SUMMARY:

Aurum will provide PMTCT services to patients in South African government clinics, GP practices and non-

governmental sites. Emphasis will include the implementation of the PMTCT diagnosis and treatment

protocols at the service outlets, early counseling and testing of pregnant mothers, provision of antiretroviral

prophylaxis to HIV infected mothers both during the pregnancy and during delivery. Emphasis will also

include provision of ARV to infants born to HIV mothers according to protocols and PCR of infants born to

HIV-infected mothers. Also included in this activity is counseling on safe infant feeding practices and

prevention of STI and HIV infection during pregnancy and while breast feeding. The primary target

populations are HIV-infected pregnant women and their infants.

BACKGROUND:

Aurum Institute for Health Research (Aurum) is a not-for-profit, public benefit organization that is committed

to improving the health of disadvantaged individuals and communities through transformational research

(the research programs are not PEPFAR-funded), management of TB and HIV programs and provision of

HIV testing, treatment and care. Aurum has received PEPFAR funding since October 2004. The main focus

of the Aurum program in the public, private and non-governmental sector is to provide HIV care and

treatment to a large number of persons in a cost-effective standardized manner ensuring a high quality of

counseling, patient care and patient monitoring. The model is centrally coordinated and designed to be

implemented on a large scale in peripheral sites that are resource-constrained and lacking basic resources

such as HIV specialists, information technology (IT) infrastructure, and laboratory and pharmacy capacity.

Aurum has established a centralized system of support which includes the following: (1) training of all levels

of healthcare workers to ensure capacity building of clinicians to manage patients in resource limited

settings with remote HIV specialist support; (2) provision and maintenance of guidelines for HIV preventive

therapy (including INH and cotrimoxazole), treatment of adults and children, prevention of mother-to-child

transmission and VCT; (3) clinical and administrative support through site visits by staff involved in

psychological support, training, clinical support and monitoring data management systems; and (4)

centralized distribution of medication and laboratory testing. This program will supplement the South African

government's ARV rollout and therefore the program adheres to national guidelines and protocols.

ACTIVITIES AND EXPECTED RESULTS:

Aurum will carry out five activities in this Program Area. All of the activities are aimed at the provision of

quality PMTCT service delivery.

ACTIVITY 1. Establishing Capacity for PMTCT at Service Outlets

This activity will include the dissemination of information on the importance of PMTCT and the application of

PMTCT protocols to all South African government clinics, GP and NGO sites funded supported through the

Aurum grant. This is also linked to the training of health workers (activity 7 below).

ACTIVITY 2: Counseling and Testing of Pregnant women

Pregnant women will receive provider-initiated counseling and testing as soon as they present to the health

care service outlet. Women who test negative during the initial testing will be encouraged to repeat testing

during the pregnancy to detect early HIV infection and ensure proper clinical care for the mother and infant.

ACTIVITY 3: Provision of Prophylactic ART

Women who are HIV-infected and pregnant will be provided with prophylactic ARVs to prevent transmission

of HIV from the mother to the unborn child. As part of the minimum service package, newborn infants will

receive the recommended prophylactic ART. Following pregnancy women will be enrolled onto the HIV care

program.

ACTIVITY 4: Early infant diagnosis using PCR

Training will be given to health care providers at South African government clinics, GP sites and NGO sites

on the importance of early infant HIV diagnosis and the correct use of the PCR test. Data collection will

include a compilation of results of all PCR tests performed.

ACTIVITY 5: Prevention of STI and HIV in pregnancy and during breast-feeding period

Counseling given to pregnant mothers will emphasize the risk of contracting STI and new HIV infections

during pregnancy and how that increases the risk of transmission to the unborn child.

ACTIVITY 6: Promotion of safe infant feeding practices

Aurum will provide education and counseling to support mothers to make correct choices around infant

feeding practices to ensure reduced risk of HIV transmission in the post-partum period while safeguarding

the health of the infant.

ACTIVITY 7: Training of Health Care Workers to provide PMTCT

Aurum will incorporate training around the provision of PMTCT into its existing training curriculum for

doctors and professional nurses and counselors. This training will include counseling of pregnant women to

encourage them to test for HIV, the prophylactic antiretroviral therapy, the modification and continuation of

antiretroviral therapy in mothers already receiving therapy the use of PCR for early infant diagnosis and

counseling around other prevention methods for STI and HIV and safe infant feeding practices. Aurum's

PMTCT activities contribute to the achievement of the PEPFAR 2-7-10 goals.

SUMMARY: The Aurum SME Project commenced in September 2007. The project seeks to extend access

of HIV related services such as prevention, counseling, testing and treatment to people that currently are

not accessing services through the existing health care system. The project specifically targets employees

of small, micro and medium sized (SME) companies as well as their partners and dependents. In the

second year of this project, the focus will be on strengthening service provision at the existing service points

as well as extending the service offering to four additional fixed sites in Mpumalanga, Limpopo and Gauteng

provinces.

BACKGROUND: Aurum provides services to SMEs at the workplace, through the use of mobile vehicles

and through a fixed testing site at the Bree Street Taxi Rank which is the busiest taxi rank in Johannesburg,

catering for an estimated 400,000 commuters a day in addition to 500 traders and 2000 taxi drivers.

ACTIVITIES AND EXPECTED RESULTS: Prevention activities will comprise prevention messaging

targeting youth and young adults that utilize the fixed Bree centre as well as a campaign that will involve the

use of counselors visiting educational institutions, sports facilities and entertainment venues within the

targeted areas. In FY 2008 these activities will be expanded through the employment and training of

additional counselors. It is anticipated that 7000 people will be reached with specific abstinence and be

faithful messaging. Messaging that specifically targets the young men and young women will encourage

abstinence, delayed sexual debut, avoidance of risk taking behavior and reduction in the number of sexual

partners. All the messaging will be provided in languages understood by the targeted group and the project

will involve an ongoing conversation with the community as opposed to short-term information blitzes. In

addition 300 individuals from the targeted companies and communities will be trained as peer educators to

use A/B focused materials.

ACTIVITY 1: Recruitment and training of youth community mobilization counselors.

