Activity 7613 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.

Targets

Target Target Value Not Applicable Indirect Number of service outlets
Indirect number of women provided with a complete package of
PMTCT services Indirect number of women provided ARV prophylaxis for PMTCT
Indirect number of people trained for PMTCT services
Number of infants born to HIV positive mothers that receive a
complete course of cotramoxizole (from 6 weeks - 1 year) Indirect number of infants born to HIV positive mothers that receive
a complete course of contramoxizole (from 6 weeks - 1 year) Number of mother-baby pairs followed up over 12 month period
Indirect number of mother-baby pairs followed up over 12 month
period Indirect number of pregnant women who received HIV counseling
and testing fo PMTCT and received their results Number of service outlets providing the minimum package of 30  PMTCT services according to national and international standards Number of pregnant women who received HIV counseling and
testing for PMTCT and received their test results Number of HIV-infected pregnant women who received
antiretroviral prophylaxis for PMTCT in a PMTCT setting Number of health workers trained in the provision of PMTCT 2,010  services according to national and international standards

Table 3.3.02: Program Planning Overview Program Area: Abstinence and Be Faithful Programs Budget Code: HVAB Program Area Code: 02 Total Planned Funding for Program Area: $ 20,029,317.00

Program Area Context:

The HIV epidemic in South Africa, with its population of 47.4 million, is unparalleled in combined scale and severity. South Africa has a highly generalized, relatively stable epidemic, with continuing high HIV prevalence and incidence. Prevalence among pregnant women attending antenatal clinics increased slightly to 30.2% in 2005, up from 29.5% in 2004. Transmission is primarily heterosexual, followed by mother-to-child transmission during pregnancy and breastfeeding.

HIV rates vary greatly by age, sex, race and geography. According to a 2005 population-based survey, HIV prevalence is 16% overall for the 15-49 age group, with almost twice as many women as men infected. In the 15-24 age group, the ratio of infected females to males is four to one. Prevalence peaks at 33% in women aged 25-29, and at 23% in men in their thirties. South Africans of European and Asian descent have much lower HIV rates than black South Africans. Prevalence across provinces ranges with the highest being 23% in Mpumalanga for the 15-49 age group. Urban informal settlements have the highest prevalence, perhaps reflecting the role of migrant labor in the epidemic.

Factors underpinning continued high HIV transmission include high rates of multiple and concurrent partners; age-mixing in sexual partnerships; and low rates of male circumcision, especially in urban settings. Levels of sexual violence are among the highest in the world. Mean age at first sex, currently about 17 years, is declining. Basic knowledge and awareness of HIV are almost universal, and exposure to HIV and AIDS communications campaigns and to interpersonal sources of HIV and AIDS information is high. Stigma towards people with HIV is declining, yet levels of personal risk perception are astonishingly low — 66% of South Africans do not see themselves at risk of HIV, often because they are faithful to, and do not recognize their potential exposure through, a trusted partner. However, the benefits of mutual fidelity as a prevention strategy are not widely understood.

The South African Government (SAG) seeks to involve all sectors of society in HIV prevention, with an emphasis on condom use for 15-25 year olds and on schools, trade unions, the trucking industry and migrant labor. Consistent with the SAG strategy, the USG Five-Year Strategy supports a comprehensive ABC approach. The AB component of the USG strategy emphasizes: abstinence and faithfulness for youth; expansion of media as well as community outreach through FBOs and CBOs; links to other preventive services; HIV testing and care. The FY 2007 COP budgets $19.5 million for 32 AB partners, roughly half of which focus on youth; other key audiences include men, teachers, and the military. As of March 2006, outreach efforts had reached 4 million people with AB messages, including 490,000 with abstinence-only messages.

USG assistance for prevention efforts complements support from other donors, including DFID/United Kingdom support to Soul City and FBOs, the Finnish and Irish governments, and the Gates and Kaiser Foundations, for youth prevention activities.

Recognizing that national prevention efforts have had limited success to date, the USG and partners have developed an action plan to strengthen the impact of USG-funded prevention activities. In the future, USG partners will focus on the factors that contribute most to continuing high incidence. Prevention interventions will more directly address: the specific sources of vulnerability to HIV for key target groups, HIV drivers and dynamics in different settings, and the contexts in which risk-taking occurs. Reflecting current patterns of infection, the USG will balance programs targeting adults with those for young people, with special emphasis on adult men and younger women.

Building on lessons from elsewhere in Africa, USG partners will intensify efforts to help individuals understand and personalize the risks associated with multiple and concurrent partners, and the benefits of mutual fidelity in the context of knowing both one's own and one's partner's HIV status. Adults in stable relationships will be a key focus, with messages for men emphasizing the risks of multiple overlapping

partners, and for women, the potential for exposure to HIV through their regular partners. Women of reproductive age and their partners will be educated about the risks of acquiring HIV in pregnancy. Soul City and Johns Hopkins University will use best practices in behavior change communication to develop and test relevant partner limitation messages.

USG/SA will scale up efforts to address the role that male attitudes, norms and behavior play in sustaining sexual networks and cross-generational sex, and high rates of concurrency and partner turnover among younger men. The focus will be on informal urban settlements, workplaces, and other settings with large male populations, especially migrant labor. The Men as Partners program will further expand efforts to build the capacity of other NGOs to implement programs that promote male sexual responsibility. Another USG partner will assist the SAG in developing a national strategy for increasing male involvement in HIV and AIDS issues.

