INTEGRATED ACTIVITY FLAG:

This Medical Care Development International (MCDI) PMTCT activity relates to other MCDI activities under the Counseling and Testing (#7905), and Basic Health Care and Support (#7904) program areas.

SUMMARY:

Medical Care Development International - South Africa (MCDI SA) seeks to prevent mother-to-child transmission (PMTCT) through a comprehensive training and support program. Target populations include women of reproductive age, pregnant women, HIV-infected infants, nurses, traditional birth attendants, traditional healers, and other healthcare workers. The major emphasis area is community mobilization and participation, and the minor emphasis areas are information, education and communication, local organization capacity building, and training. MCDI SA will address stigma and discrimination (a key legislative issue) and gender (a key legislative issue) by increasing gender equity in HIV programs.

BACKGROUND:

PEPFAR funding will be used to expand MCDI SA's ongoing PMTCT initiatives in rural Ndwedwe sub-district to three sub-districts of Ilembe District Municipality in KwaZulu-Natal province. MCDI SA PMTCT program is part of the Ndwedwe Integrated TB and HIV and AIDS program (NITHAP), funded by the USAID Child Survival Program, as well as Ilembe District Child Survival Project and UNICEF. Proposed activities are consistent with the South African Government's mission of preventing the spread of HIV. The main partner in this activity area is Ilembe District Department of Health. Other partners include The Valley Trust, National Association of People Living With HIV and AIDS (NAPWA) and University of KwaZulu-Natal (UKZN) Campus Law Clinic. Activities in this area will provide the means to empower women of reproductive age in general, pregnant women and HIV-infected pregnant women and mothers expanded access to voluntary counseling and testing (VCT), PMTCT and antiretroviral (ARV) services.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training

MCDI SA will continue to improve the capacity of local health workers to provide quality counseling and testing (CT), VCT and PMTCT; services, and educating the community on the importance of CT and PMTCT. Community Health Workers (CHWs), home-based care volunteers (HBCV), and other community influencers will ensure that HIV-infected pregnant women and mothers adhere to PMTCT treatment and feeding protocols, i.e. taking nevirapine at the onset of labor, either on arrival at the health facility for delivery, or at home in a community setting (assisted by a birth companion) and adhering to exclusive infant feeding practices until weaning commences.

Training of health providers and community outreach workers will include the following: (1) Training of sub-district trainers, Community Health Facilitators (CHF) and health facility personnel on PMTCT/VCT and household and community integrated management of childhood illnesses (C/HH IMCI) by MCDI SA and The Valley Trust; (2) CHFs will provide training to CHWs, HBCVs, Traditional Birth Attendants (TBAs), and Traditional Healers (THs) on C/HH-IMCI and Community PMTCT; (3) Households and communities as well as traditional healers and community and religious leaders will be reached by community workers and provided with information about C/HH-IMCI and PMTCT. All training activities are based on the South African Government (SAG) PMTCT protocols. In addition, community workers will be provided with sound knowledge of C/HH-IMCI and community PMTCT and will serve as community advocates for CT and PMTCT to pregnant women in the area. Community awareness is a key to increasing access to PMTCT services and adherence to government healthcare and treatment protocols.

ACTIVITY 2: Pre and Post-Natal Support Through HIV-infected Mothers Support Groups and Birth Companion Programs

MCDI SA will continue its current efforts in providing HIV-infected women with psychosocial and other support as part of the process of preventing the transmission of HIV to their child. With FY 2007 funding, MCDI SA will establish HIV-infected Mothers Support Groups in collaboration with the local NAPWA affiliate. Locally recruited lay counselors trained by MCDI SA and NAPWA will offer additional psychological support to mothers support groups, and legal support will be provided through a partnership with the University of KwaZulu-Natal (UKZN) Campus Law Clinic. These support groups will: (1) guide new mothers on appropriate feeding practices; (2) assist new mothers in developing income generation (a key legislative issue) and public awareness/anti-stigma projects (a key legislative issue); and (3) encourage information sharing on accessing and adhering to antiretroviral treatment (ART), childhood illness prevention, detection and treatment, and accessing social grants. HIV-infected mothers' support groups will be used as linkages between communities and health facility PMTCT/CT and ART services. Through the NAPWA sub-grant, four support group facilitators, who are themselves HIV-infected, will be employed to foster use of CT by pregnant women as a gateway to PMTCT services, and communities will be alerted to maternal and newborn danger signs by CHWs and HBCVs.