Aurum intends to recruit additional youth counselors who will be trained and then tasked with the provision

of youth focused messaging and education to students at educational institutions within the targeted areas,

mainly high schools and tertiary educational colleges. Young commuters that frequent the taxi ranks will

also be targeted with the specific A/B message. The training provided to the youth counselors will include

basic counseling skills, sexuality, modes of HIV transmission, gender as related to the HIV epidemic,

prevention methods, counseling for behavioral change, group and individual counseling.

ACTIVITY 2: Delivery of specific AB message to targeted youth.

An ongoing activity under this grant will be the delivery of targeted messaging to youth, attending

educational institutions in the targeted areas. Youth will also be targeted at sports venues and other

entertainment venues and the abstinence, be faithful and delay in sexual début will be delivered in one on

one and small group information and education sessions. Messaging will specifically targets young men and

young women and will encourage abstinence, delayed sexual debut, avoidance of risk taking behavior and

reduction in the number of sexual partners. All the messaging will be provided in languages understood by

the targeted group and the project will involve an ongoing conversation with the targeted communities.

SUMMARY:

This activity will building on the existing program components (care, treatment and TB-HIV) to include a

prevention activity, integrated into existing services. Aurum currently provides services in three sectors:

public, private and NGO. This funding will allow Aurum to address prevention awareness and promote

behavior change among the target populations, many of whom are at high risk (prisoners, refugees, miners

and other mobile populations), including prevention messaging for people in the care and treatment

program.

As per the South African Government ABC strategy, Aurum will address all these aspects, including

messaging and training that promotes the correct and consistent use of condoms at South African

government clinics, GP clinics and NGO sites. Aurum will continue to develop messaging for specific target

groups such as young males, young women, pregnant women, mobile populations, and other target groups

identified as being at risk in conjunction with other expert organizations. Aurum will emphasize messages

that promote healthy choices regarding sexual behaviors and avoiding risky behaviors, especially

concurrent multiple partnerships. Emphasis will be placed on avoidance of drug and alcohol abuse, delaying

sexual debut and addressing transactional sex. One of the focus areas of this program is gender with a

particular focus on addressing male norms and behaviors. Male circumcision will be encouraged within the

context of local policy and guidelines. Aurum is working with one corrections facility and aim to be working

with approximately four additional prison facilities in the next year. In one of the supported NGO facilities,

based in central Hillbrow, Aurum is targeting homeless populations and street youth. The primary target

populations are men, women, youth, prisoners and other most at risk populations (MARPs). For patients

currently enrolled on the program (HIV-infected patients) messages about HIV prevention are continuously

emphasized.

FY 2008 represents the second year of activity of the SME project which has a significant focus on

prevention activities. The partnership with City of Johannesburg has enabled the establishment of a fixed

site within the Bree Street Taxi Rank. In FY 2008, Aurum plans to undertake targeted prevention activities

involving taxi drivers at a number of taxi ranks in the three targeted provinces. Attention will be paid to

intensifying prevention activities in these groups through the syndromic management of STIs, peer

education and active screening and counseling for substance use/abuse. This will include venue-based

interventions aimed at targeting substance abuse and other risk behavior.

BACKGROUND:

Aurum supports activities which reduce the transmission of HIV through engaging target populations to

provide messaging that encourages positive choices around sexual behaviors. The target population

currently services with HIV care and treatment services are poor, underserved, and mobile. In partnership

with ReAction! Consulting, another PEPFAR partner, community messaging is delivered to communities in

the vicinity of NGO clinics in Mpumalanga through door-to-door campaigns. Utilizing the experience and

tools from this facility, Aurum will expand its prevention activities in the other settings currently supported by

Aurum. Health care workers that work in government clinics, GP clinics and NGOs will receive training from

ReAction! Consulting in order to provide support in these activities.

The mining sector is a key platform to reach men. Stepping Stones is a workshop series designed to

promote sexual and reproductive health. It addresses questions of gender, sexual health, HIV and AIDS,

gender violence, communication and relationship skills. Stepping Stones has been shown to reduce high

risk behavior and HIV incidence in a program in Africa. Aurum intends using this program in both the mining

setting and in the prison population.

The SME Project targets workers in small, micro and medium sized companies, including market traders

and taxi drivers who previously did not have access to HIV prevention, counseling and testing and treatment

services due to incompatibility of their working hours with the operating hours of the public health facilities

and the fact that the majority of SME employees do not have private health insurance. In placing services

within taxi ranks and markets, partners and dependents of SME employees will also have access to these

services.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Targeted Training to Specific Groups

Men will be targeted, especially the large prison populations supported by Aurum, and in mining settings.

Messages to men will be developed and training provided promoting behavior change, and addressing

cultural norms of manhood and masculinity. This will be done in partnership with other PEPFAR partners.

This includes messages to young men encouraging them to use condoms, reduce the number of sexual

partners and avoid risky behavior. Messaging to young women, who make up the bulk of the current

population served with Aurum's care and treatment services, will empower them to be involved in decision-

making regarding sexual choices, requiring their partners to use condoms, empowering them to use female

condoms, delaying sexual debut and avoiding gender violence. Young women will be encouraged to

develop a positive self-image.

Aurum currently offers a number of courses that cover positive living and information on HIV prevention.

The training, provided by Aurum social workers and a psychologist, will be offered to incarcerated

communities, nurses, lay counselors and peers. The trainees will become implementers and peer

educators. The training curriculum includes understanding the challenges of disclosure, how to help clients

disclose safely, and how to address HIV and AIDS stigma, and is offered twice a year. In addition a module

on Prevention with Positives will be included in the training provided to the counselors in the SME fixed and

mobile sites as well as the health care workers and peer educators.

ACTIVITY 2: Promotion of Male Circumcision as a Method of Reducing Transmission

Based on existing evidence, male circumcision has been show to have an effect on the rate of HIV

transmission. Aurum plans to undertake a situational analysis to understand the beliefs, attitudes and

practices of male circumcision to understand the barriers for widespread circumcision implementation in

limited a number of industrial and community sites. In settings where it is possible to provide circumcision,

Aurum will provide training to ensure safe methods and encourage males to opt for this procedure. Activities

will not be conducted without consent from the National Department of Health.

