PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
INTEGRATED ACTIVITY FLAG: This PMTCT activity of the Medical Research Council (MRC) is linked to activities described in the TB/HIV (#7662); ARV Services (#7660); ARV Drugs (#7661); Other Prevention (#7956) and CT (#7664) program areas.
SUMMARY: This project is implemented by a consortium of organizations, including the Medical Research Council of South Africa (MRC), the Health Systems Trust, the University of the Western Cape (UWC) and Centre for AIDS Development, Research and Evaluation (CADRE). The project focuses on improving the outcomes of HIV-infected women and their infants through multiple approaches at the facility and the community level. The project will also serve as a targeted evaluation of PMTCT effectiveness. Emphasis areas include community mobilization/participation, needs assessment, quality assurance and supportive supervision, strategic information, and training. Target populations include infants, women, pregnant women, people living with HIV (PLHIV), HIV-affected families, nurses, and other healthcare workers.
BACKGROUND: This ongoing project, started in 2006, builds on the PEPFAR-funded Good Start Cohort Study. The study results highlighted the need for greater community support for HIV-infected mothers in relation to infant feeding and postnatal care, and health systems weaknesses that have contributed to the poor performance of PMTCT programs.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Community Peer Support Project With FY 2005 and FY 2006 PEPFAR funding, UWC developed training materials and trained 36 locally-identified peer supporters in basic child health services. In FY 2007, the project will be funded through the MRC and UWC will be a sub-partner. The project will focus on identifying pregnant women in 34 project clusters, followed by providing peer support to each of these households until the infants reach six months of age. The activity aims to support exclusive infant feeding practices (either exclusive breastfeeding or formula feeding); encourage mothers to attend antenatal care and to be tested for HIV; support disclosure of HIV status; support access to child support grants; encourage women to attend clinics postnatally for immunizations; provide cotrimoxazole and access to ARV therapy if required; and support early cessation of breastfeeding for HIV-infected women choosing to breastfeed. Funding for this activity will be used to provide a stipend to peer supporters, for supervision and mentoring of peer supporters and for transport to visit mothers in the clusters. The expected results from this activity include identifying HIV-infected women and providing community peer support to these women.
ACTIVITY 2: Monitoring and Evaluation Data collectors will be recruited to determine if the provision of peer support leads to increases in exclusive infant feeding practices, and in turn, whether these practices lead to a reduction in postnatal mother-to-child transmission. Data will be collected in each of the three project districts (Umlazi, Rietvlei and Paarl). At three, six, 12, 24 weeks and 12 months after birth of the child, data collectors will visit mothers receiving peer support at home. Information on infant feeding practices, morbidity, infant growth and health-seeking behavior of mothers will be collected. Dried blood spots will be taken to determine the rate of mother-to-child transmission of HIV.
ACTIVITY 3: Peer Supporter Workshop The project team will coordinate and host a workshop to bring together people working with peer supporter programs. The workshop will encourage participants to share experiences from different models of peer support and to make recommendations to scale up these programs. The workshop will ensure sustainability of peer supporters by incorporating lessons learned into existing programs.
ACTIVITY 4: Community Voluntary Counseling and Testing (VCT) This activity will be integrated into the community peer support project. It was designed in response to the finding that many pregnant women in the community intervention facilities do not know their HIV status. The peer supporters will encourage all pregnant women in their community to attend the antenatal clinic to access VCT. The peer
supporters will receive training in HIV counseling and will be able to offer home-based VCT for expectant mothers and her family members.
ACTIVITY 5: PMTCT Integration This project will develop a baseline assessment tool to assess the integration of PMTCT within maternal and child health services using FY 2006 funds. The assessments will begin in 2006 in all 11 districts of KwaZulu-Natal and will be undertaken as a participatory project with district management teams. During FY 2007 the assessments will continue until at least one facility in each of the districts in Kwazulu-Natal has been covered. The main focus will be on providing technical assistance to district management teams to act on the identified bottlenecks to integration by developing action plans. The project aims to have one district management team workshop on PMTCT integration to discuss the results of the integration assessment in each district in KwaZulu-Natal during a 12-month period.
ACTIVITY 6: Facility-based Intervention This project will involve various interventions to improve the quality of PMTCT care. Interventions would include training health workers on HIV and infant feeding, a pilot opt-out VCT strategy for antenatal clients and strategies to include TB screening for HIV-infected pregnant women. The interventions will be site specific depending on the needs that are identified. All activities, except for the targeted evaluation and integration, take place in the same sites, namely Paarl, Rietvlei and Umlazi.
