INTEGRATED ACTIVITY FLAG:

This activity is related to PHRU activities described in the following program areas: Basic Health Care and Support (#7598), TB/HIV (#7595), CT (#7596), Condoms and Other Prevention (#7881), ARV Services (#7597) and ARV Drugs (#7600 with funding through USAID and #7495 with funding through NIH).

SUMMARY:

The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high quality care and support for PLHIV. The PHRU will use PEPFAR funds to provide high quality coverage of prevention of mother-to-child transmission of HIV (PMTCT) in Soweto (Gauteng Province), Limpopo and Mpumalanga Provinces. This will include support to pregnant women for post counseling and testing (CT), referral of women to appropriate HIV and AIDS treatment programs and support for early testing of infants exposed to HIV. The major emphasis area addressed is human resources; minor areas are information, education and communication, local organization capacity development and training. The target populations are adults, pregnant women, HIV-infected infants (0-4 years), PLHIV and their families. Issues of US legislative interest are: gender (increasing gender equity in HIV/AIDS programs, male norms and behaviors), stigma and discrimination and US-based volunteers.

BACKGROUND:

In partnership with the Gauteng Provincial Department of Health (DOH) the PHRU has been running the Soweto (Gauteng) PMTCT program since 2000. All pregnant women accessing public health antenatal clinics are reached, resulting in very high uptake rates. The PHRU offers post-partum counseling and testing (PPCT) in the maternity wards at the tertiary hospital (Chris Hani Baragwanath Hospital (Bara)) where most deliveries in Soweto take place, and provides post-exposure prophylaxis (PEP) to infants exposed to HIV. In partnership with the Rural AIDS Development Action Research Program (RADAR) and HIVSA the PHRU has supported the Limpopo Provincial DOH provide PMTCT service in the Bohlabela district since 2003. The PMTCT service is integrated into maternal and child health services. All activities are ongoing and are funded by PEPFAR. The close partnership with the DOH and emphasis on capacity building and training ensures sustainability of the programs.

All PMTCT sites use rapid HIV tests with results given on the same day. Each day a group health talk is given, followed by individual pre-test counseling. After a pregnant woman voluntarily consents to testing, the test is conducted and the results given during individual post-test counseling session. Women testing HIV-positive are then provided with ARV prophylaxis following the South African Government (SAG) guidelines. The PMTCT program is an important entry point for HIV-infected women to access palliative care and ARV treatment (ART) for themselves and their families. All women who test positive are referred for CD4 count tests, those with CD4 counts<200 cells/mm3 are referred for ART. Infants born to positive women are given nevirapine syrup in the labor wards and a PCR test is conducted at 4 - 6 weeks. Infants are given cotrimoxazole prophylaxis and other basic preventive care.

Psychosocial support is provided through on-going counseling and support groups. Information is provided on issues such as safe infant feeding practices, formula, nutrition, general healthcare, family planning, prevention for positives and disclosure. Negative women are provided with information on how to stay negative. Safe disclosure is encouraged to reduce stigma and violence (key US legislative issue). All women are encouraged to bring their partners for testing to increase male involvement in HIV and AIDS care and treatment programs and to improve male involvement in PMTCT and reduce stigma (key US legislature issues). Health workers and lay counselors are mentored, provided with debriefing and continuous in-service training on PMTCT and developments in the field.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: PMTCT, GAUTENG (urban township)

The PMTCT program in Soweto is considered a best practice model for PMTCT in South Africa with greater than 96% uptake at each stage of the cascade. The program is ongoing and will continue operating in all Soweto public antenatal clinics with funding from PEPFAR and Gauteng DOH. Staff employed with PEPFAR funding offer PMTCT to around 30,000 pregnant women annually. Around 30% are HIV-infected and about 27,500 receive their results. Following SAG guidelines for PMTCT, positive women and their babies are provided with ARV prophylaxis. Support groups run at all clinics with emphasis on HIV information, prevention for positives, informed infant feeding choices, nutrition, safe disclosure to partners, etc. Partners are encouraged to come for testing and be involved in PMTCT.

All HIV-infected women are referred for CD4 count tests and those with CD4<200 cells/mm3 are referred for ART. Currently over 60% of women accept the CD4 count test with half receiving their results. The introduction of PCR testing for infants by DOH provides the opportunity for early infant diagnosis of HIV and referral for appropriate treatment and care, currently more than 50% of babies are tested. Over time the program will become more closely integrated with ARV treatment and will improve gender equity in treatment programs.

ACTIVITY 2: PPCT, GAUTENG (urban township)

Each year, two thirds of births (around 20,000) in Soweto occur at Bara Hospital. Around 3,000 women at the time of delivery present with an unknown HIV status. In this ongoing activity, staff funded by PEPFAR work with DOH staff to provide PPCT. A PEP dose of Nevirapine syrup is provided for HIV-infected mothers' infants to reduce the risk of transmission. It has been shown that a post-exposure prophylactic dose of Nevirapine is effective if given to infants within 72 hours of birth. Approximately 2,500 women are offered PPCT, about 2,000 accept and receive their results. Around 30% of these test HIV-infected. Over 98% accept Nevirapine for their infant. The uptake of the program is high and operates seven days a week to ensure access for all women giving birth. Women who tested negative early in pregnancy will be offered a follow-up test. Positive women identified at the time of delivery are provided with psycho-social support through counseling and groups, referred for CD4 count tests and early infant diagnosis.

