Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 271
Country/Region: South Africa
Year: 2008
Main Partner: Right to Care
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $36,760,000

Funding for Care: Adult Care and Support (HBHC): $1,022,000

SUMMARY:

Right to Care's PEPFAR program was recompeted through an Annual Program Statement (APS) in 2007

and was a successful applicant. RTC will continue to use PEPFAR funds to strengthen the capacity of

healthcare providers to deliver Care and Support (C&S) services to HIV-infected individuals, and to improve

the overall quality of clinical and community-based health care services in five provinces.

BACKGROUND:

RTC's C&S services will expand from the current levels achieved using PEPFAR funds. The integrated

program of education, counseling and testing, care and ARV treatment has been implemented in five focus

areas: (1) The employed sector, where RTC is currently providing HIV services to >130,000 employees in

>32 companies; (2) FBO/NGO clinics which target underserved populations in rural areas, industrial areas,

and informal housing sectors as well as targeted gender-specific support groups and family-centered

approaches; (3) Thusong, a private practitioner program for indigent patients; (4) Small, Medium, and Micro-

Enterprise, including farm employees, with mobile treatment units; and (5) In partnership with the National

Department of Health (NDOH), capacity support for national comprehensive HIV and AIDS care,

management and treatment sites. RTC provides mentorship and technical assistance to over 15 sub-

recipients and manages their sub-agreements. These are ongoing programs expanded with NDOH

coordination and private sector support. By providing training and support to these sites RTC leverages

NDOH resources to reach an increasing number of patients. RTC has supported these sites with

infrastructure, staff, training, equipment and data management. In addition, the NDOH has recognized the

successes of RTC NGO/FBO sites and has been accrediting these sites to enable the provision of ARV

drugs and laboratory monitoring.

ACTIVITIES AND EXPECTED RESULTS:

RTC will build on past successes by consolidating and expanding its support for government sites, NGO

and FBO clinics/organizations and private sector programs. FY 2008 PEPFAR funds will be used for human

capacity development and salaries at all C&S providers; (1) NGO and FBO clinics/organizations receive sub

-awards earmarked for doctors, nurses, counselors and other healthcare workers; (2) RTC will not provide

salary support to SAG staff, but rather the salaries of health care providers seconded to DOH facilities

including support for doctors, nurses, data managers, and counselors; and (3) a capitation fee-for-service

arrangement exists with a network of private sector service providers for the Thusong and Direct AIDS

Intervention (DAI) programs.

PEPFAR funds will also be used to maintain RTC's mobile clinics. NGO and FBO clinics also use PEPFAR

funds for laboratory monitoring of HIV patients and for the procurement of health commodities such as

medical equipment, ARVs, drugs for opportunistic infections including cotrimoxazole, counseling and testing

kits, and home-based care kits.

RTC supports all the C&S providers by disseminating policies and guidelines and providing quality

assurance through sharing best practices. With FY 2008 funding RTC will provide ongoing training and

continued medical education to assure that staff is aware of the latest treatment norms.

RTC will ensure that each HIV patient at RTC-supported facilities receives a comprehensive minimum

package of C&S services and preventive care, including clinic, community and home-based services. This

minimum package includes clinical and pathology monitoring, management and treatment of opportunistic

infections, psychosocial counseling, healthy living education, prevention with positives services, nutritional

counseling, assessment, monitoring and referral, home-based care, advice and assistance on welfare

issues and applications for welfare grants, and hospice and end-of-life care for terminally-ill patients.

Emphasis will be placed on increasing the number of HIV-infected children and pregnant women in care. A

number of NGO sites are doing nutritional counseling at community level and refer for nutritional

assessment and monitoring. Examples of non USG-funded community activities include food gardens and

income generating programs in order to support patients that are on ART. In addition, sites supported by the

NDOH have dieticians for ARV-treated patients.