ACTIVITY 7: Targeted PMTCT Evaluation At the request of the NDOH, MRC has been requested to evaluate the national PMTCT program. The evaluation will be undertaken at six sites in four provinces (KwaZulu-Natal, Free State, Western Cape and Eastern Cape). It will include four cohorts of HIV-infected women who will be recruited during pregnancy and followed until their infants reach 12 months of age. Regular follow-up visits will be undertaken to determine infant feeding practices, health-seeking behavior and vertical transmission. A cross-sectional component will also be undertaken at six sites where mothers attending immunization clinics at six weeks postpartum will be asked for consent to perform an ELISA test on their infants. A positive ELISA test indicates that the infant was exposed to HIV. In this event, a further blood spot will be tested with a DNA PCR to determine early transmission rates. Mothers will also be interviewed to determine their access to PMTCT during antenatal care. Data from the cohort studies will be used to model late transmission of HIV, and this data will be taken from results obtained from the cross-sectional approach as six week testing is the recommended testing point in the national program and most infants are lost to follow up after this point. Data from the evaluation will be used by provincial and national departments of health to strengthen PMTCT service delivery.
These activities will contribute to PEPFAR's 2-7-10 goals by promoting exclusive infant feeding practices among HIV-infected women, increasing the number of pregnant women who are aware of their HIV status and who can access PMTCT, improving the quality of PMTCT services and providing strategic information regarding the operational effectiveness of PMTCT. Ensuring that more pregnant mothers are aware of their HIV status will empower more women to access PMTCT interventions, and a significant number of postnatal HIV infections will be averted by increasing the number of women who practice exclusive feeding during their infants' first year of life. These activities are in line with the USG goal of integrating maternal and child health services into primary care systems.
INTEGRATED ACTIVITY FLAG: As part of an integrated approach addressing vulnerable populations components of this Medical Research Council (MRC) activity is also described in the CT (#7664) program area.
SUMMARY: Findings from the International Rapid Assessment Response and Evaluation (I-RARE) of drug use and HIV risk behaviors among vulnerable drug using populations point to: (1) high prevalence of overlapping drug and sexual risk behaviors; (2) high prevalence of HIV in these populations; (3) high levels of alcohol use and sexual risk behaviors and (4) barriers to access and utilization of risk reduction, substance abuse and HIV services. The I-RARE evaluation's target population group included injecting drug users (IDUs), sex workers and men who have sex with men (MSM) and the study took place in Cape Town, Durban and Pretoria, South Africa.
This project build supon FY 2005 and 2006 PEPFAR investments to strengthen programs serving IDUs, sex workers and MSM by developing the capacity of organizations to deliver services that enable these populations to reduce risk of HIV infection. Activities will focus on creating multi-sectoral and multi-disciplinary consortia of substance abuse and HIV organizations and developing organizational capacity to implement targeted community-based outreach interventions, linking outreach efforts to risk reduction counseling related to drugs and HIV, and access and referral to substance abuse, HIV care, treatment, and support services. MRC also will design and implement a behavioral HIV prevention intervention to reduce sexual risk behavior associated with alcohol use in bars in Tshwane.
The major emphasis area for these activities is development of networks, linkages, and referral systems. Minor emphasis areas include community mobilization/participation; information education and communication; linkages with other sectors and initiatives; local organization capacity development; policy and guidance; quality assurance and supportive supervision; strategic information; and training. Primary target populations are men, high-risk vulnerable populations and support organizations for IDUs, sex workers, other healthcare workers, CBO's, NGO's and MSM. This project is consistent with the revised South African National Drug Master Plan and will provide guidance on how the SAG can translate strategies into action. Sustainability is addressed across all activities by developing the capacity of existing programs, creating synergy across organization and service provider networks, providing quality assurance and refresher trainings, enhancing data management systems, and providing program adjustments as necessary. Legislative issues addressed include: (1) gender, by providing information and education on male norms and behaviors regarding multiple sex partners for men and transactional sex; increasing gender equity in HIV and AIDS programs; reducing violence, increasing women's access to income and productive resources; and (2) reducing stigma and discrimination associated with HIV status and vulnerable populations.
BACKGROUND: In FY 2005, PEPFAR supported MRC to conduct a rapid assessment of drug use and HIV risk among IDUs, sex workers and MSM in Cape Town, Durban, and Pretoria. In FY 2006, PEPFAR supported the convening of public and private partners, stakeholders, and organizations serving the target populations to develop recommendations based on the findings of the rapid assessment. In FY 2007, the MRC, in collaboration with a consortium of organizations and provincial governments, is well positioned to implement interventions to reduce high-risk drug use and sexual behaviors and increase access to and utilization of services.
ACTIVITY 1: Linking and Coordination of Drug Abuse Treatment and HIV *Three separate activities focusing on the target groups are consolidated into one activity description as they share similar components* A major finding of the rapid assessment indicates a lack of linkages and coordination of drug abuse treatment and HIV services. The focus of this activity is developing the capacity of NGO/CBOs and other HIV and drug service organizations serving IDUs, sex workers and MSM to implement interventions targeting high-risk drug use and sexual behaviors and increase their access to and utilization of services. Specifically, this activity will support formalization of consortia linking drug abuse treatment and HIV service delivery organizations and development of capacity and skills among the consortia for provision of comprehensive HIV and AIDS programs tailored for drug using vulnerable populations and adapted to the local epidemic. Components will include community-based
outreach, risk reduction counseling, and access and referral to HIV counseling and testing, substance abuse, and other HIV care and treatment services, including STI services. Community workers will be trained to access hidden populations and provide risk reduction related to violence, drug use, injecting and safer sex. Existing training manuals used in other countries including Vietnam and Kenya (e.g., WHO's Training Guide for HIV Prevention Outreach to Injecting Drug Users, 2004) will be adapted to train outreach workers to plan and implement community-based outreach.
ACTIVITY 2: Managing and Monitoring Links and Coordination of Drug Treatment and HIV In preparation for activities in FY 2007, the MRC will conduct formative key informant and focus group interviews to ensure interventions are aligned with the local epidemic. This activity will support the MRC in the complete management, oversight, monitoring, and evaluation of the activities summarized under Activity 1. The MRC will regularly monitor all aspects of the activities, including ensuring that sub-partners coordinate provision of trainings by local AIDS Training Centres. The MRC will establish a system for collecting on-going data on targets and suggest program adjustments as necessary. The MRC will rapidly evaluate Activity 1 to determine the relative effectiveness of the interventions to reduce high-risk drug use and sexual behaviors and increase access and utilization of services among the three target populations. Activity 2 also addresses the needs of non-drug using female sex workers by strengthening and building the capacity of local organizations already providing services to vulnerable women in Durban.
ACTIVITY 3: Design and Implement an HIV Intervention to Reduce Sexual Risk Behavior Associated with Alcohol use in Tshwane Bars Using FY 2006 funding MRC conducted formative research to identify a range of intervention methods that may be effective in reducing HIV sexual risk behavior associated with alcohol consumption. FY 2007 funding will be used to develop specific bar-based intervention using proven methods based on sound behavioral theory and adapted to the logistical, socio-cultural and risk behavior of patrons at the participating bars.
Future plans for this project will build upon FY 2005 and 2006 PEPFAR investments and lessons learned from implementation of the interventions in FY 2007. In FY 2008, the MRC will continue to refine the interventions and rapidly scale them up to reach other provinces and underserved populations.
Plus up funding will develop integrated services for vulnerable populations at risk of contracting HIV/AIDS and expand outreach activities aimed at these populations. Funding will expand services in Durban and Cape Town for IDUs and non-intravenous drug users, women who engage in transactional sex and MSM.
Results contribute to PEPFAR 2-7-10 goals by preventing infections and increasing uptake of voluntary counseling and testing (VCT) among vulnerable drug using populations to know their status and be appropriately referred to treatment services. Also, results are aligned with South Africa goals to scale-up programs serving populations at high-risk, including IDUs, MSM, and sex workers.
INTEGRATED ACTIVITY FLAG: This activity also relates to MRC activities described in ARV Drugs (#7661), ARV Services (#7660) and PMTCT (#7955).
SUMMARY: The Medical Research Council (MRC) will carry out activities to support a comprehensive best-practice approach to integrated TB/HIV care at three existing and two new sites in KwaZulu-Natal, Mpumalanga and North West. The project aims to improve access to HIV care and treatment for tuberculosis (TB) patients by strengthening the role of TB services as an entry point for delivery of HIV and AIDS care, and by expanding TB screening to people living with HIV (PLHIV). Project results and lessons learnt will be shared with the national and provincial Departments of Health to inform existing policies and guidelines on TB/HIV care. TB patients and PLHIV are the key target populations and include pregnant women (referred to PMTCT services) and children (receiving ARVs if indicated).
BACKGROUND: The MRC initiated a best-practice approach to integrated TB/HIV care with FY 2004 PEPFAR funding. Early activities included a systematic description of barriers faced by TB patients co-infected with HIV in an accredited antiretroviral (ARV) site, and in FY 2005, activities were focused on the development and implementation of a best-practice model. Preliminary results from the model site confirmed the benefits of an integrated TB/HIV approach, reflected in a drastic reduction in patient mortality, improved quality of life for TB patients living with HIV and prolonged survival rates. Results also confirm the safety and efficacy of dual regimens, showing that antiretroviral treatment (ART) can safely be instituted within the first month of TB treatment. Activities in the three established sites will continue in FY 2007. The best-practice approach was expanded to two additional sites in FY 2006.
ACTIVITIES AND EXPECTED RESULTS: Activities include provider-initiated HIV CT; TB screening by symptoms and sputum investigations; referral to appropriate services such as PMTCT, STI and partner counseling programs; and enrollment of patients in relevant HIV care and treatment programs. Three activities will be implemented:
ACTIVITY 1: Best-Practice Model. The MRC will support implemention of a best-practice model of integrated TB/HIV care in sites providing TB and HIV services. This approach involves: (1) clinical management (CT, ART, management of adverse drug effects, STI management, preventive therapy); (2) nursing care (TB screening, patient education, treatment adherence, HIV prevention); (3) integrated TB/HIV information, education and communication; (4) nutrition intervention; and (5) palliative care and support. Activities include site renovation to meet SA accreditation requirements for ARV rollout, site and supervisory staff training, hiring key personnel, development of patient educational materials, commodities procurement, and establishment of appropriate referral links, including those with governmental ARV sites to ensure continuity. MRC will monitor CT practices, strengths and weaknesses of TB/HIV referral systems, human resources and conventional TB treatment outcomes. The MRC will implement ongoing quality assessments through onsite supervision and external quality assurance mechanisms such as checklists. Regular feedback meetings will be held with project staff to identify potential problems and to facilitate corrective action. Stigma around HIV, AIDS and TB is specifically addressed through patient education and targeted interventions such as peer group counseling and advocacy campaigns.
Results from the project will facilitate evidence-based policy formulation on expansion of integrated TB/HIV care, improve access to HIV care by co-infected TB patients, and increase TB case finding among PLHIV. Implementation of lessons learnt in the best-practice approach will facilitate rapid identification of systems and operational needs, and allow for corrective action. Results of this expanded approach to integrated TB/HIV management will facilitate national scale-up of comprehensive programs for dually-infected patients. This activity will strengthen TB services as a point of delivery of ART, by ensuring that human, financial and infrastructure needs for integrated TB/HIV programs are met through equitable allocation of scarce resources and through analyses of cost-effectiveness and cost-benefit. Increased TB case finding in HIV settings is a crucial component of disease control; yet largely lacking in routine health services. In FY 2007 the project will evaluate strategies for active TB case finding in vulnerable populations and assess implications for TB and HIV control programs.
PEPFAR funding will also be used to implement an integrated electronic patient information system at the sites to support routine data collection, facilitate patient referral and allow data transfer to the national routine TB recording and reporting system, which is now integrating HIV testing and service data.
Lastly, funds will be used to establish an International Training Centre (ITC) on multidrug-resistant TB (MDR-TB) and HIV. The ITC's focus will be on human capacity development. TB and MDR-TB infection control in HIV settings and prevention of institutional transmission and outbreaks will be a prime focus area. Training will utilize didactic, interactive adult teaching methods aimed at different health sector groups (clinical, nursing, health facility management, health facility design and maintenance), and will be enriched by mentorship programs and study tours through the SA network of MDR-TB hospitals.
ACTIVITY 2: Community TB/HIV Case Finding and Holding Among Women in PMTCT. This activity will identify pregnant women in the 34 project clusters and provide peer support to each of these households until the infants reach 6 months of age. Community peer supporters will educate households on symptoms of TB, cure rates, and adherence to TB treatment. They will refer household members with TB symptoms to health services for diagnosis. Children under 5 years who are TB contacts will be referred for TB preventive therapy, and HIV-infected mothers will be encouraged to take HIV-exposed infants for CPT, PCR testing and screening for ART.
PEPFAR funds will provide stipends to peer supporters and allow for supervision/mentoring of peer supporters and transport to visit mothers in the clusters. Expected results include: recruitment of HIV-infected women, provision of community peer support and referral of TB suspects.
ACTIVITY 3: Evaluation of a new model of TB treatment support. The WCDOH determined that the HIV adherence model is more successful than the TB DOTS model and is thus piloting a method to increase TB adherence by using the HIV adherence model. They have requested assistance to evaluate this approach, with a focus is on dually infected TB/HIV patients. Evaluation results will have policy implications for improving adherence models.
MRC's activities contribute to the PEPFAR goals by integrating TB and HIV services and expanding access to care and treatment.
Under ACTIVITY 1: The following text was amended (please just replace the paragraph that starts with "Lastly")
Lastly, funds will be leveraged with USAID/TB CAP to sustain the International Training Centre (ITC) on multidrug-resistant TB (MDR-TB) and HIV. The ITC will involve the National Department of Health in an advisory capacity. The ITC's focus will be on human capacity development.
ACTIVITY 4: MRC Durban will implement an evaluation to assess improving diagnosis of Smear-Negative TB in HIV Patients
ACTIVITY 5: MRC Durban will respond to a request from Kwa-Zulu Natal Province TB Program to implement a prevalence survey of MDR/XDR in 14 hospitals including outpatient settings. This activity is part of the KZN response plan for MDR/XDR.
IINTEGRATED ACTIVITY FLAG:
This Medical Research Council activiy is an integrated approach addressing vulnerable populations, components of this activity are also described in Condoms and Other Prevention (#7956) program area.
SUMMARY:
The MRC findings from the International Rapid Assessment Response and Evaluation (I-RARE) of drug use and HIV risk behaviors among vulnerable drug using populations, including injection drug users (IDUs), sex workers and men who have sex with men (MSM), in Cape Town, Durban, and Pretoria point to: (1) high prevalence of overlapping drug and sexual risk behaviors; (2) high prevalence of HIV in these populations; and (3) barriers to access and utilization of risk reduction, substance abuse and HIV services.