ACTIVITY 3: PMTCT, LIMPOPO/MPUMALANGA (rural facilities)

PMTCT in the Bohlabela District is run by the provincial DOH. The PHRU, through RADAR and HIVSA, supports PMTCT at Tintswalo hospital with PEPFAR funding. Activities include mentoring the counselors, assisting with referrals and providing education and support to pregnant women. Each year, around 4,000 women deliver at the hospital; about 25% are HIV-infected. RADAR will liaise with the PMTCT service providers to ensure increased uptake of HIV counseling and testing. Following SAG guidelines, ARV prophylaxis is given to the mother and infant. Women testing positive are referred for CD4 count tests and to ART if CD4<200cells/mm3. All women are encouraged to bring their infants for testing at 6 weeks. Support groups and counseling are available with emphasis on informed safe infant feeding practices, nutrition, disclosure to partners, early infant testing, HIV information, etc. HIVSA provides support groups in the district primary care clinics assisted by a US-based volunteer (key legislative issue).

These activities directly contribute to the PEPFAR 2-7-10 goals by improving access to and quality of PMTCT services, testing pregnant women, identifying HIV-infected persons, reducing transmission to infants and improving access to care and ARV treatment.

INTEGRATED ACTIVITY FLAG:

This activity is related to PHRU activities described in the following program areas: Basic Health Care and Support (#7598), TB/HIV (#7595), CT (#7596), PMTCT (#7599), ARV Services (#7597) and ARV Drugs (#7600).

SUMMARY:

The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high quality care and support for PLHIV. Building on their 2006 workshop on the feasibility of scaling-up doctor-based male circumcision, the PHRU will use FY 2007 funds to organize and facilitate a stakeholders workshop on the feasibility, acceptability, and resource requirements of alternative models of delivering circumcision as a part of a comprehensive HIV prevention program. The workshop will compare three models of male circumcision: the use of traditional healers (where they are culturally appropriate) as circumcisers; use of trained doctors; and a nurse-based approach to circumcision. The workshop will draw upon the work of Human Sciences Research Council (HSRC) (#7620) and PHRU's non-PEPFAR funded study of the feasibility and acceptability of nurse-based male circumcision. This activity, along with HSRC's partnership with traditional healers, will be used by the Health Policy Initiative (#7606) in their policy analysis of the impact of pending South African legislation restricting male circumcision to medically defined conditions and for cultural practices. In all three cases the activities will concentrate on policy issues surrounding circumcision within the South African context rather than on actual service delivery. The major emphasis area addressed in this activity is human resources; secondary emphasis areas are information, education and communication, community mobilization, and training. Healthcare workers, program managers, and local health officials are the target group for this activity. Issues of U.S. legislative interest are: gender (increasing gender equity in HIV and AIDS programs, male norms and behaviors) and stigma and discrimination.

BACKGROUND:

Although not widespread, prevalence rates for male circumcision in South Africa ranges from 20% to nearly universal among some ethnic groups. Male circumcision is a procedure that is usually done for cultural or religious reasons rather than for health benefits. This is seen among certain ethnic groups such as the Xhosa who routinely practice male circumcision as part of initiation to transition boys to manhood. In such cases the circumcision is done by traditional healers rather than by medically trained in a health facility.

A recent study conducted in South Africa showed that male circumcision reduces the risk of becoming HIV-infected. UNAIDS and WHO have stated that these results should be confirmed prior to recommendations being issued regarding policy and program development. Two further large scale studies of circumcision for HIV prevention are in progress in Uganda and Kenya, with results anticipated in 2007. In addition, the potential that HIV-infected circumcised men may have a lower chance of transmitting HIV to their partners is being tested in a separate study. If these trials return efficacious results, circumcision may be considered for both HIV-infected and uninfected men. Scaling-up male circumcision in South Africa may therefore soon become a priority, as a component of comprehensive HIV prevention programs.

In anticipation of this development, the PHRU held a workshop in June 2006 on issues related to the feasibility of scaling-up male circumcision. Contributions to this workshop were made by researchers who conducted the South African trial, academic surgeons, and included input on diverse aspects of possible interventions including training requirements, legal and ethical concerns, traditional methods, anesthesia, cultural concerns, and potential target groups. An important conclusion from this preliminary consultation was that there is little circumcision being carried out by trained surgeons. Alternatives include integration with traditional circumcision schools. A medical model with circumcision delivered by trained nurses could also be considered. PHRU is currently conducting research, with non-PEPFAR funding, on the feasibility and acceptability of a nurse-based approach to circumcision. Through non-PEPFAR funding, male circumcision would be performed by trained nurses under the supervision of a surgeon in sterile operating rooms

at primary and tertiary health facilities. It is expected that this activity would impact male norms and increasing equity in treatment programs.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Feasibility, Readiness and Acceptability of Alternative Models of Circumcision

This activity will support a workshop that compares the readiness and acceptability of alternative models of circumcision, including nurse-based male circumcision. While the workshop would focus primarily on various medical models, the role of traditional healers and practitioners would also is examined using the materials generated from the HSRC study (#7620) of traditional circumcision practices. The outcome would be a report, describing the training, legal, ethical components for alternative models of male circumcision including doctor-based and nurse-based models. .

