INTEGRATED ACTIVITY FLAG:

This activity is linked to Population Council's other activities in AB (#7614), Other Prevention (#7611), Counseling and Testing (#7612), and ARV Services (#7861).

SUMMARY:

Population Council (PC) is using PEPFAR funding to provide technical assistance (TA) to the KwaZulu-Natal Department of Health (DOH) in the development of a provincial antenatal (ANC) and postnatal (PNC) policy and evidence-based comprehensive guidelines. These will incorporate aspects of HIV prevention, counseling and testing (CT), prevention of mother-to-child transmission (PMTCT), antiretrovirals (ARV) and male involvement, which are aimed at providing pregnant women, their partners and infants with quality comprehensive care during the ANC and PNC period. Outputs will also include a provincial strategy for monitoring and supervision; a set of job aides; and training materials to support implementation. In FY 2007, PC will provide TA in the operational phase and assist in planning the implementation of guidelines in KwaZulu-Natal and other provinces. To date, this has been a provincial activity, with focus primarily on KwaZulu-Natal; however, in FY 2007 PC will work in close collaboration with the National Department of Health (NDOH) to identify new provinces for implementation. The target populations for this activity are people living with HIV and AIDS; HIV-infected pregnant women; program managers; policy makers; National AIDS Control Program Staff; other DOH Staff from three provinces; nurses and Non-governmental Organizations (NGOs). The emphasis areas for this activity are policy and guidelines, quality assurance and supportive supervision, strategic information, as well as training.

BACKGROUND:

PC currently provides TA using a participatory methodology aimed at ensuring that local, national and international evidence, and relevant guidance from the vertical HIV related programs (CT, PMTCT, ARV) feed into the development of comprehensive and integrated provincial ANC and PNC policies and guidelines. This ongoing project, commenced in 2004 with PEPFAR funding, is carried out in collaboration with the Reproductive Health and HIV Research Unit (PEPFAR funded) and three KwaZulu-Natal DOH directorates (Maternal Child and Women Health [MCWH], Sexually Transmitted Infections [STI] and PMTCT). The KZN MCWH is the lead for the provincial "Core Team." The overall function of the Core Team is to steer the development of policy and guidelines. To date, multiple stakeholders and the Core Team have developed drafts of both the policy and guidelines. As part of the process to inform the development of the policy and guidelines, the Core Team conducted focus group discussions with pregnant women to identify their maternal health needs. During this funding period, the project will move from the guideline development phase to an operational implementation phase.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Technical Assistance

PC will provide ongoing TA to the KwaZulu-Natal DOH as key drivers of the PMTCT policy and guideline development. PC will coordinate the operational implementation phase by developing further resources including guidelines for monitoring and evaluation tools, job aides and training material.

ACTIVITY 2: Strengthening Human Capacity Development

This activity is being co-funded with the KwaZulu-Natal MCWH Directorate. Once the tools are finalized, PC will coordinate the implementation planning. The KwaZulu-Natal MCWH directorate is committed to a province-wide effort to rollout PMTCT training. In alignment with a National Human Resources Plan for Health, PC will provide TA to the MCWH for the province-wide rollout of the guidelines and job aides. Using a training-of-trainers methodology, PC will use PEPFAR funds to conduct training of trainers' workshops; to coordinate and document the process; and to strengthen monitoring and evaluation systems.

ACTIVITY 3: Scale-up of the Policy/Guidelines

The final PMTCT policy and guidelines will be launched at a provincial stakeholder's workshop, which will involve all relevant local and national DOH counterparts. Dissemination will be important in order to learn from the key findings to inform future initiatives. It is anticipated that other provinces will be interested in similar initiatives and PC will offer technical assistance to adapt the tools to their specific context. PC will work with KwaZulu-Natal MCWH and the two new provinces identified by the NDOH to strengthen referral systems and linkages.

This activity will contribute to the overall PEPFAR goals of preventing 7 million new infections by strengthening PMTCT programs with policy and guidelines and an implementation plan in the province most affected by the HIV and AIDS crisis.

INTEGRATED ACTIVITY FLAG:

This activity is linked to Population Council's other activities in PMTCT (#7613), Other Prevention (#7611), Counseling and Testing (#7612), and ARV Services (#7861). Activity number three is linked to work done by EngenderHealth (#7566) and Hope worldwide (#7607) on male interventions.

SUMMARY:

Prevention efforts are key to reducing sexual transmission of HIV. In South Africa, the Population Council (PC) has implemented several prevention programs targeting young people, learners, as well as men and couples to delay sexual debut, promote faithfulness and mutual monogamy, and to reduce risk behaviors. With PEPFAR FY 2007 funds, PC intends to strengthen and expand these activities. The proposed activities are in response to requests from various government departments (provincial and national), and will draw upon exiting partnerships with South African institutions and organizations such as the Departments of Health and Education and the South African Council of Churches.

BACKGROUND:

Over the past few years, the PC has developed an expertise in developing strategies and interventions focused on men more actively in preventing HIV transmission. The first activity has been to work with the Department of Education, South African Council of Churches and local FBOs piloting interventions on AB in primary schools and mutual monogamy in churches in Mpumalanga Province and the Eastern Cape Province, respectively. These community interventions have reached couples, church members, youths, teachers, learners, parents/guardians and other stakeholders. However, reaching an adequate number of men through churches is a major challenge because fewer men than women participate in church activities. This year's activities will continue to increase male involvement through specific strategies such as strengthening couples interventions, addressing gender-based violence and educating learners. In addition, the PC will address these same issues at a macro level. Women's low power and high male control in intimate relationships is generally associated with increased HIV risk behaviors and HIV infection. Building on past work with EngenderHealth and Hope worldwide targeting men to reduce GBV, risky HIV behaviors and increase involvement in PMTCT, the PC will use FY 2007 funds to facilitate the development and integration of a broad-based national strategy on male involvement in RH and HIV focusing on: referrals and linkages, policies and guidelines, quality assurance and supportive supervision. Interventions will target program managers, program implementers, NGOs, NDOH and other stakeholders.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Integrating AB into Life Skills Program

Teachers will be trained and ongoing support will be provided to deliver a strengthened and balanced ABC program in primary schools in the province of Mpumalanga. An AB module developed and piloted under Phase 1 and Phase 2 (FY 2005/2006) will be used to strengthen the AB message and intervention into the current life skills curriculum. In addition to working with teachers and learners, peer educators, community leaders and parents/guardians will be involved to promote and reinforce supportive norms and practices to enhance AB behaviors among learners aged 10-14. In this final phase, the program will be expanded from the pilot schools to additional schools in communities comprising different socio-economic backgrounds. Engaging parents/guardians and community leaders to create a supportive environment for young learners to adopt AB related behaviors and facilitate positive community norms promoting gender equity and the rights of girls will be a key component to sustainability.

ACTIVITY 2: Strengthening FBO Prevention Activities

This activity will constitute the final phase of a program targeting youth, couples and adults as part of a faith-based HIV and AIDS initiative. Working with existing partners - the National and Provincial Council of Churches, local faith-based organizations (FBOs) and church bodies, PC will utilize a piloted curriculum on mutual monogamy and AB to reach

couples, adults and youths respectively. Church and FBO leaders will be trained to deliver AB, mutual monogamy and risk reduction messages, as well as to counsel and provide referrals for needed services. A key intervention will be to promote men's involvement to take responsibility for HIV prevention and to address gender-based violence within these communities. The proposed program will be expanded to several churches in the current areas - Alice and Butterworth in the Eastern Cape, and replicated in churches in several communities in Soweto, Gauteng.

ACTIVITY 3: Technical Assistance to Develop Male Involvement Strategy

Recognizing the lack of male involvement in HIV prevention, as well as care and support activities, the National Department of Health through its Women's Health and Genetics Unit, has requested PC to provide technical assistance (TA) to systematically develop a strategy to address male involvement in HIV and AIDS issues. In response to this request, PC intends to use FY 2007 funds to provide TA to create a multi-sectoral task team to identify priority areas for actions toward the development of a national male involvement strategy. PC will facilitate the process by coordinating the involvement of different sectors and sharing programmatic lessons.

These activities will assist the PEPFAR program to reach the overall goal of preventing 7 million new infections, by addressing key prevention interventions.

INTEGRATED ACTIVITY FLAG:

This activity is linked to Population Council's other activities in AB (#7614), PMTCT (#7613), CT (#7612), and ARV Services (#7861). Activity 2 is linked to the Research Triangle Institute activity with the South African Department of Justice, which focuses on scaling up the Rape Crisis Centers in South Africa (# 7539).

SUMMARY:

Building on past experience, the Population Council (PC) will implement two activities aimed at increasing access to post-exposure prophylaxis (PEP) and strengthening the support and referral systems, including medical and legal, for victims of rape. Major emphasis areas will be community mobilization/ participation while minor emphasis will be linkages with other sectors and initiatives and training. Target populations include girls, women, community leaders, policy-makers, National Aids Program Staff, other National Department of Health (NDOH) staff and implementing organizations.

BACKGROUND:

There has been growing alarm regarding the high levels of rape reported in South Africa. Sexual violence and violence against women have become one of considerable political importance and the Department of Justice (DOJ) has launched a major initiative to address the needs of rape victims in a comprehensive manner. Meeting the immediate healthcare needs of rape survivors (including sexually transmitted infections, treatment of injuries, and counseling) is a priority. Guidelines exist for the provision of PEP, along with these other key services; however, evidence shows that these are not often followed. In addition, there is a poor link between medical post-rape services and the necessary legal and police procedures.

Population Council (PC) and Rural Aids and Development Action Research (RADAR) have been working in Limpopo to implement and evaluate a rural, multi- sectoral model for post-rape care. A number of obstacles in providing comprehensive post-rape care at the project site were identified including uptake of service by community, institutional and provider capacity, quality of service delivery, and inter-sectoral linkages. An intervention strategy was developed to address these key challenges. A Project Advisory Committee (PAC) was formed and a hospital rape management policy was developed. Healthcare workers and other providers were trained on: multi-sectoral approach to rape management, centralization and co-ordination of post rape care, strengthening of inter-sectoral linkages with local police and community awareness. Following the interventions, a repeat evaluation at the hospital and police station indicated that the flow of patient care has been streamlined, necessitating fewer providers, fewer steps, and fewer delays in treatment. Nurses are taking a more active role in management of rape cases, using formal protocols and policies, and referral rates to other providers appears to be increasing. With support from hospital management, the hospital pharmacist has begun to dispense a full 28-day regiment of PEP on the initial visit. Community awareness campaigns have reached over 14,000 individuals in the hospital catchment area, with information about post-rape services, including PEP. Whether due to increased awareness and/or other factors, there has been an observed increase in the uptake of services at the hospital. The project is also working with national and provincial (Limpopo and Mpumalanga) Departments of Health to train healthcare workers and health managers regarding management of sexual assault, and to share policies and management tools. Although these activities have strengthened the health sector response to violence, they have also revealed weaknesses in addressing the legal needs of rape survivors. Although nurses and doctors have been trained in collecting forensic evidence, few cases are actually brought to court, and even fewer successfully prosecuted. Lack of confidence in legal proceedings discourages survivors from seeking medical care or reporting to police.

ACTIVITIES AND EXPECTED RESULTS:

In FY 2007, PC and RADAR will use this health sector-based model as a foundation to strengthen linkages with other sectors, particularly social welfare, police, and judicial, building on the relationships and gains made during the previous phase of the work. This will include the following activities:

ACTIVITY 1:

This activity will continue to focus on strengthening systems in the project site in Limpopo. The lessons learned will inform the next phase of development that will sustain PEP and strengthen relationships between hospitals, legal entities, communities and health departments at national and provincial level and inform the Department of Justice's efforts to enhance the quality of their comprehensive rape centers, The Thuthuzela ("To Comfort") Care Centers. A baseline assessment of processes and outcomes relating to the necessary legal interventions following reporting of rape cases to the hospital will be conducted. This will formally document actual prosecution rates, highlight current obstacles and points for possible intervention areas. RADAR will partner with the Tshwaranang Legal Advocacy Centre (TLAC) to bring on board two paralegal advisors and a program manager to develop an intervention strategy for engaging with the local police station and prosecutors. Training workshops will be conducted with Victim Empowerment Program volunteers, police and prosecutors in order to raise sensitivity regarding sexual violence and obstacles and obligations for reporting and prosecution of cases. Using channels developed during the previous phase, RADAR will add a legal component to the community outreach and awareness raising activities targeting the villages surrounding the project. In addition to the sexual and reproductive health related messages previously emphasized, messages focusing on a rights-based approach will be included, as well as information regarding the legal issues of reporting a rape case. PC will develop systems for monitoring and evaluating the reporting and prosecution of cases of sexual violence, as much as possible drawing on and strengthening existing record keeping systems within the hospital and police station. Building on existing relationships with government stakeholders at the national and provincial (Limpopo and Mpumalanga) Departments of Health, the project will disseminate tools and lessons learned from this model for developing a strengthened medico-legal response to sexual violence in rural areas.

ACTIVITY 2:

At the request of the DOJ, PC in collaboration with RADAR and Research Triangle Institute (RTI), will also utilize PEPFAR funds to provide technical assistance and health-related experience to guide a process of scaling up the DOJ rape care centers from 8 centers to 40 nationwide. Technical assistance will also be provided to ensure quality of post-rape care. The centers aim to offer rape survivors caring and dignified treatment, and effective prosecution of cases in the justice system. The 24-hour service centers have services that include police, counseling, doctors, court preparation and a prosecutor. Lessons learned and materials developed through the ongoing PEPFAR funded work in Limpopo will be shared. Links between the Departments of Health and Justice will be strengthened through the various partners.

These activities will assist the US Mission in attaining their goal of averting 7 million HIV infections by strengthening a key gender intervention in South Africa.

INTEGRATED ACTIVITY FLAG:

This activity is linked to Population Council's other activities in AB (#7614), Condoms and Other Prevention (#7611), PMTCT (#7613) and ARV Services (#7861).

SUMMARY:

This activity was initiated at the request of the Department of Health (DOH) and has been ongoing for two years. The Population Council (PC), in collaboration with the National Department of Health (NDOH) and the provincial health departments in North West province (NW), is using PEPFAR funding to implement and evaluate the feasibility, acceptability, effectiveness and cost of two models that integrate HIV prevention information and the routine offer of provider-initiated counseling and testing for HIV into Family Planning (FP) services. These models will be implemented in three South African districts in the North West. Integrated services have been implemented in 12 clinics and will be introduced in a further 12 clinics. In addition, referral systems, monitoring and supervision will be strengthened in all three districts and other provinces will be encouraged by the NDOH to consider scale-up of services.

BACKGROUND:

In the context of the HIV epidemic in South Africa (SA) and the South African Government (SAG) commitment to provide ARV treatment, improving access to counseling and testing (CT) for HIV in resource limited settings has broadened from primarily that of a prevention intervention to a key entry point for ARV therapy, care and support services. SA has a contraceptive prevalence rate of 62% and FP services are the most highly utilized public sector service. FP services can serve as an entry point to CT services and also an early entry point to PMTCT. This project aims to incorporate routine provider-initiated CT services into FP to improve the uptake of CT and the use of dual protection. Results so far have indicated positive changes in terms of: provider mentioning CT to clients (increased by 33.6%), provider mention of condoms (improved by 16%), and clients accepting testing (increased 38.6%). CT uptake increased by 24% and 'condom use at last sex' improved by 6.5%, while consistent condom use increased by 10%. These preliminary results indicate that the integration of HIV prevention and the routine offer of CT in FP settings is feasible, acceptable and is effective without compromising the existing quality of FP services. However, there are a number of challenges that still need to be addressed in order to improve the implementation process. These challenges include the need to: (1) strengthen the referral system for HIV-infected clients to improve continuity of care, (2) provide continued support and monitoring to implementation sites to ensure successful integration, (3) minimize the rotation of trained staff at implementation sites, and (4) improve the quality of monitoring data collected at clinic and district level.

ACTIVITIES AND EXPECTED RESULTS:

Population Council will carry out four separate activities in this Program Area.

ACTIVITY 1: Training, Ongoing Quality Assurance and Supportive Supervision

PC is extending training to other healthcare providers (i.e. assistant nurses and lay counselors), to provide HIV prevention information, risk assessment and referral or provision of CT. This activity also involves ongoing monitoring and supportive supervision to 24 project clinics and building capacity for DOH staff at district and provincial levels to sustain supervision. Funds will be used for the printing of information, education, communication (IEC) materials and job aids for integrated services. In addition, FY 2007 funds will be used to strengthen the quality of provider-initiated CT services and to strengthen monitoring at clinic and district level. This will be achieved by working with the districts to amend some of the tools as well as to provide training on their use. Target groups for these activities are healthcare providers, facility managers, program managers, LifeLine counselors (LifeLine is a PEPFAR-funded NGO), district and provincial DOH staff in the Women's Health and Genetics (WHG) and CT programs and district health informatics officers.

ACTIVITY 2: Development of Network/Linkages/Referral Systems

Strengthening referral systems for HIV-infected clients post CT will be one of the major foci in order to improve continuity of care. This activity involves raising awareness on the importance of creating links among treatment, care and support with FP services, so that HIV-infected clients can benefit from an effective referral system. Treatment sites as well as sites that provide care and support will be identified. Training will be provided to FP providers and lay counselors on appropriate referral and available sites for referral in the location. The target group for this activity includes healthcare providers, DOH program managers as well as community-based organizations and non-governmental organizations.

ACTIVITY 3: Continued Partnership with the National and Provincial Government

As part of aligning PC's work with government policy, PEPFAR funding will be used to enable the activity to work more closely with the NDOH national voluntary counseling and testing (VCT) program and to continue working with the WHG program. PC will support the NDOH by providing technical assistance (TA) to the department in terms of planning for scale-up of effective components and assisting in identifying key policy barriers in implementing integrated HIV and reproductive health services. Target groups for this activity includes national and provincial VCT program staff as well as other NDOH staff under the HIV prevention, treatment, care and support program.

ACTIVITY 4: Creating Conditions for Scale-up and Capacity Building

An evaluation of the effectiveness of integrating HIV into FP services will be completed. Funds will be used to develop and modify evaluation tools, train field workers, and to collect and analyze data. In addition, seminars will be conducted with relevant stakeholders to encourage information dissemination and use. At these seminars, innovative interventions on how to increase CT uptake will be discussed, as well as how to continue strengthening the continuum of care and support for HIV-infected individuals.

This activity will assist the South Africa PEPFAR program to reach its goal in both care and treatment by strengthening the continuum of care.

INTEGRATED ACTIVITY FLAG:

This activity is linked to Population Council's other activities in AB (#7614), Other Prevention (#7611), PMTCT (#7613), and Counseling and Testing (#7612).

SUMMARY:

ARV services are being rolled out in a phased approach in South Africa, however, barriers to accessing treatment remain at the community and health facility level, particularly for children and OVC. Data from public sector sites also reveal that CT is not acting as an effective entry point for treatment, care and support services due to poor linkages and referral systems. The Population Council (PC) will address issues around accessing treatment through 3 key activities that address these concerns, with an emphasis on linkage and referral networks.

BACKGROUND:

Over the past two years, the PC has worked closely with projects that specifically deal with increasing access to antiretroviral treatment (ART) through different entry points. Data from three separate projects show that major barriers still exist. A recent study showed that HIV-infected children in communities do not have access to ART for several reasons, including limited availability of PMTCT interventions, the limited number of facilities offering treatment, caregivers' ignorance of the HIV status of children, and a lack of programs addressing access to ART. Group discussions with caregivers and OVC service providers, as part of an elderly caregivers intervention, showed that the caregivers had very little knowledge and information on ART for children as well as relevant prevention issues. Data from public sector sites in North West province reveal that once tested for HIV, few clients are referred for assessment, treatment, wellness, or care and support services. Thus CT is not acting as an effective entry point for these services. This activity area addresses the strengthening of three key entry points to ART delivery. The following interventions are ongoing and will be expanded.

ACTIVITIES AND EXPECTED RESULTS:

Activity 1: Access to ARV Services through the Family-Centered Approach (FCA)

The objective of the FCA is to increase access to treatment for infants and children by strengthening the capacity of service providers to treat the family as a whole. The activity will build on lessons learned through the pilot program in three urban hospitals regarding the acceptability and feasibility issues. The project will be expanded to two rural facilities in the Eastern Cape province (Lusikisiki Clinic and Cecilia Makiwane Hospital) as well as an urban hospital in Free State province (Bloemfontein National District Hospital). Specific activities will include: Implementation of a short in-service training program for service providers covering information, education and communication (IEC), family-centered referral, utilizing a family treatment diary and management support for service providers. Service providers will be trained on how to recognize children with early signs of health problems and to appropriately refer. At the community level, IEC will be promoted to enhance collective family participation in CT, ultimately to access treatment services. Local NGOs and CBOs will be instrumental in linking families with health facilities. A training program for NGO and CBO community healthcare workers will be developed and implemented in accordance with South African Government standards. To enhance sustainability, partnerships will be fostered among government facilities, between facilities and NGOs and between private and public sectors.

Activity 2: OVC Treatment Access

Building on work with OVC programs and elderly caregivers in the Eastern Cape province, to understand the barriers of accessing care and treatment for OVC, this activity will focus on interventions with caregivers, OVC program managers and service providers. Activities will be conducted in two rural communities where the PC, Medical Research Council (MRC), Age-in-Action and community-based groups are working with hundreds of elderly OVC caregivers to improve the services they provide. As the final stage to this program, PC intends to incorporate information and referral to HIV testing, ART services and

HIV-related care to ensure that HIV-infected orphaned and vulnerable infants and children have the opportunity to receive timely, relevant and adequate care and treatment. Specific activities will include: 1) developing the capacity of OVC service providers to engage in relevant ART related services (e.g. referral to HIV testing, ART and TB services); 2) addressing ART information needs of caregivers; 3) facilitating access to counseling and testing, grants, and other social services; 4) educating caregivers on relevant aspects of treatment for children, e.g., treatment literacy, side effects, nutrition, adherence, how to access ART facilities; and 5) addressing concerns around disclosure of HIV status of children and counter stigma faced by infected children and affected caregivers and families.

Activity 3: Access to integrated family planning (FP) and ARV services

South Africa has a contraceptive prevalence rate of 62% and FP services are the most highly utilized public sector service. This makes FP visits an ideal entry point for counseling and testing, as well as HIV care and treatment. Therefore, PC will continue to collaborate with the Maternal Child and Women's Health (MCWH) programs as well as CT and ARV programs in North West Province (NWP) to develop and implement a model providing continuity of care. PC will identify partners providing ARVs around project clinics to develop, implement and monitor a feasible model for referral. This will include ongoing collaboration and coordination with relevant government departments. Assessing training needs for health care providers in order to develop effective referral mechanisms will be one of the first steps. It is envisioned that training of FP providers will be needed to make appropriate referrals, clinical staging of HIV, ARV monitoring and compliance. Relevant training will also be provided to participating ARV sites to enable ARV providers to discuss future reproductive intentions, and provide or refer for FP. Training materials, monitoring tools and job aides for healthcare providers will be developed where necessary, or adapted if adequate tools are already available.

These activities will assist PEPFAR to achieve its overall goal of reaching 2 million with treatment by strengthening three key entry points to service delivery.