Activities of this project build upon FY 2005 and 2006 PEPFAR investments to strengthen programs serving IDUs, sex workers, and MSM by developing the capacity of organizations in Cape Town, Durban, and Pretoria to deliver services that enable these populations to reduce their risk of HIV infection. Activities will focus on creating multi-sectoral and multi-disciplinary consortia of substance abuse and HIV organizations and developing organizational capacity to implement targeted community-based outreach interventions, and linking outreach efforts to risk reduction counseling related to drugs and HIV, and access and referral to substance abuse, HIV care, treatment, and support services.
The major emphasis area for these activities is the development of networks, linkages, and referral systems between outreach workers, NGO/CBOs, and healthcare service providers. Minor emphasis areas include community mobilization/participation; information, education, and communication; linkages with other sectors and initiatives; local organization capacity development; policy and guidance; quality assurance, quality improvement, and supportive supervision; strategic information; and training. Primary target populations are high-risk vulnerable populations, (including IDUs, sex workers, and MSM), and organizations that provide service to these populations. This project is consistent with the revised South African National Drug Master Plan and will provide guidance on how the South African Government can translate strategies into action. Across all activities, sustainability is addressed by linking HIV counseling and testing, care and support services for vulnerable populations, developing the capacity of existing programs, creating synergy across organization and service provider networks, providing quality assurance and refresher trainings, and enhancing data management systems. Legislative interests include: (1) gender, by increasing gender equity in HIV and AIDS program; reducing violence, increasing women's access to income and productive resources; and (2) reducing stigma and discrimination associated with HIV status and vulnerable populations.
BACKGROUND:
In FY 2005, PEPFAR supported the MRC to conduct a rapid assessment of drug use and HIV risk among IDUs, sex workers, and MSM in Cape Town, Durban, and Pretoria. In FY 2006, PEPFAR supported the convening of public and private partners, stakeholders, and organizations serving the target populations to develop recommendations, based on the findings of the rapid assessment. In FY 2007, the MRC, in collaboration with a consortium of organizations and provincial governments, is well positioned to implement interventions to reduce high-risk drug use and sexual behaviors and increase access to and utilization of services.
ACTIVITY 1: Linking Community-based Outreach to HIV Services among Injecting and Non-Injecting Drug Users, Drug Using MSM, and Drug Using Women Engaged in Sex Work
Three separate activities focusing on the target groups (IDUs, CSWs, and MSM) are consolidated into one activity description as they share similar components.
A major finding of the rapid assessment indicates a lack of linkages and coordination of
drug abuse treatment and HIV services. The focus of this activity is developing the capacity of NGO/CBOs and other HIV and drug service organizations serving IDUs, sex workers, and MSM to implement interventions targeting high-risk drug use and sexual behaviors and to increase their access to and utilization of services. Specifically, this activity will support the formalization of consortia linking drug abuse treatment and HIV service delivery organizations in Cape Town, Durban, and Pretoria/Johannesburg. This activity will develop the capacity and skills among the consortia for the provision of comprehensive HIV and AIDS programs tailored for drug users and adapted to the local epidemic. Components will include community-based outreach, risk reduction counseling, and access and referral to HIV counseling and testing, substance abuse, and other HIV care and treatment services. Individuals reached by outreach efforts will be linked with tailored HIV counseling, testing, treatment, and other support services. Service providers will be cross-trained to respond to issues of violence, drug abuse and HIV, including issues of sensitivity, confidentiality and stigma related to vulnerable populations. To facilitate integration among drug and HIV services, a system for referrals from counseling and testing to other services will be established in the consortia to ensure HIV-infected and HIV-negative clients are linked to appropriate prevention, care, and treatment services (e.g., antiretroviral treatment, PMTCT, palliative care, STI and tuberculosis treatment, substance abuse treatment, and transitional services including job skills and income generation activities).
ACTIVITY 2: Managing, Monitoring and Rapidly Evaluating Links and Coordination of Drug Treatment and HIV Services for Drug Using Populations
In preparation for activities in FY 2007, the MRC will conduct formative key informant and focus group interviews to ensure interventions are aligned with the current local epidemic and adapt existing training manuals for community-based outreach. This activity will support the MRC in the management, oversight, monitoring, and evaluation of the three activities summarized under Activity 1. The MRC will regularly monitor all aspects of the activities, including ensuring that sub-partners coordinate provision of trainings by local AIDS Training Centres. The MRC will establish a system for collecting data on targets on an on-going basis. The MRC will rapidly evaluate Activity 1 to determine the relative effectiveness of the interventions to reduce high-risk drug use and sexual behaviors and increase access and utilization of services among the three target populations.
Future plans for this project will build upon FY 2005 and 2006 PEPFAR investments and lessons learned from the implementation of the interventions in FY 2007. In FY 2008, the MRC will continue to refine the interventions and rapidly scale them up to reach other provinces and underserved populations.
Results contribute to PEPFAR 2-7-10 goals by preventing infections and increasing uptake of voluntary counseling and testing (VCT) among vulnerable drug using populations to know their status and be appropriately referred to treatment services. Also, results are aligned with South Africa goals to scale-up programs that serve IDUs, MSM, and sex workers; integrate VCT into other healthcare delivery and by decreasing stigma and discrimination; and increase VCT services links with referrals to health systems networks.
