Plus up funds will be used by ARK to significantly expand palliative care activities in Kwa Zulu Natal and the Western Cape. The Western Cape has recently asked ARK to assist an additional 15 ART roll out sites.

Care activities will include improving a tracking system for all individuals who test positive but who are not yet eligible for treatment, utilizing the peer advocate model developed by ARK. ARK will also improve the monitoring of the time from eligibility to entry into an ART program. Wellness activities and CD4 staging will be made more widely available at the government sites assisted by ARK. In addition ARK will expand home-based care activities and care for the care-giver activities.

INTEGRATED ACTIVITY FLAG:

This activity relates to Absolute Return for Kids (ARK) activities in CT (#7883), OVC (#7886), and ARV Services (#7507).

SUMMARY:

As part of a comprehensive treatment program, ARK's focus is to improve and enhance TB screening and treatment services for HIV-infected patients and their families. ARK will train and place required human resources (medical and counseling staff) and develop performance monitoring systems to strengthen adherence monitoring. The primary emphasis area is human resources. The target population is people living with HIV and AIDS (PLHIV) and HIV-affected families.

BACKGROUND:

ARK is a charity organization whose mission is to facilitate and support delivery of accessible and sustainable comprehensive treatment, care and support services to children and their caregivers in communities affected by HIV and AIDS and poverty. In partnership with the KwaZulu-Natal (KZN) provincial government, ARK has established an HIV and AIDS treatment program in government primary health facilities and hospitals. To date, PEPFAR funding has enabled ARK to successfully put over 9,000 patients onto ARV treatment in KwaZulu-Natal.

Dual infection rates of TB with HIV are very high. The Medical Research Council reports the national rate at 58%. Many TB/HIV co-infected individuals are unaware of their dual infection, and CT services for co-infection are limited or non-existent. With FY 2007 funding, ARK will continue its work to enhance and improve its HIV and AIDS treatment program by strengthening TB screening, care and support services for HIV-infected patients and their families.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Support to Provincial Government

ARK works with provincial government in developing the necessary processes and systems to manage the HIV care and treatment program and to ensure that the model created is scaleable, sustainable and replicable elsewhere. Specifically ARK has a mandate with provincial government to recruit and place human resources (doctors, nurses and pharmacists) in public clinics for a maximum of three years. ARK fully funds these positions, which will be taken over by provincial governments at the end of the period. The clinicians provide screening for TB, CT for HIV, and treatment management including patient consultations and treatment of opportunistic and sexually transmitted infection if necessary. ARK also provides training and mentorship to government community health workers (CHWs) to improve and enhance TB/HIV co-infected patient support. Community health workers provide care and support services including needs assessment and psychosocial support, and serve as a link, during and after TB treatment, and between the patient and the clinic to address patient needs. At government clinics, ARK strengthens data information systems to enable clinics to provide quarterly updates to provincial government to improve ongoing evaluation, data for outcomes computation and analysis.

ACTIVITY 2: Human Capacity Development

Formal and informal training and on-site mentorship is provided to all CHWs. ARK, together with the Centre for Social Science Research Unit, University of Cape Town, developed training modules for CHWs on HIV and AIDS care. The areas covered include: TB/HIV co-infection, TB treatment guidelines for adults and children, maternal and child care in the context of HIV and AIDS, and adherence to TB and ART treatment. ARK provides overall supervision of the program, ensuring ongoing mentorship of the trained CHWs.

ACTIVITY 3: Screening for TB with HIV-infected Patients

All HIV-infected individuals entering the program will be assessed for the presence of active TB. An inquiry about symptoms that would suggest active TB and any history of TB or known/likely exposure will be ascertained. For patients who report that they have received treatment of active TB or LTBI in the past, the adequacy of the treatment will be assessed. A physical examination that includes examination of extrapulmonary sites of disease, such as lymph nodes, and chest radiography will be performed.

