SUMMARY:

The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high quality care

and support for people living with HIV and AIDS (PLHIV). The PHRU will use PEPFAR funds to provide high

quality coverage of prevention of mother-to-child transmission of HIV (PMTCT) in Soweto (Gauteng

province) and Mpumalanga provinces. This will include support to pregnant women for pre- and post- test

counseling and testing (CT), information on safe infant feeding choices, referral of women to appropriate

HIV and AIDS treatment programs and support for early testing of infants exposed to HIV. The major

emphasis area addressed is human resources; minor areas are information, education and communication,

local organization capacity development and training. The target populations are adults, pregnant women,

HIV-infected infants (0-5 years), PLHIV and their families.

BACKGROUND:

In partnership with the Gauteng Provincial Department of Health (DOH) the PHRU has been running the

Soweto (Gauteng) PMTCT program since 2000. All pregnant women accessing public health antenatal

clinics are reached, resulting in very high uptake rates. The PHRU offers post-partum counseling and

testing (PPCT) in the maternity wards at the tertiary hospital (Chris Hani Baragwanath Hospital (Bara))

where most deliveries in Soweto take place, and provides post-exposure prophylaxis (PEP) to infants

exposed to HIV. The PHRU has supported the Mpumalanga Provincial DOH by providing PMTCT service in

the Bushbuckridge district since 2003. The PMTCT service is integrated into maternal and child health

services. All activities are ongoing and are funded by PEPFAR. The close partnership with the DOH and

emphasis on capacity building and training ensures sustainability of the programs. All PMTCT sites use

rapid HIV tests with results given on the same day. Each day a group health talk is given, followed by

individual pre-test counseling. After a pregnant woman voluntarily consents to testing, the test is conducted

and the results given during individual post-test counseling session. Women testing HIV-infected are then

provided with ARV prophylaxis following the South African Government (SAG) guidelines. The PMTCT

program is an important entry point for HIV-infected women to access palliative care and antiretroviral

treatment (ART) for themselves and their families. All women who test positive are referred for CD4 count

tests, those with CD4 counts<200 cells/mm3 are referred for ART. Infants born to positive women are given

nevirapine syrup in the labor wards and a PCR test is conducted at 4 to 6 weeks. Infants are given

cotrimoxazole prophylaxis and other basic preventive care. Psychosocial support is provided through

ongoing counseling and support groups. Information is provided on issues such as safe infant feeding

practices, formula, nutrition, general healthcare, family planning, prevention for positives and disclosure.

Negative women are provided with information on how to stay negative. Safe disclosure is encouraged to

reduce stigma and violence. All women are encouraged to bring their partners for testing to increase male

involvement in HIV and AIDS care and treatment programs and to improve male involvement in PMTCT and

reduce stigma. Health workers and lay counselors are mentored, provided with debriefing and continuous in

-service training on PMTCT and developments in the field.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: PMTCT, Gauteng (urban township)

The PMTCT program in Soweto is considered a best practice model for PMTCT in South Africa with greater

than 96% uptake at each stage of the cascade. The program is ongoing and will continue operating in all

Soweto public antenatal clinics with funding from PEPFAR and Gauteng DOH. Staff employed with

PEPFAR funding offer PMTCT to around 30,000 pregnant women annually. Around 30% are HIV-infected

and about 27,500 receive their results. Following SAG guidelines for PMTCT, positive women and their

babies are provided with ARV prophylaxis. Support groups run at all clinics with emphasis on HIV

information, prevention for positives, informed infant feeding choices, nutrition, safe disclosure to partners,

etc. Partners are encouraged to come for testing and be involved in PMTCT. All HIV-infected women are

referred for CD4 count tests and those with CD4<200 cells/mm3 are referred for ART. Currently over 60%

of women accept the CD4 count test with half receiving their results. The introduction of PCR testing for

infants by DOH provides the opportunity for early infant diagnosis of HIV and referral for appropriate

treatment and care, currently more than 50% of babies are tested. During FY 2008, the program will

become more closely integrated with ARV treatment and will improve gender equity in treatment programs.

ACTIVITY 2: Post-Partum Counseling and Testing (PPCT), Gauteng (urban township)

Each year, two thirds of births (around 20,000) in Soweto occur at Bara Hospital. Around 3,000 women at

the time of delivery present with an unknown HIV status. In this ongoing activity, staff funded by PEPFAR

work with DOH staff to provide PPCT. A PEP dose of nevirapine syrup is provided for HIV-infected mothers'

infants to reduce the risk of transmission. It has been shown that a post-exposure prophylactic dose of

nevirapine is effective if given to infants within 72 hours of birth. Approximately 2,500 women are offered

PPCT, about 2,000 accept and receive their results. Around 30% of these test HIV-infected. Over 98%

accept nevirapine for their infant. The uptake of the program is high and operates seven days a week to

ensure access for all women giving birth. Women who tested negative early in pregnancy will be offered a

follow-up test. Positive women identified at the time of delivery are provided with psychosocial support

through counseling and groups, referred for CD4 count tests and early infant diagnosis.