These activities will contribute to the PEPFAR goal of preventing 7 million new infections.

ACTIVITY 2: Male Circumcision Using Nursing Staff

No male circumcision training or service delivery will take place without the express consent of the National Department of Health. In the absence of such approval and based on discussions with the PEPFAR South Africa team, funds could fully or partially be reprogrammed. Should the approval for safe clinical male circumcision activities be given, PHRU is proposing the following male activities:

This activity assumes that the South African Government will change legislation to allow male circumcision to take place on a large scale in South Africa. Recognizing that specialized surgical and other staff are in short supply, this activity will look at alternative models to scale-up male circumcision. This will include training nurses to do male circumcision, paying staff to perform circumcisions and paying for materials required to perform male circumcision. Training, mentoring and implementation will be the main areas of emphasis and developed in consultation with NDOH and JHPIEGO. It is likely that this activity will take place initially in Gauteng, but may be expanded to other provinces on request of the National Department of Health.

INTEGRATED ACTIVITY FLAG: This activity is related to PHRU activities in TB/HIV (#7595), CT (#7596), PMTCT (#7599), Condoms and Other Prevention (#7881), ARV Services (#7597) and ARV Drugs (#7600). This partner may benefit from the Partnership for Supply Chain Management ARV Drugs activity (#7935), which will explore current pain and symptom management practices, drug availability and cost, and provide recommendations.

SUMMARY: The Perinatal HIV Research Unit (PHRU) will use PEPFAR funds to continue to provide quality holistic care for PLHIV comprising of elements in the preventive care package, medical care and psychosocial support categories in Gauteng, rural Limpopo, Mpumalanga and Western Cape provinces. Clients are monitored, prepared and referred for antiretroviral treatment (ART). Linkages to counseling and testing (CT), the prevention of mother-to-child transmission (PMTCT) and referral to ARV services will be strengthened. The major emphasis area is human resources, minor emphasis areas are development of networks, local organization capacity development and training. A family centered approach targets HIV-infected adults, children and infants. Issues of US legislative interest are: gender, stigma and discrimination, and US-based volunteers.

BACKGROUND: Since 2002, PHRU has established palliative care programs in Gauteng, rural Limpopo and Mpumalanga provinces for people identified as HIV-infected through PMTCT and CT (also funded by PEPFAR). Primary health care nurses are the main providers of care under physician supervision. The Department of Health (NDOH) guidelines for HIV care and laboratory testing are used to ensure compatibility with South African Government (SAG) treatment sites. In South Africa, a care program covers the period from testing positive through end of life care. A holistic approach is taken comprising elements of the preventive care package for adults and children, clinical services, psychosocial support, healthy lifestyle promotion and preparation and transition of clients onto ART when required.

These programs are predominately accessed by women; however PHRU is attempting to redress this imbalance (key legislative area). Men are encouraged to participate through CT programs which specifically target men (key legislative area). Clients are encouraged to bring partners, children and other family members. A focus of the program is to identify HIV-infected infants and children and to provide family centered care and support. Quality assurance, client retention, monitoring and evaluation are integral parts of the program.

The aim of the programs is to delay progression of HIV to AIDS by providing palliative care and support to HIV-infected clients who do not yet qualify for ART. Care includes: screening for active TB, preventative treatment for latent TB infection, cotrimoxazole prophylaxis for OIs, syphilis screening, symptomatic screening for syndromic STIs, screening for cervical cancer, provision of family planning and regular CD4 counts. Opportunistic illnesses are treated using a formulary based on the South African Essential Drug List. Support for clients, their families and community members is provided through support groups and education sessions at all sites covering issues such as basic HIV and AIDS information, HIV services, PMTCT, ART, opportunistic infections, TB, prevention, disclosure, prevention, nutrition, stigma (key legislative issue), positive living and adherence.

ACTIVITIES AND EXPECTED RESULTS: ACTIVITY 1: Soweto, Gauteng The Soweto care program was initiated in 2002 serving over 4,500 adults with around 700 people being transferred onto ART and others who have been referred to SAG rollout sites. Support groups and education sessions are run by an NGO partner, HIVSA.

Since 2004, a focus has been to identify children requiring care, ART and psychosocial support through linkages to PMTCT and infant testing. Over 630 children are currently receiving care and referred for growth monitoring and routine immunizations. Support programs are in development to assist caregivers and children, in particular around issues of bereavement, disclosure, dealing with stigma and discrimination, positive living and life skills.

ACTIVITY 2: Bohlabela, Rural Mpumalanga/Limpopo The Bohlabela District in Limpopo/Mpumalanga province is one of the poorest in South

Africa. Access to information and HIV healthcare and support is a basic need. The PHRU in partnership with Rural AIDS Development Action Research Program (RADAR) and HIVSA established a wellness clinic at Tintswalo hospital and a district wide support network for people living with HIV and AIDS. Since 2003, over 2,000 people have accessed the wellness clinic and 2,500 have accessed support groups running in the district clinics. A training program has been implemented to train nurses, lay facilitators, counselors and local NGOs to provide effective support to people living with HIV and AIDS and the preventive care package, pain and symptom management, basic education on HIV, CT, HIV treatment services and related issues to the broader community. Disclosure is encouraged to reduce stigma, discrimination, improve male norms and attitudes and reduce violence. US-based volunteers have worked in these programs. Expansion of medical care to the district primary health care clinics and to prepare for down referral from tertiary facilities is planned.

ACTIVITY 3: Tzaneen, Rural Limpopo Since 2003, the University of Limpopo (UL) has been supporting the DOH to develop a district-wide wellness program based in the primary health care clinics in the Letaba sub-district of the Mopani District in Limpopo province. PHRU partnered with UL to formalize and expand the program. With PEPFAR funding health workers have been trained in HIV care of adults and children and infrastructural support provided. HIVSA has provided training to support group members to enable them to run more effective support groups and provide better information to people in the district. The Mopani District (population 1 million) is extremely poor. The program operates in the primary care clinics with support by a medical doctor and aims expand to the whole district. Over 600 people have enrolled and more than 100 are now on treatment and supported at the clinics. On going in-service training and mentoring occurs at the clinics. US-based volunteers support the program. These activities will be continued and expanded to additional groups with FY 2007 funding.

ACTIVITY 4: Western Cape In 2006, PHRU partnered with a number of organizations in the Western Cape including the University of Stellenbosch, Red Cross Hospital and the Desmond Tutu HIV/AIDS Foundation that support a number of DOH ART sites. PEPFAR funds support these programs to improve linkages to primary care clinics for down referral, and to provide holistic care and support to people on ART and their families. Training staff to assist with scale-up and sustainability are focus areas. These activities will be continued and strengthened and will reach additional people with FY 2007 funds.

With plus up funds PHRU will support one of its sub-partners, HIVSA, to expand palliative care services in rural areas in Mpumalanga, Western Cape, and Limpopo and in urban areas in Gauteng Province. HIVSA utilizes male involvement, door to door, home-based care, and youth friendly models. HIVSA will implement systems to ensure that all PHRU assisted ART sites will reduce loss to ART initiation from the time tested positive until eligible for ART and will improve uptake of ART as soon as a patient is eligible. Support group models will also be expanded. HIVSA will also assist PHRU treatment programs to better monitor care provided to family members.

These activities directly contribute to the PEPFAR 2-7-10 goals by improving access to and quality of palliative care for HIV-infected individuals and their families.

INTEGRATED ACTIVITY FLAG:

This activity is related to PHRU activities described in the following program areas: Basic Health Care and Support (#7598), CT (#7596), PMTCT (#7599), Condoms and Other Prevention (#7881), ARV Services (#7597) and ARV Drugs (#7600).

SUMMARY:

The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high quality care and support for PLHIV. PHRU will use PEPFAR funds to continue its TB services to patients accessing care in Soweto (Gauteng), rural Limpopo/Mpumalanga Provinces and in the Western Cape. The TB/HIV program is integrated into all programs by providing screening, referring people with active TB to National TB treatment sites and providing preventative treatment for latent TB. The program is also linked to National TB treatment sites providing HIV care and treatment. The major emphasis area is human resources, minor emphasis areas are information, education and communication, development of networks/linkages/referrals and training. The primary target populations are HIV-infected adults and children. Issues of US legislative interest are: gender (increasing gender equity in HIV and AIDS programs, male norms and behaviors), stigma and discrimination and US-based volunteers.

BACKGROUND:

PHRU established palliative care programs in Soweto (Gauteng) and in rural Limpopo and Mpumalanga and have partnered with organizations in the Western Cape to provide care and support to people identified as HIV-infected through PMTCT and CT.

High rates of TB in South Africa continue to be challenging and MDR TB is considered to be on the rise. The PHRU will strengthen its emphasis on diagnosis of TB via its PMTCT program (through screening during CT when possible), and through screening of all patients testing positive. Once tested positive, all patients enter a wellness program where they will be screened and treated according to WHO protocols for TB. In South Africa, a wellness program covers the period from testing positive to needing treatment. The high HIV prevalence in South Africa requires a cost-effective package of care and support for people with HIV prior to ARV treatment. Primary health care nurses are the main providers of care under physician supervision in these programs. The programs follow the Department of Health guidelines for HIV care and laboratory testing to ensure compatibility with South African Government treatment sites. The programs have been approved by the medical ethical review board of the University of the Witwatersrand.