Furthermore, Birth Companions will be identified and trained to accompany pregnant women in all stages of the antenatal and postnatal periods. They will foster best practices in antenatal care, child bearing, and infant feeding and care, including ensuring that HIV-infected mothers adhere to PMTCT protocols related to self-administration of nevirapine in the home, when delivery does not take place in a facility. In addition, birth companions will promote referral to the two ARV service centers in Ilembe sub-district. The Support Group Facilitators will work with the district Department of Health Community Health Facilitators, TBAs, HBCVs and CHWs to identify Birth Companions among the community, family members or volunteers.

This project contributes to PEPFAR 2-7-10 goals by improving uptake and access of PMTCT services at public health facilities, facilitating the linkages between PMTCT and ART services, and providing psychosocial support to HIV-infected pregnant women and mothers, ensuring better adherence to PMTCT protocols and reducing the number of new infant infections.

INTEGRATED ACTIVITY FLAG:

This activity relates to Medical Care Development International-South Africa's (MCDISA) activities in PMTCT (#7903) and CT (#7905). 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:

MCDISA will carry out activities to support expansion of holistic, comprehensive community HIV and AIDS and TB care and support from Ndwedwe sub-district to the other 3 sub-districts of Ilembe District in KwaZulu-Natal province. Emphasis areas are quality assurance and supportive supervision, development of network/linkages/referral systems, and local organization capacity building. Specific target populations are people living with HIV and AIDS and/or TB and their families.

BACKGROUND:

With FY 2007 PEPFAR funding will be used to expand the primary activities of training, support and supervision of home-based care volunteers (HBCVs) and Directly Observed Treatment, Short-course (DOTS) providers, as well as the introduction of software to monitor home-based patient care. This will help to improve quality of care and treatment adherence for those on TB medication and/or ARV; facilitate linkages between HIV and AIDS and TB-related community-based projects with the local health facilities; and build capacity among relevant community-based organizations (CBOs). The activities proposed are expansions of those previously implemented by MCDISA in Ndwedwe sub-district and are in line with the PEPFAR and SAG objective of providing quality palliative care for HIV-infected and -affected individuals. The key program partner is the South African National Department of Health (NDOH), whose current policies on HIV and TB care and gender equity inform all project objectives, and whose representatives are actively engaged in the design and implementation of activities to promote consistency and long-term sustainability. The NDOH has agreed to provide staff and financial support for project activities, as needed. Other project partners include South African non-governmental organizations (NGO) The Valley Trust, the National Association of People With AIDS (NAPWA), and Rational Pharmaceutical Management Plus (RPM Plus).

ACTIVITES AND EXPECTED RESULTS:

ACTIVITY 1: Training, Support and Supervision of HBCVs

Due to the large distances between households and health facilities throughout the Ilembe District, HBCVs are a crucial part of a comprehensive system of care for people living with HIV and AIDS (PLHIV) and people living with TB (PLWTB) and play a significant role in their day-to-day treatment. As part of its ongoing USAID-funded Child Survival Project and the ongoing Ndwedwe Integrated HIV/AIDS Tuberculosis Project, MCDISA will broaden its existing integrated home-based care (HBC) program in Ndwedwe sub-district to the three other sub-districts of the Ilembe District: Maphumulo, eNdondakusuka and kwaDukuza. PEPFAR funds will be used to train new HBCVs in comprehensive home-based care skills during a three-week course on providing quality care for community members, including elements of the preventive care package, pain and symptom management and other palliative care services for PLHIV and PLWTB. Trainers from The Valley Trust will assist with this activity. Supervisory training and checklists will be provided, also in collaboration with The Valley Trust. Ilembe District community health facilitators (CHFs), who are responsible for overseeing HBCV activities in the District, and previously trained HBCVs will be provided with refresher training in comprehensive home-based care skills for patients and their families. The training will be in compliance with NDOH policies for HBCVs and to support the universal application of at least the minimum standard package of services for PLHIV, and as well as to improve linkages with health facility staff. The comprehensive training will include: clinical diagnosis and care; DOTS support for TB treatment and ARV adherence; TB suspect sputum collection; basic nursing care including physical assessment, pain and symptom management, and appropriate referral to a health facility; counseling on HIV and AIDS and TB prevention; managing stigma and discrimination, and

coping with the emotional difficulties of illness and loss; assessing nutritional status and counseling on health-supportive food selection, storage, handling and preparation, basic hygiene and sanitation; education of household members in providing ongoing physical, psychosocial and spiritual support, end-of-life care; and facilitating access by patients and their families to all the health, legal, economic and social support services available to them. Universal precautions such as the use of gloves will also be emphasized.

Distinctions between the needs of adults and children will be emphasized, as well as gender-specific issues such as integrating males into household care practices (key legislative issue); increasing male knowledge of effective HIV prevention measures; increasing women's and girls' use of healthcare services; and recognizing and addressing domestic abuse against women and girls. Monthly meetings will be held between HBCVs and facility staff members to promote consistent quality care. Trained HBCVs will also become eligible for registration with the NDOH and to receive a government stipend for their work.

Community-based organizations (CBOs) will be identified and supported to serve as supervisors of HBCVs. CBOs will also distribute HBCV supply kits, provide care for caregivers, assist with training, and arrange for HBCVs to receive recognition for their work at community gatherings. MCDISA will provide participating HBCVs with regular incentives, such as cell phone airtime, so that they will have the means to remain in contact with the supervising CBOs, clients and health facilities. Supervised by MCDISA, the CBOs will work in collaboration with CHFs to monitor and maintain the quality of services provided.

ACTIVITY 2: Introduction of Software to Monitor HBC Visits

Once HBCVs are trained, supported and supervised, and strong linkages are established with facility staff, it will be important to monitor HBCVs activities. Consequently, the introduction of software to monitor HBC visits is proposed. The Outreach Home-Based Care Database Software Program will be installed on DOH computers to tracks HBC monthly visit rates, activities during visits, client conditions, and the number of OVC in target communities. The system includes paper forms that are filled out by HBCV and their CBO supervisors, and the data is then captured and analyzed at the District level. As part of its collaboration with MCDISA, the RPM Plus project has agreed to collaborate with MCDISA to help institute this system as a pilot test of the concept. MCDISA will collect and analyze the data initially and will train Ilembe District health information officers to continue using the system to monitor the performance of its ongoing HBC program with potential scale-up to the KwaZulu-Natal provincial level. This system will strengthen the capacity of the District Health Office in monitoring health events at the community level and provide data to show the breakdown by gender of those receiving care services. The data also will be used to monitor the project's HBCV activities and inform project management decisions. The ultimate focus of this tool is to provide feedback to service providers with a focus on quality improvement.

These results contribute to the PEPFAR 2-7-10 goals by improving access to and quality of care and support for PLHIV and PLWTB and their families.

INTEGRATED ACTIVITY FLAG:

This activity also relates to Medical Care Development International-South Africa (MCDI SA) activities in PMTCT (#7903) and Basic Health Care and Support (#7904) program areas.

