SUMMARY:

This project is implemented by a consortium of organizations, including the Medical Research Council of

South Africa (MRC), the Health Systems Trust, the University of the Western Cape (UWC) and Centre for

AIDS Development, Research and Evaluation (CADRE). The project focuses on improving the outcomes of

HIV-infected women and their infants through multiple approaches at the facility and the community level.

The project will also include a targeted evaluation of PMTCT effectiveness. Emphasis areas include

community mobilization/participation, needs assessment, quality assurance and supportive supervision,

strategic information, and training. Target populations include infants, women, pregnant women, people

living with HIV (PLHIV), HIV-affected families, nurses, and other healthcare workers.

BACKGROUND:

This ongoing project, started in FY 2005, builds on the PEPFAR-funded Good Start Cohort Study. The

study results highlighted the need for greater community support for HIV-infected mothers in relation to

infant feeding and postnatal care, and health systems weaknesses that have contributed to the poor

performance of PMTCT programs.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Community Peer Support Project

With FY 2005 and FY 2006 PEPFAR funding, UWC developed training materials and trained 36 locally-

identified peer supporters in basic child health skills. In FY 2007, the project focused on identifying pregnant

women in 34 project clusters, followed by providing peer support to each of these households until the

infants reached six months of age. The activity aimed to support exclusive infant feeding practices (either

exclusive breastfeeding or formula feeding); encourage mothers to attend antenatal care and to be tested

for HIV; support disclosure of HIV status; support access to child support grants; encourage women to

attend clinics postnatally for immunizations; provide cotrimoxazole and access to antiretroviral (ARV)

therapy if required; and support early cessation of breastfeeding for HIV-infected women choosing to

breastfeed. In FY 2008, the project will focus more on the early neonatal period, with the peer supporter

visits beginning within 24-48 hours after delivery. This change in focus is aimed at created greater linkages

between communities and the facility-based PMTCT programs. During their initial visits, peer supporters will

ensure that HIV-infected women's infants received nevirapine and that the women are aware of ongoing

PMTCT-specific care during the postnatal period. Funding for this activity will be used to provide a stipend

to the peer supporters, for supervision and mentoring of peer supporters and for transport to visit mothers in

the clusters. The expected results from this activity include identifying HIV-infected women and providing

community peer support to these women from the antenatal stage until the infants reach 10 weeks of age.

ACTIVITY 2: Monitoring and Evaluation:

Data collectors will be recruited to determine if the provision of peer support leads to increases in exclusive

infant feeding practices, uptake of PMTCT-specific care (e.g. nevirapine CD4 testing, infant six week

testing, cotrimoxazole) and improved infant HIV-free survival at 12 weeks. Data will be collected from

mothers enrolled in the project when their infants reach 12 weeks. Information on infant feeding practices,

morbidity, infant growth and health-seeking behavior of mothers will be collected. Dried blood spots will be

taken to determine the rate of mother-to-child transmission of HIV at 12 weeks. This data will be used to

determine the effectiveness of the peer supporter program on infant survival. The data will be reported to

the provincial departments of health and based on the findings the provinces will determine how the peer

supporter program should be scaled up.

ACTIVITY 3: Community Voluntary Counseling and Testing (VCT)

Using FY 2007 Funding, development of a pilot community-based VCT project for pregnant women is

underway. FY 2008 funding will ensure continuation of this pilot project. This activity is being undertaken in

the rural district of Sisonke in KwaZulu-Natal. It was designed in response to the finding that many pregnant

women in this district do not know their HIV status and are not accessing facility-based antenatal VCT. FY

2008 funding will ensure employment of community VCT counselors who will go door to door in their

communities identifying pregnant women and offering them home-based pre-test counseling. If women

agree to be tested, a mobile testing team led by a nurse will visit the home to perform the testing and post-

test counseling. Other household and family members will also be able to receive VCT. This project aims to

assess the feasibility and acceptability of a home-based VCT model in a rural area in South Africa.

ACTIVITY 4: PMTCT Integration

During FY 2006, this project developed a baseline assessment tool to assess the integration of PMTCT

within maternal and child health services. The assessments began in 2006/2007 in all facilities in two

districts in KwaZulu-Natal and were undertaken as a participatory process with district management teams.

During FY 2007, the results of the assessments were fed back to districts during workshops where district

teams identified interventions aimed at improving PMTCT service delivery. Examples of interventions

include provider-initiated opt-out antenatal HIV testing and an intervention to adapt the infant Road to

Health Chart to improve the identification of HIV exposed infants. The main focus has been on providing

technical assistance to district management teams to act on the identified bottlenecks to integration by

developing action plans. During FY 2008, the project aims to implement the identified interventions in the

two districts in KwaZulu-Natal and to monitor the effect of the interventions on key PMTCT indicators.

ACTIVITY 5: Facility-based Intervention

This project will involve various interventions to improve the quality of PMTCT care. Interventions would

include training health workers on appropriate use of PMTCT and HIV registers and training on

HIV/TB/PMTCT integration. During FY 2006 and 2007, two training workshops on TB/HIV/PMTCT registers

were held in Sisonke district with 50 people trained. The revised registers have been introduced in the

district. During FY 2008, the project plans to implement strategies to improve the linkages between the TB,

HIV and PMTCT program through management training, information system support and operational

research activities. This activity will be undertaken in Sisonke district, a rural part of KwaZulu-Natal.

Activity Narrative:

These activities will contribute to PEPFAR's 2-7-10 goals by promoting exclusive infant feeding practices

among HIV-infected women, increasing the number of pregnant women who are aware of their HIV status

and who can access PMTCT, improving the quality of PMTCT services and providing strategic information

regarding the operational effectiveness of PMTCT. Ensuring that more pregnant mothers are aware of their

HIV status will empower more women to access PMTCT interventions, and a significant number of

postnatal HIV infections will be averted by increasing the number of women who practice exclusive feeding

during their infants' first year of life. These activities are in line with the USG goal of integrating maternal and

child health services into primary care systems.

PMTCT National Public Health Evaluation (PHE)

Title of Study: Targeted National PMTCT Evaluation

Time and Money Summary: The Consortium (Medical Research Council of South Africa (MRC), the Health

Systems Trust, the University of the Western Cape (UWC) and Centre for AIDS Development, Research

and Evaluation (CADRE) is using FY 2007 funds to conduct an analysis of the cohort data described below

and consultation with relevant experts and stakeholders to develop the research plan for the cross-sectional

national PMTCT survey. The initial modeling analyses and research planning activities will be completed

within one year of receipt of funds. The project started in July 2007 and the project is expected to run over

three years. The activities described in the 2007 COP are expected to be completed in the first year of

funding. There will be no funds leveraged from other sources.

Local Co-investigator: The Principal Investigator for the MRC CDC-PEPFAR award is Mickey Chopra. This

project will be conducted through a consortium of research partners, including the following co-investigators:

Debra Jackson from University of the Western Cape; Mark Colvin and Alan Matthews from CADRE (Dr.

