SUMMARY:

The Human Sciences Research Council (HSRC) will provide technical support, including ongoing

monitoring and evaluation (M&E) to prevention of mother-to-child transmission (PMTCT) activities in 50

antenatal care clinics (ANCs) and surrounding communities in the Eastern Cape and Mpumalanga. Once

the PMTCT program in the Eastern Cape is running smoothly, HSRC will embark on similar activities in an

underserved district in Mpumalanga. The District in Mpumalanga is still to be determined and will be

determined in consultation with the provincial department of health. The major emphasis area will include

quality assurance and supportive supervision, with community mobilization, local organization capacity

development, strategic information, and training as minor emphases. The primary target populations include

pregnant women, people living with HIV and AIDS (PLHIV), families affected by HIV and AIDS, public and

private healthcare workers, community-based organizations (CBOs) and non-governmental organizations

(NGOs).

BACKGROUND:

This project will contribute to the PEPFAR objective of preventing HIV infections in the PMTCT priority area.

The project was in the FY 2006 and FY 2007 COPs, but is currently in the early stages of implementation

because funding was awarded late. At the request of the provincial government, the district was changed

and it took longer to establish partnerships with provincial and local health authorities than anticipated.

HSRC will provide technical support for the implementation of PMTCT services according to national

guidelines, and will seek to actively engage communities served by the specified ANCs. HSRC will also

seek to establish partnerships with relevant CBOs and NGOs conducting HIV-related work in the area,

develop reciprocal referral networks and strengthen peer support group systems to enhance family support

(especially husbands, partners, mothers and mothers-in-law) and support from traditional birth attendants

(TBAs) for the PMTCT program.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Rapid Assessment

Using FY 2006 funding, a baseline assessment is currently underway to identify gaps and challenges to

PMTCT implementation in the district. The assessment will identify program elements that are in need of

strengthening, and provide a baseline measure by which to assess the success of systems strengthening

activities.

ACTIVITY 2: Systems Strengthening

Once the baseline assessment has been completed, program strengthening activities will commence.

HSRC will promote the use of health facilities for newborn delivery among pregnant women and their

families. All pregnant women attending the 26 antenatal clinics in the Kouga Local Service Area (LSA) of

the Eastern Cape will be encouraged to have confidential counseling and testing (CT) for HIV infection

during pregnancy. Women who test HIV-positive will be referred to the nearest accredited ART site for

clinical staging, a CD4 count, and initiation of ART, if indicated (according to the national ART guidelines).

Women who do not meet the criteria for initiation of ART will be referred to a wellness program and/or

relevant social support services. HIV-infected pregnant women will be counseled about disclosure, and

encouraged to refer their partners for HIV testing. Women identified as HIV-infected during pregnancy (and

who do not have long-term ART initiated prior to delivery), and their infants, will be given a short course of

ART prophylaxis at delivery for PMTCT. This regimen will be adapted once the dual therapy protocol

becomes policy in the Eastern Cape province. HIV exposed infants will be tested using PCR, and at 15 to

18 months using appropriate tests to determine their HIV infection status. Infants found to be infected will be

referred to the local health services for follow-up, monitoring and initiation of treatment if eligible. Most of the

programmatic work will be done by staff already employed by district health services, or by traditional birth

attendants in the target communities. FY 2008 PEPFAR funds will be used to employ additional staff to

strengthen PMTCT programs in the Kouga area. The Eastern Cape Department of Health has agreed to

take over the funding of these positions after the initial phase of system strengthening.

ACTIVITY 3: Technical Assistance

HSRC will provide technical assistance to strengthen M&E systems and will seek to coordinate the M&E

and PEPFAR-related reporting activities with routine district health M&E activities to minimize any

unnecessary duplication of work. At the clinic level this will be paper-based. HSRC will employ a dedicated

M&E specialist, a community engagement and outreach activity specialist, and a data manager. HSRC will

mobilize community leaders, FBOs, CBOs, district councils, traditional leaders and traditional birth

attendants in the region to support PMTCT interventions.