INTEGRATED ACTIVITY FLAG:
This activity also relates to the Medical Research Council's activities in ARV Services (#7660) and TB/HIV (#7662).
This activity is carried out to support a comprehensive best-practice approach to integrated TB/HIV care, that will improve access to HIV care (counseling and testing, care and treatment, screening, referral, pharmaceuticals) for TB patients, and promoting TB screening (and eventual TB treatment as required) among patients attending HIV clinics, with particular reference in this activity to provision of ARV drugs to TB patients meeting eligibility criteria according to the South Africa HIV treatment guidelines. Activities are focused in three provinces of South Africa. The major emphasis area is commodity procurement.
A best-practice approach to integrated TB/HIV care was initiated by the Medical Research Council (MRC) with FY 20004 PEPFAR funding. Early activities included a systematic description of barriers faced by TB patients co-infected with HIV in an accredited ARV site, and the development and implementation of a best-practice model in FY 2005. Preliminary results from the model site confirmed the benefits of an integrated TB/HIV approach, reflected in a drastic reduction in patient mortality, improved quality of life of TB patients with HIV and prolonged survival. Results also confirm the safety and efficacy of dual regimens, showing that ART can safely be instituted within the first month of TB treatment.
Expansion of the best-practice approach to two additional sites in different geographical settings was started in FY 2006 based on lessons learned in the start-up sites, including essential human resource needs, the importance of negotiated partnerships with departments of health (DOH), and the challenges posed by dual stigma. Activities in the three existing sites will continue in FY 2007, with expansion to two additional sites in remote rural settings where active TB screening among people living with HIV (PLHIV) will be implemented. These sites are characterized by extreme poverty, poor health infrastructure and limited health care access for patients. The challenges of and novel solutions for treatment delivery in such settings will be specifically addressed, as will strengthening of systems for treatment adherence. Activities are implemented directly by MRC and by contracted sub-partners Life Esidimeni, World Vision and the Foundation for Professional Development (a PEPFAR partner).
Activities carried out in this program area include commodity procurement, logistics, distribution, pharmaceutical management and cost of ARV drugs to confirmed TB patients meeting South African government (SAG) ARV enrollment criteria. Provider-initiated HIV counseling & testing will be offered to all patients and those qualifying for ART identified as quickly as possible. Initiation of antiretroviral treatment (ART) will be based on CD4 count, based on existing governmental policies. Patients (including children) with a CD$ count < 200 will be eligible for ARV initiation after one month of conventional TB treatment, while those with a CD4 count < 50 will be fast-tracked for immediate ART initiation based on clinical status.
ARV drug procurement will be done according to projected estimates based on HIV prevalence and the estimated proportion of patients eligible for ART. As per the USG PEPFAR Task Team requirement, only generic drugs approved by the SA Medicines Control Council (MCC) and the US Food and Drug Administration (FDA) will be used. Referral links to an accredited ART site will be established for each TB patient initiated on ARVs in the participating sites in order to allow seamless transition and ART access upon discharge. Sites that are not yet accredited for ART rollout will be assisted to acquire SAG accreditation, which would ensure the necessary continuity of care.
Activities will be directed towards eliminating bottlenecks in ART provision (particularly
human resource capacity), addressing weaknesses and limitations in down-referral systems, documenting and managing drug adverse effects, and monitoring of treatment adherence. Integration of TB and HIV services will be a prime target to facilitate quick and seamless patient access to ARV drugs, thereby decreasing patient morbidity and mortality.
Review of HIV counseling and testing practices, strengths and weaknesses of TB/HIV referral systems, human resource analyses, treatment adherence, drug adverse effects and conventional TB treatment outcomes in patients on dual therapy will be recorded. TB patients and PLHIV constitute the principal target populations and include pregnant women (referred to PMTCT services) and children (receiving ARVs if indicated).
Ongoing quality assessment and quality improvement will be implemented through on-site supervision and external quality assurance mechanisms such as checklists. Regular feedback meetings will be held with project staff to identify potential problems and rapidly facilitate corrective action.
Results from the project will facilitate evidence-based policy formulation on expansion of integrated TB/HIV care while increasing and improving access to ART of eligible TB patients. TB services in SA will in future form a vital link to accredited government ARV sites. This project will contribute to strengthening of the role of TB services as point of delivery of ARVs, by ensuring that human, financial and infrastructure needs for comprehensive TB/HIV programs are met through equitable allocation of scarce resources and through analyses of cost-effectiveness and cost-benefit.
Funding will be used to support sites to implement the pharmaceutical elements of the best-practice approach to integrated TB/HIV care, including drug distribution and supply chain logistics to meet SA accreditation requirements for ARV rollout, site staff training, pharmaceutical management to maintain MCC and FDA quality standards, and the cost of ARVs.
The MRC activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa 5-year Strategic Plan by integrating TB and HIV services and expanding access to care and treatment.