Matthews is also a SACEMA Fellow); Ameena Goga from University of the Witswatersrand; and Tanya

Doherty and Wesley Solomons from the Medical Research Council.

Project Description: At the request of the National Department of Health (NDOH), MRC has been requested

to evaluate the national PMTCT program. In FY 2007 the project focuses on analysis of cohort data, review

of the literature and beginning modeling the transmission data from the previous PEPFAR funded PMTCT

cohort study. This will provide estimates of postnatal HIV transmission across three sites with different infant

feeding patterns. FY 2007 also focuses on the development of a cross-sectional study design and planning.

As part of this planning process, during FY 2007 relevant national, provincial and local stakeholders are

engaged to assure relevance of the cross-sectional survey for program policy and planning. During FY 2008

the project will undertake a nationally representative survey of facilities providing PMTCT in all nine

provinces. This cross-sectional component will take place at immunization clinics where mothers who are

bringing their infants for six week immunizations will be asked for consent to perform an ELISA test on their

infants. A positive ELISA test indicates that the infant was exposed to HIV. In this event, a further blood spot

will be tested with a DNA PCR to determine early transmission rates. Mothers will also be interviewed to

determine their access to PMTCT during antenatal care. Finally, after completion of the cross-sectional

survey, data from the cohort studies will be used to model late transmission of HIV, and this data will be

taken from results obtained from the cross-sectional approach as six week testing is the recommended

testing point in the national program and most infants are lost to follow up after this point. Data from the

evaluation will be used by provincial and national departments of health to strengthen PMTCT service

delivery.

Status of Study/Progress to Date: A study protocol has not yet been developed. A study protocol will have

been developed and submitted to the MRC Research Ethics Committee and the CDC for review during FY

2007.

Lessons Learned: Not applicable. This project has only just started.

Information Dissemination Plan: Once the evaluation has been completed, presentation of data will be

made to national and provincial stakeholders in PMTCT and HIV and AIDS Policy and Programs. In

addition, the consortium will develop policy briefs for policymakers summarizing the key findings in simple

language and making brief practical policy recommendations. Presentations will also be made at relevant

scientific meetings and manuscripts prepared for submission to peer review journals in the field of public

health and/or HIV and AIDS.

Activities: FY 2008 COP activities will be expanded to include: (1)Cross-sectional survey of a representative

national sample of PMTCT sites throughout South Africa. (2) On-going development of models for postnatal

transmission of HIV based on the previously conducted cohort study, national data and national and

international literature in coordination with South African Centre for Epidemiologic Modeling Analysis

(SACEMA). FY 2008 COP activities will be planned in greater detail once the initial planning phase (using

FY 2007 funds) has been conducted.

Budget Justification for FY 2008 Monies (please use US dollars):

Salaries/fringe benefits: $150,000

Equipment: $10,000

Supplies: $5,000

Travel: $100,000

Participant Incentives: $10,000

Laboratory testing: $200,000

Other: $25,000

Total: $500,000

SUMMARY:

There are these separate programs being implemented by the Medical Research Council (MRC) in this

program narrative. The first focuses on vulnerable populations, the second on gender-based violence and

HIV, and the third on male circumcision. MRC's FY 2008 activities in the area of vulnerable populations

build on FY 2005, 2006 and 2007 PEPFAR investments to strengthen programs serving IDUs, sex workers

and MSM by developing the capacity of organizations to deliver services that enable these populations to

reduce risk of HIV infection. Activities will focus on creating multi-sectoral and multi-disciplinary consortia of

substance abuse and HIV organizations and developing organizational capacity to implement targeted

community-based outreach interventions, linking outreach efforts to risk reduction counseling related to

drugs and HIV, and access and referral to substance abuse, HIV care, treatment, and support services. In

addition, the MRC will design and implement a behavioral HIV prevention intervention to reduce sexual risk

behavior associated with alcohol use in bars in Tshwane. The major emphasis areas are the development

of networks, linkages, and referral systems; and information, education and communication. Emphasis

areas include local organization capacity building; quality assurance and supportive supervision; and

training. Target populations are men, women, pregnant women, youth at risk, high-risk vulnerable

populations and support organizations for IDUs, sex workers, other healthcare workers, community-based

organizations (CBOs), non-governmental organizations (NGOs) and MSM.

BACKGROUND:

Findings from the South African-conducted International Rapid Assessment Response and Evaluation (I-

RARE) of drug use and HIV risk behaviors among vulnerable drug using populations (injecting drug users

(IDUs), sex workers and men who have sex with men (MSM) point to: high prevalence of overlapping drug

and sexual risk behaviors; high prevalence of HIV in these populations; high levels of alcohol use and

sexual risk behaviors and barriers to access and utilization of risk reduction, substance abuse and HIV

services.

In FY 2005, PEPFAR supported MRC to conduct a rapid assessment of drug use and HIV risk among IDUs,

sex workers and MSM in Cape Town, Durban, and Pretoria. In FY 2006, PEPFAR supported the convening

of public and private partners, stakeholders, and organizations serving the target populations to develop

recommendations, based on the findings of the rapid assessment. In FY 2007 and FY 2008, the MRC, in

collaboration with a consortium of organizations and provincial governments is in the process of

implementing interventions to reduce high-risk drug use and sexual behaviors and increase access to and

utilization of services.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Linking and Coordination of Drug Abuse Treatment and HIV

Finding of the rapid assessment indicate lack of linkages and coordination of drug abuse treatment and HIV

services. This activity focuses ondeveloping the capacity of Non government organizations (NGOs) and

community-based organizations (CBOs) and other HIV and drug service organizations serving IDUs, sex

workers and MSM to implement interventions targeting high-risk drug use and sexual behaviors and

increase their access to and utilization of services. This activity will support the formalization of consortia

linking drug abuse treatment and HIV service delivery organizations and the development of capacity

among the consortia for the provision of comprehensive HIV and AIDS programs tailored for drug using

vulnerable populations and adapted to the local epidemic. Components will include community-based

outreach, risk reduction counseling, access and referral to HIV counseling and testing, substance abuse,

and other HIV care and treatment services, including STI services. Community workers will be trained to

access hidden populations and provide risk reduction related to violence, drug use, injecting and safer sex.

Existing training manuals will be adapted to train outreach workers to implement community-based

outreach. FY 2008 activities will be expanded to include underserved areas outside of the Durban, Cape

Town, Tshwane metropolitan areas and in Mpumalanga province.

ACTIVITY 2: Design and Implement an HIV Intervention to Reduce Sexual Risk Behavior Associated with

Alcohol use in Tshwane Bars

Using FY 2006 funding, MRC conducted formative research to identify a range of intervention methods that

may be effective in reducing HIV sexual risk behavior associated with alcohol consumption. FY 2007

funding was used to develop specific bar-based intervention using methods proven to be effective in prior

research. Future plans for this project build on FY 2006 and FY 2007 PEPFAR investments. In FY 2008, the

MRC will continue to refine the interventions and make recommendations for implementation in other

provinces and locations. FY 2008 COP activities will involve completing the pilot; collecting three-month

follow-up data; making recommendations for adapting and scaling up the intervention to diverse socio-

cultural settings.

ACTIVITY 3: Design and Implement an HIV Intervention to Reduce Sexual Risk Behavior Associated with

Alcohol Use in Cape Town

Formative work related to (1) the design of a behavioral intervention aimed at reducing alcohol-related

sexual HIV risk and gender-related violence for women in Cape Town, (2) designing behavioral

interventions aimed at reducing drug abuse during pregnancy and associated HIV risk behavior, (3)

designing behavioral interventions aimed at reducing drug-related HIV risk behavior among first time

juvenile offenders and (4) better understanding the pathways through which alcohol affects HIV

transmission and quantifying this association.

ACTIVITY 4: Effective delivery of PEP after rape: challenge of compliance

Monitoring and support of patients on anti-retroviral therapy (ART) is an important aspect of AIDS treatment

and the daily support to patients to facilitate medication adherence during the initial stage is seen as an

essential aspect of care (NDOH National Antiretroviral treatment Guidelines, 2004). Many lessons on how

to support patients receiving post-exposure prophylaxis after a sexual assault can be gained from the ART

program, and include extensive pre-treatment information and education, encouraging use of tools such as

adherence diaries and motivational interviews during the initial period of pill-taking. The MRC is currently

Activity Narrative: engaged in a small proof of concept study that will lead to the development and testing of an information

leaflet for patient education and adherence diary and of a model of providing nurse-led telephonic support in

sites in the Western Cape and Eastern Cape with funds from Irish Aid. MRC will build on this work by

developing two components of health service delivery and undertake an evaluation to determine impact of

these on compliance with 28 day PEP courses. The first model of service delivery would be a model of

nurse-led counseling for rape survivors that could be provided during the routinely scheduled weekly follow

up visits to which patients are currently invited in services. The counseling would include adherence

counseling, but would mostly focus on providing general psychological support for rape victim/survivors.

The second model would be of follow up contact with victim/survivors on intermittent occasions during the

28 day period over which PEP is recommended. The model would seek to establish contact on days 2, 5,

13 and 20 after rape either by cell phone (~70% of South Africans have these) or home visit with the aim of

providing support and encouraging adherence. The counseling model would build on existing good practice

in the services. MRC will identify examples, study the approach and content of counseling in these settings,

and develop a short training intervention that would train staff to follow the counseling model. The

telephonic intervention would build on the MRC research in progress, but would in addition develop a model

of home visitation that would be feasible and affordable for health services, building again on current good

practice. The interventions will be implemented in the Western Cape, Eastern Cape and Gauteng Provinces

in 24 sites providing care to sexual assault victim/survivor. Target population includes all victim/survivors of

gender-based violence, including men, women and children of all ages. Victim/survivors would be given a

leaflet about rape and HIV with an adherence diary. Staff at the sites will be trained to provide counselling

during weekly follow up visits.

Activity 5: A rapid appraisal of traditional male circumcision (mc) and initiation processes

At the request of the NDOH, MRC will implement a rapid appraisal of traditional mc practices in 7 provinces

of South Africa. The purpose of the activity is to gain an in-depth understanding of the processes, practices

and meaning of initiation for boys and to gain an in-depth understanding of the community's response to the

finding that mc plays in the role of HIV prevention. The rapid appraisal will be conducted through the

implementation of focus groups, in-depth interviews and key informant interviews. The findings will be

presented to the ministry of health together with a policy brief highlighting how HIV prevention messages

and behavior change can be integrated into traditional male circumcision processes.

Results contribute to PEPFAR 2-7-10 goals by preventing infections among vulnerable drug using

populations, and encouraging them to know their status and be appropriately referred to treatment services.

The gender-based violence component will ensure prevention of transmission to survivors of sexual assault,

and the rapid appraisal will help formulate policy around the incorporation of HIV prevention into traditional

initiation processes

SUMMARY:

The Medical Research Council (MRC) in partnership with University of the Western Cape (UWC) will

strengthen basic care and support to people living with HIV (PLHIV) by developing training modules, and by

improving monitoring and evaluation of the impact of nutritional support provided to PLHIV. The proposed

project aims to train and build capacity throughout South Africa. This project will implement a mixture of

short and distance learning courses, and related mentoring activities. The overall aim of this activity is to (a)

strengthen nutrition programs in relation to HIV and AIDS and TB; (b) facilitate future development of

community-based programs; and (c) enable evaluation of the effects of nutrition interventions through other

programs. The target population includes national, provincial, district, sub-district, and facility level nutrition,

maternal and child health, TB and HIV managers, and non-governmental organization's (NGO) managers

who are involved in the management of TB and HIV programs at either the facility or community level.

BACKGROUND:

Significant resources are invested in providing nutrition supplements to many patients on antiretroviral

treatment (ART). Hundreds of nutrition advisors and dieticians have been employed to provide nutrition

counseling, and the Department of Social Development is implementing a large HIV and AIDS livelihoods

program aimed at improving access to nutrition.

There has not been a formal evaluation of nutrition programs. However, reports from provincial government

and other food and nutrition programs in the country strongly point to the lack of human resource capacity to

implement, monitor, and evaluate these interventions optimally. This project aims to strengthen the capacity

of provincial, district and sub-district nutrition and HIV managers to design, monitor, and evaluate facility

and community-based food and nutrition interventions targeting people infected with HIV and TB.

ACTIVITES AND EXPECTED RESULTS:

Building such capacity is particularly challenging since a large number of people need to be reached but as

these people (managers) are in positions of responsibility they cannot be removed from their posts for

significant periods. The School of Public Health at the University of the Western Cape has conducted short

courses on nutrition policies and programming, nutrition information management and nutrition science for

more than 10 years, recently in collaboration with Tulane University's School of Public Health and Tropical

Medicine. However, the impact of such short courses is limited by the lack of follow up to consolidate and

implement such learning. Experience suggests that the combination of intensive face-to-face sessions along

with distance learning materials that encourage the implementation of knowledge learned, followed by

feedback and further learning can be an effective strategy. This project therefore aims to create learning

modules including a mix of face-to-face and distance learning formats. These modules are described in

detail below.

ACTIVITY 1: Nutritional Aspects of the Management of HIV and TB

This module will summarize the latest scientific evidence on the relationship between nutrition and TB/HIV;

provide updates on latest nutritional guidelines for HIV; include challenges of implementing clinical

guidelines; and provide information on aspects to consider when implementing nutrition interventions in

primary healthcare settings.

ACTIVITY 2: Nutrition Programming and Planning

This will build upon a module created by the University of the Western Cape with input from Tulane

University. The focus of this module is on community-based HIV and nutrition programs. This module will

emphasize the design, development, and implementation of community-based health and nutrition

programs, and their adaptation and application to addressing the HIV epidemic.

ACTIVITY 3: Nutrition Information Systems, Including Program Monitoring and Evaluation

This course will be based on existing modules used at Tulane University and University of the Western

Cape; a recent short course on this topic, run by UWC and Tulane with UNICEF support, provides a basis

for a distance module. Each of these modules will consist of five days of face-to-face teaching along with

readings and exercises that focus on the implementation of what has been learned. Participants may take

related distance learning courses that will count towards a masters degree in public nutrition, to be

developed under this program.

ACTIVITY 4: Mentoring and Trouble-shooting

The capacity to follow up with people trained through this process, and others working in national and local

offices, will be developed. Mentoring is already part of the UWC teaching procedures, with participants

conferring with faculty during the period of their learning (mostly in a distance format). These efforts will be

expanded to supporting nutritional interventions, which will require some strengthening of UWC/Tulane

capacities themselves. Trouble-shooting problems, as they arise, may form an integral part of this process.

The people who can provide this mentoring may be from UWC/Tulane, from other institutions (e.g. faculty of

other universities who participated in the UWC/Tulane training - and who may be providing similar training

themselves). Some resources will be needed for the mentors' time and travel expenses even though some

mentoring can be done at a distance by email for example.

Through the strengthening of and integration of nutrition into basic HIV and AIDS and TB services, the MRC

and its partners will help PEPFAR achieve its 2-7-10 goals.

SUMMARY:

The Medical Research Council (MRC) will carry out activities to support a comprehensive best-practice

approach to integrated TB/HIV care at existing sites and new sites in KwaZulu-Natal, North West, Eastern

Cape, Western Cape and Mpumalanga. The project aims to improve access to HIV care and treatment for

tuberculosis (TB) patients by strengthening the role of TB services as an entry point for delivery of HIV and

AIDS care, and by expanding TB screening to people living with HIV (PLHIV). Project results and lessons

learnt will be shared with the national and provincial Departments of Health to inform existing policies and

guidelines on TB/HIV care. TB patients and PLHIV are the key target populations and include pregnant

women (referred to PMTCT services) and children (receiving ARVs if indicated).

BACKGROUND:

The MRC initiated a best-practice approach to integrated TB/HIV care with FY 2004 PEPFAR funding. Early

activities included a systematic description of barriers faced by TB patients co-infected with HIV in an

accredited antiretroviral (ARV) site, and in FY 2005, activities were focused on the development and

implementation of a best-practice model. Preliminary results from the model site confirmed the benefits of

an integrated TB/HIV approach, reflected in a drastic reduction in patient mortality, improved quality of life

for TB patients living with HIV and prolonged survival rates. Results also confirm the safety and efficacy of

dual regimens, showing that antiretroviral treatment (ART) can safely be instituted within the first month of

TB treatment. Activities in the established sites will continue in FY 2008. The best-practice approach will be

expanded to additional sites in FY 2008 i.e. one site in Mpumalanga, 2 sites in the Western Cape, one site

in the Eastern Cape and one more site in the North West. The best-practices model drew from lessons

learnt in the start-up sites, such as the need for essential human resources, the importance of negotiated

partnerships with health departments, and the challenges posed by dual stigmatization and discrimination.

The new sites are characterized by extreme poverty, poor health infrastructure, cross border migration and

limited healthcare access. Meeting the challenges of an integrated TB/HIV approach in such settings will be

specifically addressed, as will strengthening down-referral capacity in existing sites. Activities are

implemented by the MRC and sub-partners, World Vision and the Foundation for Professional Development

(a PEPFAR prime partner).

ACTIVITIES AND EXPECTED RESULTS:

Activities include provider-initiated HIV CT; TB screening by symptoms and sputum investigations; referral

to appropriate services such as PMTCT, STI and partner counseling programs; and enrollment of patients in

relevant HIV care and treatment programs. Three activities will be implemented:

ACTIVITY 1: Best-Practice Model

The MRC will support implementation of a best-practice model of integrated TB/HIV care in sites providing

TB and HIV services. This approach involves: (1) clinical management (CT, ART, management of adverse

drug effects, STI management, preventive therapy); (2) nursing care (TB screening, patient education,

treatment adherence, HIV prevention); (3) integrated TB/HIV information, education and communication; (4)

nutrition intervention; and (5) palliative care and support. Activities include site renovation to meet SA

accreditation requirements for ARV rollout, site and supervisory staff training, hiring key personnel,

development of patient educational materials, commodities procurement, and establishment of appropriate

referral links, including those with governmental ARV sites to ensure continuity of care. MRC will monitor CT

practices, strengths and weaknesses of TB/HIV referral systems, human resources and conventional TB

treatment outcomes. The MRC will implement ongoing quality assessments through onsite supervision and

external quality assurance mechanisms such as checklists. Regular feedback meetings will be held with

project staff and Provincial representatives in the relevant programs to identify potential problems and to

facilitate corrective action. Stigma around HIV, AIDS and TB is specifically addressed through patient

education and targeted interventions such as peer group counseling and advocacy campaigns. Results

from the project will facilitate evidence-based policy formulation on expansion of integrated TB/HIV care,

improve access to HIV care by co-infected TB patients, and increase TB case finding among PLHIV.

Implementation of lessons learnt in the best-practice approach will facilitate rapid identification of systems

and operational needs, and allow for corrective action. Results of this expanded approach to integrated

TB/HIV management will facilitate national scale-up of comprehensive programs for dually-infected patients.

This activity will strengthen TB services as a point of delivery of ART, by ensuring that human, financial and

infrastructure needs for integrated TB/HIV programs are met through equitable allocation of scarce

resources and through analyses of cost-effectiveness and cost-benefit. Increased TB case finding in HIV

settings is a crucial component of disease control; yet largely lacking in routine health services. In FY 2008

the project will continue to evaluate strategies for active TB case finding in vulnerable populations and

assess implications for TB and HIV control programs. PEPFAR funding will also be used to implement an

integrated electronic patient information system at the sites to support routine data collection, facilitate

patient referral and allow data transfer to the national routine TB recording and reporting system, which is

now integrating HIV testing and service data. Lastly, funds will be used to support an International Training

Centre (ITC) on multidrug-resistant TB (MDR-TB) and HIV. The ITC's focus will be on human capacity

development. TB and MDR-TB infection control in HIV settings and prevention of institutional transmission

and outbreaks will be a prime focus area. Training will utilize didactic, interactive adult teaching methods

aimed at different health sector groups (clinical, nursing, health facility management, health facility design

and maintenance), and will be enriched by mentorship programs and study tours through the SA network of

MDR-TB hospitals.

ACTIVITY 2: Community TB/HIV Case Finding and Holding Among Women in PMTCT

This activity will identify pregnant women in the 34 project clusters and provide peer support to each of

these households until the infants reach 6 months of age. Community peer supporters will educate

households on symptoms of TB, cure rates, and adherence to TB treatment. They will refer household

members with TB symptoms to health services for diagnosis. Children under 5 years who are TB contacts

will be referred for TB preventive therapy, and HIV-infected mothers will be encouraged to take HIV-

exposed infants for CPT, PCR testing and screening for ART. In addition, adherence support for all

household members on TB treatment, to pregnant women/mothers taking ART and infants on CPT or ART

will be provided. PEPFAR funds will provide stipends to peer supporters and allow for

Activity Narrative: supervision/mentoring of peer supporters and transport to visit mothers in the clusters. Expected results

include: recruitment of HIV-infected women, provision of community peer support and referral of TB

suspects. MRC's activities contribute to the PEPFAR goals by integrating TB and HIV services and

expanding access to care and treatment.

SUMMARY:

Within this program area, the Medical Research Council (MRC) supports two activities directed by different

project directors. The first project focuses on capacity building for organizations to support HIV counseling

and testing among high-risk populations while the second project integrates HIV counseling and testing into

TB control services. The major emphasis area for these activities is the development of networks, linkages,

and referral systems between outreach workers, non-governmental and community-based organizations

(NGOs, CBOs), and healthcare service providers. Minor emphasis areas include community

mobilization/participation; information, education, and communication; linkages with other sectors and

initiatives; local organization capacity development; policy and guidance; quality assurance, quality

improvement, and supportive supervision; strategic information; and training. Primary target populations are

high-risk vulnerable populations, (including injecting drug users (IDUs), sex workers, and men who have sex

with men (MSM)), and organizations that provide service to these populations. This project is consistent

with the revised South African National Drug Master Plan and will provide guidance on how the South

African Government can translate strategies into action. Across all activities, sustainability is addressed by

linking HIV counseling and testing, care and support services for vulnerable populations, developing the

capacity of existing programs, creating synergy across organization and service provider networks,

providing quality assurance and refresher trainings, and enhancing data management systems. The project

will focus on (a) increasing gender equity in HIV and AIDS programs, reducing violence, increasing

women's access to income and productive resources; and (2) reducing stigma and discrimination

associated with HIV status and vulnerable populations.

BACKGROUND:

In FY 2005, PEPFAR supported the MRC to conduct a rapid assessment of drug use and HIV risk among

IDUs, sex workers, and MSM in Cape Town, Durban, and Pretoria. In FY 2006, PEPFAR supported the

convening of public and private partners, stakeholders, and organizations serving the target populations to

develop recommendations, based on the findings of the rapid assessment. In FY 2007, the MRC, in

collaboration with a consortium of organizations and provincial governments, is well positioned to implement

interventions to reduce high-risk drug use and sexual behaviors and increase access to and utilization of

services.

The MRC initiated a best-practice approach to integrated TB/HIV care with FY 2004 PEFAR funding. The

project aims to improve access to HIV care and treatment for tuberculosis (TB) patients by strengthening

the role of TB services as an entry point for delivery of HIV and AIDS care, and by expanding TB screening

to people living with HIV (PLHIV). TB patients and PLHIV are the key target populations and include

pregnant women (referred to PMTCT services) and children (receiving antiretroviral treatment (ART) if

indicated). Activities in the established sites will continue in FY 2008. The best-practice approach will also

be expanded to additional sites in FY 2008. The new sites are characterized by extreme poverty, poor

health infrastructure, cross-border migration, and limited healthcare access. Meeting the challenges of an

integrated TB/HIV approach in such settings will be specifically addressed as will strengthening of down-

referral capacity in existing sites. The MRC and sub-partners, World Vision and the Foundation for

Professional Development, implement activities.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Linking Community-based Outreach to HIV Services among Injecting and Non-Injecting Drug

Users, Drug-Using MSM, and Drug-Using Women Engaged in Sex Work

Three separate activities focusing on the target groups (IDUs, CSWs, and MSM) are consolidated into one

activity description as they share similar components.

A major finding of the rapid assessment indicates a lack of linkages and coordination of drug abuse

treatment and HIV services. The focus of this activity is developing the capacity of NGOs and CBOs and

other HIV and drug service organizations serving IDUs, sex workers, and MSM to implement interventions

targeting high-risk drug use and sexual behaviors and to increase their access to and utilization of services.

Specifically, this activity will support the formalization of consortia linking drug abuse treatment and HIV

service delivery organizations in Cape Town, Durban, and Pretoria/Johannesburg. This activity will develop

the capacity and skills among the consortia for the provision of comprehensive HIV and AIDS programs

tailored for drug users and adapted to the local epidemic. Components will include community-based

outreach, risk reduction counseling, and access and referral to HIV counseling and testing, substance

abuse, and other HIV care and treatment services. Individuals reached by outreach efforts will be linked

with tailored HIV counseling, testing, treatment, and other support services. Service providers will be cross-

trained to respond to issues of violence, drug abuse and HIV, including issues of sensitivity, confidentiality

and stigma related to vulnerable populations. To facilitate integration among drug and HIV services, a

system for referrals from counseling and testing to other services will be established in the consortia to

ensure HIV-infected and HIV-negative clients are linked to appropriate prevention, care, and treatment

services (e.g., antiretroviral treatment, PMTCT, palliative care, STI and tuberculosis treatment, substance

abuse treatment, and transitional services including job skills and income generation activities).

ACTIVITY 2: Managing, Monitoring and Rapidly Evaluating Links and Coordination of Drug Treatment and

HIV Services for Drug Using Populations

Activity Narrative:

In preparation for activities in FY 2007, the MRC will conduct formative key informant and focus group

interviews to ensure interventions are aligned with the current local epidemic and adapt existing training

manuals for community-based outreach. This activity will support the MRC in the management, oversight,

monitoring, and evaluation of the three activities summarized under Activity 1. The MRC will regularly

monitor all aspects of the activities, including ensuring that sub-partners coordinate provision of trainings by

local AIDS training centers. The MRC will establish a system for collecting data on targets on an ongoing

basis. The MRC will rapidly evaluate Activity 1 to determine the relative effectiveness of the interventions to

reduce high-risk drug use and sexual behaviors and increase access and utilization of services among the

three target populations.

Plans for this project will build upon FY 2005 and 2006 PEPFAR investments and lessons learned from the

implementation of the interventions in FY 2007. In FY 2008, the MRC will continue to refine the

interventions and rapidly scale them up to reach other provinces and underserved populations.

Results contribute to PEPFAR 2-7-10 goals by preventing infections and increasing uptake of voluntary

counseling and testing (VCT) among vulnerable drug using populations to know their status and be

appropriately referred to treatment services. Results are aligned with South Africa goals to scale up

programs that serve IDUs, MSM, and sex workers; integrate VCT into other healthcare delivery and by

decreasing stigma and discrimination; and increase VCT services links with referrals to health systems

networks.

ACTIVITY 3: Best-Practice Model

The MRC will support implementation of a best-practice model of integrated TB/HIV care in sites providing

TB and HIV services. This approach involves: (1) clinical management (counseling and testing, ART,

management of adverse drug effects, STI management, preventive therapy); (2) nursing care (TB

screening, patient education, treatment adherence, HIV prevention); (3) integrated TB/HIV information,

education and communication; (4) nutrition intervention; and (5) palliative care and support. Activities

include site renovation to meet South African accreditation requirements for ARV rollout, site and

supervisory staff training, hiring key personnel, development of patient educational materials, commodities

procurement, and establishment of appropriate referral links, including those with governmental ARV sites

to ensure continuity of care. MRC will monitor CT practices, strengths, and weaknesses of TB/HIV referral

systems, human resources and conventional TB treatment outcomes. The MRC will implement ongoing

quality assessments through onsite supervision and external quality assurance mechanisms such as

checklists. Regular feedback meetings will be held with the provincial team as well as project staff to identify

potential problems and to facilitate corrective action. Stigma around HIV, AIDS and TB is specifically

addressed through counseling, patient education and targeted interventions such as peer group counseling

and advocacy campaigns.

The current counseling and testing model incorporates both VCT and provider-initiated testing and

counseling. The preferred model is determined by provincial guidelines regarding voluntary or provider

initiated counseling and testing. Counseling and testing is a vital component of the integrated TB/HIV model

as it is the point of entry into the project. Other counseling activities also include group counseling with TB

patients, group counseling in health care facility waiting areas, ARV adherence counseling, and community

outreach counseling.

SUMMARY:

The Medical Research Council (MRC) will support a comprehensive best-practice approach to integrated

TB/HIV care that will improve access to HIV care (counseling and testing, care and treatment, screening,

referral, pharmaceuticals) for TB patients. This activity will also promote TB screening (and eventual TB

treatment as required) among patients attending HIV clinics, with particular reference to provision of

antiretroviral drugs (ARVs) to TB patients meeting eligibility criteria according to the South Africa HIV

treatment guidelines. Activities are focused in five provinces of South Africa. The major emphasis area is

human capacity development and strategic information.

BACKGROUND:

A best-practice approach to integrated TB/HIV care was initiated by the MRC with FY 2004 PEPFAR

funding. Early activities included a systematic description of barriers faced by TB patients co-infected with

HIV in an accredited ARV site, and the development and implementation of a best-practice model in FY

2005. Preliminary results from the model site confirmed the benefits of an integrated TB/HIV approach,

reflected in a drastic reduction in patient mortality, improved quality of life of TB patients with HIV and

prolonged survival. Results also confirm the safety and efficacy of dual regimens, showing that ART can

safely be instituted within the first month of TB treatment.

Expansion of the best-practice approach to two additional sites in different geographical settings was

started in FY 2006 based on lessons learned in the start-up sites, including essential human resource

needs, the importance of negotiated partnerships with departments of health (DOH), and the challenges

posed by dual stigma. Activities in the existing sites will continue in FY 2008, with expansion to additional

sites in remote rural settings where active TB screening among people living with HIV (PLHIV) will be

implemented. These sites are characterized by extreme poverty, poor health infrastructure, cross border

migration and limited health care access for patients. The challenges of novel solutions for treatment

delivery in such settings will be specifically addressed, as will strengthening of systems for treatment

adherence. Activities are implemented directly by MRC and by contracted sub-partners World Vision and

the Foundation for Professional Development (a PEPFAR partner).

ACTIVITIES AND EXPECTED RESULTS:

Activities include commodity procurement, logistics, distribution, pharmaceutical management, and cost of

ARV drugs to confirmed TB patients meeting South African government (SAG) ARV enrollment criteria.

Provider-initiated HIV counseling and testing will be offered to all patients and those qualifying for ART

identified as quickly as possible. Initiation of ART will be based on CD4 counts and on SAG policies.

Patients (including children) with a CD4 count < 200 will be eligible for ARV initiation after one month of

conventional TB treatment, while those with a CD4 count < 50 will be fast-tracked for immediate ART

initiation based on clinical status.

ARV drugs will be procured according to projected estimates based on HIV prevalence and the estimated

proportion of patients eligible for ART. As per the USG PEPFAR Task Team requirement, only generic

drugs approved by the SA Medicines Control Council (MCC) and the US Food and Drug Administration

(FDA) will be used.

Referral links to an accredited ART site will be established for each TB patient initiated on ARVs in the

participating sites in order to allow seamless transition and ART access upon discharge. Sites that are not

yet accredited for ART rollout will be assisted to acquire DOH accreditation, which will ensure the necessary

continuity of care. Activities will be directed towards eliminating bottlenecks in ART provision (particularly

human resource capacity), addressing weaknesses and limitations in down-referral systems, documenting

and managing drug adverse effects, and monitoring of treatment adherence.

Integration of TB and HIV services will facilitate quick and seamless patient access to ARV drugs, thereby

decreasing patient morbidity and mortality. Review of HIV counseling and testing practices, strengths and

weaknesses of TB/HIV referral systems, human resource analyses, treatment adherence, drug adverse

effects and conventional TB treatment outcomes in patients on dual therapy will be recorded. TB patients

and PLHIV constitute the principal target populations and include pregnant women (referred to PMTCT

services) and children (receiving ARVs if indicated).

Ongoing quality assessment and quality improvement will be implemented through on-site supervision and

external quality assurance mechanisms such as checklists. Regular feedback meetings will be held with

project staff to identify potential problems and rapidly facilitate corrective action. Results from the project will

facilitate evidence-based policy formulation on expansion of integrated TB/HIV care while increasing and

improving access to ART for eligible TB patients. TB services in South Africa will in future form a vital link to

accredited government ARV sites. This project will contribute to strengthening of the role of TB services as

point of delivery of ARVs, by ensuring that human, financial and infrastructure needs for comprehensive

TB/HIV programs are met through equitable allocation of scarce resources and through analyses of cost-

effectiveness and cost-benefit.

Funding will be used to support sites to implement the pharmaceutical elements of the best-practice

approach to integrated TB/HIV care, including drug distribution and supply chain logistics to meet SA

accreditation requirements for ARV rollout, site staff training, pharmaceutical management to maintain MCC

and FDA quality standards, and the cost of ARVs. Where applicable, sites will be prepared to comply with

the requirements of accreditation for ART in order to ensure continuity of care.

The MRC activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa 5-year Strategic Plan

by integrating TB and HIV services and expanding access to care and treatment.

SUMMARY:

This activity is carried out to support a comprehensive best-practice approach to integrated TB/HIV care,

that will improve access to HIV care (counseling and testing, care and treatment, screening, referral,

pharmaceuticals) for TB patients, and promoting TB screening (and eventual TB treatment as required)

among patients attending HIV clinics, with particular reference in this activity to provision of ARV drugs to

TB patients meeting eligibility criteria according to the South Africa HIV treatment guidelines. Activities are

focused in five provinces of South Africa. The major emphasis area is human capacity development and

strategic information.

BACKGROUND:

A best-practice approach to integrated TB/HIV care was initiated by the Medical Research Council (MRC)

with FY 2004 PEPFAR funding. Early activities included a systematic description of barriers faced by TB

patients co-infected with HIV in an accredited ARV site, and the development and implementation of a best-

practice model in FY 2005. Preliminary results from the model site confirmed the benefits of an integrated

TB/HIV approach, reflected in a drastic reduction in patient mortality, improved quality of life of TB patients

with HIV and prolonged survival. Results also confirm the safety and efficacy of dual regimens, showing

that ART can safely be instituted within the first month of TB treatment.

Expansion of the best-practice approach to two additional sites in different geographical settings was

started in FY 2006 based on lessons learned in the start-up sites, including essential human resource

needs, the importance of negotiated partnerships with departments of health (DOH), and the challenges

posed by dual stigma. Activities in the existing sites will continue in FY 2008, with expansion to additional

sites in remote rural settings where active TB screening among people living with HIV (PLHIV) will be

implemented. These sites are characterized by extreme poverty, poor health infrastructure, cross border

migration and limited health care access for patients. The challenges of novel solutions for treatment

delivery in such settings will be specifically addressed, as will strengthening of systems for treatment

adherence. Activities are implemented directly by MRC and by contracted sub-partners World Vision and

the Foundation for Professional Development (a PEPFAR partner).

ACTIVITIES AND EXPECTED RESULTS:

Activities include provider-initiated HIV counseling and testing, TB screening by symptoms and sputum

investigations, referral to appropriate services (PMTCT, STI, partner-counseling) and enrollment in relevant

HIV care and treatment programs. The MRC will support sites to implement a best-practice model of

integrated TB/HIV care. This approach involves: (1) clinical management (CT, antiretroviral treatment

(ART), management of drug adverse effects, STI management, preventive therapy); (2) nursing care (TB

screening, patient education, treatment adherence, HIV prevention); (3) integrated TB/HIV information,

education and communication; (4) nutrition intervention; and (5) palliative HIV and AIDS care and support.

Activities include renovation of the sites to meet South African accreditation requirements for ART rollout,

site staff training, supervisory staff training to maintain quality standards, hiring of key personnel,

development of patient educational material, procurement of the required commodities, and establishment

of appropriate referral links, including those with governmental ARV sites to ensure continuity. The MRC

will monitor CT practices, strengths and weaknesses of TB/HIV referral systems, human resource analyses,

and conventional TB treatment outcomes.

The MRC will implement ongoing quality assessment through onsite supervision and external quality

assurance mechanisms such as utilization of checklists. Regular feedback meetings will be held with

project staff to identify potential problems and to facilitate corrective action.

Stigma around HIV and AIDS and TB is specifically addressed through patient education and targeted

intervention strategies such as peer group counseling and advocacy campaigns.

Results from the project will facilitate evidence-based policy formulation on expansion of integrated TB/HIV

care and will help to increase and improve access to HIV care of co-infected TB patients and increasing TB

case finding among PLHIV. Implementation of lessons learned in the model-based best-practice approach

will facilitate rapid identification of systems and operational needs and will allow for corrective action.

Analysis of the strengths and weaknesses of an expanded approach to integrated TB/HIV management will

facilitate national scale-up of comprehensive programs for patients with dual infection.

TB services in SA will in future form a vital link to accredited public sector ARV sites. This project will

strengthen TB services as point of delivery of ART, by ensuring that human, financial and infrastructure

needs for comprehensive TB/HIV programs are met through equitable allocation of scarce resources and

through analyses of cost-effectiveness and cost-benefit. Increased TB case-finding in HIV settings is a

crucial component of disease control, yet largely lacking in routine health services.

In FY 2007 the project evaluated strategies for active TB case finding in vulnerable populations and

assessed its implications for TB and HIV control programs. In 2008 the project will implement and continue

to evaluate these strategies across sites. Activities will be directed towards eliminating bottlenecks in ART

provision (particularly those due to human resource capacity), addressing weaknesses and limitations in

down referral systems, documenting and managing drug adverse effects, and monitoring of treatment

adherence. Integration of TB and HIV services will be a prime focus, to facilitate quick and seamless

patient access to ARV drugs, thereby decreasing patient morbidity and mortality.

Funding will also be used to implement an integrated electronic patient information system at the different

sites to support routine data collection, to facilitate patient referral and to allow data transfer to the national

routine TB recording and reporting system, which is now integrating HIV testing and service data.

The MRC activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year Strategic

Plan by integrating TB and HIV services and expanding access to care and treatment.

SUMMARY:

This Medical Research Council of South Africa's project focuses on improving the performance of HIV

services in the public health sector. This will be achieved through a mixture of directly strengthening HIV

prevention services through interventions at the clinic level such as improving prevention activities. It will

also provide important new surveillance data on high-risk groups and increase the capacity of managers to

use data for decision-making.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Strengthening Health Information Systems

With FY 2006 and FY 2007 funds the Medical Research Council (MRC), in collaboration with Western Cape

Department of Health (WCDOH), have engaged with senior and district level managers to empower them to

use data for decision making. Managers have assessed primary health care (including TB/HIV) information

systems. Important changes in the way that data are collected and used have been made. Management

teams now regularly analyze routine data to measure performance of programs. To date these activities

have been conducted in select districts in the Western Cape province, but with FY 2008 funds this activity

will expand to cover the entire province. The MRC will consolidate the lessons learnt in strengthening health

information systems, and this will be used to support the expansion of a comprehensive TB/HIV program

including implementing changes in responsibilities for data collection and analysis. The organization will

produce a series of user-friendly guides and manuals to allow replication of the process of assessing and

improving information and monitoring systems in other provinces. The MRC is currently in negotiation with

the KwaZulu-Natal provincial government where a similar process of audit and quality improvement will be

implemented. Technical support to other provinces in using the materials and tools will be provided on an

ad hoc basis and as requested.

ACTIVITY 2: Respondent Driven Sampling (RDS) Surveys

With FY 2006 and FY 2007 funds, the MRC in collaboration with the WCDOH conducted two surveys using

RDS to gather behavioral and epidemiological surveillance data. These surveys capture high-risk groups

that have been missed by other surveillance methods. Specifically, these groups include men who have

multiple younger female partners and women who have multiple older male sex partners. The information

gathered from these surveys is used to guide the development of HIV prevention activities, especially those

targeting male norms and behaviors. With FY 2008 funds, the MRC will provide training and technical

support to allow the replication of RDS surveys in other parts of the country. Partner organizations that have

the capacity to perform surveys in other provinces such as KwaZulu-Natal and Gauteng will be trained and

supported to conduct RDS surveys and to perform the appropriate analysis. The MRC will also continue to

conduct surveys in the Western Cape in particular to evaluate interventions with men and women who have

multiple partners.

ACTIVITY 3: Implementation of Male Intervention the Western Cape

Following the findings of the RDS survey in 2006 that found very high levels of risky sexual behaviors

among a large network of peri-urban men, the WCDOH requested the MRC to assist them in designing,

managing and evaluating an intervention specifically targeting older men who have multiple younger female

sexual partners. The intervention will be aimed at shifting the social norms around multiple, concurrent

partners and increasing the availability and use of condoms. In the first year of the intervention the MRC will

complete the design of the intervention, gain permission from the relevant authorities and stakeholders,

recruit and train facilitators, and pilot the intervention. The intervention will based upon the peer opinion

leader approach in peri-urban setting. The intervention will build upon the RDS methodology to recruit men

who have characteristics of peer opinion and then work with them to model HIV safer attitudes and

behaviors.

ACTIVITY 4: Evaluation of a Prevention with Positives Intervention

With FY 2007 funds the MRC in collaboration with WCDOH and Human Sciences Research Council has

developed an intervention to reduce high-risk sexual behavior among people living with HIV (PLHIV) and in

particular among those who are on antiretroviral treatment (ART). The intervention is based upon two

interventions that have been previously used in the United States: Healthy Relationships, and Options for

Health. The former intervention is based on small support groups of PLHIV and typically builds on existing

support groups where they already exist while the latter is health-provider driven and builds upon existing

opportunities created during one-on-one clinical consultations by PLHIV receiving care and treatment. The

MRC will measure its effectiveness by measuring self-reported behavior changes and recording changes in

incidence of sexually transmitted diseases. In the second year of the intervention the MRC will aim to reach

all clinical settings that are providing ART in the Western Cape.

ACTIVITY 5: Strategic Information (SI) Activities Requested by the South African Government

The MRC will use a portion of the FY 2008 funds to conduct Strategic Information activities at the request of

provincial or national Departments of Health. The MRC has a close working relationship with the South

African Government and frequently receive requests for technical assistance in areas such as those

described in Activities 1 and 2. These exact activities have not yet been determined but the MRC will work

closely with the SAG as such opportunities for collaboration arise.

These activities described in this section are in line with the South African Government's priorities and those

described in the PEPFAR South Africa Five-Year Strategy.

SUMMARY:

In FY 2008, the MRC will use PEPFAR funding to engage in formative work that will lead to specific

interventions in the future. This formative work includes developing service quality measures (SQMs) to

improve the quality of drug treatment services especially in areas such as access to services (including HIV

related services such as VCT), barriers to HIV and drug service use, quality of HIV and drug services, and

service outcomes. The goal of this activity in FY 2008 is to establish policy and operational advisory groups

with key stakeholders in the drug abuse and HIV policy, service planning, and treatment delivery arenas to

address issues of service quality and develop systems for service improvement. The major emphasis areas

are local organization capacity building and the development of networks, linkages, referral systems, and

service quality improvement mechanisms; and information, education and communication. Minor emphasis

areas include community mobilization/participation; linkages with other sectors and initiatives; and training.

Primary target populations are key stakeholders in the HIV and substance abuse treatment policy arena as

well as substance abuse treatment service providers.

This project is consistent with the revised South African National Drug Master Plan and will provide

guidance on how the South African Government can translate strategies into action. Sustainability is

addressed across all activities, by developing the capacity of existing service providers to measure service

quality and service performance, providing ongoing technical support to stakeholders via regular telephone

and videoconferences, enhancing data management systems, and providing program adjustments as

necessary. This project also directly addresses the NSP for HIV and AIDS by identifying a set of

standardized indicators that can be used to monitor service quality and service performance.

BACKGROUND:

Using FY 2008 funding, the MRC will engage in formative work in the area of improving drug treatment

services through the integration of drug treatment services with HIV services. The formative work will result

in the development of specific interventions that will be implemented in subsequent years. The formative

work, (FY 2008 funding)will ensure that serrvice quality measures (SQMs) to improve the quality of drug

treatment services especially in areas such as integration of HIV and substance abuse services, provision

of wraparound HIV services in substance abuse treatment settings, access to services (including HIV

related services such as VCT), barriers to HIV and drug service use, quality of HIV and drug services, and

service outcomes are developed. These SQMs will help South African Department of Health improve the

quality of its substance abuse services by creating the means to empirically measure the results achieved in

service priority areas such as access to services (including HIV related services such as VCT and including

access to services for vulnerable groups such as women), quality of HIV and substance abuse services and

service outcomes thereby creating a platform to guide policy and service improvements. Such

improvements in the efficiency, effectiveness, and equitability of treatment in South Africa are especially

important in the light of the relationship that is increasingly being established between drug and alcohol

abuse, high-risk sexual behaviors and HIV. It is also important in the light of recent policy initiatives which

call for better quality and standardized data on service performance and service quality within the substance

abuse treatment sector. Calls for better monitoring of substance abuse treatment quality are in keeping with

policies such as the National Drug Master Plan and the new Substance Abuse Bill that is currently being

reviewed by parliament.

The use of SQMs provides a platform for the monitoring of service quality and service performance which is

currently lacking in South Africa, despite a commitment to measuring service outcomes. This project has a

strong policy component that is integral to the start-up of the project as well as to the uptake of SQMs as a

routine part of the substance abuse treatment system functioning. The project allows for an iterative process

of feedback between policy advisory and technical advisory groups and service providers. This process

moves beyond the previous top-down approaches that have been implemented in attempts to regulate the

treatment sector (and which have so far failed to make much of an impact). This project therefore has the

potential to strengthen the substance abuse policy making process, particularly around the integration of

HIV services into substance abuse services and the provision of wraparound rather than standalone

services. Apart from policy goals, this project directly allows for quality improvement in health care delivery.

The use of SQMS will help us identify areas that can be changed to improve service quality, client outcomes

and service delivery (despite local challenges). Over time the use of SQMs will allow us to test whether

changes made to the system impact on service quality.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Formation of an advisory group

FY 2008 funding will be used to set up an advisory group that will consist of a policy and operational

subcommittee. This advisory group will be made up of 22 members;12 of whom will be key stakeholders in

the drug abuse and HIV policy and service planning and monitoring arena at a national level and ten of

whom will be key individuals from the treatment delivery arena at a provincial level. For the latter, the

stakeholders will represent substance abuse treatment service providers in the Western Cape, Gauteng and

KwaZulu-Natal provinces. A core function of this activity will be to build capacity among these 22

stakeholders to address issues of service quality and service performance. This activity will also support

the development within these groups for the monitoring of service quality, outcomes and performance.

FY2008 activities include building capacity among an advisory group of key stakeholders to collaboratively

identify a set of quality improvement goals for the drug abuse treatment sector; identify potential service

quality measures (SQMs) addressing each of the stated goals, taking into account current infrastructure

capabilities; review these SQMs to ensure that they are feasible to use, appropriate for the South African

context, and culturally sensitive; identify barriers to SQM implementation; and develop implementation

strategies that are sensitive to logistical and resource barriers and to cultural differences.

ACTIVITY 2: Recommendations to integrate drug treatment services and HIV services:

Based on the discussions with the advisory group, South African Government and other key stakeholders,

MRC will develop a set of recommendation that will be used to develop specific interventions in FY 2009 to

integrate drug treatment services and HIV services.

Results contribute to PEPFAR 2-7-10 goals by addressing the linkages between drugs, alcohol treatment

and HIV treatment.Results are aligned with South African goals of improving substance abuse management

information systems and building capacities among service providers to monitor their service quality and

service performance. This project will help strengthen the South African health management information

system as it helps identify standardized measures of the effectiveness, efficiency and equitability substance

Activity Narrative: abuse treatment services and of the HIV services provided in substance abuse settings. As such, it allows

for theidentification of areas in which the current treatment system can be improved. It will also help us

monitor the extent to which barriers to HIV services (including VCT) in substance abuse treatment exist,

consumer perceptions of service quality, and the extent to which HIV services are integrated into substance

abuse treatment settings.