ACTIVITY 3: PMTCT, Mpumalanga (rural facilities)

PMTCT in the Bushbuckridge District is run by the provincial DOH. The PHRU and HIVSA, support PMTCT

at Tintswalo hospital with PEPFAR funding. Activities include mentoring the counselors, assisting with

referrals and providing education and support to pregnant women. Each year, around 4,000 women deliver

at the hospital; about 25% are HIV-infected. PHRU will liaise with the PMTCT service providers to ensure

increased uptake of HIV counseling and testing. Following SAG guidelines, ARV prophylaxis is given to the

mother and infant. Women testing positive are referred for CD4 count tests and to ART if

CD4<200cells/mm3. All women are encouraged to bring their infants for testing at 6 weeks. Support groups

and counseling are available with emphasis on informed safe infant feeding practices, nutrition, disclosure

to partners, early infant testing, HIV information, etc. HIVSA provides support groups in the district primary

care clinics assisted by a US-based volunteer.

Activity Narrative: These activities directly contribute to the PEPFAR 2-7-10 goals by improving access to and quality of

PMTCT services, testing pregnant women, identifying HIV-infected persons, reducing transmission to

infants and improving access to care and ARV treatment.

SUMMARY:

The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high quality care

and support for PLHIV. Building on their 2006 workshop on the feasibility of scaling-up doctor-based male

circumcision, the PHRU are using FY 2007 funds to organize and facilitate a stakeholders workshop on the

feasibility, acceptability, and resource requirements of alternative models of delivering circumcision as a

part of a comprehensive HIV prevention program. The workshop compares three models of male

circumcision: the use of traditional healers (where they are culturally appropriate) as circumcisers; use of

trained doctors; and a nurse-based approach to circumcision. The workshop draws upon the work of

Human Sciences Research Council (HSRC) and PHRU's non-PEPFAR funded study of the feasibility and

acceptability of nurse-based male circumcision. This activity will be used by the Health Policy Initiative in

their policy analysis of the impact of pending South African legislation restricting male circumcision to doctor

-based programs and will be coordinated with JHPIEGO and the NDOH TBD support to the NDOH. FY

2008 funds will be used to conduct an additional symposium, similar to that held with FY 2007 funds, which

will continue to involve major stakeholders in the policy analysis, brainstorming, and other major issues

surrounding male circumcision. The major emphasis area addressed in this activity is human capacity

development. Healthcare workers, program managers, and local health officials are the target group for this

activity.

BACKGROUND:

Although not widespread, prevalence rates for male circumcision in South Africa ranges from about 30%

national average to nearly universal among some ethnic groups. Male circumcision is a procedure that is

usually done for cultural or religious reasons rather than for health benefits. This is seen among certain

ethnic groups such as the Xhosa who routinely practice male circumcision as part of boys' initiation to the

transition to manhood. In such cases the circumcision is done by traditional healers rather than by medically

trained staff in a health facility. A recent study conducted in South Africa showed that male circumcision

reduces the risk of becoming HIV-infected. UNAIDS and WHO have stated that these results should be

confirmed prior to recommendations being issued regarding policy and program development. Two further

large scale studies of circumcision for HIV prevention are in progress in Uganda and Kenya, with results

anticipated later in 2007. Scaling-up male circumcision in South Africa may soon become a priority, as a

component of comprehensive HIV prevention programs. In anticipation of this development, the PHRU held

workshops in 2006 and 2007 on issues related to the feasibility of scaling-up male circumcision.

Contributions to this workshop were made by researchers who conducted the South African trial,

academics, surgeons, and included input on diverse aspects of possible interventions including training

requirements, legal and ethical concerns, traditional methods, anesthesia, cultural concerns, and potential

target groups. An important conclusion from this preliminary consultation was that there is little circumcision

being carried out by trained surgeons. A medical model with circumcision delivered by trained nurses could

also be considered. PHRU is currently conducting research, with non-PEPFAR funding, on the feasibility

and acceptability of a nurse-based approach to circumcision. Through non-PEPFAR funding, male

circumcision would be performed by trained nurses under the supervision of a surgeon in sterile operating

rooms at primary and tertiary health facilities. It is expected that this activity would impact male norms and

increasing equity in treatment programs.

ACTIVITIES AND EXPECTED RESULTS

ACTIVITY 1: Male Circumcision Using Nursing Staff

No male circumcision training or service delivery will take place without the express consent of the National

Department of Health. In the absence of such approval and based on discussions with the PEPFAR South

Africa team, funds could fully or partially be reprogrammed. Should the approval for safe clinical male

circumcision activities be given, PHRU is proposing the following male activities:

This activity assumes that the South African Government will change legislation to allow male circumcision

to take place on a large scale in South Africa. Recognizing that specialized surgical and other staff are in

short supply, this activity will look at alternative models to scale-up male circumcision. This will include

training nurses to do male circumcision, paying staff to perform circumcisions and paying for materials

required to perform male circumcision. Training, mentoring and implementation will be the main areas of

emphasis and developed in consultation with NDOH and JHPIEGO. It is likely that this activity will take

place initially in Gauteng, but may be expanded to other provinces on request of the National Department of

Health.