ARK clinical and counseling staff will work with patients with infectious TB to identify their close contacts for screening and preventative treatment. ARK will also integrate TB screening into established PMTCT programs at ARK sites. HIV-infected infected patients who are candidates for, but who do not receive, TB preventive therapy will be assessed periodically for symptoms of active TB as part of ongoing management of HIV infection.

ACTIVITY 4: CT for DOTS Program

Patients with TB constitute an important "sentinel" population for HIV screening. The benefits of identifying previously unrecognized HIV infection are substantial in terms of both the opportunities for preventing future HIV transmission and the large potential benefits to the patient of antiretroviral therapy. Knowledge of the HIV serostatus of TB patients may also influence the treatment of their TB. ARK will work with established DOTS programs in its sites to promote the routine offering of CT for TB patients in order to increase the number of TB patients undergoing HIV CT. ARK will offer training to DOTS observers on HIV and AIDS and co-infection, and treatment and referral options. ARK will work with healthcare providers, administrators, and designated TB controllers to promote routine offering of CT and more coordinated care for patients with TB and HIV in government clinics through strengthening, and in some cases, establishing referral systems between the TB control programs and HIV and AIDS programs. Referrals and service use will be tracked to monitor the use of CT services among TB clients. ARK will also facilitate the sharing of information from the treatment program to the TB program and through the TB register.

For TB patients who test positive for HIV, ARK CHWs will ensure that patients who are awaiting ARV treatment are adequately informed about ART and are prepared to take treatment adherently. All patients who are pre-assessed undergo a treatment literacy program and are educated about "Positive Living." Patients are encouraged to motivate their partners/spouses to get tested.

ACTIVITY 5: Treatment, Care and Support

Individuals accessing ARK's services will be staged and entered into ARK's ARV treatment program. The program provides patient uptake, patient consultation, ongoing assessment and monitoring, CT and drug provision. HIV-infected patients, without active TB and not in-need of ARV treatment, will be offered isoniazid prophylaxis, monitoring, and ongoing counseling support for 6 months. At the end of the 6 months, these patients will be reassessed for further treatment. HIV-infected patients with active TB, will be linked with DOTS and ARK's community health workers will provide them with ongoing TB treatment management and support. Once the patient has been successfully treated for TB, ARK will enroll the patient onto ART.

Adherence support is a critical component, complementing clinical services. ARK utilizes a family centered approach for care and treatment. ARK-trained CHWs conduct pre-treatment home visits and provide ongoing psychosocial support to patients and their families. CHWs promote and support disclosure to partners and family, partner testing and facilitate treatment access. CHWs are required to facilitate support groups for their clients and ensure that all patients and their families have access to grants, spiritual support and psychological support and counseling where indicated. ARK will strive to identify children needing TB treatment and ART through ARK's OVC care and support, and CT programs.

This activity will contribute to PEPFAR's goals of 2-7-10 by providing care and treatment to many South Africans through ARK's TB/HIV program.

INTEGRATED ACTIVITY FLAG: This activity relates to Absolute Return for Kids (ARK) activities in CT (#7883), TB/HIV (#7882) and ARV Services (#7507).

SUMMARY: ARK's activities are aimed at improving the lives of orphans and other children made vulnerable by HIV and AIDS through strengthening school communities to meet the needs of orphans and vulnerable children (OVC); identifying OVC and assisting them to access government social grants, community support as well as appropriate referral to health facilities; and nutritional support through establishing sustainable food gardens in the schools. The primary emphasis areas for these activities are community mobilization, training, local organization capacity development and development of network/linkages/referral systems. Specific target populations include OVC and caregivers.

BACKGROUND: ARK is a charity organization whose mission is to facilitate and support delivery of accessible and sustainable comprehensive treatment, care and support services to children and their caregivers in communities affected by HIV and AIDS and poverty.

