SUMMARY:

University Research Co., LLC (URC) works with the national and provincial Departments of Health in South

Africa to expand access to and uptake of HIV testing and counseling. URC's major strategy is to assist

NDOH/PDOHs in implementing provider-initiated HIV testing, with the option to opt-out, to reduce missed

opportunities for HIV identification and further spread of HIV in the country. URC will use a collaborative

approach for rapidly expanding the HIV testing services. The approach will include integrating HIV testing

with antenatal care, sexually transmitted infections (STI), tuberculosis (TB), family planning (FP) and

general clinical service areas. Training of program managers and healthcare providers in strategies to

expand uptake of HIV testing and counseling rapidly will be a focus. URC will place temporary clinical staff

to provide HIV testing in high volume facilities where current staff are unable to meet the demand for

testing, thus ensuring that HIV clients are referred for onward treatment and support services. Finally URC

will strength supervision and monitoring systems to ensure provision of high quality HIV testing. Support will

also be provided to improve recording and reporting systems for HIV testing at all levels. The major

emphasis area is local organization capacity development, with minor emphasis on quality assurance and

supportive supervision, network/linkages/referral systems, and training. The activity targets public health

workers, community-based organizations (CBOs) and faith-based organizations (FBOs), program managers

and community volunteers, youth and adults, and STI, TB, and general clinic attendees.

BACKGROUND:

Uptake of HIV testing remains low due to limited provision of this service at most facilities, staff shortages

as well as stigma and perceptions about poor follow-up and treatment options available for people with HIV

and AIDS. Since 2006, URC has been working through a CDC-funded program to expand uptake of HIV

testing at healthcare facilities in five provinces (Mpumalanga, KwaZulu-Natal, Limpopo, North West, and

Eastern Cape) to increase uptake of HIV testing. The basic strategy is to help healthcare facilities introduce

provider-initiated HIV testing and counseling as referred to in the HIV & AIDS and STI Strategic Plan for

South Africa, 2007-2011. This is being achieved by integrating provider-initiated HIV testing, with the option

to opt-out, with TB, STI, FP, antenatal care and other general clinical services targeting both adults and

youth. In FY 2008, URC will continue using the district-based HIV testing expansion model whereby public

healthcare facilities will be assisted to increase uptake of HIV testing through direct provision of high quality

provider-initiated services as well as through referrals to CT where direct HIV testing provision is not

possible. In clinics that lack the requisite number of staff or the existing staff do not have the appropriate

skills for initiating HIV testing; URC will place temporary staff (counselors and testers) to roll out the HIV

testing services. The maximum duration of temporary staff assignments to a facility will not exceed six

months. URC will develop the capacity of healthcare workers in their ability to provide high quality provider-

initiated CT services, including post-test counseling for HIV-infected and uninfected persons.

ACTIVITIES AND EXPECTED RESULTS:

URC will carry out eight separate activities in FY 2008.

ACTIVITY 1: Assist NDOH to Streamline Policies and Develop Guidelines on Provider-initiated HIV Testing

and Counseling

URC will work with the National Department of Health (NDOH) to develop a policy framework to streamline

the integration of provider-initiated HIV testing in clinical settings. URC will support policy dialogue

workshops at national and provincial levels to expedite the development of the policy framework as well as

operational plans.

ACTIVITY 2: Develop District-based HIV Testing Expansion Strategy

URC, in consultation with provincial health offices, will identify target districts for HIV testing rollout. All

facilities in a district will be covered under URC's HIV testing expansion program. URC will assist each

focus district in developing a strategy for increasing uptake of provider-initiated HIV testing services. A

typical strategy will include the following elements: (a) training facility staff in provision of HIV testing

services; (b) monitoring key performance indicators (number of people trained; number of people who

receive the HIV testing services, number of HIV-infected people referred for onward treatment and support

services percent of providers who follow national guidelines for HIV testing and counseling; quality of testing

services); (c) maintaining a training schedule (who will be trained, when will they be trained); and (d)

supervising and mentoring (who will be responsible for providing supervision and mentoring to facilities to

ensure the HIV testing is being integrated and the quality of services are per national standards, etc.). Each

district will establish a HIV testing expansion team representing HIV, maternal and child health, TB, and STI

directorates. These teams will be responsible for reviewing results every three months to determine if HIV

expansion strategies are producing desired results.

ACTIVITY 3: Establish Baseline HIV Testing and Counseling Uptake Levels in Each New Facility

URC staff will review clinic logs and patient records to establish baseline HIV testing uptake, and referrals

for antiretroviral treatment (ART) in various clinical settings (TB, STI, antenatal health clinic, etc.). These

assessments will help the facility teams identify clinical services that are offering CT as well as the levels of

uptake. The rapid assessments will also examine the quality of services that may be affecting the CT

uptake. The assessments will target both service providers and CT clients (those who accept and those

who opt-out). Observations, chart and record reviews, and interviews are some of the approaches that will

be used for data collection.

ACTIVITY 4: Training

URC will work with the departments of health to train clinic staff (doctors, nurses, midwives, counselors, and

testers) in provider-initiated HIV testing and counseling. Training will focus on how to provide basic pre-test

information and how to provide post-test counseling to HIV-infected and uninfected persons. The training

will also include a module on the management of provider-initiated HIV testing, which covers logistics,

recording and reporting, referral systems for HIV testing (for sites that are unable to provide testing within

their sites) and ART. Specific case studies will be presented and participants will work in groups to identify

Activity Narrative: gaps in CT services and suggest possible solutions. URC will provide job-aids, wall charts, and other

needed materials to improve compliance with clinical and counseling guidelines.

ACTIVITY 5: Referrals and Linkages

Not all service providers or facilities will be able to offer HIV testing within their facilities. In such instances,

URC will work with provincial and district departments of health to develop referral linkages to ensure that

clients have easy access to services. URC will also develop linkages between CT sites and sites offering

ARV treatment.

ACTIVITY 6: Community Linkages

URC will assist each participating healthcare facility to develop community linkages to increase awareness

as well as uptake of HIV testing services. This will be done through building partnerships with local

community- and faith-based organizations working in the catchments areas of clinics.

ACTIVITY 7: Compliance Audits

URC will conduct annual compliance assessments in a sample of participating facilities to assess whether

the staff complies with the national HIV testing and counseling guidelines. These assessments will also

examine the quality of performance data reported to the program.

ACTIVITY 8: Strengthening Quality Assurance and Supervision System

URC will train district and facility-level supervisors in quality assurance and quality improvement methods

and facilitative supervision techniques for improving the quality of CT services. These activities are

expected to increase uptake of HIV CT in 150 healthcare facilities (100 current and 50 new facilities) by

assisting them to rapidly expand CT services. Facilities receiving URC assistance will provide HIV testing

results to 100,000 men and women as a result of the integration of HIV CT with other high volume health

services. URC will train 1,400 healthcare workers in CT integrated with antenatal care, TB, STI and general

health services. By focusing on promoting the uptake of counseling and testing through community

structures and increasing local capacity, URC will contribute to the PEPFAR goals of 10 million people in

care and 7 million infections averted.