Activity Narrative:

ACTIVITY 3: Prevention and Treatment of Sexually Transmitted Infections (STIs)

Aurum will continue to provide training to health care workers on the syndromic management of STIs as a

means of preventing the transmission of HIV, as many of the populations currently served with HIV care and

treatment services are at high risk. Aurum will encourage the use of male and female condoms to prevent

the spread of STIs. In FY08 the SME Project will focus on the issue of identification and treatment of STIs in

taxi drivers and will provide these services within the Bree Street taxi rank.

ACTIVITY 4: Education to Prisoners and Miners on Gender

Various organizations that are involved in gender issues and a framework will be established to provide

education and programs to males based at the corrections facility and a company within the mining industry.

One of these is the Stepping Stones workshops to be implemented with peer groups. The 14 sessions for

the separate peer groups cover the following topics: introduction for the group and development of group

skills; Images of Men and Women: Exploration of Ideals and Realities; Images of Sex and Sexual Health

Problems; Exploration of Love: What We Look for and Expect to Give; Exploring our Sexuality: Problems

and Concerns about Sex and Reproductive Health; Conception and Contraception; STDs and HIV; Safer

Sex; Gender-based Violence; Let's Look Deeper: Why we Behave in the Ways We Do; Assertiveness Skills:

Part 1; Assertiveness Skills: Part 2; Dealing with Loss; Let's Prepare for the Future: Future Decisions and

Changes.

Activity 5: Prevention with Positives

People that are identified as being HIV positive through counseling or testing will be rapidly assessed for

additional risk behaviors. Once these have been identified the counselor will negotiate with the HIV positive

client around methods of reducing the risk of transmitting the infection to other people or of becoming

infected with additional strains of the virus. The session will end with the client either being referred for

additional support or arranging a follow-up session with the counselor. This service will be provided at all

fixed and mobile sites as well as within the workplace and in occupational clinics within the SME project.

Activity 6: Venue-based Interventions targeted at reducing substance abuse and other risky behavior.

In FY 2008, Aurum will commence venue-based interventions that will target nightclubs, shebeens, taxi

ranks and sports venues and will involve one on one encounters where a rapid assessment will be made of

an individuals risk behavior such as substance and alcohol abuse. The counseling session will aim to

identify the risk that that behavior places the individual in terms for transmission of HIV and other STIs and

will involve referral of the individual for further assistance.

SUMMARY:

Aurum's palliative care program provides care to patients infected with HIV following HIV counseling and

testing, and screening for treatment eligibility in accordance with South African Government (SAG)

guidelines. The facilities where palliative care is provided include general practitioners' clinics, non-

governmental clinics and public sector sites. These sites are located mainly in the Gauteng, North West

Mpumalanga and KwaZulu-Natal. Patients are also assessed for opportunistic infections and eligibility for

ART and provided with preventive therapy i.e. INH and cotrimoxazole. Emphasis areas include human

resources, commodity procurement, logistics, quality assurance and training. The primary target populations

are people living with HIV (PLHIV), HIV-infected children, prisoners, homeless people and street youth.

BACKGROUND:

This is an ongoing program funded by PEPFAR since October 2004. The PEPFAR-funded project aims to

rapidly expand access to HIV care and treatment to South Africans living with HIV, and especially in areas

(such as mining areas) where Aurum is familiar and other partners are less likely to work. Aurum has

established a number of general practitioner (GP) clinics which are capable of providing care to large

numbers of HIV-infected individuals and achieving high quality results. In order to ensure sustainability of

this model, Aurum has partnered with Faranani Solutions, a network of general practitioners from a

previously disadvantaged population. Advantages of this model, now termed the Auranani model, are that

Aurum has been able to secure lower consultation rates for GPs and GPs are encouraged to provide

assistance at their local hospital clinics. The presence of trained individuals in these public health facilities

will enable the transfer of knowledge to nurses and doctors in the public sector. It is hoped that this model

can be used to rapidly scale up delivery of HIV services in South Africa, in partnership with government

efforts. Sites are located throughout the country, but are concentrated in Gauteng, North West province and

KwaZulu-Natal. There is only one site each in the Northern Cape and the Western Cape. A further

extension of Aurum's program is to include care and treatment services in HIV prevention trial sites of the

Aurum Institute in the North West and KwaZulu-Natal. Thus patients are being diagnosed in early stages of

their disease and are being counseled and prepared for antiretroviral therapy (ART) and palliative care. In

both these provinces there is a close collaboration with SAG, and patients are referred to public sector

facilities for ART initiation. These clinics are will be used in the future as down referral facilities In FY 2006

Aurum fostered new relationships with non-governmental organizations (NGOs) and public sector sites. A

number of primary healthcare clinics attached to NGO and faith-based organizations (FBOs) have been

established. Metro Evangelical Services, a sub-partner, is a FBO providing training, housing and health

services for the homeless and street youth of Hillbrow, Johannesburg. An HIV center has been established

to provide CT and HIV services to this population. In Gauteng, a contract has been concluded with Chris

Hani-Baragwanath hospital for support and a contract for extension of these services to other parts of

Gauteng is being negotiated with the provincial health departments. In the North West, Aurum supports the

provision of HIV Care at Tshepong Hospital through the provision of medical and nursing staff. In addition,

through the establishment of a walk-in clinic at Jade Square in Klerksdorp Aurum provides care for HIV

patients that are not able to currently access care through the public hospital. Aurum has met with the

KwaZulu-Natal Department of Health about sites attached to the Medical Research Council. Furthermore, in

Mpumalanga, one of Aurum's sub-partners, Reaction Consulting, has worked with the provincial health

department to strengthen support for Ermelo Hospital, and in the Northern Cape, Aurum's public-private

partnership with De Beers Consolidated Mines in the Danielskuil area has been discussed. In the Limpopo

area, discussions are underway with Anglo Platinum and the Limpopo Department of Health to provide

support to a down-referral clinic based in the Capricorn district close to one of the Anglo Platinum mines.

Aurum intends to continue to support the Department of Correctional Services in Johannesburg but also to

expand activities to other Gauteng-based correctional facilities, namely Pretoria. A number of Aurum's sites,

Caritas Care, MES and Duff Scott collaborate with the local health departments that provide funding for

inpatient care to palliative care patients. In FY 2008, the SME project will commence the provision of care

and support services to HIV positive SME employees including market traders and taxi drivers and their

partners and dependents in targeted sites in Gauteng, Mpumalanga and Limpopo provinces.

ACTIVITIES AND EXPECTED RESULTS:

PEPFAR funding will be used to fund all central staff responsible for monitoring and evaluation of the

program. FY 2008 funds will also be used to provide training and human resources at the sites. Focus areas

of training include how to run support groups, disclosure and stigma, special counseling situations such as

couples and children, and the prevention of mother-to-child transmission. Care will be provided through

occupational health care clinics, the mobile vehicles, the GP network and at the fixed service points such as

Bree Street site.

ACTIVITY 1: Monitoring for Opportunistic Infections

At each of the patient visits, a full physical examination including pain and symptom management of the

patient is conducted to exclude the existence of opportunistic infections (OI). If a client presents with an OI,

further investigations and management of the infection including the provision of cotrimoxazole may occur

at the site, or the patient may be referred to another healthcare service. Adherence to OI medications

(including cotrimoxazole prophylaxis and TB treatment) is also part of the package of services. Effort will be

made to ensure equitable access to care services for both males and females.

ACTIVITY 2: Provision of Prophylactic Medication

Patients with CD4 below 200 will receive elements of the preventive care package including cotrimoxazole

preventative therapy. It is expected that 30% of all patients receiving palliative care will be receiving

cotrimoxazole preventive therapy.

ACTIVITY 3: Psychosocial and Spiritual Support As part of a holistic approach to palliative care, patients

receive counseling by trained staff member at each clinic visit. A psychologist, a dietician and a social

worker based within the central office is responsible for education, training and support of site staff. Some of

the sites have established psychological and spiritual support groups. The Basic Package of Care including

acceptance of status, disclosure, prevention with positives, opportunistic infections, adherence counseling,

treatment literacy and nutrition counseling will be included at all Aurum funded sites (private sector).

ACTIVITY 4: Work with prisons

Aurum provides technical assistance to the Department of Corrections in Gauteng province in three areas:

1) assist in the development of the ART and care delivery system, 2) training health care workers on ART

and holistic palliative care, and; 3) development of a data management system to track prisoners who are

Activity Narrative: receiving ART and care support. Patients will be encouraged to bring family members in the facilities.

Training on couple counseling and counseling for children is given to the health providers. Family members

will be encouraged to test for HIV and will be provided education and counseling on HIV and TB. Those

family members that test HIV positive will be enrolled into Aurum's care program and will be provided with

all the services as already described above. 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 or the five categories of palliative care services. Aurum's palliative care

services contribute to the PEPFAR goals of 10 million people in care by increasing the quality of care.

ACTIVITY 5: Work with SME Employees

Aurum has established a project that strengthens the provision of services to SME employees, their

partners and dependents initially within the Johannesburg CBD. The project will be expanded to an

additional site in Gauteng as well as to Witbank and Polokwane. Aurum has developed partnerships with

the Johannesburg City Council and with individual companies that have existing occupational health care

clinics. Utilizing these partnerships and the mobile vehicles and GP network, HIV positive clients will be

screened for the presence of opportunistic infections, provided prophylactic therapy and provided education

on nutrition.

SUMMARY:

Aurum's TB/HIV program aims to integrate HIV care with TB prevention and treatment. This integration is

planned at all the HIV treatment sites which include general practitioners' clinics and community clinics

throughout the country. In addition, Aurum plans to improve TB/HIV integration at Chris Hani-Baragwanath

Hospital in Gauteng by providing support to the TB clinic in the form of nursing staff and data management

support. In addition, Aurum plans to work with the Platinum mining industry to insure TB/HIV integration

within the mining health services and to provide mobile services to contacts of miners who are treated with

TB. In the Eastern Cape, Aurum intends to provide support to Themba TB hospital to ensure they receive

accreditation to provide HIV services. Emphasis areas include human resources, infrastructure, commodity

procurement, logistics, quality assurance and training. The primary target populations are people living with

HIV (PLHIV), HIV-infected children, prisoners, homeless people and street youth. TB/HIV Care is a new

activity under the SME Project. The screening and identification of TB

cases among the employed sector and taxi drivers is of particular importance as they come into contact with

a large number of people each day and successful treatment will result in the prevention of several new

infections. In addition, successful identification and treatment of TB in the employed sector, including

Traders and Taxi drivers will ensure they continue to be economically active and are able to support

themselves and their dependents and continue to run a viable business. SMEs contribute half of the total

employment in South Africa and 75% of the employed people in Johannesburg utilize Taxis to commute to

and from work.

BACKGROUND:

The main focus of the Aurum program in the public, private and NGO sector is to provide HIV care and

treatment to a large number of persons in a cost-effective standardized manner ensuring a high quality of

counseling, patient care and patient monitoring. The model is centrally coordinated and designed to be

implemented on a large scale where the peripheral sites are in resource-constrained settings and lack HIV

specialists, information technology (IT) infrastructure, and laboratory and pharmacy capacity. Aurum has

developed a centralized system of support which includes the following: (1) training of all levels of

healthcare workers to ensure capacity building of clinicians to manage patients in resource-poor settings

with remote HIV specialist support; (2) provision and maintenance of guidelines for HIV preventive therapy

(including INH and cotrimoxazole), treatment of adults and children, prevention of mother-to-child

transmission and voluntary counseling and testing; (3) clinical and administrative support through site visits

by staff involved in psychological support, training, clinical support and monitoring data management

system; and (4) centralized distribution of medication and laboratory testing.

This program will supplement the South African government ARV rollout plan and therefore the program

adheres to national guidelines and protocols.

This is a new activity that only received PEPFAR funding since FY 2007, although Aurum has received

PEPFAR funds for other activities such as TB preventive therapy described in the FY 2006 COP under

palliative care. In most areas, clients are referred to the public health clinics for definitive diagnosis and

treatment of TB. Aurum is initiating a program where healthcare workers at sites are able to diagnose TB

patients using algorithms and guidelines that are in line with the National Department of Health (NDOH).

Healthcare workers then refer patients to public sector clinics for treatment. In addition, patients who test

HIV-infected under the counseling and testing program will be screened for TB.

ACTIVITIES AND EXPECTED RESULTS:

There are seven main activities in this program area.

ACTIVITY 1: TB Preventive Therapy for HIV-infected Individuals

CD4 count testing is done 6-monthly or 3-monthly in patients with CD4 above or below 350 respectively.

Patients are given TB preventive therapy with 300mg isoniazid taken daily for 6 months after exclusion of

TB, repeated every 2 years. Aurum expects that a minimum of 10% of all palliative care patients will require

TB preventive therapy. This integration will be implemented at all the HIV treatment sites run by general

practitioners and community clinics throughout the country. Sites include the Metro Evangelical Services

Clinic, which provides services for the homeless population and street youth of Hillbrow, Johannesburg, and

the Medical Research Council (MRC) sites, providing care primarily to women. Aurum's sites are located

primarily in Gauteng, North West and KwaZulu-Natal. There are sites in all the other provinces but only one

site in each of Northern Cape and Western Cape

ACTIVITY 2: Diagnosis and Treatment of TB in the HIV-infected

When initiating the ARV program or the palliative care program, a symptom screen and a chest radiograph

will be done on each patient. At each clinic visit, there is symptom screening by trained nurses. Guidelines

for screening tuberculosis will be followed and monitored. An evaluation of current screening practices is

currently underway and this will be used to ensure improved monitoring of screening and standardization of

the TB screening process. At Tshepong hospital the project will be enrolling new patients who are started

on treatment onto a TB screening process (including symptom screening, sputum testing and chest

radiography) to identify the most appropriate screening methods.

ACTIVITY 3: Support for HIV-TB integration services at Chris Hani-Baragwanath hospital

Aurum will provide support to provide TB/HIV integration services at the Chris Hani-Baragwanath hospital, a

large government hospital in Gauteng. Aurum will employ a nurse and counselor who will provide HIV

counseling and testing to all TB patients and ensure referral of those who test positive to the HIV clinic. In

addition, Aurum will develop a data system that will assist in ensuring successful incorporation of these

patients in the HIV care program.

ACTIVITY 4: Public-Private Partnership within Platinum Mining Industry

Aurum is establishing a partnership with Anglo Platinum and other platinum mining companies to strengthen

Activity Narrative: their TB/HIV integration activities within their mining facilities. In addition, a program to trace dependents

and household contacts of miners diagnosed with TB will be introduced. This program will include

household visits with HIV education and counseling, HIV testing, TB screening and referral for TB and HIV

services. Aurum aims to visit around 800 households with approximately 5 persons per household. In

addition, public TB services in the communities will be strengthened to cope with the increased workload.

Originally support to the platinum mining industry was to include a PHE, but as this PHE was not approved,

the funding is reprogrammed back into the TB-HIV services to support service delivery in this industry.

ACTIVITY 5: Support at Eastern Cape Themba TB hospital

Aurum will provide support to the Eastern Cape Themba hospital to assist them to obtain accreditation for

the national CCMT program. This support will include provision of limited renovation, staff and technical

support.

ACTIVITY 6: TB screening at Johannesburg Correctional Facility

Aurum will be undertaking a TB and HIV screening project at Johannesburg Correctional Facility. This will

determine HIV and TB prevalence and appropriateness of various screening methods. In addition it will

determine yield and cost-effectiveness of routine screening within the prison. This will be started with FY

2007 funding and completed in FY 2008. The project is expected to provide information that may lead to

routine screening in other facilities.

ACTIVITY 7: TB Activities in the SME Project

People identified as HIV infected through the counselling and testing process performed by the SME Project

will be screened for the presence of TB symptoms and referred for treatment to the nearest TB centre for

follow-up. At some sites, sputum collection will be performed according to South African government

protocols and the clients will then be informed of the results and referred for treatment. All HIV positive

clients who do not have active TB will be offered IPT and training on the use of IPT will be provided to

Aurum clinical staff, counselors, peer educators and staff at occupational health clinics. Education sessions

to SME employees will include the simple identification of TB symptoms, importance of treatment and

importance of IPT in HIV and their contacts.

ACTIVITY 8: Tembisa HIV-TB Integration

With FY08 reprogramming funds, Aurum will implement an integrated TB-HIV model for Tembisa (outside

Johannesburg) that will utilize the principles of intensive case finding, isoniazid prophylaxis and infection

control to improve TB-HIV services at Tembisa hospital, Tembisa Main Clinic and Winnie Mandela Clinic.

Additional clinics in the sub-district will also be identified for strengthening activities. This activity would aim

to engage private and civil society partners to ensure horizontal integration at the household level, utilizing

mobile services and capacity development of clinics.

In addition to these activities, Aurum will conduct a public health evaluation, described elsewhere in the

COP.

Title of study:

A preliminary study of screening for tuberculosis in a South Africa Correctional Facility

Expected timeframe:

June 2007 - June 2009 (Please note that this timeline is already delayed as the protocol development has

not been completed)

June 2007 - December 2007: Protocol development; Submission for ethical approval; Development of

participant information sheet and data collection forms

January 2008 - March 2008: Sourcing screening tools (sputum microscopy, culture and drug susceptibility

testing, CXR, urine test for HIV and LAM testing); Translation of all forms into relevant languages; Piloting of

all relevant forms; Design of database; Appointment of research nurses; Training of research nurses; TB

awareness campaigns within the correctional facility

April 2008 - December 2008: Recruitment of participants; Follow up of participants

January 2009 - May 2009: Finish follow up of participants; Begin write up of papers; Analysis of initial data

May 2009 - June 2009: Finish analysis of data; Finish write up of report; Dissemination of results

Total Projected Budget: $109,000

Local Co-Investigators:

Aurum Institute for Health Research:

a) Dr. Lilanganee Telisinghe: Study design, study management, data analysis, report writing

b) Dr. Mikateko Shisana: Study design, study management, negotiation with relevant authorities, data

analysis, report writing

c) Dr. Salome Charalambous: Study design, advice on study implementation, data analysis, report writing,

managerial oversight and support at the site

d) Professor Gavin Churchyard: Study design, advice on study implementation

Chris Hani Baragwanath Hospital:

a) Dr. Alan Karstaedt: Study design, advice on study implementation

Department of Correctional Services:

a) Dr. Gladys Nthageni: Study design, advice and assistance with implementation and support at the site

b) Dr. David Mathabathe: Study design, advice and assistance with implementation, support at the site and

liaison with prison authorities

London School of Hygiene & Tropical Medicine:

a) Dr. Alison Grant: Study design, advice on study implementation, data analysis, and report writing

b) Dr. Katherine Fielding: Study design, advice on study implementation, data analysis, and report writing

Project Description:

Correctional facilities provide a unique environment for the spread of tuberculosis. Currently in South

African correctional facilities, all new enrollees are seen by the medical team and screened for tuberculosis

using past history and current symptoms. We propose to actively screen a representative population of the

Johannesburg correctional facility, and we will also be offering screening to the staff, to determine the

prevalence of tuberculosis, among the offenders, and the staff. This will give a more accurate picture of the

burden of the disease and aid the control program by demonstrating how best to use new and existing

screening tools.

Evaluation questions:

Primary objective: Determine the prevalence of active tuberculosis among offenders in the Johannesburg

correctional facility in South Africa.

Secondary objectives:

a) Determine the proportion of prevalent TB that is undiagnosed

b) Comparing screening methods (symptoms, CXR, sputum microscopy, sputum culture and the new urine

LAM - Mycobacterial Lipoarabinomannan testing) to determine the optimal screening tool for active TB

among offenders

c) Investigate risk factors for prevalent TB, including HIV infection

d) Explore the prevalence of drug resistant TB

e) Explore the prevalence of TB among correctional facility staff that have volunteered to be tested

Anticipated study outcomes:

The results of this study will give a more accurate picture of the burden of tuberculosis within the

correctional facility. Screening will be done using a symptom questionnaire, sputum for microscopy and

culture, chest X-ray and the new urine Lipoarabinomannan test. Study participants will also we offered

testing for HIV. These results will aid the control programme by demonstrating how best to use new and

existing screening tools or tuberculosis. This, will not only improving the health of the offenders but also the

health of the staff.

The new experimental urine LAM (Mycobacterial Lipoarabinomannan) test for TB will be used in this study,

and its sensitivity and specificity and positive and negative predictive values will be calculated. This may

guide the future use of this tool in screening for tuberculosis.

Methods:

Following informed voluntary consent, all study participants will be screened for TB using a questionnaire

(with information on demographics and symptoms of active tuberculosis), two sputum specimens for

microscopy and culture, a chest X-ray and a urine specimen for LAM testing.

Activity Narrative: All study participants will be offered voluntary counselling and testing for HIV. If consent is provided, a rapid

test will be performed, and the results made available to the individual. The results of the rapid test will not

be used in the study. A second urine sample will be collected, for research purposes, if consent is provided.

It will be anonymously linked to the data gathered and will be anonymously tested for HIV. The results of

the urine tests will not be given to the study participants.

Any participant with a positive result on screening for TB will be recalled and reviewed with a further

symptom screen, two further sputum samples for microscopy and culture and a repeat CXR, for evidence of

active TB. All positive results obtained for an offender will be made available to the medical unit at the

correctional facility, so that they can be further evaluated and treated if appropriate.

If a diagnosis of TB has been made, we will ask the health services staff at the correctional facility to collect

extra information for these offenders on a study questionnaire, at 2 months, to judge response to treatment.

All offenders will have their medical records reviewed at 3 and 6 months, and if necessary at a later stage,

to see if they have been diagnosed with TB or any other condition.

If treatment is required for a staff member, a referral letter will be written to their preferred provider. With

their permission, we will contact staff members at 3 and 6 months to see if they have been diagnosed with

TB or any other condition.

The duration of recruitment will be April 2008 to December 2008 (9 months). Follow up of medical files will

be completed by May 2009.

Population of Interest:

The setting is a Medium B, Johannesburg correctional facility in Johannesburg, South Africa. The

population studied will be:

a) A representative sample of the Medium B, correctional facility population - both new admissions and

currently incarcerated offenders who have already been sentenced

b) All "members" (staff) working in Medium B of the facility (total estimated at 200-300) will be offered

confidential screening on a voluntary basis

The sampling procedure will be as follows:

OFFENDERS - Medium B: Total Sample Size 1000

Group 1:

a) New Entrants

b) Sample size 500

c) Consecutive new admissions

Group 2:

a) Sentenced Incarcerated Offenders

b) Sample size 500

c) Random sample from a list of existing offenders with a predicted stay greater than 6 months

STAFF - Medium B

All staff members will be offered confidential screening on a voluntary basis

Dissemination Plan:

All data will initially be presented to the Department of Corrections. Following this, we aim to present the

preliminary data at an appropriate conference and to publish the findings in a peer reviewed journal if

appropriate.

Budget for Year 1:

Object Classification Amount

Salaries/Fringe benefits $54,500

Equipment $0

Supplies $16,500

Travel $0

Participant Incentives $0

Laboratory testing $31,500

Other $6,300

Total $109,000

SUMMARY:

The Aurum program provides HIV counseling and testing (CT) for patients in private general practitioner

(GP) practices and non-governmental sites. Where Aurum provides support in the public sector, the

voluntary counseling and testing (CT) human resources and commodities are provided by the South African

government. Emphasis areas include human resources, commodity procurement and quality assurance.

The primary target populations are people living with HIV (PLHIV), HIV-infected children, prisoners,

homeless people and street youth. The SME Project will continue and expand counseling and testing

services offered to SME employees, their partners and dependents through fixed and mobile sites located

within targeted workplaces, mobile clinics and sites located within taxi ranks.

BACKGROUND:

Aurum Institute for Health Research (Aurum) is a not-for-profit, public benefit organization that is committed

to improving the health of disadvantaged individuals and communities through transformational research

(the research programs are not PEPFAR-funded), management of TB and HIV programs and provision of

HIV testing, treatment and care. The main focus of the Aurum program in the public, private and non-

governmental sector is to provide HIV care and treatment to a large number of persons in a cost-effective

standardized manner ensuring a high quality of counseling, patient care and patient monitoring. The model

is centrally coordinated and designed to be implemented on a large scale in peripheral sites that are

resource-constrained and lacking basic resources such as HIV specialists, information technology (IT)

infrastructure, and laboratory and pharmacy capacity. Aurum has established a centralized system of

support which includes (1) training of all levels of healthcare workers to ensure capacity building of

clinicians to manage patients in resource limited settings with remote HIV specialist support; (2) providing

and maintaining guidelines for HIV preventive therapy (including INH and cotrimoxazole), treatment of

adults and children, prevention of mother-to-child transmission and CT; (3) providing clinical and

administrative support through site visits by staff involved in psychological support, training, clinical support

and monitoring data management systems; and (4) maintaining a centralized distribution of medication and

laboratory testing. This program will supplement the South African government's antiretroviral rollout and

therefore the program adheres to national guidelines and protocols. This is an ongoing program funded by

PEPFAR since October 2004. It is a facility-based program in which Aurum works with general practitioners,

a faith-based organization (FBO) and within the public sector. In addition the SME Project will expand its

services to three additional fixed sites and two additional mobile clinics within Gauteng, Mpumalanga and

Limpopo.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Establishing Capacity for CT

This activity will take place in two primary health clinics and two prison clinics. This activity will include the

provision of and training of staff in these clinics as well as provision of running expenses for these clinics.

ACTIVITY 2: Counseling and Testing

HIV counseling and testing is conducted at selected GP sites, primary health centers and mobile units. The

counseling and testing includes pre- and post -test counseling and rapid finger prick testing with a screening

and a confirmatory test. Provision has been made for the mobile units.

ACTIVITY 3: Quality Control of HIV Testing

External Quality control is done at Aurum CT sites. Specimens are supplied on a monthly basis to the CT

sites and each staff member on site tests these. This is reported to Aurum by Thistle. Feedback on these

results is given at the quarterly refresher training.

ACTIVITY 4: Training on Voluntary Counseling and Testing

A five-day course is given to all new personnel involved in CT. In addition, an annual meeting is held and

new findings, discussions on counseling, running of support groups are covered. Training includes a focus

on stigma and discrimination.

ACTIVITY 5: Data Management

All encounters are recorded on a standardized form and then captured onto a centralized database that is

used for reporting.

ACTIVITY 6: Supply and Distribution of Testing Kits

Kits are ordered using a form that is faxed to, and authorized at, Aurum. The supplier then delivers the kits

to the sites.

ACTIVITY 7: Marketing and Promotion

Educational pamphlets and campaigns are provided. Various methods are being used to market and

encourage counseling and testing. Some sites (MES and Aurum Klerksdorp) run CT campaigns over short

periods of time. Other sites run activities on commemorative days such as Valentine's Day and World AIDS

Day. Marketing material is developed locally by the site according to their needs.

ACTIVITY 8: Expansion of Counseling and Testing in SME Sector

Activities in FY08 will include the expansion of counseling and testing services to additional sites in SMES

in Witbank Central Business District and Polokwane Central Business District. In addition an additional fixed

site will be established in partnership with the City of Johannesburg. This will enable market traders, taxi

drivers, commuters and SME employees and their dependents to access counseling and testing.

Partnerships will continue to be to be developed with individual SMEs to provide counseling and testing

onsite, within occupational health clinics where they exist or within Aurum's mobile vehicles. Additional staff

Activity Narrative: will be hired and trained to provide these services. In addition, occupational health staff will also be trained

and supplied with testing kits. As yet there remain restrictions of the use of rapid test kits by persons not

registered with the Health Professions Council but in the event of a change in the regulations, Aurum will be

in apposition to test and equip a number of lay counselors to also perform rapid testing.

Aurum will contribute to the PEPFAR 2-7-10 goals by promoting and providing counseling and testing

services to allow for entry into HIV care and treatment programs.

SUMMARY:

Aurum Health Research (Aurum) will use FY 2008 PEPFAR funding to continue an ongoing clinical program

that works through general practitioners and community clinics throughout the country, and to expand the

program to three public hospitals in the Eastern Cape, North West and Gauteng provinces. The emphasis

areas for this activity are human capacity development, local organization capacity building, and strategic

information. Target populations include infants, children and youth; adults, including men and women of

childbearing age; and people living with HIV (PLHIV), including HIV-infected pregnant women, infants and

children.

BACKGROUND:

The focus of the Aurum program in the public, private, and non-governmental sector is to provide HIV care

and treatment to a large number of persons in a cost-effective standardized manner ensuring a high quality

of counseling, patient care and patient monitoring. The model is centrally coordinated and implemented on

a large scale in peripheral sites that are resource-constrained and lacking in HIV specialists, information

technology (IT) infrastructure, and laboratory and pharmacy capacity. Aurum achieves this by having a

centralized system of support which includes the following: (1) training of all levels of healthcare workers to

ensure capacity building of clinicians to be able to manage patients in resource-poor settings with remote

HIV specialist support; (2) provision and maintenance of guidelines for HIV preventive therapy (including

INH and cotrimoxazole), treatment of adults and children, prevention of mother-to-child transmission and

voluntary counseling and testing; (3) clinical and administrative support through site visits by staff involved

in psychological support, training, clinical support and monitoring data management system; and (4)

centralized distribution of medication and laboratory testing.

The S Buys group (a private company) is responsible for the centralized procurement and distribution of

antiretroviral and preventive therapy. Negotiations with research-based pharmaceutical companies have

ensured that GlaxoSmithKline (GSK) drugs are available at access prices and members of the community

without medical insurance are able to access these medications.

ACTIVITIES AND EXPECTED RESULTS:

PEPFAR funds will be used in this program area to purchase, store and distribute ARV drugs. Patients who

are medically eligible for, but cannot afford, antiretroviral therapy will receive the drugs at no cost from

enrolled sites. The drugs will be prescribed using the South African Government's (SAG) eligibility criteria

and drug regimens. Generic medications purchased comply with the USG PEPFAR Task Force requirement

of U.S. Federal Drug Administration approval as well as approval from the Medicines Control Council of

South Africa.

The pharmacy plan comprises:

(1) Warehousing and stock control of drugs: A computerized system of stock control will ensure an audit

trail and batching abilities from the warehouse to patients.

(2) National distribution of medication: Through a courier service, S Buys is able to distribute medication

anywhere in South Africa within 24 hours of receiving the request. ARV drugs are dispensed centrally on a

monthly basis, and Aurum has not experienced any stock-outs.

(3) Named patient dispensing: Dispensing centrally at the pharmacy ensures that medication is controlled

and it facilitates a strict audit trail to the patient.

(4) S Buys pharmacy has in place stock control, pricing based on volume purchasing (where possible) and

has a process for checking compliance with ART guidelines.

(5) Integration with the Aurum Health Research (AHR) Project: This integration will help ensure adherence

to protocols, as well as communication between pharmacists and AHR. It will also allow for the integration

of data from drug dispensing sites.

(5) Aurum is working with sub-partners to ensure Department of Health accreditation for a number of sites,

allowing drugs to be provided by the government. A number of sites have already been accredited.

(6) Aurum will participate in the training of professional nurses in pharmacy skills.

Aurum's activities in ARV drugs contribute to the 2-7-10 PEPFAR goal of 2 million people receiving

antiretroviral treatment.

SUMMARY:

This activity provides support services at public facilities providing antiretroviral therapy as part of the

national ARV rollout and HIV care and treatment at primary health centers, clinical trial sites and general

practitioner (GP) practices. ART is provided in accordance with the National Department of Health (NDOH)

guidelines. The emphasis areas are renovation, human capacity development, and local organization

capacity building. The primary target populations are people affected by HIV and AIDS, HIV-infected

children, prisoners, homeless people and street youth.

BACKGROUND:

This is an ongoing activity funded since FY 2004, providing access to HIV care and treatment in the public,

private and NGO sector. This activity takes place in the following NDOH ARV sites: (1) Madwaleni Hospital,

Eastern Cape; (2) Tshepong Hospital, North West; and (3) Chris Hani-Baragwanath Hospital, Gauteng. In

addition Aurum intends to provide ARV services in FY 2008 to sites added in FY 2007: (4) Ermelo Hospital,

Mpumalanga, and (5) Thembisa Hospital, Gauteng. In FY 2008, Aurum intends to provide support to a

further two public sector hospitals. Aurum plans to provide support for down-referral in the following areas:

North West Province (Kanana clinic), Limpopo Province (Mathe-bathe clinic), Madwaleni-linked primary

health centers, Gauteng down-referral program and Northern Cape (Danielskuil clinic).

A number of sub-partners are involved in implementation of this activity:

1. Faranani Network is described in the Basic Health Care and Support activity and this network supports

treatment of people without medical insurance in general practitioner (GP) sites.

2. Reaction Consulting is based in the Mpumalanga Area. This is a public-private partnership with X-Strata

which provides the clinics. This organization received direct PEPFAR funding in FY 2007.

3. MES Impilo, a faith-based organization based in Hillbrow, Johannesburg, functions as a home-based

care center for the homeless population of Hillbrow, including street youth.

4. Medical Research Council (MRC) site based in KwaZulu-Natal, provides HIV services to prevention trial

participants (microbicides, diaphragms) who are found on screening to be HIV-infected.

5. De Beers Consolidated Diamond Mines has developed a public-private partnership in the town of

Danielskuil, Northern Cape where contractors and partners of employees are treated for HIV.

In addition, new sub-partners are envisaged as follows:

8. Department of Correctional Services: Aurum will provide support for HIV services including HIV

counseling, laboratory monitoring and preventive therapy in two correctional facilities - the Johannesburg

Correctional Facility and one other facility. The drug and laboratory costs would be funded by the South

Africa Government (SAG).

Additional sub-partners involved in the implementation of central activities include:

9. S Buys will be involved with procurement, dispensing and distribution of medications and will provide

pharmacy support at the Chris Hani-Baragwanath Hospital.

10. Toga Laboratories will assist with laboratory testing. Toga has negotiated with Bayer to secure reduced

pricing for viral load testing for the Aurum program. Toga is piloting a new initiative to place point-of-care

lactate tests at some of Aurum facilities to facilitate early recognition of ART adverse events.

11. Kimera Solutions will provide specialist HIV clinical support to doctors in the form of training and onsite

mentoring with regular site visits.

ACTIVITIES AND EXPECTED RESULTS:

The program activities include:

ACTIVITY 1: Wellness of HIV-infected Individuals

Human resources, laboratory monitoring and counseling services for patients who are enrolled into HIV care

are included (described in other sections of the COP). Aurum provides a continuum of care from provision

of counseling, preventive therapy and preparation for ART. In some sites (MRC, Reaction) patients are

referred to public health facilities for initiation of ART.

ACTIVITY 2: Provision of ARVs to Children

Provision of ARVs to children is a recent focus of the program. Aurum has partnered with Wits Paediatrics

(sub-partner of Reproductive Health Research Unit) to provide training for two Aurum clinicians. These

clinicians attend a pediatric clinic once a week to gain experience in pediatric care. This will help capacitate

Aurum to provide ARV services at pediatric units. Aurum is actively encouraging partners to provide

services to children and have provided for HIV PCR testing for children in this COP. One of the Aurum GPs

is involved in routine treatment of orphans and vulnerable children and has enrolled onto the Aurum

program as a provider. Also, Metro Evangelical Services and Caritas Care Centre have a few orphans

enrolled onto their hospice. We will attempt to expand to other partners who provide care to orphans and

vulnerable children.

ACTIVITY 3: M&E

M&E is a central component of the Aurum program. Every patient contact is recorded on a standardized

form and a unique patient identifier is allocated by the central Aurum office. The information is then

couriered or faxed to the central office where the data is captured in a database. Monitoring visits take place

at the sites to ensure adherence to guidelines and completeness of data collection. Quarterly reports are

Activity Narrative: produced for all stakeholders. Aurum also provides a data management system for the Adult ARV clinic at

Chris Hani-Baragwanath and Tshepong hospital in North West program. This system will also be

implemented at Thembisa hospital.

Provision of laboratory services is per a standardized schedule of follow-up in accordance with SAG

guidelines.

The program started in March 2005 and has established 60 treatment sites where about 7000 patients are

receiving ART and 80% achieve virological success at 6 months.

Aurum will contribute to the PEPFAR 2-7-10 goals by providing quality HIV care and treatment services in

the public, private and NGO sector.