In partnership with the KwaZulu-Natal (KZN) provincial government, ARK has established a comprehensive antiretroviral HIV and AIDS treatment program in government primary health centers and hospitals. Specifically, ARK works with the provincial government to identify sites and areas for capacity building including human resources, human capacity development, and modest infrastructure. Last year with other donor funds, the ARK Child Services program piloted its interventions through schools and community care workers to identify and assist OVC to access government grants; improve access to health facilities; access counseling; and providing a seven-day school-based feeding and sustainable food gardens. To date 5,000 children from 12 schools in rural KZN are fed daily; 327 children have been assisted to access grants; 61 children referred to health facilities; 700 received the services of social workers; and 50 destitute families were provided with monthly food parcels. With FY 2007 PEPFAR funding, ARK will expand its child services program in KZN communities.

ARK's activities will be implemented in partnership with the provincial government of KZN, specifically with Departments of Education, Health and Social Development. The KZN Departments of Education and Social Development support expansion of this project.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Support to Provincial Government ARK will work with provincial government to develop the necessary processes and systems to manage the OVC program and to ensure that the model created is scaleable, sustainable and replicable. ARK will employ social workers and nursing staff to work with the local government schools in linking sick children to primary healthcare facilities at which ARK's ARV treatment program is in place.

ACTIVITY 2: Community Mobilization This activity will mobilize and empower school communities to meet the needs of OVC. Schools will form clusters (4 - 8 schools per cluster) around primary healthcare facilities at which ARK's ARV program is in place. These schools will be empowered with knowledge, skills and strategies to plan, execute and monitor interventions that respond to the needs of orphans and vulnerable children attending their schools. This activity will provide a strong base in the community by utilizing available resources (schools and educators) to ensure that vulnerable children are cared for. This activity is in line with one of the key strategies of the government to mobilize and strengthen community-based responses for the care, support and protection of orphans and other children made vulnerable by HIV and AIDS. ARK will develop a tool which accurately and reliably identifies children who fit the profile of the target population including those in need of grants who have not accessed one.

ACTIVITY 3: Healthcare Support Each cluster of schools will be allocated at least one registered community health nurse who will visit the schools to assist with the identification of sick children needing ARV

treatment and other health services. ARK will develop a tool which accurately and reliably identifies children who fit the profile of ARK's target population; HIV-infected children and those in need of ARV treatment. Each cluster of schools will have a social worker who will oversee home visits, conduct needs assessments and refer sick siblings to the relevant healthcare facility.

ACTIVITY 3: Economic and Social Support Community care workers (CCW) will be recruited to assist orphans and vulnerable children in accessing suitable social and health facilities. These community workers (3-4 community workers per school) will be trained to identify OVC, follow-up through home visits, conduct needs assessments, and assist with access to birth certificates and government grants. Each cluster of schools will have a social worker who will be responsible for supervising the community workers and following up the more serious cases. The CCW will co-ordinate the referral system between teachers and community workers and will ensure appropriate case management. The community workers will also be trained to facilitate support groups for the children especially groups for child-headed households and will focus on special needs of girls.

ACTIVITY 4: Food Security ARK will provide nutrition support through the establishment of food gardens in the cluster of schools. Schools will work with the community workers to initiate food gardens. ARK will partner with KZN provincial government, specifically the Department of Agriculture's extension officers, and other NGOs that provide training for the development of food gardens and ongoing agricultural support. ARK will provide the resources such as gardening equipment, services of an agricultural organization to train and mentor the schools for the sustainability of the food gardens.

ACTIVITY 5: Capacity development ARK will provide both formal and informal training per cluster for two social workers, 18 - 24 community care workers, as well as 80 educators and institutional management teams in the schools. ARK will utilize existing and will develop specialized training modules where needed, that will address topics such as: the developmental stages of the child (male and female); grant access; child protection, special needs of the girl child, and minimizing stigma. Training of community workers will be conducted in collaboration with accredited service providers such as the National Association of Child Care Workers (NACCW). The Valley Trust will provide training in establishing food gardens. ARK will provide overall support and supervision to the project, ensuring ongoing mentorship of the trained groups, as well as liaison with other partners for knowledge sharing and identifying opportunities for growth. Through home visits, Child Care workers (CCW) will be able to train and support caregivers to better care for their children.