This activity also relates to the Medical Research Council's activities in ARV Drugs (#7661) and TB/HIV (#7662).
The Medical Research Council (MRC) will carry out activities to support a comprehensive best-practice approach to integrated TB/HIV care at three ongoing and two new sites in three provinces of South Africa, KwaZulu-Natal, Mpumalanga and the Western Cape. The project will improve access to HIV care and treatment for tuberculosis (TB) patients by strengthening the role of TB services as entry point for delivery of HIV and AIDS care, and by expanding TB screening in people living with HIV (PLHIV). Project results and lessons learned will be shared with the National Department of Health (NDOH) to inform existing policies and guidelines on TB/HIV care. TB patients and PLHIV constitute the principal target populations and include pregnant women (referred to PMTCT services) and children (receiving ARVs if indicated). The major emphasis will be on development of network/linkage/referral systems, with minor emphasis on human resources, local organization capacity development, and quality assurance.
A best-practice approach to integrated TB/HIV care was initiated by the Medical Research Council with FY 2004 PEPFAR funding. Early activities included a systematic description of barriers faced by TB patients co-infected with HIV in an accredited antiretroviral (ARV) site, and in FY 2005, activities were focused on the development and implementation of a best-practice model. Preliminary results from the model site confirmed the benefits of an integrated TB-HIV approach, reflected in a drastic reduction in patient mortality, improved quality of life for TB patients with HIV and prolonged survival rates. Results also confirm the safety and efficacy of dual regimens, showing that ART can safely be instituted within the first month of TB treatment.
Activities in the three established sites will continue in FY 2007. The expansion of the best-practice approach to two additional sites in different geographical settings was started in FY 2006. The best practices model drew from lessons learned in the start-up sites which highlighted the need for essential human resources, the importance of negotiated partnerships with health departments, and the challenges posed by dual stigmatization and discrimination. The new sites are characterized by extreme poverty, poor health infrastructure and limited healthcare access. The challenges of, and novel solutions for an integrated TB/HIV approach in such settings will be specifically addressed, as will strengthening of down-referral capacity in the existing sites. Activities are implemented directly by the MRC and by contracted sub-partners, Life Esidimeni, World Vision and the Foundation for Professional Development (a PEPFAR prime partner).
Activities include provider-initiated HIV counseling and testing, TB screening by symptoms and sputum investigations, referral to appropriate services (PMTCT, STI, partner-counseling) and enrollment in relevant HIV care and treatment programs.
The MRC will support sites to implement a best-practice model of integrated TB/HIV care. This approach involves: (1) clinical management (CT, antiretroviral treatment (ART), management of drug adverse effects, STI management, preventive therapy); (2) nursing care (TB screening, patient education, treatment adherence, HIV prevention); (3) integrated TB/HIV information, education and communication; (4) nutrition intervention; and (5) palliative HIV and AIDS care and support. Activities include renovation of the sites to meet South African accreditation requirements for ART rollout, site staff training, supervisory staff training to maintain quality standards, hiring of key personnel, development of patient educational material, procurement of the required commodities, and establishment of appropriate referral links, including those with governmental ARV sites to ensure continuity. The MRC will monitor CT practices, strengths and weaknesses of TB/HIV referral systems, human resource analyses, and conventional TB treatment outcomes. The MRC will implement ongoing quality assessment through onsite
supervision and external quality assurance mechanisms such as utilization of checklists. Regular feedback meetings will be held with project staff to identify potential problems and to facilitate corrective action.
Stigma around HIV and AIDS and TB is specifically addressed through patient education and targeted intervention strategies such as peer group counseling and advocacy campaigns.
Results from the project will facilitate evidence-based policy formulation on expansion of integrated TB/HIV care and will help to increase and improve access to HIV care of co-infected TB patients and increasing TB case finding among PLHIV. Implementation of lessons learned in the model-based best-practice approach will facilitate rapid identification of systems and operational needs and will allow for corrective action. Analysis of the strengths and weaknesses of an expanded approach to integrated TB/HIV management will facilitate national scale-up of comprehensive programs for patients with dual infection. TB services in SA will in future form a vital link to accredited public sector ARV sites. This project will strengthen TB services as point of delivery of ART, by ensuring that human, financial and infrastructure needs for comprehensive TB/HIV programs are met through equitable allocation of scarce resources and through analyses of cost-effectiveness and cost-benefit. Increased TB case-finding in HIV settings is a crucial component of disease control, yet largely lacking in routine health services. In FY 2007 the project will therefore evaluate strategies for active TB case finding in vulnerable populations and assess its implications for TB and HIV control programs.
Activities will be directed towards eliminating bottlenecks in ART provision (particularly those due to human resource capacity), addressing weaknesses and limitations in down referral systems, documenting and managing drug adverse effects, and monitoring of treatment adherence. Integration of TB and HIV services will be a prime focus, to facilitate quick and seamless patient access to ARV drugs, thereby decreasing patient morbidity and mortality.