The aim of the programs is to delay the progression of HIV to AIDS by providing palliative care and support to HIV-infected clients who do not yet qualify for ARV treatment. Care includes: elements of the preventive care package, screening for active TB, preventative treatment for latent TB infection, cotrimoxazole prophylaxis for opportunistic infections, syphilis screening, symptomatic screening for syndromic STIs, screening for cervical cancer, provision of family planning and regular CD4 counts. Opportunistic illnesses are treated using a formulary based on the South African Essential Drug List.

Support for clients, their families and community members is provided by support groups and education sessions at all sites covering issues such as basic HIV and AIDS information, HIV services, PMTCT, ARV treatment, opportunistic infections, TB, prevention, disclosure, prevention, nutrition, stigma (key legislative issue), positive living and adherence. Training of professional and lay staff takes place on a regular basis.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Soweto, Gauteng

In 2002 a care program was initiated in Soweto, a large urban area south-west of Johannesburg with very high HIV prevalence (30% in the ante-natal clinics). A holistic approach is provided to all enrolled in the wellness program and covers clinical services, psychosocial support, and healthy lifestyle promotion, including exercise, nutrition, and decreasing the use of alcohol and tobacco. To date over 4,500 adults have accessed the

program with PEPFAR support. Support groups and education sessions, run by HIVSA, are available to all clients. All clients are symptom screened for TB at each visit and are referred for TB treatment to the government TB treatment clinics. PHRU is supporting the Charles Hurwitz Hospital, a government TB treatment facility, to integrate TB and HIV care and treatment.

Expanding the program with FY 2007 funds, the PHRU proposes to link TB screening into the PMTCT service in Soweto and screen all pregnant women for active TB and refer those with positive results to government TB treatment sites. PHRU will work with public facilities to ensure that care for both TB and HIV is monitored and coordinated.

Training for health care professionals working at the PHRU and its partners (including the provincial Department of Health) in all aspects of HIV palliative care takes place on an ongoing basis.

ACTIVITY 2: Bohlabela, Rural Mpumalanga/Limpopo

The Bohlabela district in Mpumalanga/Limpopo is one of the poorest in South Africa. Access to information and HIV healthcare and support is a basic need for all people living with HIV. The PHRU in partnership with Rural AIDS Development Action Research Program (RADAR) and HIVSA established a wellness clinic at Tintswalo hospital and a district-wide support network for people living with HIV and AIDS. Since 2003, over 2,000 people have accessed the wellness clinic and more than 2,500 have accessed the support groups. A training program has been implemented to train nurses and lay facilitators, counselors and NGOs to provide effective support to people living with HIV and AIDS and basic education on HIV, TB, CT, HIV services and related issues to the broader community and build the capacity of linked local organizations. All clients are screened for active TB at each visit. US-based volunteers (key legislative issue) have supported this program.

ACTIVITY 3: Tzaneen, Rural Limpopo

Since 2003, the University of Limpopo has been supporting the Department of Health to develop a wellness program based in the primary healthcare clinics in the Tzaneen District. In 2004 the PHRU partnered with the University of Limpopo to formalize and expand the program. The PHRU has mentored the program, assisted with training health workers and has provided infrastructural support. In addition, HIVSA has provided training to support group members to enable them to run more effective support groups, and provide better information to people in the district. The program takes a district health approach and aims to operate throughout the district. Over 600 people have enrolled in the program and more than 100 have been referred to ART sites for ARV treatment. People on treatment are supported at the primary care clinics through this program. The program will be expanded to other sub-districts in the Tzaneen area. All clients attending Wellness services will be screened for active TB at each visit. US-based volunteers (key legislative issue) have supported this program.

ACTIVITY 4: Western Cape

In 2006, the PHRU has partnered with a number of organizations in the Western Cape including the University of Stellenbosch, Red Cross Children's Hospital and the Desmond Tutu HIV/AIDS Foundation. The aim is to support government ART sites to scale-up and develop down referral systems. PHRU will continue to screen HIV-infected clients for TB and those who are found to be co-infected will be referred to public sites for treatment. Expansion of these activities is planned.

These activities will contribute to the PEPFAR 2-7-10 goals by providing TB/HIV care and services to HIV-affected people.

INTEGRATED ACTIVITY FLAG:

This activity is related to Perinatal HIV Research Unit (PHRU) activities described in the following program areas: Basic Health Care and Support (#7598), TB/HIV (#7595), PMTCT (#7599), Condoms and Other Prevention (#7881), ARV Services (#7597) and ARV Drugs (#7600).

SUMMARY:

The approach taken by the PHRU is one of comprehensive, high quality care and support for people living with HIV (PLHIV). PHRU will use PEPFAR funds to promote voluntary counseling and testing (VCT) through HIV prevention workshops and health promotion activities, and to pregnant women at PMTCT to increase uptake of VCT for HIV. In particular, services will be promoted to men in an effort to increase gender equality in HIV and AIDS programs (key legislative issue) and make them available to adolescents as part of a prevention program. The major emphasis area is human resources; minor areas include local organization capacity development, community mobilization/participation, and information, education, and communication. The target populations are the general population with a focus on men and adolescents. Issues of US legislative interest are: gender (increasing gender equity in HIV and AIDS programs, male norms and behaviors) and stigma and discrimination.

BACKGROUND:

This VCT program is an ongoing activity operated in partnership with a local non-governmental organization, HIVSA, and other VCT organizations in Soweto (Gauteng). The program will be expanded to rural Limpopo and Mpumalanga. HIV services in Soweto have been mainly accessed by women and this project aims to improve gender equity in these services. In June 2005, the IMBIZO project, which broadens access to HIV and AIDS information, was established. This project was designed to enhance male involvement in counseling and testing and other health services. IMBIZO drop-in centers operate five days a week and are located close to areas where men congregate and are easily accessible. The concept of the IMBIZO program is one designed by men for men and evolved from research that indicated that men preferred to be counseled by men at locations away from the primary healthcare clinics. Within the project, marginalized communities such as men who have sex with men are encouraged to access VCT. A focus of this program is to reduce stigma associated with HIV (key legislative issue), to encourage disclosure, to support partners and family members with HIV and to promote active engagement with HIV services. A program promoting IMBIZO to partners of pregnant women is being run in the antenatal clinics, with the aim of increasing male involvement in PMTCT and fatherhood. Reduction of violence and coercion, also main components of IMBIZO, is a major focus of the program that addresses US key legislative issues. Outreach activities take place in prisons, workplaces, hostels, sports matches and other places where men congregate. PHRU offers a couple counseling service called "Tshwarisanang" through external foundation funding and all other PHRU VCT services can refer to them.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: IMBIZO - Men's Health Centers

Male IMBIZO centers are funded by PEPFAR. The project receives approximately 300 drop-in clients and performs approximately 140 VCT each month. A male registered nurse manages the program. Clients are referred to local clinics for HIV services and treatment. Stigma decreases men's uptake of VCT services and innovative strategies to increase men using VCT are being developed. At risk male populations such as men who have sex with men, migrants, prisoners are focus populations. This program will expand to rural Limpopo and Mpumalanga provinces. Information on TB, PMTCT, HIV services, prevention, nutrition, etc., is available. Clients are counseled on prevention and condoms are distributed. Support is given to clients to encourage disclosure, to decrease stigma, to mitigate domestic violence (key legislative issue) and to provide support to partners. To increase male support of PMTCT programs, pamphlets have been designed for male partners of pregnant women that explain PMTCT, encourage active involvement in

fatherhood, encourage men to access the IMBIZO centers and to go for VCT. Outreach activities take place regularly with community organizations, workplace programs and health services. Mobile VCT is used to take VCT to communities that do not have easy access to health care services. A focus of this program is to reduce stigma, increase male involvement in all services relating to HIV thus increasing gender equity (key legislative issue). U.S.-volunteers will support the rural program.

ACTIVITY 2: Adolescents

Adolescents have special healthcare needs which they are often reluctant to address; some of these are sexuality, pregnancy, drug and alcohol abuse, sexually transmitted infections (STI), gender and mental health issues, coercion, violence, transgenerational sex and abuse. They are at high risk of contacting HIV and other sexually transmitted infections. Through a proposed specialized adolescent clinic PHRU will address these needs with FY 2007 PEPFAR funding by offering comprehensive counseling and care services that are youth-friendly, confidential and empowering to clients so that they may make informed and responsible healthcare choices, including being empowered to abstain and delay sexual debut. Through VCT, education and counseling, PHRU will increase awareness of HIV. The clinic in Soweto will be based close to where adolescents congregate. Services will comprise: VCT and confidential and free care; information, education and counseling on sexual and reproductive health; health information; counseling and appropriate referral for violence abuse and mental health issues; contraceptive information and counseling on individual choices; STI information, including information on effective prevention and syndromic management of STIs, amongst others. PEPFAR funds will be used to establish and staff this project.

These activities will contribute to the PEPFAR 2-7-10 goals by increasing access to and improving quality of VCT services, particularly to difficult to reach populations of men and adolescents in urban and rural districts in South Africa.

INTEGRATED ACTIVITY FLAG:

This activity is related to PHRU activities described in the following program areas: Basic Health Care and Support (#7598), TB/HIV (#7595), Counseling and Testing (#7596), PMTCT (#7599), Condoms and Other Prevention (#7881), and ARV Services (#7597).

SUMMARY:

The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high quality care and support for people living with HIV (PLHIV). The PHRU will use FY 2007 funds to continue to provide high quality holistic ARV treatment and psychosocial support in Gauteng, rural Limpopo and Mpumalanga, and Western Cape. These funds will contribute towards ARV drugs and services. Clients are provided with ARV treatment (ART), pre-treatment literacy, adherence counseling and adherence support groups. Linkages from CT, PMTCT, basic care and support will be strengthened. The major emphasis area is commodity procurement. Minor emphasis areas are information, education and communication, local organization capacity development and training. The family-centered approach targets HIV-infected adults, children and infants.

BACKGROUND:

Since 1998 the PHRU has provided comprehensive treatment, care and support to PLHIV. The PHRU has received funding from PEPFAR since 2004 to support ART services in Gauteng, rural Limpopo and Mpumalanga, and Western Cape provinces. PHRU directly purchases ARVs with PEPFAR funds and has demonstrated the ability to rapidly scale up treatment. PHRU has adopted a family-centered approach and clients are encouraged to bring partners and other family members for testing and treatment. Currently over 660 children and 3,300 adults are being supported on ART with funding from PEPFAR, with about one third supported through PEPFAR-funded ARV drugs. PHRU is supporting government treatment sites in Gauteng, Limpopo, Mpumalanga and Western Cape provinces. PHRU is expanding activities to directly support scale-up at government ART sites and support down referral systems. PHRU works with the provincial health departments to ensure safe transfer for the participants to ongoing care within the South African Government (SAG) rollout program to ensure sustainability. PHRU supports, trains and mentors healthcare workers involved in the management, care and treatment of HIV-infected individuals. All programs follow national guidelines for ARV treatment. Quality assurance, client retention, monitoring and evaluation form an integral part of the program. PHRU provides regular training for professional and lay staff on ART issues such as adherence, medical treatment, and appropriate regimens.

All sites have psychosocial support programs which provide community-based assistance, support groups and education covering issues such as basic HIV and AIDS information, HIV services, HIV treatment, treatment literacy, adherence, TB, positive living, nutrition, prevention, opportunistic infections and TB. The comprehensive care approach leads to stigma reduction, increased disclosure, and improved adherence to ART.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: ADULTS, SOWETO

Funding from PEPFAR supports over 250 adults on treatment in the family-centered PMTCT program.. The adult treatment program is ongoing and drugs are purchased for over 1100 people at the PHRU clinic based at Chris Hani Baragwanath Hospital (Bara). The program provides treatment, monitoring and support for adults who meet the SAG guidelines for treatment. HIVSA, an NGO partner, provides treatment literacy and adherence support. This activity will be continued and expanded with FY 2007 funds.

ACTIVITY 2: PREGNANT WOMEN, SOWETO

This program was started in the maternity section at Bara in July 2005 by PHRU in partnership with the Department of Obstetrics and Gynecology. In Soweto 8,000 pregnant women annually are identified as positive with an estimated 1,600 needing treatment. Following SAG guidelines, pregnant women who are eligible for treatment are offered

HAART. In order to fast-track women onto treatment, PHRU is training and mentoring the doctors and nurses. The program is being expanded to other ART sites in the area with FY 2007 funds. HIVSA will continue to provide treatment literacy and adherence support.

ACTIVITY 3: CHILDREN, SOWETO

The PHRU clinic identifies HIV-infected children who need treatment through PMTCT and children of adults who are already on treatment. This activity will continue and will be strengthened through additional counselors with FY 2007 funds. As part of a comprehensive family-centered approach, children are put onto treatment following SAG treatment guidelines with ARVs purchased by PHRU according to USG and SAG guidelines. More than 600 children are already on treatment procured and supplied through the PHRU pharmacy system. Staff are trained on an ongoing basis in pediatric ARV provision.

ACTIVITY 4: FRANCHISE, GAUTENG

This program targets uninsured workers in densely populated areas in Johannesburg. ARVs will be made available and affordable through a franchising scheme, and supplied free of charge or at a significantly discounted rate to patients unable to purchase their own medication. Those who can afford to pay for all or a portion of their drugs will be expected to do so. ARV drugs will be procured and supplied within the service by trained providers. This program will test the viability of a stand-alone ART full service clinic in downtown Johannesburg and provide lessons learned about demand for ART outside the public sector, willingness and ability to pay for services, and the cost-effectiveness of this model of delivery.

These activities will contribute substantially to the PEPFAR 2-7-10 goals of providing ARV treatment to two million people.

INTEGRATED ACTIVITY FLAG:

This activity is related to activities described in the following program areas: Basic Health Care and Support (#7598), TB/HIV (#7595), Counseling and Testing (#7596), PMTCT (#7599), Condoms and Other Prevention (#7881), and ARV Drugs (#7600).

SUMMARY:

The Perinatal HIV Research Unit (PHRU) provides comprehensive care and support for people living with HIV (PLHIV). PHRU will use PEPFAR funds to provide high quality, holistic ARV treatment and psychosocial support in Soweto (Gauteng), rural Limpopo and Mpumalanga, and the Western Cape. PHRU will also use PEPFAR funds to provide personnel and ARV drugs for these services. Clients are provided with ART, pre-treatment literacy, adherence counseling and access to adherence support groups. Linkages from CT, PMTCT, and palliative care will be strengthened. The major emphasis area for ARV services is human resources, minor emphasis areas are information, education and communication (IEC), local organization capacity development, and training. A family-centered approach targets HIV-infected adults and children.

BACKGROUND:

Since 1998 PHRU has provided comprehensive treatment, care and support to PLHIV. Since 2004, PEPFAR funding has supported ARV treatment and South African Government (SAG) ART sites in Gauteng, rural Limpopo and Mpumalanga provinces, and the Western Cape. PHRU is purchases ARVs and has scaled-up treatment for over 4000 adults and children. PHRU's family-centered approach encourages clients to bring partners and other family members for testing and treatment. PHRU is expanding activities to scale up government ART sites and to investigate down referral systems. With FY 2007 funds, PHRU will work with provincial health departments to ensure safe transfer of participants to ongoing care within the SAG rollout program. PHRU will support, train and mentor healthcare workers involved in the management, care and treatment of HIV-infected individuals. All programs follow national guidelines for ART. PHRU provides regular training on ART issues such as adherence, medical treatment, and appropriate regimens. A NGO partner, HIVSA, provides all sites with psychosocial support programs providing community-based support, support groups and education. They cover issues such as basic HIV and AIDS information, HIV services and treatment, treatment literacy, adherence, TB, positive living, nutrition, prevention, opportunistic infections and TB. The comprehensive care approach leads to stigma reduction, increased disclosure, and improved adherence to ART. Throughout the comprehensive program, PHRU has established a continuous set of assessment functions to improve the quality of care at ART service sites.

ACTIVITIES AND EXPECTED RESULTS:

All of the activities described in this section will be continued and expanded with FY 2007 funds.

ACTIVITY 1: ADULTS, SOWETO

Funding from PEPFAR supports over 250 adults on treatment in the family-centered PMTCT program. The program is ongoing and drugs are being purchased for over 1,100 people at the PHRU clinic based at Chris Hani Baragwanath Hospital (Bara). The program provides treatment, monitoring and support for adults who meet SAG guidelines for treatment. HIVSA provides treatment literacy and adherence support.

ACTIVITY 2: PREGNANT WOMEN, SOWETO

This program has been initiated in the maternity section at Bara in July 2005 by PHRU in partnership with the Department of Obstetrics and Gynecology. In Soweto 8,000 pregnant women are identified annually as HIV-infected, with around 1,600 needing treatment. Following SAG guidelines, pregnant women eligible for treatment are offered HAART. In order to fast-track women onto treatment, PHRU is training and mentoring doctors and nurses. The program is being expanded to other ART sites in the area through FY 2007 funds. HIVSA provides treatment literacy and adherence support.

ACTIVITY 3: CHILDREN, SOWETO

The PHRU identifies HIV-infected children who need treatment through PMTCT and children of adults who are already on treatment. As part of a comprehensive family-centered approach, these children are put onto treatment following SAG treatment guidelines with ARVs purchased by PHRU according to USG and SAG guidelines. More than 600 children are already on treatment procured and supplied through the PHRU pharmacy system. Staff is trained on an ongoing basis in pediatric ART.

ACTIVITY 4: RURAL MPUMALANGA AND LIMPOPO

At Tintswalo hospital, Limpopo, in partnership with Rural AIDS Development Action Research Program (RADAR), adults and children are identified as needing treatment in the palliative care and PMTCT programs. RADAR supports the ART site at the hospital with over 500 clients on treatment. This program will continue to support the ART site at Mapulaneng hospital which has started over 900 clients on treatment, and is assisting other sites for ART accreditation. Human capacity building is fundamental to sustainability of the program and PHRU provides staff, training and mentoring existing treatment staff. HIVSA offers district-wide support in the primary care clinics that includes treatment literacy, adherence counseling and group support for these clients.

ACTIVITY 5: TZANEEN, LIMPOPO

PHRU in partnership with the University of Limpopo is supporting the Limpopo Department of Health wellness program operating in the district's primary healthcare clinics. Currently clients are referred to the ART sites including Letaba hospital and CN Phatudi hospital with over 800 clients. Through Choice, a local NGO, clients are provided with a treatment readiness program, referred to rollout sites when they become eligible for treatment and given adherence support. Due to vast distances to the hospitals, clients on ART are supported in local primary care clinics.

ACTIVITY 6: FRANCHISE, GAUTENG

This program targets uninsured workers in densely populated areas in Johannesburg. ARVs will be made available and affordable through a franchising scheme, and supplied free of charge or at significantly discounted rates to patients unable to purchase their own medication. ARV drugs will be procured and supplied within the service by trained providers. This program will test the viability of a stand-alone ART full service clinic in Johannesburg and provide lessons learned about demand for ART outside the public sector, willingness and ability to pay for services, and the cost-effectiveness of this model of delivery.

ACTIVITY 7: WESTERN CAPE

A number of partners and SAG ART sites have been identified in the Western Cape that need support to scale up their activities. These include the Desmond Tutu HIV/AIDS Foundation, the University of Cape Town and Stellenbosch University. These partners are supporting SAG ART sites and provide training, mentoring and support. Many ART sites in tertiary hospitals are reaching capacity and the PHRU is encouraging innovative down referral mechanisms to be explored. This activity is relatively new and the partnerships will continue to be strengthened.

These activities will contribute substantially to the PEPFAR 2-7-10 goal of providing ARV treatment to two million people by supporting SAG treatment sites.