ACTIVITY 6: Referrals and Linkages ARK works in partnership with other NGOs, local government and government departments. ARK has had extensive consultations with the Departments of Education, Health and Social Development to ensure support of this program. Other local service providers, NGOs, CBOs and FBOs will be identified for referrals to and from ARK services.

The Department of Social Development has acknowledged the significant contributions from ARK in the policy development processes for OVC and this will continue. ARK participates in the National Action Committee for Children Affected by HIV and AIDS (NACCA).

ARK's OVC activities directly contribute to PEPFAR's goal of 2-7-10 by providing care to 10 million people, including OVC.

INTERGRATED ACTIVITY FLAG:

This activity also relates to Absolute Return for Kids' (ARK) activities in ARV Services (#7507), OVC (#7886) and TB/HIV (#7882).

SUMMARY:

ARK's focus is to provide antiretroviral treatment (ART) and accompanying support to primary HIV-infected caregivers with children. This includes the encouragement and support for the voluntary counseling and testing (VCT) of partners and children, to ensure complete family coverage and earlier access to ongoing treatment, care and support. Although the primary focus of ARK is on the caregivers of children, ARK offers its services to the entire population in all of its service areas. VCT services will be delivered in all of ARK's supported communities.

The primary emphasis areas for these activities are community mobilization, local organization capacity development, human resources, and training. Primary target populations include adult women and men and their families.

BACKGROUND:

ARK is a charity organization whose mission is to facilitate and support delivery of accessible and sustainable comprehensive treatment, care and support services to children and their caregivers in communities affected by HIV and AIDS and poverty.

In partnership with the KwaZulu-Natal (KZN) Provincial Government, ARK has established a comprehensive ART program in government primary health centers and hospitals. ARK works with the provincial government to identify sites and areas for capacity-building in areas including human resources, human capacity development, modest infrastructure improvements and service delivery. ARK's activities enable the provincial government to increase the number of patients counseled, tested, and provided ART and related services.

To date PEPFAR funding has enabled ARK to successfully provide over 9,000 patients onto ARV treatment in KZN through the sustained development of primary care facilities and their down referral sites in five districts, in primarily peri-urban and rural communities.

With FY 2007 funding, ARK will provide VCT services to children and spouses/partners of caregivers, as well as other household members. This will be linked to home visits undertaken by ARK's community adherence workers. Home visits serve to evaluate the psychosocial situation of patients, the degree of family support, and issues related to disclosure. Although ARK's treatment target population is predominantly mothers, caregivers, and their spouses/partners and children, increased attention is being given to encourage men, single women and children to come forward for testing and treatment.

ACTIVITIES AND EXPECTED RESULTS:

ARK's primary objective is to keep mothers alive to continue caring for their children in order to reduce the incidence of orphans and vulnerable children (OVC). Early, widespread testing and access to ARVs reduces the likelihood of morbidity and mortality from HIV. This, in turn, increases the likelihood of survival of family units, which guard income security and ongoing nurturing required by children in these households. Furthermore, the psychosocial component of counseling and testing forms a vital component for behavior change.

ACTIVITY 1: Support to Provincial Government for VCT Services

ARK works with the KZN provincial government to develop the necessary processes and systems to manage a comprehensive HIV and AIDS treatment program, and to ensure that the model created is scaleable, sustainable and replicable elsewhere. ARK, in partnership with KZN provincial government, will provide training and mentoring for government employed lay counselors and community adherence workers working at these primary sites where ARK's ARV treatment program exists. ARK will ensure that management systems are in place to support the work of the counselors and the delivery

of VCT.