Funding will also be used to implement an integrated electronic patient information system at the different sites to support routine data collection, to facilitate patient referral and to allow data transfer to the national routine TB recording and reporting system, which is now integrating HIV testing and service data.
The MRC activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year Strategic Plan by integrating TB and HIV services and expanding access to care and treatment.
This activity is linked with the USAID partner, University of North Carolina/MEASURE Evaluation Strategic Information COP entry (#8044). In FY 2007, MEASURE Evaluation will provide technical assistance to the Medical Research Council (MRC) to conduct the activities described below.
SUMMARY: The MRC will continue to strengthen the health system to support the expansion of a comprehensive tuberculosis (TB)/HIV program in collaboration with the Western Cape Department of Health (WCDOH) through four approaches: 1) assessing the current use of information and identifying what information is needed to make strategic and operational decisions to improve service delivery; 2) assessing the quality of existing health information through an assessment of select Quarterly Indicators across all six districts; 3) improving the quality of existing health information systems by reviewing and clarifying the rationale for collecting certain indicators, the format of the data collection tools, and by developing Standard Operating Procedures (SOP) for data quality; and 4) improving the ability for related information systems to interface, to assess program outputs and outcomes across the systems, including the quality of services and the efficiency by which those services are provided. The primary emphasis areas for these activities are monitoring, evaluation and reporting, and secondary emphasis areas are proposed staff and other strategic information (SI) activities. Specific target populations include senior and mid-level managers involved in the TB/HIV program.The CDC previously supported the Medical Research Council to conduct a national Youth Risk Behavior Survey (2002), which includes risk behaviors associated with HIV risk. In order to measure behavioral changes over time and to provide information for designing HIV prevention interventions among youth the survey must be repeated
BACKGROUND: The WCDOH strategy, "Healthcare 2010," states it will decentralize management structures to the district and sub-district level to strengthen local management capacity and expertise at the ground level to significantly improve service delivery and ensure participation and local networking in the provision of primary healthcare services. The WCDOH already has one of the largest TB/HIV programs in South Africa and the decentralization strategy will significantly impact the success of this program. To have the greatest impact on health outcomes, this decentralization process needs to be based on evidence and strategic planning. Efficient implementation will depend on timely production and utilization of strategic information at appropriate levels of management to monitor and evaluate service delivery and its outcomes. The project aims to empower health management teams to use information for strategic and operational decision-making to improve the functioning of the health system. In FY 2006, the MRC is a sub-partner under MEASURE Evaluation and carries out these activities at the request of the WCDOH. For FY 2007, MRC will be the prime partner. FY 2006 activities have recently Begun which have resulted in a draft of the work plan for the upcoming year.
ACTIVITES AND EXPECTED RESULTS: The MRC will carry out five activities in this Program Area. ACTIVITY 1: Needs Assessment The first activity will be to repeat the initial assessment (which is currently planned to begin in FY 2006) to ascertain how information is used and to identify information that is required to make strategic and operational decisions. Program managers at the provincial and district level will be trained to collect and analyze data. Staff at all levels will participate in this process to ensure data is not only used at the highest levels, but also by those who collect it. The activity results will include identifying why targets for the comprehensive TB/HIV program are not being met, and possible reasons for the gap. The WCDOH has a plan to institutionalize the activity once the tools and SOPs are finalized. ACTIVITY 2: Data Quality Assessments The second activity is to continue auditing the quality of existing health information by selecting a random sample of the Quarterly Indicators across all six districts in the
Western Cape. Program managers and information officers will be trained to conduct self-audits on the quality of key indicators used to monitor the comprehensive TB/HIV program. The project will pay for the external facilitation and documentation of this process based on existing data quality assessment models. By the end of 2007, all training curricula and materials will be developed and the activity will continue directly through the WCDOH. ACTIVITY 3: Implementation of Data Quality Recommendations The third activity is to implement recommendations identified by the data quality assessments. This will improve the quality of existing health information systems by reviewing and clarifying the rationale for the indicators that are collected, the data collection tools, and by developing data quality SOPs. The activity will lead to improving the interface among related information systems, which will enable the assessment of program outputs and outcomes. Project facilitators will work with district teams in an action learning mode of working. ACTIVITY 4: Training on Data Use The final activity is to continue ongoing work with the WCDOH senior management and district management teams to act upon findings from the data quality assessments. Also, there will be periodic reviews of the data to link results of program outputs and outcomes to management decisions and competency. Through this activity, MRC will continue to build the capacity of WCDOH by training and working with managers to more effectively manage a growing program. ACTIVITY 5: Multiple Risk Behavior Study (MRBS) In collaboration with the National Department of Health, the MRC will conduct the second MRBS which will provide outcome and impact level reporting of PEPFAR indicators specifically around youth behavior. It covers many areas of youth risk behavior, but USG will only support that portion which revolves around HIV risk. By improving the data management system and the use of strategic information in the Western Cape for TB and HIV services, the quality of TB and HIV services will improve. It is expected that resources will be used more efficiently and that the number of persons accessing these services will increase.