ACTIVITY 4: Expansion

Activities will be expanded with FY 2008 funding to include:

PMTCT program integration (wraparound) with family planning, reproductive health, and ART services, and

positive prevention interventions for HIV-infected women in the Kouga Local Service Area (LSA). The

impact of the project on the PMTCT delivery system in the Kouga LSA will be monitored, and when service

delivery quality is satisfactory, support will gradually phase out (based on service delivery indicators and

achievement of more than 80% PMTCT uptake in the district), and similar program implementation and

support service activities will be initiated in a new geographic region in an underserved area of Mpumalanga

province. The area will be selected in consultation with the provincial department of health and the CDC,

and an analysis of key PMTCT indicators by district. The district with the most need will be selected. This

activity will increase gender equity in HIV and AIDS programs by increasing women's access to HIV

information, treatment, care and support.

The HSRC PMTCT Program contributes to the PEPFAR 2-7-10 goals and objectives by strengthening

PMTCT service delivery, increasing uptake of PMTCT and decreasing the number of new infections.

Activity Narrative: SUMMARY:

SUMMARY:

The HSRC is using PEPFAR funds to implement and determine the effectiveness of two prevention-with-

positives interventions to reduce HIV transmission risks for their partners.

The prevention-with-positives (PwP) activity will adapt and pilot an existing CDC intervention for promoting

HIV status disclosure and behavioral risk-reduction strategies among people living with HIV (PLHIV). This

intervention is known as Healthy Relationships. It is a support-group-based intervention designed to reduce

HIV transmission risks for people living with HIV (PLHIV) and their partners using an interactive approach

that includes educational, motivational, and behavioral skill building components. Once this intervention has

been piloted, a second individualized intervention will be developed and pilot-tested for effectiveness. Both

interventions will include messages on condom use for PLHIV. The major emphasis area for the activity is

gender and human capacity development. Target populations include men and women of childbearing age,

National AIDS Control Program staff, HIV-infected pregnant women and health care workers, doctors,

nurses, community-based organizations (CBOs), faith-based organizations (FBOs) and non-governmental

organizations (NGOs).

BACKGROUND:

Among adults, the predominant mode of HIV transmission in South Africa is through heterosexual

intercourse. PLHIV are an important group to target for HIV prevention activities (both to prevent re-infection

with other HIV strains, and to prevent transmission to others), but to date prevention in this group has

received little attention. Behavioral risk-reduction interventions targeting PLHIV will reduce new HIV

infections and will complement behavior change prevention, including condom usage, efforts currently

targeting uninfected people. Until now, people who knew they were infected with HIV had been largely

ignored by HIV risk-reduction strategies in South Africa. There is an urgent need to develop behavioral and

other supportive interventions to assist PLHIV to manage sexual situations, avoid acquiring new sexually

transmitted infections, and to prevent the transmission of HIV to uninfected sexual partners. For behavioral

risk-reduction to be successful among PLHIV, de-stigmatization must be an integral part of the intervention.

Although there is also a need for broad-based stigma-reduction interventions at a community/population

level, interventions for PLHIV can assist in managing the adverse effects of HIV-related stigma, including

the hazards of disclosure of their HIV-infected status. The Healthy Relationships intervention is a small

(support) group-based intervention which has been packaged and disseminated as part of CDC's

Replication Project (REP). It has been implemented successfully in several U.S. states as part of an

initiative by the CDC to provide HIV prevention interventions for PLHIV. This intervention has been adapted

for local conditions and materials have been translated into isiXhosa, the predominant local language in the

Eastern Cape. A second individualized intervention is being considered as many PLHIV have not yet

reached a point when they are willing to disclose their status to others (including other PLHIV). The second

intervention will focus on individual (one-on-one) positive prevention activities.

ACTIVITIES AND EXPECTED RESULTS:

This activity was in the FY 2006 COP and FY 2007 COP, but implementation has been delayed due to late

receipt of funds. The HSRC will use PEPFAR funding to adapt and implement the Healthy Relationships

Program in the area around Mthatha in South Africa's Eastern Cape province. Funds will be used to employ

ten support group facilitators and an administrative staff person to undertake formative evaluations at

baseline and at one, three and six months after enrollment, and to develop or purchase training materials

and videos. Each group of ten PLHIV participating in the Healthy Relationships intervention will attend five

sessions of two hours each over a one to two month period. The effects of the intervention will be evaluated

using before and after comparisons, and by comparisons to PLHIV who have not yet taken part in the

intervention. A process evaluation will also be conducted.

The project will establish how well these interventions work in a rural under-resourced South African setting

and will also determine the feasibility of scaling-up these interventions in other rural areas with a high HIV

prevalence. The interventions will be framed by the challenges PLHIV face in establishing and maintaining

satisfying relationships, with special emphasis on strategies for disclosing HIV-positive status to a sex

partner. Skills for making effective HIV disclosure decisions will be taught for disclosing HIV status to non-

sex partners, particularly family members, friends, and employers. The interventions will also address

building skills for reducing HIV transmission risk through behavior change with a particular focus on male

norms and behavior. Risk-reduction strategies arise naturally in the context of disclosing HIV status, with

different implications for practicing protected and unprotected sex with HIV-infected partners, HIV-negative

partners, and partners of unknown HIV status. An advocacy component will be incorporated to train

participants to advocate for HIV testing and risk behavior reduction among partners, family members, and

friends. In this way, the impact of the intervention will be spread among their social and sexual networks.

Participants in both field tests will be assessed at baseline, immediately post-intervention, and at one, three

and six months after completion of the intervention. Once the evaluation of these two interventions has

been completed, they will be further adapted if necessary and expanded to other parts of the Eastern Cape,

including the Kouga LSA. The HSRC will train additional lay counselors and other healthcare workers

working in the public sector or for local NGOs, community-based organizations or faith-based organizations,

in the delivery of positive prevention interventions, and will undertake monitoring and evaluation of the

program.

FY 2008 COP activities will be expanded to include:

The development and adaptation of another PwP intervention, to be delivered as an individual intervention

by community health workers. Individual PwP interventions are needed because issues of stigma and fear

to disclose one's HIV serostatus may serve as barriers to participation in group-based PwP interventions.

The one-on-one intervention will be based on the Options for Health PwP intervention developed by Fisher

et al. This intervention will be adapted for use in a rural South African setting, and adapted for delivery by

community health workers instead of clinicians (task-shifting). Following a formative phase to adapt the

existing intervention in consultation with service providers and PLHIV in Region E of the Eastern Cape,

training materials will be modified and translated into the local language (isiXhosa). This new intervention

will be implemented and evaluated among 400 PLHIV participating in ART programs or wellness programs

in Region E of the Eastern Cape. This individual intervention is likely to consist of 3 one-hour individual

Activity Narrative: sessions with a lay counselor delivered over a 1-month period. Both process and outcome evaluations will

be conducted. Participants will be interviewed at baseline, at the end of the intervention, and at three and

six months from the start of the intervention to assess the impact of the intervention on risk behavior, and

disclosure.

In addition, the Healthy Relationships PwP intervention will be expanded to another geographic region in

the Eastern Cape, most likely the Kouga LSA ensuring linkages with the HSRC PMTCT program activities

being implemented in that same geographic region. HIV-infected pregnant women will be targeted for this

PwP activity. The main purpose of these new activities is to increase the range of evaluated PwP

interventions available to accommodate the varying needs of PLHIV and to expand the types of settings for

providing PwP interventions, and to scale-up the coverage of PwP programs in South Africa.

These activities will contribute to the PEPFAR goals by developing prevention strategies for PLHIV and their

partners, thus having an impact on prevention of new infections. This activity will also contribute to the

National Strategic Plan (NSP) goal of halving the incidence of new HIV infections by 2011.

SUMMARY:

PEPFAR funds will be used to support monitoring and evaluation (M&E) of orphaned and vulnerable

children (OVC) interventions at two sites: Kopanang in the southern Free State Province and Kanana near

Orkney in the North West Province. The HSRC has been involved in promoting and evaluating OVC

interventions at these sites since 2002, but has not received PEPFAR support for these activities previously.

The emphasis area for this project is monitoring and evaluation and building capacity of local indigenous

organizations to deliver quality OVC care.

BACKGROUND:

In 2002, the HSRC and the Nelson Mandela Children's Fund established an evaluation and intervention

project to work with OVC at four sites in South Africa. The main aims of the project were to:

1) Improve the social conditions, health, development and quality of life of OVC;

2) Support families and households coping with an increased burden of care for affected and vulnerable

children;

3) Strengthen community-based support systems as an indirect means of assisting vulnerable children;

4) Build capacity in community-based systems for sustaining care and support to vulnerable children and

households, over the long term.

A number of existing interventions were supported, a baseline evaluation was conducted to inform future

interventions, and new interventions believed to represent best practice were developed and implemented.

Funding for these activities ended in March 2007. PEPFAR funds will be used to conduct M&E of OVC

activities at two of the four sites.

At Kopanang in the southern Free State, interventions are being carried out by Diketso Eseng Dipuo

(DEDI). These include a family support program, early childhood development, and capacity-building

activities. Local facilitators hold workshops with the community, complemented by a program of ongoing

home visits. Activities conducted during home visits include child assessment, and assisting with completing

documentation to qualify for social grants. The intervention also includes a Local Economic Development

(LED) component whereby families are encouraged to form small savings societies (stokvels) and receive

basic guidance in establishing themselves as micro-enterprises. An AIDS awareness campaign was carried

out in February 2007, reaching approximately 650 youth, but its impact has not yet been evaluated.

At Kanana in the North-West Province interventions are being carried out by Child Welfare North-West

(CWNW). CWNW has four OVC interventions in the area: 1) Three Child Protection Projects (CPP); 2) a

Victim Empowerment Project (VEP); 3) a Kinship Project; and 4) a Child Care and Stimulation Project

(CCSP).

ACTIVITIES AND EXPECTED RESULTS:

PEPFAR funds will be used to conduct an evaluation of OVC interventions at the Kopanang and Kanana

sites to assess whether the interventions represent good practices and to determine the cost-effectiveness

of these interventions. The same evaluation methods will be used at each site. Both quantitative and

qualitative methods will be used. These include:

1) Observations carried out during site visits;

2) A review of annual progress reports for the five-year period 2003-2008;

3) Focus group discussions and interviews with beneficiaries and key informants;

4) Costing of the interventions.

Interventions will be assessed using a set scoring system on a scale of 0 to 20. A project will be assessed

as representing good practice if it scores 16-20, promising practice if it scores 10-15, and poor practice if it

scores less than 10.

Once the evaluation is completed, feedback will be given to the organizations providing services with

recommendations for program strengthening, and positive reinforcement for interventions that are working

well. The results of the evaluation will be shared widely within the OVC community. HSRC will also liaise

with the Department of Social Development and propose incorporation of cost-effective and good

interventions into OVC policies and strategies.

These activities will contribute to PEPFAR 2-7-10 goals by identifying good practice OVC interventions and

contributing to the delivery of quality OVC programs.

TITLE OF STUDY: Review of counseling and testing (CT) programs, policies and practices in South Africa.

TIME AND MONEY SUMMARY: The Human Sciences Research Council (HSRC) will use FY 2007 funds to

conduct a review of counseling and testing (CT) programs, policies and practices in South Africa. The

estimated start date is October 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. The HSRC has applied

for $300,000 in Year 1 of this activity (FY 2007 funds), and a further $300,000 in Year 2 (FY 2008 funds).

There will be no funds leveraged from other sources.

LOCAL CO-INVESTIGATOR: The Principal Investigator for the HSRC's CDC-PEPFAR award is Laetitia

Rispel. Carol Metcalf will serve as the lead local co-investigator on HSRC's counseling and testing activities.

Other HSRC co-investigators will include Laetitia Rispel, Heidi van Rooyen, Geoff Setswe, and Charles

Hongoro.

PROJECT DESCRIPTION: The HSRC will use PEPFAR funds to conduct a public health evaluation (PHE)

of counseling and testing (CT) activities in South Africa. The purpose of this activity is to obtain information

on current CT practice, with a view to promote good program practices. The HSRC will include services that

have a reputation for best practice or for offering innovative forms of CT. The sample will also include CT

services that differ by type of provider (public, private, NGO); models of delivery; and that include a range of

geographic settings throughout South Africa, both urban and rural. Structured and semi-structured

interviews and field observations will be conducted with service managers, frontline service providers, and

clients. Statistics will be gathered on numbers of clients tested, reasons for testing (if available), HIV

seroprevalence among clients, and client demographics. Information will be collected on charges for

services, staff training, staff supervision, quality assurance practices, types of HIV tests used, counseling

models used and whether the model is theory-based and/or evidence-based, outreach activities, policies

and practices relating to consent and disclosure, and integration and linkages with other relevant health and

social services. For a limited number of services using different models of delivery, cost information will be

gathered for purposes of a comparative evaluation. The HSRC will try to include examples of integrated,

stand-alone, and mobile or home-based services in the evaluation, as well as different forms of counseling

delivery (e.g. individual, couples, and small group).

This activity will gather evidence relevant for effective and cost-effective scaling up of CT services in South

Africa, thus contributing indirectly to the overall 2-7-10 PEPFAR objectives (2 million individuals on

treatment, 7 million infections averted and 10 million people in care). The results of this activity will be used

to improve quality of CT services, which should impact indirectly on the number of people tested and

referred to treatment, care and support. This activity will also contribute to achieving the goals of the South

African National Strategic Plan on HIV and AIDS and STIs, 2007-2011 (NSP) of reducing the incidence of

HIV infection by 50% and making treatment available to 80% of PLHIV who qualify for treatment according

to national guidelines.

STATUS OF STUDY/PROGRESS TO DATE: A study protocol has not yet been developed. A study

protocol will be developed and submitted to the HSRC Research Ethics Committee and the CDC for review

once the HSRC receives FY 2007 funding for this activity.

LESSONS LEARNED: Not applicable. This project has not yet started.

INFORMATION DISSEMINATION PLAN: Once the review and evaluation has been completed, the HSRC

will host a one-day symposium for CT program managers and policymakers to discuss the results and to

plan for appropriate action based on the findings. Select providers that are examples of good practices or

innovative HIV testing and counseling strategies will be invited to speak at the symposium. The HSRC will

facilitate the development of an implementation plan to ensure that the results of the targeted evaluation are

turned into action. he findings of the review and evaluation, combined with stakeholder recommendations

from the symposium will be published in the form of a report which will be distributed to policymakers in

national and provincial government and made available for free download on the HSRC Press website. In

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

language and making brief practical policy recommendations.

Activities: FY 2008 COP activities will be expanded to include:

(1) A targeted evaluation of barriers and facilitators to HIV testing from a client perspective. Methods may

include exit interviews with people attending outpatient health facilities, structured one-on-one interviews

with people recruited from the general community (community-based surveys), and focus group

discussions. The HSRC will convene a workshop with health officials and policymakers to discuss the

findings and to develop practical strategies to address the problems identified with a view to increasing

counseling and testing uptake.

(2) An assessment of provider-initiated TC in healthcare settings (such as casualty and emergency

departments) with a pilot intervention project to increase the use of provider-initiated CT in these settings.

This will be modeled on similar projects that have been conducted in U.S. hospitals with CDC support.

(3) A pilot project to implement one of the models of good practice identified as part of FY 2007 activities in

a new setting, or alternatively to adapt or translate training and intervention materials from one of the

models of good practice to promote scale-up. The choice of intervention or model will be based in part in the

findings of the initial program evaluation.

FY 2008 COP activities will be planned in detail once the initial evaluation (using FY 2007 funds) has been

conducted.

BUDGET JUSTIFICATION FOR YEAR 1 MONIES:

Salaries/fringe benefits: $ 150,000

Equipment: $5,000

Activity Narrative: Supplies: $5,000

Travel: $60,000

Participant Incentives: $0

Laboratory testing: $0

Other: $80,000

Total: $300,000

SUMMARY:

The Human Sciences Research Council (HSRC) will use PEPFAR funding to support the South African

national population-based HIV prevalence and behavioral risk survey in 2008. Data will be used to enhance

national HIV and AIDS program indicators and to compare South Africa's HIV epidemic to the global

pandemic. FY 2008 COP activities are expanded to include surveillance activities among most-at-risk

populations (MARPs) including men who have sex with men (MSM), discordant couples, and refugees, as

well as an evaluation of the impact of the national antiretroviral treatment (ART) rollout.

BACKGROUND:

The following section provides background for the listed activities.

1) The HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011 (NSP) assigns the HSRC the task of

conducting national HIV prevalence and behavioral surveys every two to five years. The results of the

previous two surveys have succeeded in drawing attention to gender inequalities in the HIV epidemic in

South Africa. Preparatory activities will take place in 2007 and the fieldwork will begin in early 2008. The

Nelson Mandela Foundation, the Nelson Mandela Children's Fund, the Swiss Agency for Development and

Cooperation, and the HSRC funded the surveys conducted in 2002 and 2005. The HSRC received support

from PEPFAR and the National Institute for Communicable Diseases to conduct HIV incidence testing on

dried blood spot samples (using the BED assay) in the 2005 survey. HIV incidence could be estimated for

the first time in a national population-based sample of the general population. HSRC plans to seek co-

funders for the 2008 survey.

HSRC is considering a couples sub-study as part of the 2008 national household survey to obtain an

estimate of the prevalence, patterns, and factors associated with discordant HIV serostatus among people

in established sexual partnerships. This sub-study is contingent on mobilizing adequate funding and human

resources, and devising a sampling strategy that does not compromise the main survey.

2) During the 1980s, the South African HIV epidemic was largely confined to MSM and people who had

received contaminated blood products. The epidemic became generalized in the early 1990s, and attention

shifted away from MSM. HIV prevention programs generally do not include messages or interventions

targeting MSM. The gap in knowledge about HIV in MSM and services for this group is a priority area in the

NSP.

3) Information on the number and characteristics of serodiscordant couples in South Africa, and the

strategies they use to prevent HIV transmission to the uninfected partner, is lacking. As people in long-term

partnerships tend to have unprotected sex, and the majority of people living with HIV (PLHIV) in South

Africa are unaware of their status, it is probable that a substantial portion of new HIV infections are acquired

from primary (as opposed to casual) sexual partners. The uninfected partners constitute an important but

neglected MARP, and current HIV prevention programs do not address the needs of discordant couples.

4) Refugees face many challenges in accessing HIV prevention treatment and care services. Specific

challenges include poverty, migration, a lack of social support, language barriers, xenophobia and

discrimination. Political and economic upheaval in several African countries has led to dramatic increase in

the number of refugees (both legal and illegal) in recent years. Although accurate statistics are unavailable,

it is believed that South Africa has one of the largest refugee populations.

5) South Africa currently has the largest number of people receiving ART, as well as the largest number of

people needing ART (but not currently receiving treatment). Since the national ART rollout in 2004, the

number of people receiving ART has expanded rapidly, but falls short of the goal, in part because resource

constraints have not been able to keep up with demand. Task shifting of treatment provision to less

specialized health workers (nurses instead of doctors), and making use of primary health-care centers

rather than hospitals have been used to try to meet the demand. One of the two key goals of the NSP is to

ensure that 80% of those needing ART have access to ART by 2011. To date a number of evaluations of

local programs and programs of specific providers (e.g. workplace programs provided by the Anglo group of

companies) have been conducted, but there has been no broad-based national evaluation of the national

ART program.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: 2008 HIV Prevalence Survey

HSRC will use PEPFAR funds to conduct the 2008 national population-based HIV prevalence survey in

South Africa. The survey will include children, youth, and adults of all ages. The survey will include children

under the age of two for the first time (UNICEF will partially fund this). A large portion of funding will be

devoted to HIV antibody testing and other related tests at an accredited national laboratory. Funds will also

be used to support the analysis and the publication of a report, scheduled for release on World AIDS Day.

Results will be analyzed by gender, thus providing information for increasing gender equity in HIV and AIDS

programs. In addition, HSRC will conduct a detailed risk assessment on a sample of youth, which will

provide information on male norms and behaviors. Following the publication of the report, additional

secondary analyses will be conducted including an assessment of trends using data from the 2002, 2005

and 2008 surveys. The 2008 survey will be the third survey to conduct population-based HIV surveillance

combined with behavioral surveillance on a national level and this will provide new knowledge and will

provide a benchmark for the M&E objectives of the NSP. In addition, qualitative methods (e.g. focus group

discussions) may be used to collect in-depth information on select topics to provide a better understanding

of the findings of the national household survey. Lastly, as part of the survey, HSV-2 behavioral questions

and biologic markers will be obtained for seroprevalence, behavioral and demographic data on HSV-2 and

HSV-2/HIV co-infection, allowing for the monitoring of trends, and for the development of the evidence base

for improving HIV prevention programs and local and national guidelines and policies.

ACTIVITY 2: Surveillance of HIV and Risk Behavior Among MSM

HSRC will conduct an assessment of the prevalence of HIV and risk behavior among MSM. This activity will

complement the surveillance information on the general population, and will provide strategic information

Activity Narrative: about MSM as identified in the NSP. This evaluation will be conducted in nine or ten large South African

cities. MSM aged 18 years and older will be recruited by means of respondent-driven sampling (RDS). RDS

is the best method of recruiting a representative (generalizable) sample of MSM because no sampling

frame exists, and other methods are more prone to sampling bias. As RDS is only suitable for use in urban

areas and no satisfactory method is known for recruiting MSM from rural areas, rural MSM will not be

included. Participants will be tested anonymously for HIV, provided with voluntary counseling and testing

and asked questions about sexual and other risk behavior using a structured questionnaire, based on the

one used to collect demographic and behavioral surveillance information on youth and adults in the national

household survey. Additional questions, specific to MSM will be added. Semi-structured interviews will be

conducted with MSM recruited through gay organizations, including HIV-infected MSM, and key informants

in order to assess the HIV prevention, treatment, care and support needs of MSM in South Africa. The

results of this activity will help meet the objectives of the NSP and will be used to develop recommendations

for addressing current program deficiencies and barriers to accessing services among MSM.

ACTIVITY 3: Surveillance of Discordant Couples and Assessment of HIV Prevention Strategies and Support

Needs

This project aims to estimate the number of PLHIV whose primary sexual partner is HIV-negative, and to

ascertain the demographic and social characteristics of discordant couples. HSRC will assess barriers and

facilitators to disclosure of HIV-serostatus to one's primary partner, and strategies that discordant couples

are using to prevent HIV transmission to the uninfected partner. A combination of qualitative and

quantitative methods will be used, and interviews will be conducted with couples, as well as individual

interviews with both HIV-infected and uninfected people. This activity will address an important gap in

strategic information, as outlined above. The results will be used to raise awareness of discordant couples

among the general population (including people who are unaware that they are in discordant partnerships)

and among policymakers, and will inform the development of prevention programs for discordant couples.

ACTIVITY 4: Assessment of HIV and Risk Behavior Among Refugees

A small exploratory study will assess the prevalence of HIV and risk behavior among a sample of registered

refugees. Refugees will be recruited using information from the UNHCR database. Methods of measuring

HIV and risk behavior will be similar to those used in the national household survey. This activity may be

expanded to include a larger number of refugees and illegal immigrants in subsequent years.

ACTIVITY 5: Assessment of the Impact of the National ART Roll-out

An evaluation will be conducted through a retrospective cohort study of a selection of patients from

government-accredited ART sites in all provinces. Information will be collected through individual interviews

with patients receiving ART and patientswho havediscontinued ART, and throughreviews of medicalrecords

(includingthe records of personswho havedied).