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

innovative prevention possibilities, which will result in a lower transmission rate.

SUMMARY:

The Perinatal HIV Research Unit (PHRU) will use PEPFAR funds to continue to provide quality holistic care

for PLHIV comprising of elements in the preventive care package, medical care and psychosocial support

categories in Gauteng, rural Limpopo, Mpumalanga and Western Cape provinces. Clients are monitored,

prepared and referred for antiretroviral treatment (ART). Linkages to counseling and testing (CT), the

prevention of mother-to-child transmission (PMTCT) and referral to ARV services will be strengthened. The

major emphasis area is human resources, minor emphasis areas are development of networks, local

organization capacity development and training. A family-centered approach targets HIV-infected adults,

children and infants.

BACKGROUND:

Since 2002, PHRU has established palliative care programs in Gauteng, rural Limpopo and Mpumalanga

provinces for people identified as HIV-infected through PMTCT and CT (also funded by PEPFAR). Primary

health care nurses are the main providers of care under physician supervision. The Department of Health

(NDOH) guidelines for HIV care and laboratory testing are used to ensure compatibility with South African

Government (SAG) treatment sites. In South Africa, a care program covers the period from testing positive

through end of life care. A holistic approach is taken comprising elements of the preventive care package

for adults and children, clinical services, psychosocial support, healthy lifestyle promotion and preparation

and transition of clients onto ART when required. These programs are predominately accessed by women;

however PHRU is attempting to redress this imbalance. Men are encouraged to participate through CT

programs which specifically target men. Clients are encouraged to bring partners, children and other family

members. A focus of the program is to identify HIV-infected infants and children and to provide family-

centered care and support. Quality assurance, client retention, monitoring and evaluation are integral parts

of the program. The aim of the programs is to delay progression of HIV to AIDS by providing palliative care

and support to HIV-infected clients who do not yet qualify for ART. Care includes: screening for active TB,

preventative treatment for latent TB infection, cotrimoxazole prophylaxis for OIs, syphilis screening,

symptomatic screening for syndromic STIs, screening for cervical cancer, provision of family planning and

regular CD4 counts. Opportunistic illnesses are treated using a formulary based on the South African

Essential Drug List. Support for clients, their families and community members is provided through support

groups and education sessions at all sites covering issues such as basic HIV and AIDS information, HIV

services, PMTCT, ART, opportunistic infections, TB, prevention, disclosure, prevention, nutrition, stigma,

positive living and adherence.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Soweto, Gauteng

The Soweto care program was initiated in 2002 serving over 4,500 adults with around 700 people being

transferred onto ART and others who have been referred to SAG rollout sites. Support groups and

education sessions are run by an NGO partner, HIVSA. Since 2004, a focus has been to identify children

requiring care, ART and psychosocial support through linkages to PMTCT and infant testing. Over 630

children are currently receiving care and referred for growth monitoring and routine immunizations. Support

programs are in development to assist caregivers and children, in particular around issues of bereavement,

disclosure, dealing with stigma and discrimination, positive living and life skills.

ACTIVITY 2: Bushbuckridge, Rural Mpumalanga/Limpopo

The Bushbuckridge District in Limpopo/Mpumalanga province is one of the poorest in South Africa. Access

to information and HIV healthcare and support is a basic need. The PHRU in partnership with Rural AIDS

Development Action Research Program (RADAR) and HIVSA established a wellness clinic at Tintswalo

hospital and a district wide support network for people living with HIV and AIDS. Since 2003, over 2,000

people have accessed the wellness clinic and 2,500 have accessed support groups running in the district

clinics. A training program has been implemented to train nurses, lay facilitators, counselors and local

NGOs to provide effective support to people living with HIV and AIDS and the preventive care package,

pain and symptom management, basic education on HIV, CT, HIV treatment services and related issues to

the broader community. Disclosure is encouraged to reduce stigma, discrimination, improve male norms

and attitudes and reduce violence. US-based volunteers have worked in these programs. Expansion of

medical care to the district primary health care clinics and to prepare for down referral from tertiary facilities

is planned.

ACTIVITY 3: Tzaneen, Rural Limpopo

Since 2003, the University of Limpopo (UL) has been supporting the DOH to develop a district-wide

wellness program based in the primary health care clinics in the Letaba sub-district of the Mopani District in

Limpopo province. PHRU partnered with UL to formalize and expand the program. With PEPFAR funding

health workers have been trained in HIV care of adults and children and infrastructural support provided.

HIVSA has provided training to support group members to enable them to run more effective support

groups and provide better information to people in the district. The Mopani District (population 1 million) is

extremely poor. The program operates in the primary care clinics with support by a medical doctor and aims

expand to the whole district. Over 600 people have enrolled and more than 100 are now on treatment and

supported at the clinics. On going in-service training and mentoring occurs at the clinics. US-based

volunteers support the program. These activities will be continued and expanded to additional groups with

FY 2008 funding.

ACTIVITY 4: Western Cape

In 2006, PHRU partnered with a number of organizations in the Western Cape including the University of

Stellenbosch, Red Cross Hospital and the Desmond Tutu HIV/AIDS Foundation that support a number of

DOH ART sites. PEPFAR funds support these programs to improve linkages to primary care clinics for

down referral, and to provide holistic care and support to people on ART and their families. Training staff to

assist with scale-up and sustainability are focus areas. These activities will be continued and strengthened

and will reach additional people with FY 2007 funds. With FY 2008 funds PHRU will continue to support one

Activity Narrative: of its sub-partners, HIVSA, to expand palliative care services in rural areas in Mpumalanga, Western Cape,

and Limpopo and in urban areas in Gauteng Province. HIVSA utilizes male involvement, door to door, home

-based care, and youth friendly models. HIVSA will implement systems to ensure that all PHRU assisted

ART sites will reduce loss to ART initiation from the time tested positive until eligible for ART and will

improve uptake of ART as soon as a patient is eligible. Support group models will also be expanded. HIVSA

will also assist PHRU treatment programs to better monitor care provided to family members. Retention in

care after HIV diagnosis will be a focus for FY 2008.

In all of the above activities, PLHIV will receive at least one clinical and one other category of palliative care

service. Palliative care to family members of PLHIV or OVC will be provided in at least two of the five

categories of palliative care services.

These activities directly contribute to the PEPFAR 2-7-10 goals by improving access to and quality of

palliative care for HIV-infected individuals and their families.

SUMMARY:

The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high quality care

and support for PLHIV. PHRU will use PEPFAR funds to continue its TB services to patients accessing care

in Soweto (Gauteng), rural Limpopo/Mpumalanga Provinces and in the Western Cape. The TB/HIV program

is integrated into all programs by providing screening, referring people with active TB to National TB

treatment sites and providing preventative treatment for latent TB. The program is also linked to National TB

treatment sites providing HIV care and treatment. The major emphasis areas are human capacity

development and local organization capacity building. The primary target populations are HIV-infected

adults and children.

BACKGROUND:

PHRU established palliative care programs in Soweto (Gauteng) and in rural Limpopo and Mpumalanga

and have partnered with organizations in the Western Cape to provide care and support to people identified

as HIV-infected through PMTCT and CT. High rates of TB in South Africa continue to be challenging and

MDR-TB is considered to be on the rise. The PHRU will strengthen its emphasis on diagnosis of TB via its

PMTCT program (through screening during CT when possible), and through screening of all patients testing

positive. Once tested positive, all patients enter a wellness program where they will be screened and

treated according to WHO protocols for TB. In South Africa, a wellness program covers the period from

testing positive to needing treatment. The high HIV prevalence in South Africa requires a cost-effective

package of care and support for people with HIV prior to ARV treatment. Primary health care nurses are the

main providers of care under physician supervision in these programs. The programs follow the Department

of Health guidelines for HIV care and laboratory testing to ensure compatibility with South African

Government treatment sites. The programs have been approved by the medical ethical review board of the

University of the Witwatersrand. The aim of the programs is to delay the progression of HIV to AIDS by

providing palliative care and support to HIV-infected clients who do not yet qualify for ARV treatment. Care

includes: elements of the preventive care package, screening for active TB, preventative treatment for latent

TB infection, cotrimoxazole prophylaxis for opportunistic infections, syphilis screening, symptomatic

screening for syndromic STIs, screening for cervical cancer, provision of family planning and regular CD4

counts. Opportunistic illnesses are treated using a formulary based on the South African Essential Drug

List. Support for clients, their families and community members is provided by support groups and

education sessions at all sites covering issues such as basic HIV and AIDS information, HIV services,

PMTCT, ARV treatment, opportunistic infections, TB, prevention, disclosure, nutrition, stigma positive living

and adherence. Training of professional and lay staff takes place on a regular basis.

ACTIVITIES AND EXPECTED RESULTS:

PHRU will continue to work with the national and provincial departments of health and specifically with the

HAST (HIV, AIDS STI, and TB) managers to prioritize interventions designed to address weaknesses

(identified by the departments of health) in the DOTS and TB/HIV programs. PHRU will focus on improving

policy adherence and patient follow-up. Individuals will be hired for each site as tracers to track patients and

ensure that referrals are completed. PHRU is setting aside funding to develop (with other relevant partners

or agreement counterparts) standardized tools to ensure that policies and guidelines recommended by

NDOH are followed, including guidelines for infection control. PHRU will continue to integrate TB/HIV

interventions with existing agreement programs as they work seamlessly and side by side with government

employees at government facilities.

ACTIVITY 1: Soweto, Gauteng

In 2002 a care program was initiated in Soweto, a large urban area south-west of Johannesburg with very

high HIV prevalence (30% in the ante-natal clinics). A holistic approach is provided to all enrolled in the

wellness program and covers clinical services, psychosocial support, and healthy lifestyle promotion,

including exercise, nutrition, and decreasing the use of alcohol and tobacco. To date over 4,500 adults have

accessed the program with PEPFAR support. Support groups and education sessions, run by HIVSA, are

available to all clients. All clients are symptom screened for TB at each visit and are referred for TB

treatment to the government TB treatment clinics. PHRU is supporting the Charles Hurwitz Hospital, a

government TB treatment facility, to integrate TB and HIV care and treatment. Expanding the program with

FY 2008 funds, PHRU proposes to link TB screening into PMTCT service in Soweto and screen all

pregnant women for active TB and refer those with positive results to government TB treatment sites. PHRU

will work with public facilities to ensure that care for both TB and HIV is monitored and coordinated. Training

for health care professionals working at PHRU and its partners (including the provincial Department of

Health) in all aspects of HIV palliative care takes place on an ongoing basis.

ACTIVITY 2: Bushbuckridge, Rural Mpumalanga/Limpopo

Bushbuckridge district in Mpumalanga/Limpopo is one of the poorest in South Africa. Access to information

and HIV healthcare and support is a basic need for all people living with HIV. PHRU in partnership with

Rural AIDS Development Action Research Program (RADAR) and HIVSA established a wellness clinic at

Tintswalo hospital and a district-wide support network for people living with HIV and AIDS. Since 2003, over

2,000 people have accessed the wellness clinic and more than 2,500 have accessed the support groups. A

training program has been implemented to train nurses and lay facilitators, counselors and NGOs to provide

effective support to people living with HIV and AIDS and basic education on HIV, TB, CT, HIV services and

related issues to the broader community and build the capacity of linked local organizations. All clients are

screened for active TB at each visit.

ACTIVITY 3: Tzaneen, Rural Limpopo

Since 2003, the University of Limpopo has been supporting the Department of Health to develop a wellness

program based in primary healthcare clinics in Tzaneen District. In 2004 PHRU partnered with University of

Limpopo to formalize and expand the program. PHRU has mentored the program, assisted with training

health workers and has provided infrastructural support. In addition, HIVSA has provided training to support

group members to enable them to run more effective support groups, and provide better information to

people in the district. The program takes a district health approach and aims to operate throughout the

Activity Narrative: district. Over 600 people have enrolled in the program and more than 100 have been referred to ART sites

for ARV treatment. People on treatment are supported at primary care clinics through this program. The

program will be expanded to other sub-districts in the Tzaneen area. All clients attending Wellness services

will be screened for active TB at each visit. US-based volunteers have supported this program.

ACTIVITY 4: Western Cape

In 2006 PHRU partnered with a number of organizations in the Western Cape including the University of

Stellenbosch, Red Cross Children's Hospital and the Desmond Tutu HIV/AIDS Foundation. The aim is to

support government ART sites to scale-up and develop down referral systems. PHRU will continue to

screen HIV-infected clients for TB and those who are found to be co-infected will be referred to public sites

for treatment. Expansion of these activities is planned. These activities will contribute to the PEPFAR 2-7-10

goals by providing TB/HIV care and services to HIV-affected people.

SUMMARY:

The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high quality care

and support for people living with HIV (PLHIV). PHRU will use PEPFAR funds to promote voluntary

counseling and testing (CT) through HIV prevention workshops and health promotion activities, and to

pregnant women at PMTCT to increase uptake of CT for HIV. In particular, services will be promoted to men

in an effort to increase gender equality in HIV and AIDS programs and make them available to adolescents

as part of a prevention program. The major emphasis area is human resources; minor areas include local

organization capacity development, community mobilization/participation, and information, education, and

communication. The target populations are the general population with a focus on men and adolescents.

BACKGROUND:

This CT program is an ongoing activity operated in partnership with a local non-governmental organization,

HIVSA, and other CT organizations in Soweto (Gauteng). The program will be expanded to rural Limpopo

and Mpumalanga. Women have mainly accessed HIV services in Soweto and this project aims to improve

gender equity in these services. In June 2005, the IMBIZO project, which broadens access to HIV and AIDS

information, was established. This project was designed to enhance male involvement in counseling and

testing and other health services. IMBIZO drop-in centers operate five days a week and are located close to

areas where men congregate and are easily accessible. The concept of the IMBIZO program is one

designed by men for men and evolved from research that indicated that men preferred to be counseled by

men at locations away from the primary healthcare clinics. Within the project, marginalized communities

such as men who have sex with men are encouraged to access CT. A focus of this program is to reduce

stigma associated with HIV, to encourage disclosure, to support partners and family members with HIV and

to promote active engagement with HIV services. A program promoting IMBIZO to partners of pregnant

women is being run in the antenatal clinics, with the aim of increasing male involvement in PMTCT and

fatherhood. Reduction of violence and coercion, also main components of IMBIZO, is a major focus of the

program. Outreach activities take place in prisons, workplaces, hostels, sports matches and other places

where men congregate. PHRU offers a couple counseling service called "Tshwarisanang" through external

foundation funding and all other PHRU CT services can refer to them.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: IMBIZO - Men's Health Centers

Male IMBIZO centers are funded by PEPFAR. The project receives approximately 300 drop-in clients and

performs approximately 140 CT each month. A male registered nurse manages the program. Clients are

referred to local clinics for HIV services and treatment. Stigma decreases men's uptake of CT services and

innovative strategies to increase men using CT are being developed. At-risk male populations such as men

who have sex with men, migrants, and prisoners are focus populations. This program will expand to rural

Mpumalanga provinces. Information on TB, PMTCT, HIV services, prevention, nutrition, etc., is available.

Clients are counseled on prevention and condoms are distributed. Support is given to clients to encourage

disclosure, to decrease stigma, to mitigate domestic violence, and to provide support to partners. To

increase male support of PMTCT programs, pamphlets have been designed for male partners of pregnant

women that explain PMTCT, encourage active involvement in fatherhood, and encourage men to access

the IMBIZO centers and to go for CT. Outreach activities take place regularly with community organizations,

workplace programs, and health services. Mobile CT is used to take CT to communities that do not have

easy access to healthcare services. A focus of this program is to reduce stigma, increase male involvement

in all services relating to HIV thus increasing gender equity. U.S.-volunteers will support the rural program.

ACTIVITY 2: Adolescents

Adolescents have special healthcare needs which they are often reluctant to address; some of these are

sexuality, pregnancy, drug and alcohol abuse, sexually transmitted infections (STI), gender and mental

health issues, coercion, violence, transgenerational sex and abuse. They are at high risk of contacting HIV

and other STIs. Through a proposed specialized adolescent clinic PHRU will address these needs with FY

2007 PEPFAR funding by offering comprehensive counseling and care services that are youth-friendly,

confidential and empowering to clients so that they may make informed and responsible healthcare choices,

including being empowered to abstain and delay sexual debut. Through CT, education and counseling,

PHRU will increase awareness of HIV. The clinic in Soweto will be based close to places to where

adolescents congregate. Services will comprise CT and confidential and free care; information, education

and counseling on sexual and reproductive health; health information; counseling and appropriate referral

for violence abuse and mental health issues; contraceptive information and counseling on individual

choices; STI information, including information on effective prevention; and syndromic management of STIs.

PEPFAR funds will be used to establish and staff this project.

ACTIVITY 3: CT Plus

In the Western Cape a mobile CT program providing counseling and testing, point of care CD4 counts, TB

screening and referral into care and ART services programs will be supported. The Western Cape has very

high TB prevalence. This program will provide CT to underserved populations.

ACTIVITY 4: Couple Counseling

PEPFAR funds will be used to expand an existing couple counseling program operating at the PHRU in

Soweto. Specialized counseling for couples has proven to be effective for preventing further infection

particularly in discordant couples. In many programs lay counselors do not have sufficient expertise to

counsel couples and therefore a referral service is essential.

ACTIVITY 5: Farm Workers

A CT activity linked to care and ART for farm workers in the Westcoast winelands region of the Western

Cape will be expanded to other districts in the region. The male CT program will expand to target all men

including men who have sex with men and other vulnerable male groups in Soweto (Gauteng) and

Activity Narrative: Bushbuckridge (Mpumalanga).

These activities will contribute to the PEPFAR 2-7-10 goals by increasing access to and improving quality of

CT services, particularly to hard-to-reach populations of men and adolescents in urban and rural districts in

South Africa.

SUMMARY:

The approach taken by the Perinatal HIV Research Unit (PHRU) is one of comprehensive, high-quality care

and support for people living with HIV (PLHIV). The PHRU will use FY 2008 funds to continue to provide

high-quality holistic antiretroviral treatment (ART) and psychosocial support in Gauteng, rural Limpopo and

Mpumalanga, and Western Cape. These funds will contribute towards antiretroviral (ARV) drugs and

services. Clients are provided with ART, pre-treatment literacy, adherence counseling and adherence

support groups. Linkages from CT, PMTCT, basic care and support will be strengthened. The emphasis

areas are human capacity development and local organization capacity building. The family-centered

approach targets HIV-infected adults, children and infants.

BACKGROUND:

Since 1998 the PHRU has provided comprehensive treatment, care and support to people living with HIV

(PLHIV). The PHRU has received funding from PEPFAR since 2004 to support ART services in Gauteng,

rural Limpopo and Mpumalanga, and Western Cape provinces. PHRU directly purchases ARVs with

PEPFAR funds and has demonstrated the ability to rapidly scale up treatment. PHRU has adopted a family-

centered approach and clients are encouraged to bring partners and other family members for testing and

treatment. Of patients supported by the PHRU, about one-third is supported through PEPFAR-funded ARV

drugs. PHRU is expanding activities to directly support scale-up at government ART sites and support down

referral systems. PHRU works with the provincial health departments to ensure safe transfer for the

participants to ongoing care within the South African Government (SAG) rollout program to ensure

sustainability. PHRU works only in government facilities, where government takes the lead in all aspects of

the program. The PHRU together with government counterparts identify gaps that will slow down

implementation according to national and provincial guidelines. Upon request from the facility, PHRU

provides support through a Memorandum of Understanding to fill the gaps and work towards the provincial

financing of related activities. PHRU supports, trains and mentors healthcare workers involved in the

management, care and treatment of HIV-infected individuals. All programs follow national guidelines for

ARV treatment. Training is adequately and broadly proclaimed by provincial government through training

programs that are approved by the province and adhere to all guidelines and standards of the national

government. Quality assurance, client retention, monitoring and evaluation form an integral part of the

program. PHRU provides regular training for professional and lay staff on ART issues such as adherence,

medical treatment, and appropriate regimens.

All sites have psychosocial support programs which provide community-based assistance, support groups

and education covering issues such as basic HIV and AIDS information, HIV services, HIV treatment,

treatment literacy, adherence, TB, positive living, nutrition, prevention, opportunistic infections and TB. The

comprehensive care approach leads to stigma reduction, increased disclosure, and improved adherence to

ART.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Adults, Soweto

Funding from PEPFAR supports adults on treatment in the family-centered PMTCT program. The adult

treatment program is ongoing and drugs are purchased for patients at the PHRU clinic based at Chris Hani

Baragwanath Hospital (Bara). The program provides treatment, monitoring and support for adults who meet

the SAG guidelines for treatment. HIVSA, an NGO partner, provides treatment literacy and adherence

support. This activity will be continued and expanded with FY 2008 funds.

ACTIVITY 2: Pregnant Women, Soweto

This program was started in the maternity section at Bara in July 2005 by PHRU in partnership with the

Department of Obstetrics and Gynecology. In Soweto 8,000 pregnant women annually are identified as

positive with an estimated 1,600 needing treatment. Following SAG guidelines, pregnant women who are

eligible for treatment are offered HAART. In order to fast-track women onto treatment, PHRU is training and

mentoring the doctors and nurses. The program is being expanded to other ART sites in the area with FY

2008 funds. HIVSA, an NGO partner, will continue to provide treatment literacy and adherence support.

ACTIVITY 3: Children, Soweto

The PHRU clinic identifies HIV-infected children who need treatment through PMTCT and children of adults

who are already on treatment. This activity will continue and will be strengthened through additional

counselors with FY 2008 funds. As part of a comprehensive family-centered approach, children are put onto

treatment following SAG treatment guidelines with ARVs purchased by PHRU according to USG and SAG

guidelines. ARV drugs for children are supplied through the PHRU pharmacy system. Staff is trained on an

ongoing basis in pediatric ARV provision.

ACTIVITY 4: Franchise, Gauteng

This program targets uninsured workers in densely populated areas in Johannesburg. ARVs are made

available and affordable through a franchising scheme, and supplied free of charge or at a significantly

discounted rate to patients unable to purchase their own medication. Those who can afford to pay for all or

a portion of their drugs are expected to do so. ARV drugs are procured and supplied within the service by

trained providers. This program provides a stand-alone ART full service clinic in downtown Johannesburg

and provides lessons learned about demand for ART outside the public sector, willingness and ability to pay

for services, and the cost-effectiveness of this model of delivery.

ACTIVITY 5: Sub-partners

A number of partners in the Western Cape have been identified and are supported to provide ARV

treatment. Most of these partners receive ARV drugs from the Department of Health and PEPFAR funds are

provided to support the services to expand and develop down-referral systems. Pediatric treatment is a

priority. It is likely that additional partners will be identified to enable increased access to treatment.

Activity Narrative:

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

million people.

SUMMARY:

The Perinatal HIV Research Unit (PHRU) provides comprehensive care and support for people living with

HIV (PLHIV). PHRU will use PEPFAR funds to provide high quality, holistic ARV treatment and

psychosocial support in Soweto (Gauteng), rural Limpopo and Mpumalanga, and the Western Cape. PHRU

will also use PEPFAR funds to provide personnel and ARV drugs for these services. Clients are provided

with ART, pre-treatment literacy, adherence counseling and access to adherence support groups. Linkages

from CT, PMTCT, and palliative care will be strengthened. The emphasis areas for ARV services are

renovation, gender, human capacity development, local organization capacity building, and TB. A family-

centered approach targets HIV-infected adults and children.

BACKGROUND:

Since 1998 PHRU has provided comprehensive treatment, care and support to PLHIV. Since 2004,

PEPFAR funding has supported ARV treatment and South African Government (SAG) ART sites in

Gauteng, rural Limpopo and Mpumalanga provinces, and the Western Cape. PHRU purchases ARVs and

provides treatment for adults and children. PHRU's family-centered approach encourages clients to bring

partners and other family members for testing and treatment. PHRU is expanding activities to scale up

government ART sites and to investigate down referral systems. With FY 2008 funds, PHRU will work with

provincial health departments to ensure safe transfer of participants to ongoing care within the SAG rollout

program. PHRU will support, train and mentor healthcare workers involved in the management, care and

treatment of HIV-infected individuals. All programs follow national guidelines for ART. PHRU provides

regular training on ART issues such as adherence, medical treatment, and appropriate regimens. A NGO

partner, HIVSA, provides all sites with psychosocial support programs providing community-based support,

support groups and education. They cover issues such as basic HIV and AIDS information, HIV services

and treatment, treatment literacy, adherence, TB, positive living, nutrition, prevention, opportunistic

infections and TB. The comprehensive care approach leads to stigma reduction, increased disclosure, and

improved adherence to ART. Throughout the comprehensive program, PHRU has established a continuous

set of assessment functions to improve the quality of care at ART service sites.

ACTIVITIES AND EXPECTED RESULTS:

All of the activities described in this section will be continued and expanded with FY 2008 funds.

ACTIVITY 1: Adults, Soweto

Funding from PEPFAR supports women on treatment in the family-centered PMTCT program. The program

is ongoing and provides treatment, monitoring and support for adults who meet SAG guidelines for

treatment. HIVSA provides treatment literacy and adherence support.

ACTIVITY 2: Pregnant Women, Soweto

This program has been initiated in the maternity section at Bara in July 2005 by PHRU in partnership with

the Department of Obstetrics and Gynecology. In Soweto 8,000 pregnant women are identified annually as

HIV-infected, with around 1,600 needing treatment. Following SAG guidelines, pregnant women eligible for

treatment are offered HAART. In order to fast-track women onto treatment, PHRU is training and mentoring

doctors and nurses. The program is being expanded to other ART sites in the area through FY 2008 funds.

HIVSA provides treatment literacy and adherence support.

ACTIVITY 3: Children, Soweto

The PHRU identifies HIV-infected children who need treatment through PMTCT and children of adults who

are already on treatment. As part of a comprehensive family-centered approach, these children are put onto

treatment following SAG treatment guidelines with ARVs purchased by PHRU according to USG and SAG

guidelines. Staff is trained on an ongoing basis in pediatric ART.

ACTIVITY 4: Rural Mpumalanga and Limpopo

At Tintswalo Hospital, Limpopo, in partnership with Rural AIDS Development Action Research Program

(RADAR), adults and children are identified as needing treatment in the palliative care and PMTCT

programs. RADAR supports the ART site at this hospital, as well as Mapulaneng hospital, and is assisting

other sites for ART accreditation. Human capacity building is fundamental to sustainability of the program

and PHRU provides staff, training and mentoring existing treatment staff. HIVSA offers district-wide support

in the primary care clinics that includes treatment literacy, adherence counseling and group support for

these clients.

ACTIVITY 5: Tzaneen, Limpopo

PHRU in partnership with the University of Limpopo is supporting the Limpopo Department of Health

wellness program operating in the district's primary healthcare clinics. Currently clients are referred to the

ART sites including Letaba hospital and CN Phatudi hospital. Through Choice, a local NGO, clients are

provided with a treatment readiness program, referred to rollout sites when they become eligible for

treatment and given adherence support. Due to vast distances to the hospitals, clients on ART are

supported in local primary care clinics.

ACTIVITY 6: Franchise, Gauteng

This program targets uninsured workers in densely populated areas in Johannesburg. ARVs are made

available and affordable through a franchising scheme, and supplied free of charge or at significantly

discounted rates to patients unable to purchase their own medication. ARV drugs are procured and supplied

within the service by trained providers. This program provides a stand-alone ART full service clinic in

Johannesburg and provides lessons learned about demand for ART outside the public sector, willingness

and ability to pay for services, and the cost-effectiveness of this model of delivery.

ACTIVITY 7: Western Cape

Activity Narrative:

A number of partners and SAG ART sites have been identified in the Western Cape that need support to

scale up their activities. These include the Desmond Tutu HIV/AIDS Foundation, the University of Cape

Town and Stellenbosch University. These partners are supporting SAG ART sites and provide training,

mentoring and support. Many ART sites in tertiary hospitals are reaching capacity and the PHRU is

establishing innovative down referral mechanisms.

In FY 2008, all activities will expand. Additional partners are likely to be identified in order to increase

access to treatment. A specific emphasis will be placed on pediatric treatment. In addition, tracing and

tracking programs will be implemented to ensure retention in care. Renovations will be made as necessary

per facility. Training for all categories of health workers and task shifting strategies will be implemented in

FY 2008. Task shifting focuses on the effective utilization of existing staffing skills.

These activities will contribute substantially to the PEPFAR 2-7-10 goal of providing ARV treatment to two

million people by supporting SAG treatment sites.