SUMMARY:

Building on its USAID child survival program, MCDI SA will use PEPFAR funding to carry out activities to support the KwaZulu-Natal Department of Health (KZNDOH) efforts to improve and increase use of the counseling and testing services through three components: training of local health workers to provide comprehensive counseling and testing services; strengthening the capacity of HIV and/or AIDS support groups for networking with voluntary counseling and testing (VCT) centers and communities for the reduction of stigma and discrimination; and incorporating community-based, youth-focused, home-based care, outreach and other approaches to promote VCT uptake. Emphasis areas are information, education and communication (IEC), community mobilization/participation, development of network/linkages and local organization capacity building. The primary target populations are general population, especially youth and people living with HIV (PLHIV).

BACKGROUND:

This project will expand on and strengthen activities that MCDI SA has been working on in KwaZulu-Natal (KZN) for the last 10 years through funding from the USAID Health and Child Survival Grants Program to promote VCT services in the following ways:(1) training of health workers and lay counselors for provision of pre-test counseling and VCT services for youth and adults in HIV and STI prevention; (2) community outreach, education and advocacy to promote VCT; (3) strengthening the capacity of HIV and AIDS support groups to become eligible for registration as cooperatives; (4) training for HIV and AIDS support groups to promote HIV counseling and testing in VCT and PMTCT sites and in communities with an emphasis on fighting against stigma and discrimination; and (5) establishing youth clubs for girls and boys in-school and out-of-school for promotion of VCT. Partners include: the KZNDOH, The Valley Trust (TVT), the National Association of People Living with HIV and AIDS (NAPWA) and Community Health Committees (CHC).

ACTIVITIES AND EXPECTED RESULTS:

MCDI SA will carry out three separate activities in this Program Area.

ACTIVITY 1: Training of Healthcare Workers

MCDI SA will continue to work toward improving the capacity of local health workers to provide quality VCT services and to educate the community on the importance of VCT in preventing HIV transmission and as an entry point for treatment and care. A core team of sub-district trainers will be trained on VCT, home based-care, antiretrovirals (ARVs) and tuberculosis (TB) treatment adherence. In turn, they will train facility nurses on National Department of Health (NDOH) VCT protocols, so that each primary health care facility will have at least two nurses trained on the protocols.

ACTIVITY 2: Establishing and Strengthening Support Groups

MCDI SA has demonstrated that one key way to combat stigma and discrimination in health facilities and in communities is through providing easy access to HIV and AIDS support groups. Existing HIV and AIDS support groups in Ndwedwe sub-district will be strengthened to become eligible to be registered as cooperatives. Sub-districts will be able to work closely with other organizations in a self-sustainable and self-sufficient entity. MCDI SA will also identify viable VCT and PMTCT sites in other sub-districts of Ilembe District to establish additional HIV and AIDS support groups, with the goal of strengthening their capacity to become sustainable registered cooperatives. Support groups members will receive training and education on counseling and advocacy. Support group facilitators, known as Community Development Facilitators (CDFs) will receive ongoing training in promoting VCT services and the related HIV and AIDS, TB,

antiretroviral treatment (ART) and nutrition issues from MCDI SA and NAPWA.

ACTIVITY 3: Information, Education and Communication

A mobile education unit, staffed by two trained HIV-infected individuals from NAPWA's support groups, will travel between tribal authorities to conduct information and education campaigns at, and in close proximity to, VCT sites. This will assist to: (1) raise knowledge and awareness about VCT services for HIV and AIDS, STIs and TB patients; and (2) explain how stigma, discrimination and sexual abuse are undermining the health and well-being of their families, friends and neighbors.

Community church groups, traditional healers and traditional leaders will be trained and enlisted to actively participate in these IEC campaigns. Based on successful workshops conducted in Ndwedwe sub-district as part of a previous project, MCDI SA will hold additional workshops for influential community members to educate them on VCT services and the harmful effects of stigma and discrimination. Support group members will be included in the training to discuss their own experiences with stigma and discrimination and the benefits of using VCT services.

These results contribute to the PEPFAR 2-7-10 goals by improving access to, and quality of counseling and testing services in order to identify HIV-infected persons and to increase the number of persons receiving ARV services.