PEPFAR funds facilitate partner linkages and a referral system between treatment sites-based care, and

other non-medical C&S services. At each site RTC will identify a community-based care organization to add

to the counseling capacity of the site. Peer counselors complement the NDOH appointed clinic staff. The

Thusong program is linked with a national network of care organizations. The expansion of the strategic mix

of clinic, home and community-based C&S will bring more C&S services to the doorstep of impoverished

populations such as farm workers, rural communities and residents of informal settlements.

Public-private partnerships (PPPs) have also been formed to ensure longer term sustainability. These

include, for example, those with the provincial DOH, where value is seen by the government in accrediting

specific clinics in order to provide ARVs and pathology monitoring thereby reducing the overall cost on one

donor. In addition PPPs are being explored with a number of organizations to provide holistic and

comprehensive care and treatment services to HIV-infected patients.

NGO clinics also receive cooperative funding from donors and patient fees. Knowledge sharing between

treatment sites and networks is being facilitated by Value Based. Referral mechanisms linking primary sites

to tertiary sites for complicated patients have been integrated into the RTC network of sites.

A number of NGO clinics also have gender-specific C&S programs. For example, the ACTS (Aids Care

Training and Support) clinic has a series of comprehensive monthly support groups aimed at young men or

young women who are HIV-infected. Support group members meet to discuss challenges and problems and

provide each other with support and guidance. These programs include family-centered approaches.

Expansion of gender-specific activities with FY 2008 PEPFAR funding is planned.

Right to Care will continue to use PEPFAR funds to strengthen capacity of healthcare providers to deliver

C&S services to HIV-infected individuals and to improve quality of clinical and community-based health care

services in five provinces. RTC will strengthen links between counseling and testing and care. For those

Activity Narrative: testing positive a tracer system will reduce loss to treatment registration. Those who test positive will be

tracked so that they benefit from wellness services and are tested every six months for their CD4 counts to

ensure that they commence ART as soon as they become eligible.

By reaching patients with care and support services at various outlets, RTC will contribute to the PEPFAR

goal of providing services to 10 million HIV-infected and affected individuals. In addition, RTC activities will

support the USG Five-Year Strategy for South Africa by training health care workers in care and support

services, significantly expanding access to and quality of palliative care services.

Funding for Care: TB/HIV (HVTB): $3,395,000

SUMMARY:

Right to Care (RTC) will use FY 2008 PEPFAR funds in five provinces to strengthen the capacity of

healthcare providers to deliver TB/HIV services, identify TB and HIV co-infected individuals, and improve

the overall quality of clinical and community-based healthcare services. The major areas of emphasis are

human capacity development and local organization capacity building. Target populations include people

infected with TB/HIV, public health care providers and local organizations.

BACKGROUND:

Throughout South Africa, active TB incidence rates are rising, reaching 608 per 100,000 per annum. HIV-

infected patients are at significant risk for developing TB, and 58% of patients attending TB clinics have

been identified as HIV-infected. Of primary importance is the identification of TB in HIV infected individuals,

with over 60 percent of co-infected patients being sputum negative. Improved and early diagnosis of TB in

HIV-infected individuals improves outcomes of morbidity and mortality. Co-infected individuals need to be

initiated on antiretroviral therapy, according to standard treatment guidelines, to ensure improvement in

mortality, morbidity and TB cure rates. RTC will support the South African government's TB program and

the World Health Organization's policy on collaborative TB/HIV activities.

Since FY 2006 RTC has received funding for TB/HIV and plans to integrate the services for TB/HIV for all

co-infected patients at sites throughout the RTC network with the FY 2008 funding. The additional activities

at each of the sites will be: (1) access to HIV counseling and testing for patients with TB, (2) improved

access to induced sputum for TB diagnosis in HIV-infected individuals, (3) improved linkages between the

HIV and TB programs at each of the sites through referral, notification and follow-up; (4) infrastructure

support to develop TB sputum rooms with appropriate infection control procedures to prevent the

transmission of TB. Activities are currently limited by budget to the sites at Themba Lethu Clinic, Sizwe

Hospital, Kimberley Hospital, Shongwe and 4 NGO sites. (5) FBO/NGO clinics focusing on underserved

populations in rural areas, industrial areas and informal housing sectors as well as targeted gender specific

support groups and family centered approaches will be targeted. The programs will promote sustainability

through training of health care workers and partnerships with the National Department of Health (NDOH) to

partially fund the ongoing running cost and staff components, over time.

ACTIVITIES AND EXPECTED RESULTS:

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

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

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

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

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

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

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

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

government facilities.

With FY 2008 funding, the program will be expanded to all sites in the RTC network. RTC support to

government sites will include infrastructure, human capacity development, salaries and training. Technical

assistance will be provided to improve the integration of TB and HIV services and referral between the sites

treating each of the diseases. In all cases where RTC provides salary support an agreement is made with

the facility where positions will be created and funded by provinces in due course. Oftentimes a government

position has been created, but not filled, and RTC supports a consultant to fill the position until such time as

the province successfully recruits for it.

PEPFAR funds will enable long-term sustainability through support of, salaries, training and human capacity

development at all RTC-supported TB/HIV clinics, in the form of sub-awards for NGO and FBO clinics and

direct salary support for government sites. PEPFAR funds will also be used to adapt existing training

materials to specific TB/HIV issues, and address infrastructure needs, such as HIV counseling rooms in TB

clinics and specialized sputum induction rooms that comply with occupational and environmental safety

standards. This will enhance both safety of obtaining sputum samples and increase sensitivity for positive

sputum test.

At TB/HIV treatment sites, emphasis will be placed on identification of co-infected individuals, through

promoting routine HIV counseling and testing for TB patients and TB screening of HIV patients who present

with risk factors. Co-infected patients will be evaluated for correct application of ARVs and TB medications.

Those on combined ARV and TB treatment will be monitored for the development of Immune Reconstitution

Inflammatory Syndrome. Emphasis is placed on adherence support to address the increased risk of non-

compliance due to high pill burden, and overlapping toxicities, particularly hepatotoxicity. Human capacity

development in the management of anticipated drug interactions and shared adverse effects is an additional

expected result. Family and community support network will be educated and trained in basic TB knowledge

to help support the client with his/her treatment to improve compliance.

In addition to sputum collection, the implementation of low-cost, high through-put, digital, mobile chest x-ray

technology, access to screening x-rays will be improved at rural, distant sites and in underserved

populations. FY 2008 PEPFAR funding will be used to purchase and equip one mobile x-ray facility to assist

the program in rural Northern Cape and Mpumalanga provinces. While x-ray is not a microbiological

diagnosis, it is a simple method to augment diagnosis. TB bactecs and bone marrow procedures are not

planned for the sites at present.

Although the current government policy includes access to INH for primary TB prophylaxis, most clinics do

not have the required capacity or experience to provide this. INH is provided to Helen Joseph by the

provincial government. RTC will evaluate INH prophylaxis at the Helen Joseph Hospital using evidence-

based locally relevant data collected within the unit. In collaboration with the local National Health

Laboratory Services ongoing monitoring of the evolution of mycobacterial resistance and effect on incidence

of TB at the hospital will be undertaken. PEPFAR funds will be used for human capacity development,

consultant and sessional salaries and infrastructure, but not for the purchase of INH prophylaxis.

Activity Narrative:

RTC and several of its sub-partners will also continue to incorporate TB/HIV training in ART courses for

doctors, nurses and lay counselors to ensure quality of care.

Through induced sputum and chest x-ray, this program will improve TB case finding, improved sputum

diagnosis and early TB treatment initiation. Through improved adherence to TB treatment, and improved

notification and referral, the aim is to improve TB cure rates. Through improved HIV counseling and testing

and referral to ARV treatment, overall TB cure rates and mortality outcomes are anticipated.

Overall the planned activities include monitoring and evaluating the outcomes of the integration of TB and

HIV services on patients' outcomes, hospital stays, and mycobacterial outcomes of cure and resistance.

By reaching patients with TB/HIV therapy at various outlets, RTC will contribute to the PEPFAR goal of

providing services to 10 million HIV-affected individuals. In addition, the activities support the USG Five-

Year Strategy for South Africa by training health care workers in TB/HIV services, significantly strengthening

these services and their integration into HIV and primary health care services.

Funding for Prevention: HIV Testing and Counseling (HVCT): $1,616,000

SUMMARY:

Right to Care's PEPFAR program will be recompeted through an Annual Program Statement (APS) in 2008.

Right to Care (RTC) will use FY 2008 PEPFAR funds to identify HIV-infected individuals by supporting

selected antiretroviral treatment (ART) sites and through direct community-based access to counseling and

testing (CT) in seven provinces, namely KwaZulu-Natal, Free State, Eastern Cape, Limpopo, Mpumalanga,

Western Cape and Northern Cape. CT is used as a prevention mechanism to promote abstinence, be

faithful and condoms, as well as an entry-point into care, support and ART. It is also an essential tool for

fighting stigma and discrimination. The major area of emphasis is human resources. Minor areas of

emphasis include community mobilization/participation, training and workplace program. Specific target

populations include university students, adults, pregnant women, HIV-infected infants, truckers, and public

and private sector healthcare providers.

BACKGROUND:

RTC's CT services are a continuation of ongoing activities. CT was originally part of RTC's holistic

education, testing, care and treatment program for the employed sector, known as the Direct AIDS

Intervention (DAI) program. RTC's CT activities have since expanded their reach through a range of

partnerships with government sites, private sector providers and non-governmental and faith-based clinics

and organizations, and are now reaching substantial numbers of clients from predominantly vulnerable

populations, through clinic-based and mobile CT services.

RTC is currently implementing a program of CT for vulnerable populations. Testing is conducted by nurse

networks, General Practitioner (GP) networks, mobile CT clinics or by sub-partner non-governmental

organizations (NGOs). RTC implements workplace programs and often collaborates with a private sectorr

partner, Alexander Forbes' Comprehensive Health and Wellness Solutions.

Uptake of on-site CT is reaching high proportions. Almost 90% of employees volunteer to go for CT. RTC

supports the Access CT activities of treatment partners, including the Thusong network of private

practitioners, several government sites, and non-governmental and faith-based organization sites. CT

training is conducted by RTC's Training Unit as well as by several of RTC's sub-partners.

All RTC CT initiatives are coordinated through the Proudly Tested campaign. This campaign, a registered

trade mark under RTC, is intended to create a brand that promotes regular CT for individuals and groups in

all social levels. High-profile leaders within communities will promote this brand and strategy to create

increased social acceptance of CT. The Proudly Tested activities will also include commercial CT, which will

receive technical support through PEPFAR funds.

ACTIVITIES AND EXPECTED RESULTS:

RTC used FY 2008 funds to consolidate and expand its existing activities; building on past successes. RTC

tested more than 52,000 clients, and trained 180 healthcare workers and lay counselors in the first three

quarters of FY 2007.

ACTIVITY 1: Assistance to South African Government Sites

FY 2008 funds will support the continuation of assistance to government sites, NGO, and FBO clinics as

well as to private practitioners to ensure the widespread availability of CT services. PEPFAR funds will

largely be used for human capacity development including (a) salaries for consultants and part-time

healthcare workers at all CT providers; (b) sub-grants for NGO and FBO clinics and organizations that are

partially earmarked for nurses and lay counselors; (c) direct salary support for lay counselors and nurses at

government sites; and (d) support for a fee-for-service arrangement with private contractors such as the

private and Access CT programs and a network of private practitioners for the Thusong program. PEPFAR

funds will also be utilized to address minor infrastructure needs such as for the delivery of CT services at

NGO, FBO and government sites, for the maintenance of RTC's mobile clinics, and for the procurement and

distribution of HIV test kits for NGO and FBO clinics.

ACTIVITY 2: Support for CT Providers

RTC will support all its CT providers by disseminating guidelines on CT, by providing quality assurance

through sharing best practices and supportive supervision, and by offering guidance on monitoring and

reporting of results. RTC and several of its sub-partners will also provide ongoing training in CT services for

lay counselors and nurses (either employed by RTC or its partners, or external health workers) to ensure

strict adherence to CT protocols and high quality counseling. RTC will also support healthcare providers in

public health facilities to implement provider-initiated testing and counseling (PITC) as recommended in the

HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011. Providers will be trained on PITC as well

as on conducting HIV rapid tests. This activity will include internal and external quality assurance around

rapid testing.

ACTIVITY 3: Prevention and Behavior Change

The success of CT as a prevention activity should include promoting prevention and behavior change

including "abstinence, be faithful and condom use", reducing stigma, encouraging disclosure and couple

counseling. HIV-infected individuals are referred from CT to care services. RTC's counselors are trained to

provide counseling services in all prevention areas. In FY 2007 RTC will maintain models of increasing

transition to care including the use of CD4 count testing at the time of CT to encourage early patient staging

for referral. Access to a 24-hour call center for post-test counseling has also proven to be beneficial.

ACTIVITY 4: Strengthening Expansion of Referral Networks and Increasing Initiation to Treatment

The strengthening and expansion of referral networks and linkages with care and treatment services for

clients identified as HIV-infected remains one of the central focus areas of RTC's CT activities. Linkages

with community mobilization and outreach activities will be continued to promote the uptake of CT services

and to normalize CT-seeking behavior using community lay counselors and educators. These linkages and

Activity Narrative: capacity building with indigenous organizations will affect long-term sustainability. Prior to all CT activities,

referral linkages will be established for direct referral at the time of CT. A CT module through Therapy Edge,

an electronic patient database system, is being developed to track all positive CT clients, for call center

counselors to follow-up and direct referral and regular CD4 test.

ACTIVITY 5: Community-based CT

The strategic mix of clinic-based and community-based CT will see further expansion of activities which will

bring CT services to the doorstep of impoverished populations and high-risk, male dominated groups such

as truck drivers, farm workers, small and medium enterprise (SME) employees, DAI contract/temporary

workers, tertiary students, rural communities and residents of informal settlements. Mobile and rural clinics,

home-based CT in partnership with the Home Loan Guarantee Company, and clinic-linked units will be

established in vulnerable communities. Through a public-private partnership, RTC will increase CT uptake

in a cost-sharing model with commercial companies. PEPFAR funds will be used for technical support,

training and CT kits, while the commercial partner will cover the substantial direct cost of nurses, facilities

and other direct activities. This cost-sharing model will enable CT of contract workers, employees and

unemployed persons.

Emphasis will be placed on consolidating and expanding CT services for couples, infants and children, and

cross-testing (testing STI and TB patients for HIV and vice versa, and testing of pregnant women).

FY 2008 funds for counseling and testing will be used by Right to Care to expand services in government

sites, NGO and FBO clinics as well as to private practitioners to ensure the widespread availability of CT

services. The organization will assist the National Department of Health and the provincial Departments of

Health in Gauteng, Northern Cape, and Mpumalanga with activities for National Testing Week. The South

African National Testing Week will include enhanced testing at mobile and facility-based sites and other non

-traditional testing sites. Right to Care will also focus on improving provider-initiated testing and counseling.

RTC's CT activities will contribute to the PEPFAR 2-7-10 goals by identifying HIV-infected individuals for

care, support and treatment and preventing infection in those who are HIV-negative. This will contribute to

the PEPFAR vision outlined in the Five-Year Strategy for South Africa by expanding access to, and

availability and quality of CT services.

Funding for Treatment: ARV Drugs (HTXD): $1,173,000

SUMMARY:

Right to Care (RTC) will use FY 2008 PEPFAR funds to procure and distribute antiretroviral (ARV) drugs to

partner antiretroviral treatment (ART) sites and programs in five provinces to expand ART for eligible HIV-

infected individuals. Funds are used to procure ARV drugs used in non-governmental and faith-based

organizations (NGOs, FBOs), and remote treatment sites. RTC will continue to refer HIV-infected individuals

identified through counseling and testing (CT), care, and support services, when indicated, into ART

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

building. Populations to be targeted include people living with HIV (PLHIV) and pharmacists.

BACKGROUND:

Since 2005 PEPFAR funds have been used for human capacity development and for consultant and

sessional salaries for employees that augment NGO clinics and government sites. Pharmacists are

employed at each site as it grows and as numbers of patients on treatment rise above 500. RTC will

continue ARV drug activities, which have been PEPFAR-funded since 2004, when RTC began supporting

the purchase of ARV drugs for patients treated through NGOs, FBOs, and the Clinical HIV Research Unit

(CHRU). Pharmaceutical procurement and supply is managed by Rightmed Pharmacy, an independent

pharmacy established that meet the South African pharmacy regulations.

ACTIVITIES AND EXPECTED RESULTS:

With FY 2008 funding, RTC will consolidate and expand its existing activities, building on past successes in

procuring and supplying ARV drugs to its treatment sites/programs. RTC sites have had no stock-outs to

date on any drugs despite global shortages in stavudine and lamivudine. All RTC-supported government

sites receive drugs through internal government systems.

PEPFAR funds will continue to be used for the procurement and distribution of ARV drugs via Rightmed

Pharmacy for the current NGO and FBO clinics as well as for the Thusong program. The Thusong program

provides ART to those unable to access care through Department of Health (DOH) sites. ARV scripts are

forwarded to Rightmed, which handles all the procurement, logistical and pharmaceutical management,

dispensing and distribution of ARVs. The drugs are delivered to the treatment sites via an independent

courier company on a weekly basis. Treatment sites receive batches of drugs for multiple patients, with

drugs labeled and dispensed on a patient-named basis. Drugs are then securely stored at the site and

dispensed to the patient on a monthly basis. Where sites are able to harness the capacity of a pharmacist,

direct procurement is facilitated. Sub-awards for clinics will also include funding for pharmacy staff.

Following DOH accreditation of the NGO and FBO clinics, the South African government will take over the

costs of the drugs and labs. RTC will re-channel funds that were allocated to ARVs and labs to supporting

additional staff, human capacity development and minor infrastructure adjustments. Additional staff,

including dieticians and social workers, may be hired to meet the full staff complement for an accredited

ARV clinic as defined by government. RTC is working with each site to ensure that the South African

government takes responsibility for these salaries at accredited sites as soon as feasible. With government

taking over the cost of ARVs, and the increased number of pharmacists receiving training, sustainability is

addressed. The provision of additional staff that are trained and the clinical space adjustments will

contribute to the improvement of quality treatment outcomes.

In FY 2008, RTC will use PEPFAR funds for direct salary support for pharmacists and pharmacy assistants

at government treatment sites to enhance the widespread and sustainable availability of ARV drug services.

Subject to needs assessments, PEPFAR funds may be used to upgrade infrastructure and equipment

needs at government sites and at NGO and FBO clinics. RTC will also expand the current pharmacist

expertise in pediatric care and procurement. Expertise from Rightmed Pharmacy will be used in training and

mentorship at various government and NGO sites.

In FY 2008, RTC will procure and supply ARV drugs to RTC-supported treatment programs and sites,

directly contributing to the 2-7-10 goal of two million people treated. RTC will support the PEPFAR vision

outlined in the Five-Year Strategy for South Africa by expanding access to ART services for adults and

children, building capacity for ART service delivery, and increasing the demand for and acceptance of ARV

treatment.

Funding for Treatment: Adult Treatment (HTXS): $29,554,000

SUMMARY:

Right to Care (RTC) will use FY 2008 PEPFAR funds to strengthen the capacity of healthcare providers to

deliver ARV treatment (ART) services to eligible HIV-infected individuals in five provinces. Emphasis will be

placed on increasing the number of HIV-infected children and pregnant women on ART. The emphasis

areas are renovation, gender, human capacity development, and local organization capacity building. The

primary target populations are people living with HIV (PLHIV), public and private healthcare providers.

BACKGROUND:

RTC's ARV Treatment (ART) services are a continuation of activities, which have been USG-funded since

2002. Originally initiated as a holistic education, testing, care and treatment program for the employed

sector (called the Direct AIDS Intervention (DAI) program), RTC's ART activities have expanded their reach

through a range of partnerships with government sites, private sector providers and NGO and FBO clinics

and organizations. RTC is now reaching substantial numbers of people from predominantly vulnerable

populations in five provinces. RTC's ART activities consists largely of support for the ART services of all of

RTC's treatment partners, including its Thusong network of private practitioners, many government sites

and NGO and FBO clinics and organizations. In addition, RTC itself implements the ART components of the

DAI and other partnership workplace programs. ART training is conducted by RTC's Training Unit as well as

by several sub-partners. With FY 2008 funding, RTC will expand its pediatric treatment, expand into a male-

only clinic and increase its focus on reducing stigma and encouraging disclosure. RTC will consolidate and

expand its support for government sites, NGO and FBO clinics and organizations and private sector

programs, and build on past successes (over 22,500 people reached with ART by the third quarter of FY

2007).

ACTIVITIES AND EXPECTED RESULTS:

RTC will use PEPFAR funds to accelerate the implementation of the national rollout plan at government

sites in partnership with the National Department of Health (NDOH). As the procurement of ARV drugs and

lab services is undertaken by government in these sites, PEPFAR funds will be used to expand access to

treatment. RTC has successfully negotiated for the NDOH to supply certain NGO and FBO sites with ARVs

and laboratory services, freeing PEPFAR funds to support new treatment sites.

PEPFAR funds will be used for: (1) human capacity development and salaries (consultant and part-time

healthcare workers) at all ART facilities: NGO and FBO clinics and organizations receive sub-awards for

doctors, nurses, pharmacists and counselors, and a fee-for-service arrangement exists with the network of

private sector service providers for the Thusong and private programs; (2) developing a training program for

pharmacy assistants as human capacity development for the distribution of ARVs and HIV services; (3)

addressing minor infrastructure needs where necessary at NGO, FBO and government sites, and to

maintain RTC's mobile clinics; (4) NGO and FBO clinics use PEPFAR funds for the laboratory monitoring of

HIV patients, as well as for the procurement of health commodities; and (5) covering the costs of labs for

the new mobile clinic treatment program servicing remote communities in Mpumalanga, in collaboration with

another PEPFAR-funded partner, FHI.

Down referral sites will be established with the Department of Health in Gauteng and Mpumalanga in FY

2007 for stable patients. Human capacity, minor infrastructure and training will be provided to these sites. A

'smart card' system is being developed with Therapy Edge and Supply Chain Management Service to track

transfer of patient data.

RTC supports its ART providers by disseminating policies and guidelines and sharing best practices.

Ongoing quality assurance and supportive supervision is undertaken by centralized treatment experts. RTC

and several of its sub-partners will also provide training in ART services for health workers. In the delivery of

medical ART services, doctors are given ongoing support in clinical decision-making, prescribing and case

management by RTC's team of medical HIV experts, through RTC's Expert Treatment Program (ETP). The

ETP management model enables primary healthcare providers to communicate directly with HIV experts.

ETP uses a sophisticated web-based IT tool in the form of TherapyEdge, licensed to RTC, which enables

the effective management of patients and includes a secure patient database. The Clinical Mentorship and

Preceptorship Program (CMPP) will continue to enhance the provision of HIV care and clinical expertise

across the intermediate levels of health care within the overburdened public healthcare system. Through

human capacity development, increased numbers of people will receive care, support and treatment. The

anticipated benefit of the mentorship program is the dissemination of training and knowledge gained by

healthcare personnel in the urban academic site to rural and smaller sites around the country.

A new PPP, the AIDS Treatment Institute (ATI), is proposed with Vodacom and the DOH. Vodacom will

provide all infrastructure requirements for a HIV care and treatment centre for indigent patients, with the

DOH supplying all ARV and covering lab costs. PEPFAR funds will be used for training, human capacity

development of necessary health care workers, and ongoing technical assistance. This clinic is targeted to

provide treatment for 10,000 patients, care and support to 15,000 patients, CT to 40,000 individuals and

prevention education to 100,000 in FY 2008. Vodacom, other private sector organizations and DOH will

provide over 90% of support for this program, and PEPFAR funds will provide less than 10% of the PPP

budget.

RTC will ensure that each ART patient at RTC-supported facilities receives a minimum package of ART

services, including clinical and pathology monitoring, adherence counseling and support, and follow-up of

defaulting ART patients. Adherence activities will include a focus on reducing stigma and encouraging

disclosure in order to enhance drug compliance and to improve patient retention. Emphasis will be placed

on increasing the number of HIV-infected children and pregnant women on ARVs according to the national

treatment guidelines. Mobile clinics are used to bring ART services to farm workers and other vulnerable

populations in rural areas of the Northern Cape and Mpumalanga.

To support the implementation of ART, adherence counseling and support is implemented through

individual counseling, support groups and direct observed therapy, either clinic-based or community-based.

In order to complement clinic staff, support is provided to at least one community-based care organization to

partner with each treatment site. This team is tasked with monitoring patients' adherence, providing support

Activity Narrative: such as nutrition, wellness and welfare services, and providing home-based care services for those that are

terminally ill. The team also provides referral services to clinics and in some cases, arranges transport or

hospice services.

RTC anticipates opening a male-only clinic in partnership with the Clinical HIV Research Unit (CHRU) at

Wits University. This clinic will focus on recruiting adult males from local industries dominated by males in

the private sector as well as males from indigent populations. Patients in this clinic will receive ART

services, clinical and pathology monitoring, with specific adherence and other support designed to meet the

needs of men. Best practices on adherence and support as well as clinical care from this clinic will be

shared with other RTC partners.

In FY 2008, RTC will contribute to increased patients on ART at various sites towards the PEPFAR

treatment target of 2 million patients, and will train healthcare workers in ART services. RTC will support the

PEPFAR vision outlined in the Five-Year Strategy for South Africa by expanding access to ART services for

adults and children, building capacity for ART service delivery, and increasing the demand for and

acceptance of ARV treatment.

Subpartners Total: $14,231,565
Refilwe Christian Clinic: $837,385
CARE International: $947,460
Nightingale Hospice: NA
Seboka Training and Support Network: NA
Friends for Life: $58,154
Ndlovu Medical Trust: $2,621,272
Vuselela: $46,154
Thusong Private Practitioners Program: $1,275,065
Valley Trust: NA
Center for Positive Care: NA
National Institute for Community Development and Management: NA
Alexandra Clinic: NA
International Federation of Red Cross and Red Crescent Societies: NA
Heartlines: $1,700,000
ACTS Community Clinic: $855,100
Alexander Forbes Health Management Services: NA
Reaphela CCMT Clinic: $837,385
Gauteng Provincial Department of Health: $837,385
Masoyi Home Based Care: $36,923
Northern Cape AIDS Forum: $46,154
Witkoppen Health And Welfare Centre: $766,043
Clinical HIV Research Unit: $726,137
Mpumalanga Department of Health: $1,181,492
Northern Cape Department of Health: $1,459,456