ARK will strengthen or initiate VCT services at all sites identified by the provincial health department and assigned to ARK for support. To better ensure sustainability, where possible, ARK will use the counselors available through the District HIV program. ARK will also employ counselors and train existing employed community care workers to provide counseling for VCT services. Where infrastructure support is required, ARK will, in consultation with the facility managers and district managers, decide on the most cost-effective infrastructure support (prefab or modest renovations). ARK's OVC program, through the social workers and community workers placed at schools, will establish links with clinic services to ensure better and more efficient referral of children in need of testing and care, including their caregivers and immediate family.

ACTIVITY 2: Human Capacity Development

Formal and informal training and onsite mentorship will be provided to all lay counselors in the program. ARK, in partnership with the Centre for Social Science Research at the University of Cape Town, will continue to develop and improve training modules for lay counselors. The areas covered in training include: basic and advanced counseling skills, positive living, disease progression, opportunistic infections, risk reduction for HIV transmission and safer sex. Counseling and ongoing training will be in line with the National Department of Health (NDOH) Guidelines. ARK will provide mentorship and supportive supervision to lay counselors in the program to ensure high quality standards for VCT. Testing is conducted by nurses at the VCT site in accordance with NDOH standards. Support in terms of systems management and coordination of lay counseling will be provided to VCT sites.

ACTIVITY 3: Referrals and Linkages

Community care workers and social workers will be recruited to assist OVC and their caregivers in accessing ARK-assisted primary health facilities for VCT. They will coordinate the referral system between caregivers, children and VCT services. ARK will inform and coordinate activities with local NGOs, CBOs, and FBOs to establish effective referral networks for VCT services. Lay counselors will refer HIV-infected individuals to ARK's ARV treatment sites.

VCT activities will directly contribute to PEPFAR's goal of 2-7-10 by counseling substantial numbers of South Africans as part of VCT. VCT contributes directly to the goal of 10 million people receiving care.

INTEGRATED ACTIVITY FLAG:

This activity also relates to Absolute Return for Kids (ARK) activities in Counseling and Testing (#7883), OVC (#7886) and TB/HIV (#7882).

SUMMARY:

ARK's focus is to provide ART and accompanying support to HIV-infected caregivers of children, their spouses, and children. Primary emphasis areas are human resources, quality assurance, local organization capacity development, and training. Target populations include OVC, people living with HIV (PLHIV), HIV-infected pregnant women, HIV-affected families, and caregivers.

BACKGROUND:

ARK is a charity organization whose mission is to facilitate and support delivery of accessible and sustainable comprehensive treatment, care and support services to children and their caregivers in communities affected by HIV and poverty.

ARK's mission is to facilitate and support delivery of accessible and sustainable comprehensive treatment, care and support services to children and their caregivers in communities affected by HIV and AIDS. In partnership with the KwaZulu-Natal Department of Health (KZNDOH), ARK, as the implementing partner, has established an antiretroviral treatment program in government primary health facilities and hospitals. Specifically, ARK works with the KZNDOH to identify sites and areas for capacity building, including human resources, modest infrastructure support, and organizational capacity development. PEPFAR funding has enabled ARK to successfully enroll over 9,000 patients in ART in KZN.

FY 2007 funding will enable ARK to provide ARV treatment to existing and new patients, strengthen the infrastructure of the ARV delivery system in targeted sites, provide human resources, and build local institutional capacity to deliver ARV services. ARK provides treatment in accordance with national treatment guidelines.

ACTIVITIES & EXPECTED RESULTS:

ARK's primary objective is to keep mothers alive to continue caring for their children. The primary caregiver's continued survival and potential ability to earn a living while receiving ARV treatment will have a substantial impact on the extended family.

Activity 1: Support to KZNDOH

ARK works with the KZNDOH to develop the necessary processes and systems to manage the ARV program, to ensure that the model created is scaleable, sustainable and replicable elsewhere. Capacity-building is site specific. Upon identification of a site, an analysis of the needs of each site will be done with respect to staffing (doctors, nurses, pharmacists and pharmacy assistants), clinical equipment, management systems, patient advocacy and temporary structures. The most pressing requirements are met in order to speed up the ability for patients to receive treatment. Where necessary ARK provides support in the ARV site and pharmacy accreditation process.

ARK's ARV program focuses on a network of clinics operating within a district, in order to create a sustainable and efficient system that supports the continuum of care and up and down referral.

While patients are being assessed for treatment, a community health worker (CHW) from ARK's palliative care program is allocated to the patient. This CHW will conduct a pre-treatment home visit and will provide ongoing support to the patient and his/her family. Should a patient be non-adherent or lost to follow-up, the CHW will investigate the reasons for this, acting as the link between the patient and the clinic. ARK facilitates the integration process for ART, TB, other palliative care, and maternal HIV services.

Activity 2: Human Resources

ARK conducts a thorough needs analysis of human resource capacity prior to initiating support to the treatment program at each site. Once it has been determined that KZNDOH has budgeted for the identified posts needed, within a period of three years, ARK recruits all the necessary medical staff required for the successful rollout of ART. The staff recruited vary from site to site but include doctors, nurses, pharmacists and pharmacy assistants. In addition ARK employs data capturers for monitoring and evaluation of the program.

Activity 3: Family-Centered Treatment Services

Although ARK's primary goal is to provide ARV service support to primary caregivers with children, ARK assists in the treatment of all HIV-infected adults and children requiring ART at ARK sites in KZN. All patients considered for ART need to meet both medical and psychosocial criteria before starting therapy. The psychosocial criteria are designed to ensure that the patient is prepared and ready to adhere to ART. All patients being assessed undergo a treatment literacy program and are educated about positive living. Patients are encouraged to motivate their partners/spouses to get tested and, if necessary, enter the treatment program. Although ARK's treatment target population is predominantly mothers and children, increased attention is being given to encourage and increase male partner (and men in general) participation. ARK-employed doctors and nurses are responsible for treatment management, patient consultations and the treatment of opportunistic and sexually transmitted infections. Pharmacists are responsible for the dispensing of medication.

Activity 4: Pediatrics

HIV-infected parents and caregivers will be encouraged and educated by the medical staff to get their children tested and to enter the treatment program where indicated. Staff in the local midwifery and obstetric units will be trained to refer HIV-infected mothers and their babies to the ARK ART program, ensuring access to full ART services when indicated. All at-risk infected infants with HIV diagnosis confirmed by PCR will be monitored, and have immediate access to ARVs and related services including the preventive package of care. Children identified through ARK's OVC program (also PEPFAR-funded) will be referred to the clinic by community care workers and social workers.

Activity 5: Human Capacity Development

Key staff are provided with a two week orientation training which covers all aspects of ARK's ARV program areas including employee policies and procedures, onsite mentorship from experienced ARK staff, and an introduction to key performance areas. The areas covered in training include: ARV treatment guidelines for adults and children, adherence, opportunistic and sexually transmitted infections as well as the value of community access, adherence and refresher on prevention, including prevention for HIV-infected people. Staff are invited and encouraged to attend formal training offered by external providers including other PEPFAR partners such as the Foundation for Professional Development (FPD).

Activity 6: Reporting and Quality Assurance/Improvement

ARK provides computers and employs data capturers at all sites. Data is captured from patient folders and transferred to ARK's data center, allowing for ongoing evaluation and outcome analysis. Adherence rates, death rates and loss to follow-up are closely monitored. Quarterly updates are provided to the KZNDOH and information is used within the clinics to strengthen service delivery.

To ensure high standards and quality of care in line with the national guidelines, all ARK staff are provided onsite, on-the-job training. This is followed up with regular onsite mentorship and site evaluation by ARK's national executive and provincial management teams. Informal training sessions are conducted quarterly by national staff. Staff are also encouraged to attend formal external training courses offered by FPD.

These activities contribute to PEPFAR's 2-7-10 goals by increasing the number of South

Africans on treatment.