USG partners will promote delayed sexual activity among younger adolescents, and explicitly discourage cross-generational and transactional sex among girls and young women. FBOs, other NGOs and the Department of Education will further expand HIV education, emphasizing abstinence and faithfulness through schools, churches and other community fora. These programs will educate young women about the risks associated with sex with older men, enhance their self-esteem, and develop the skills they need to abstain. Complementary activities will target adult family and community members, highlighting the need to prevent sexual violence and create safer contexts for young women. Linkages between AB and OVC programs will ensure that orphans and other at-risk youth receive HIV prevention education.

Strong linkages to couple counseling and testing will be established. Post-test counseling will emphasize mutual fidelity for HIV-negative couples, and supported disclosure and referral to positive prevention, PMTCT, care and treatment for those who test positive. Many AB partners will also receive funds for Condoms and Other Prevention activities, in order to provide a comprehensive approach for individuals in the general population who continue to engage in risky behavior.

By using multiple entry points and multi-level interventions, USG partners will seek to achieve a "tipping point" for changing societal norms and achieving sustainable behavior change. Interpersonal communication and outreach through CBO/FBO networks, with their potential for sustainability, will shape new community norms and help individuals internalize these norms. Media programs, which reach almost 90% of youth and adults, will support these efforts with consistent, unified messages across communities that emphasize increased male responsibility, personal risk perception, and community action to support healthy behaviors. A new "reality"-style talk-show will highlight real life, individual success stories in adopting abstinence and fidelity, encouraging other individuals and communities to adopt these prevention strategies.

The USG is committed to improving the quality of prevention activities. Partners will be encouraged to adopt theory-based interventions, best practices, as well as standards and guidelines, such as those developed for peer education by the Harvard Rutanang program. The USG will convene prevention partners regularly to enhance coordination and synergy, and use of a common set of clear, actionable, behavioral messages. Findings from the 2006 HIV and AIDS communications survey will be used to develop a national strategy for HIV and AIDS communication, and to inform and harmonize prevention interventions.

Program Area Target: Number of individuals reached through community outreach that promotes 1,403,953 HIV/AIDS prevention through abstinence (a subset of total reached with AB) Number of individuals reached through community outreach that promotes 7,487,917 HIV/AIDS prevention through abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention programs 29,436 through abstinence and/or being faithful

Table 3.3.02:

Activity 7614

Activity 7614 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.

Targets

Target Target Value Not Applicable Indirect number of community outreach HIV/AIDS prevention
programs that promote abstinence Indirect number of community outreach HIV/AIDS prevention
programs that promote abstinence and/or being faithful Indirect number of individuals reached with community outreach
HIV/AIDS prevention programs that promote abstinence (subset of AB) Indirect number of mass media HIV/AIDS prevention programs that
promote abstinence Indirect number of individuals reached with community outreach
HIV/AIDS prevention programs that promote abstinence and/or being faithful Number of individuals reached through community outreach that
promotes HIV/AIDS prevention through abstinence (a subset of total reached with AB) Number of individuals reached through community outreach that 19,400  promotes HIV/AIDS prevention through abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention 520  programs through abstinence and/or being faithful

Table 3.3.02:

Activity 7611 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).

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.

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 com+A1munity, 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.

Targets

Target Target Value Not Applicable Indirect number of community outreach HIV/AIDS prevention
programs that are not focused on abstinence and/or being faithful Indirect number of mass media HIV/AIDS prevention programs that
are not focused on abstinence and/or being faithful Indirect number of individuals reached with community outreach 2,500  HIV/AIDS prevention programs that are not focused on abstinence and/or being faithful Indirect estimated number of individuals reached with mass media
HIV/AIDS prevention programs that are not focused on abstinence and/or being faithful Indirect number of individuals trained to provide HIV/AIDS
prevention programs that are not focused on abstinence and/or being faithful Indirect number of targeted condom service outlets
Number of targeted condom service outlets
Number of individuals reached through community outreach that
promotes HIV/AIDS prevention through other behavior change beyond abstinence and/or being faithful Number of individuals trained to promote HIV/AIDS prevention
through other behavior change beyond abstinence and/or being faithful

Table 3.3.05:

ACTIVITY 7612

Activity 7612 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.

Targets

Target Target Value Not Applicable Indirect number of service outlets providing counseling and testing
Indirect number of individuals who received counseling and testing
Indirect number of individuals trained in counseling and testing
Number of clients receiving a referral for post test care and support
services Number of clients screened for TB
Number of service outlets providing counseling and testing 24  according to national and international standards Number of individuals who received counseling and testing for HIV
and received their test results (including TB) Number of individuals trained in counseling and testing according to 309  national and international standards

Table 3.3.09:

ACTIVITY 7861

Activity 7861 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.

Targets

Target Target Value Not Applicable Indirect number of ART service outlets providing treatment
Indirect number of individuals receiving treatment at ART sites
Indirect number of current clients receiving continuous ART for
more than 12 months at ART sites Number of service outlets providing antiretroviral therapy 30  Number of individuals who ever received antiretroviral therapy by
the end of the reporting period Number of individuals receiving antiretroviral therapy by the end of
the reporting period Number of individuals newly initiating antiretroviral therapy during
the reporting period Total number of health workers trained to deliver ART services, 2,010  according to national and/or international standards

Table 3.3.11: