. The activity targets adult and adolescent men and women of reproductive age. Although not specific targets, other most-at-risk populations (e.g., sex workers, clients of sex workers, truckers, sex partners of HIV-infected persons) are expected to use these community services.

BACKGROUND:

People with newly diagnosed sexually transmitted infections (STIs) are at greatly increased risk for contracting other STIs, including HIV. The STI diagnostic encounter provides an opportunity to encourage CT in this high risk population. People evaluated for an STI whose HIV tests are positive can be immediately referred to HIV care services, including clinical staging, health/prevention education, and (if applicable) life-saving antiretroviral therapy. Prevention counseling is beneficial regardless of HIV status, and likely particularly beneficial to uninfected individuals who remain at continued risk of acquiring HIV. The STI encounter can also identify partners who need treatment, allowing opportunities to identify and encourage HIV testing in sex partners. In South Africa, several service models exist to provide STI diagnosis and treatment, including public clinics and primary care services incorporating STI services. Currently, patients who have or are suspected to have new STIs are often not yet specifically targeted for HIV CT. This new activity, not previously funded by PEPFAR, supports routine offering of HIV CT services in a high volume, public community facility. The proposed approach is to normalize CT by sensitizing healthcare providers and offering a simple and proven-effective CT model that has been conducted in STD clinics and other settings internationally. The model employs confidentiality and a respectful approach (reducing stigma and discrimination) while promoting HIV testing. The prime partner, CDC's Division of STD Prevention, will work through a subcontract with the parastatal national STI Reference Centre (STIRC) to oversee the project, hire staff, and procure needed commodities. The implementing organization will be an existing public STI clinic or primary care site already working with STIRC and willing to initiate routine CT services. It is assumed that the program will scale up and allow tools/curricula to become widely available in South Africa.

ACTIVITIES AND EXPECTED RESULTS:

A program needs assessment will be conducted to identify current barriers to routine CT in the facility and the community. Based on assessment results, an existing simple and proven-effective HIV CT model that has been successfully used internationally will be adapted to the South African context and facility/setting. All facility providers will be encouraged to take a short training course to promote their understanding and encouragement of routine HIV testing for all patients with new or suspected STIs. HIV CT will be promoted as an expected norm for this clinical situation. Providers will also be instructed to ask all patients to see the HIV counselor as part of their routine care. The counselors (staff specially trained in CT) will provide prevention counseling that strongly encourages HIV testing and uses a goal setting approach to reduce high risk behavior through the patient's chosen goal such as faithfulness with a concordant partner, consistent and correct condom use, or other means.

Specific activities include: (1) Conduct program needs assessment to understand barriers to CT; (2) Hire one clinic supervisor to oversee activities and provide quality assurance (QA) and data collection; (3) Hire two prevention counselors to provide CT; (4) Conduct in-depth training for supervisor/counselors on high quality CT, testing (including rapid tests), confidentiality, respectful approaches, expected QA strategies, and efficient referral

to additional services; (5) Train all (approximately ten) healthcare providers on encouraging CT, confidentiality, respectful approaches (clinic wide training); (6) Develop referral system and tracking system to determine if referred patients achieved expected services; and (7) Develop systems to collect, analyze, and disseminate program data on test uptake, receipt of test results, effectiveness of the referral system, and quality of counseling.

Expected results include: (1) Identify HIV-infected persons to allow speedy referral to HIV clinical services; (2) Provide proven effective prevention counseling for HIV uninfected clients at high risk for sexual HIV acquisition; (3) Development of effective referral system for other prevention/care services; and (4) Analyze and disseminate program data to enhance future program services. All new programs will be in compliance with existing national guidelines. Achievements over the past 12 months include: (1) initial technical trip and site visits, (2) development and submission of protocol to Gauteng provincial officials and CDC, and (3) development of training materials.

These results contribute to PEPFAR 2-7-10 goals by preventing new HIV infections with risk-reduction counseling aimed at behavior change, identifying new HIV infections through increased testing and referring more people to antiretroviral therapy and other health services.

These funds of $1,182,000.00 partially support the management and staffing expenses of the HHS/CDC/South Africa office and are integrated with (#8057). The funds will cover ongoing and new staffing needs to provide technical, financial and contractual oversight of over 52 CDC partners implementing the PEPFAR program in South Africa.

The total management and staffing budget for CDC is $6,000,000. Of this, $1,182,000 is charged to GHAI and $4,818,000 is charged to the CDC/GAP base budget. Within the total budget, the cost of ICASS is estimated at $509,655 and Capital Security Sharing is estimated at $161,345.

In FY 2006, the HHS/CDC/South Africa office was responsible for the obligation of about $65,000,000 in PEPFAR funding. In FY 2007, this amount will increase to roughly $130,000,000. CDC staff also has oversight responsibility for $21,000,000 of Health Resources and Service Administration (HRSA) projects. Staff responsibilities include monitoring design, implementation, and evaluation of funded activities; providing technical direction and assistance to assure that activities are implemented in accordance with OGAC technical guidance; and working closely with in-country and international partners to assure synergy and avoid duplication. Staff participate actively in the Inter-Agency Task Force to design the overall comprehensive PEPFAR program that meets the needs of South Africa and OGAC. Moreover, HHS/CDC staff participate in Technical Working Groups (TWG) of the Task Force that work to coordinate all partners in a particular technical area to ensure complementary and synergistic activities. Staff is also regularly tasked to participate in ad hoc working groups to address specific issues as they arise.

As of FY 2006, the HHS/CDC South Africa office employs a total of 34 positions. Six are U.S. direct hires, 24 are local hires and 4 are contractors. In FY 2007, HHS/CDC is requesting approval for 5 additional positions. Four of the proposed positions are envisioned as local hires and one as a contractor. The staffing matrix provides a more detailed presentation of these positions. The local hire positions are as follows: 1) one counseling and testing officer/coordinator; 2) one clinical officer for treatment; 3) one prevention program officer; and 4) one driver. The contractor position is to work in the area of TB/HIV and the electronic TB surveillance system (ETR.Net). These are priority positions to support areas of greatest need.

A table detailing the HHS/CDC/South Africa staffing pattern for PEPFAR is attached as Appendix 17. In addition to salaries, benefits and travel costs, the management budget includes direct operating costs (such as utilities, administrative and logistic support, etc.), ICASS charges and Capital Security Sharing. The total CDC budget for staffing and associated management costs in FY 2007 is $6,000,000 and is attached as Appendix 18.

Table 3.3.15: