SUMMARY:

The PATH prevention of mother-to-child transmission (PMTCT) project will improve the quality, availability,

and uptake of comprehensive PMTCT services in Eastern Cape by strengthening systems that support the

delivery of high-quality, comprehensive PMTCT services, building the capacity of health facilities and staff to

provide comprehensive PMTCT services, and increasing community engagement and leadership in

promoting, supporting, and utilizing PMTCT services. Emphasis areas include training and community

mobilization/participation, with minor emphasis on quality assurance and supportive supervision. Primary

target populations include people living with HIV (PLHIV), pregnant women, HIV-exposed and infected

infants, South African-based volunteers and nurses, and provincial and district HIV and PMTCT

coordinators.

BACKGROUND:

With FY 2007 funding, PATH in collaboration with the Eastern Cape Department of Health (ECDOH)

initiated a PMTCT program in Amatole, OR Tambo and Cacadu districts. The PATH PMTCT program

supports the South African Government's HIV/AIDS/STI Strategic Plan for 2007-2011, the Eastern Cape's

Comprehensive HIV/AIDS/STI/TB Program, and the Strategic Plan for US-SA Cooperation. PATH, the

prime partner, provides technical, programmatic, and financial leadership. The ECDOH, provides all the

facilities, systems, and local personnel. Health Information Systems Program (HISP) is responsible for

monitoring and evaluation. South African Partners, an NGO, leads the community support and mobilization

interventions. There is also a small grants program for community-based organizations. PATH will address

the root causes of gender inequity by examining values and norms. The project provides information and

support for infant feeding choices and helps clients assess their needs, considering issues such as the risk

of stigma and discrimination associated with not breastfeeding. The project provides holistic psychosocial

support to HIV-infected women. Community mobilization is led by PLHIV leaders--the majority of whom are

women, to increase knowledge about PMTCT, promote understanding of PMTCT as the equal responsibility

of men and the community, and work toward transforming current norms, stigma and discrimination that

hold women solely responsible for having HIV and transmitting HIV to children.

ACTIVITIES AND EXPECTED RESULTS:

This program will strengthen the ability of current PMTCT facilities to provide a minimum package of

services, enable the ECDOH to expand PMTCT services by training and supporting providers such that

they can provide comprehensive services, and raise awareness of and support for PMTCT service use

within communities. The project is focused on the public sector and dependent communities only.

ACTIVITY 1: Systems strengthening

Building on FY 2007 activities, FY 2008 resources will be used to ensure continuity of system strengthening

activities. One set of interventions will strengthen human resource capacity: training existing but untrained

facility staff (e.g., nurses, midwives, lay counselors) to provide PMTCT services, reinforcing the skills of

current PMTCT staff, and orienting other staff (e.g., child/wellness clinic nurses, community health workers)

who help ensure a continuum of care. Training will focus on HIV counseling and testing, measuring CD4 cell

counts, clinical staging, psychosocial support, antiretroviral treatment (ART), and follow up and care for the

exposed child, including piloting polymerase chain reaction (PCR) testing. A second set of interventions will

ensure that monitoring and supervision systems are fully operational at all levels (district, local service area,

facility), providing on-site technical support as needed. A third set of interventions will strengthen ECDOH

data and logistic systems, improving the quality of data recorded, collected, reported, and used at all levels.

The project will also work with the ECDOH to address specific policy and guideline issues that directly affect

PMTCT services. Finally, the project will improve referral systems, especially referral of pregnant or

postpartum women and their children to antiretroviral (ARV) care and treatment sites and pediatric centers.

ACTIVITY 2: Capacity building

The project works at all levels of service delivery to strengthen the provision of high-quality, comprehensive

PMTCT services. The project will focus on priority hospitals and select feeder-community health centers

and clinics to ensure that women have access to the full continuum of PMTCT services, from the first

antenatal care visit through follow-up of the mother and baby after birth. The package of interventions will

be tailored to each facility's needs and may include training in essential PMTCT skills, monitoring and

supervision to maintain high-quality services and/or upgrade staff skills, data management for ongoing

corrections and decision-making, integration of services to give women and babies necessary care and

treatment, and linkages to the community so that PMTCT is accepted and used widely.

ACTIVITY 3: Increasing community engagement and leadership

One of ECDOH's priorities is to broaden the role of the community in promoting, supporting, and utilizing

PMTCT services. This includes providing health education, reducing stigma, generating demand for

services, working with the partners and families of HIV-infected women to increase support for PMTCT,

developing community networks for client follow-up, and strengthening tangible links between the

community and the facility. Underlying these interventions is the need to build capacity of community

networks and organizations to implement and monitor programs. Interventions will strengthen HIV

prevention programs, provide PMTCT information, and reduce stigma in the community; strengthen peer

support for HIV-infected pregnant women to increase demand for and adherence to PMTCT and ARV

regimens; and improve community-facility collaboration to increase local ownership and utilization of

services. The ECDOH is the driving force of this project and all of the investments in human capital will

benefit their workers and the communities. Human capacity development is at the center of this project as

described in the training and systems strengthening activities above.

ACTIVITY 4. Preparing for a transition to dual therapy for PMTCT

The new HIV & AIDS and STI Strategic Plan for South Africa calls for a new policy on the drug regimen

used in PMTCT, suggesting that the policy should be updated according to the WHO Guidelines. The

purpose of this activity is to conduct an assessment to assist ECDOH in planning for the implementation of

Activity Narrative: the policy change and to suggest a set of criteria to inform how and when the introduction of dual therapy

should be introduced at the facility level. The assessment will look at the critical components of the health

system including policy, financing, human resources, training, supply systems, service management and

referrals, and information and monitoring systems to establish what will be needed to implement the

pending policy. PATH will also establish a pilot project in six sites in the EC (upon ECDOH approval) and

implement dual therapy services to establish a "better practice" model. This will be rolled out to other

districts and facilities. In addition, PATH will work with the ECDOH to strengthen referral systems for HIV-

infected pregnant women ensuring that all treatment eligible pregnant women are fast- tracked to treatment

programs.

ACTIVITY 5: Maternal nutrition and infant feeding job aids and materials

In FY 2007 PATH developed a series of job aids and print materials for both health workers and mothers

such as handouts on feeding options, flip charts and/counseling cards for infant feeding counselors on

feeding options, AFASS, lactation and breastfeeding, etc., basic maternal nutrition guidance, a wall chart

linking each antiretroviral drug with a statement on its implications for food intake at the time when it is

taken, etc. FY 2008 activities will focus on dissemination and utilization of these materials.

FY 2008 COP activities will be expanded to include:

ACTIVITY 6. Creating Linkages between Reproductive Health (RH) and PMTCT

This activity will effectively link prevention of HIV and prevention of unintended pregnancies into PMTCT

settings in the EC. The work will provide evidence-based information and recommendations for decision-

makers and program managers to improve policy and practice for integrating RH services into PMTCT

settings. Current integration policy and practices will be explored, as will client fertility intentions and

desires. The community will be consulted on what services should be integrated and to strengthen

community ownership of service delivery and to increase demand for RH services. The PMTCT continuum

will be analyzed to determine when clients are most likely to want internalize information that could

influence their uptake of services. Lay counselors and professional nurses will be trained and community

mobilization will be expanded to improve access to and utilization of RH services.

ACTIVITY 7. Preparing nurse/midwives to expand their role in HIV and AIDS prevention and treatment

This activity targets professional nurses from maternity wards and expand their roles and responsibilities in

terms of HIV prevention and treatment. The focus will be on hospitals where the need for task shifting is

greatest. Activities will improve attitudes, motivation, knowledge and skills. Participatory training approaches

will be used to work with this cadre to define the problems and to create solutions to ensure quality

comprehensive services.

The PATH PMTCT project contributes to the PEPFAR 2- 7-10 goals by strengthening PMTCT services

hence preventing vertical transmission of HIV.