SUMMARY:

Reproductive Health and Research Unit (RHRU), as part of an outreach project in deprived inner city areas,

will implement four Other Prevention projects: Firstly, the provision of outreach prevention, clinical and

support services to commercial sex workers at an inner city primary health care clinic as well as prevention

information and condoms in the many brothels in Hillbrow, Johannesburg. Secondly, RHRU's sub-partner,

CARE, will offer home-based information, support and referral, and capacity building activities to improve

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

organizations (NGOs). Prevention measures will be used as the entry point to household-based work.

Thirdly, RHRU will continue to provide a new program of prevention work for HIV-infected individuals, using

"motivational interviewing" techniques to reduce risky behavior. Lastly, RHRU will promote the uptake of

male circumcision through integration with existing services. Activities will include training, workshops and

other outreach covering condom usage and negotiation. Concurrent partner/partner reduction strategies

and HIV risk reduction will be integrated into all Other Prevention activities. The primary emphasis area for

these prevention activities is human development. The primary target populations for these interventions

are women, men, adolescents, people living with HIV, HIV-infected women including pregnant women,

commercial sex workers and their partners/clients, brothel owners, community-based and non-

governmental organizations (CBOs/NGOs). The sex worker component will be expanded in FY 2008 to an

additional neighborhood in Johannesburg. Prevention with Positives (PwP) will also be continued in all CT

and treatment programs.

BACKGROUND:

RHRU, a unit of the University of the Witwatersrand in Johannesburg, currently provides technical support

to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South

Africa, which includes the national ARV roll-out. Under PEPFAR funding since FY 2004, RHRU has

provided regular on-site support, direct treatment, training and quality improvement to Department of Health

sites in three provinces. RHRU will continue these activities, and will continue both an inner city program

(Johannesburg) and a district-wide program (Durban), focusing on providing support to complete up and

down treatment referral networks. In addition, RHRU will continue the provision of counseling and testing

(CT), palliative care and prevention services. RHRU will seek to develop models of service delivery that can

be replicated and expanded, and produces findings from lessons learned and targeted evaluations to

disseminate and share with others. It should be noted that the success of antiretroviral treatment (ART)

scale-up depends on the comprehensive approach detailed in other program areas. In particular, the

strengthening of referral from other primary healthcare programs such as tuberculosis (TB), family planning,

antenatal/postnatal and STI services is critical. Prevention is an integral part of this system, and RHRU will

focus its condoms and other prevention program on high-risk groups such as commercial sex workers and

their clients, people infected with HIV, and also on building capacity of the CBOs and NGOs with which it

works. RHRU will also continue to develop strategies to address underserved communities affected by HIV,

such as couples (both concordant and discordant), high risk groups such as young people, and gender-

based interventions with women at risk, including pregnant women and commercial sex workers, and men.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: HIV Prevention for Women At Risk

RHRU will continue to target a large community of commercial sex workers with prevention and care

services, as well as treatment referral. The project is located in the deprived Johannesburg inner city, which

is densely populated, transitory and poor, with high HIV and unemployment rates. All women will be referred

for CT, and those with appropriate CD4 counts will be referred for ARV treatment. New treatment sites will

be identified in needy areas of the city, and the organization will work with local public sector clinics in the

area to sensitize staff to the special needs of this difficult-to-reach group and to provide outreach clinics in

local brothels, which are the hub of commercial sex workers in Hillbrow and Berea Johannesburg. RHRU

will also work with brothel owners, and clients and partners of commercial sex workers to increase their

awareness and affect a change in their norms and behaviors regarding HIV and AIDS. A specific focus will

be on changing gender norms through workshops and trainings, which will include such topics as

alternatives to risky behavior, women's rights, and reduction of gender-based violence. The project will

provide prevention outreach services including management of sexually transmitted infection (STI),

provision of condoms together with messages regarding correct and consistent use of condoms,

contraception and HIV prevention education including cross-generation and transactional sex, as well as

support for those who wish to leave sex work. The project will play a critical role in raising awareness of HIV

services and prevention through workshops and event days, and by distributing IEC materials. Furthermore,

this gender-related project will conduct HIV counseling and testing on high risk and difficult-to-access

groups, and will relate to the development of health networks and linkages by providing referral to HIV and

TB care and treatment services where necessary. To aid the expansion and sustainability of this program,

the local health authority will also contribute to this project. In addition, a manual has been developed to

provide a toolbox for other health authorities seeking to replicate this program, and technical consultation

will be provided. RHRU will share this with the Medical Research Council and others involved with high risk

populations.

ACTIVITY 2: Prevention with Positives

There is very little focus on prevention in South Africa among people already infected with HIV. Prevention

work to encourage safe-sex behaviors and limit infection and re-infection for those already positive is

currently being developed by some South African organizations. Innovative prevention methods, the

development of which will draw on models that have proven successful in other settings, will be introduced

in South Africa. Clinicians will be trained in this specific focus area, and the program will be monitored and

evaluated for efficacy. Programs that are proven successful will be expanded into other areas and used as

examples for other organizations. In addition, RHRU is currently adapting a flipchart on contraception for

HIV-infected clients for use by South African health care providers. This will be piloted in FY 2007-2008 and

will contribute to improved prevention for positive clients and will be integrated into care and treatment

programs.

ACTIVITY 3: Community-Based Prevention

Activity Narrative:

RHRU will extend care and support services further into inner city areas, and incorporate prevention and

behavior change into their activities. With a combination of private sector and PEPFAR funding, RHRU runs

an information and support center in a high-risk area. A team of counselors and caregivers will be launched

from this center into the surrounding community. Team members will link with 30 households a week, with

the primary purpose of educating them on HIV prevention and understanding risk. Using prevention

messages as the entry to the household they will also assist them as needed with home-based care,

reaching orphans and vulnerable children, men and women, as well as contributing to the destigmatization

of HIV and AIDS.

ACTIVITY 4: Male Circumcision

No male circumcision training or service delivery will take place without the express consent of the National

Department of Health. In the absence of such approval and based on discussions with the PEPFAR South

Africa team, funds could fully or partially be reprogrammed. Should the approval for safe clinical male

circumcision activities be given, RHRU is proposing the following male activities:

Male circumcision has been identified as an important biological intervention that protects men from HIV

infection. It also creates opportunities to engage with men over a variety of reproductive health and risk-

taking issues. Men are grossly under-represented in terms of access to counseling and testing, as well as

HIV clinical services, including ART. Circumcision programs may allow expanded access to all forms of

care, including HIV testing. However, while the biological protection against HIV transmission has been

demonstrated beyond doubt, issues such as acceptability, operationalization, disinhibition and

programmatic integration, still remain. RHRU will explore the acceptability of integrating male circumcision

into existing services to broaden uptake. This will include piloting "opt out" circumcision for neonates, and

developing methods of raising awareness raising and counseling that address target groups including males

and young people. All activities will be conducted in accordance with the South African Government's new

Strategic Plan.

In FY 2007- FY 2008, RHRU will continue to undertake M&E activities to inform and develop quality HIV

care. RHRU will be in a position to conduct targeted evaluations (TE) and Public Health Evaluations (PHE)

of some of its prevention related projects in FY 2008-09. For each PHE, a detailed proposal will be

developed and submitted to PEPFAR for review and funding approval.

RHRU will contribute to PEPFAR 2-7-10 goals by providing prevention services to a most-at-risk population

in a densely populated, poor, and highly transient inner city community.

SUMMARY:

The Reproductive Health and HIV Research Unit's (RHRU) Basic Care and Support activities for FY 2008

will be part of an integrated program and will specifically include: (1) palliative care arising from clinical (both

ARV and non-ARV) services rendered by RHRU staff through the activities described under the ARV

Services program area; (2) the provision of psychosocial support to commercial sex workers, (3) the

provision of support, home-based care and referral; and (4) the implementation of health provider training in

all aspects of palliative care. The major emphasis area for these activities is quality assurance and

supportive supervision, with additional focus on human resources, development of referral systems, and

training. Populations targeted for these interventions include PLHIV (children, youth and adults), HIV-

affected families, commercial sex workers, refugees, and public sector doctors, nurses, pharmacists,

traditional healers and other health care workers

BACKGROUND:

RHRU, a unit of the University of the Witwatersrand in Johannesburg, currently provides technical support

to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South

Africa, which includes the national ARV rollout. Under PEPFAR funding since FY 2004, RHRU has provided

regular on-site support, direct treatment, training and quality improvement to DOH sites in 3 provinces. The

RHRU will continue these activities, which include inner city, district wide and rural programs focusing on

providing support to complete up and down treatment referral networks. In addition, RHRU will continue the

provision of counseling and testing (CT), palliative care, and prevention services. RHRU continues to

develop models of service delivery that can be replicated and expanded, and produces findings from

lessons learned and targeted evaluations to disseminate and share with others. It should be noted that the

success of ARV treatment scale-up depends on the comprehensive approach detailed in other program

areas. In particular, the strengthening of referral from other primary healthcare programs such as TB, family

planning, antenatal/postnatal and STI treatment is critical. Basic Health Care and Support is an integral part

of this system, and the RHRU will focus this part of its program on PLHIV, in impoverished areas such as

the Hillbrow neighborhood in Johannesburg, and at PHC clinics in Durban, and rural areas of the North

West Province by delivering high quality palliative care, psychosocial support, and intensive training of

doctors, nurses, and other health care professionals. Furthermore, RHRU will continue to develop strategies

to address underserved communities affected by HIV, such as couples, high risk groups such as

adolescents, and gender-based interventions with women at risk, including pregnant women, commercial

sex workers, and men.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Provision of Palliative Care

Through comprehensive support and quality improvement programs to the Johannesburg inner city,

eThekwini District in Durban, and through Mobile Clinical Support Teams operating in North West, KwaZulu-

Natal (KZN) and Gauteng provinces, RHRU will continue to provide the preventive care package and

opportunistic infection prevention and treatment, identification and treatment of syndromic STIs, provision of

regular CD4 counts, and pain and symptom management in conjunction with ARV treatment to adults and

children in partnership with the DOH. In addition, STI treatment will be provided to HIV-infected patients at a

network of local health authority sites in the inner city of Johannesburg. This includes the Women At Risk

Project that reaches commercial sex workers through a clinical and support outreach service that moves

between the inner city brothels, and a special service run from the clinic every weekday morning (see the

Other Prevention section for more details). Integrated reproductive health/HIV services will be provided to

HIV infected clients at a large family planning clinic in the Durban CBD and via the gender-related projects

described in the Other Prevention program area. Furthermore, health care and support will be provided to in

-patients at an HIV step-down and palliative care facility in KwaZulu-Natal. Lastly, as described in the Other

Prevention section, RHRU will provide home-based care in the deprived inner city suburb of Hillbrow

through its new program of community outreach.

ACTIVITY 2: Psychosocial Support

RHRU or its sub-partners will provide psychosocial support through counseling, wellness programs and

befriending. RHRU will assist with income generation, material support programs, and support group

facilitation. RHRU will be key in the strengthening of adherence initiatives through their work in HIV

treatment sites and within the community. RHRU will also assist the DOH in providing technical resources,

continuity and support to the up and down referral processes that must take place to enable ARV program

scale-up. Currently men are under-represented in seeking ARV treatment, and a family-based approach to

care ensures all family members are provided with treatment and prevention initiatives where appropriate.

Therefore, RHRU will also address gender issues by developing and providing specialized services such as

family clinic days 3 days per week, male clinic 5 days per week for CT and ART, and male only support

groups for families and men in order to improve access for these two key groups. In addition working with

antenatal and postnatal clinics, RHRU will provide psychosocial support and specialized adherence

counseling for HIV-infected pregnant women and new mothers, and will work with pediatric treatment sites

to provide specialized adolescent counseling and psycho social support. Through the Women At Risk

project, commercial sex workers are provided with support and information on appropriate topics at

outreach sites by community health workers, and referred into other psychosocial services as required,

including support groups, workshops on CSW-relevant issues (such as gender violence and gender norms

and behaviors), prevention with positives interventions, and income generation projects to provide peer

support and encourage the exiting of sex work. Refugee populations, often a neglected, overlooked group,

will also be targeted with services provided by RHRU. A special program for the care of refugees will be

expanded to include more systematic identification of refugees seeking assistance through public facilities.

These individuals will be counseled and provided full referral and follow up services to the NGO and private

sectors to receive care, treatment and support if they are ineligible to receive services through the public

sector programs.

ACTIVITY 3: Human Capacity Development

The objective of the training is to increase skills in the delivery of quality palliative care services including

Activity Narrative: elements of the preventive care package. RHRU will provide on-site and didactic training to DOH and NGO

doctors, nurses and counselors, and will specifically target ARV and non-ARV sites that need to be able to

care for, manage and appropriately refer HIV-infected clients. RHRU will also provide mentoring to DOH

staff via bedside teaching, case reviews, the sharing of quality improvement approaches, and support

during consultations. RHRU's Primary Health Care Project will provide tools, training and on-site guidance

to DOH staff in primary healthcare sites relating to quality improvement of primary healthcare services,

including palliative care. This project will also provide support to ARV treatment and is described in the ARV

Services section. In FY 2007-2008, RHRU will continue to undertake M&E activities to inform and develop

quality HIV care. RHRU will be in a position to conduct Public Health Evaluations (PHE) of some of its

palliative care related projects in FY 2008-2009. For each PHE, a detailed proposal will be developed and

submitted to PEPFAR for review and funding approval.

These activities contribute significantly to both the vision outlined in the USG Five-Year Strategy for South

Africa and to the 2-7-10 objectives by ensuring that HIV-infected individuals and their families are able to

access comprehensive care, and by expanding access to these services in both the public and private

sector.

SUMMARY:

The Reproductive Health Research Unit's (RHRU) TB-HIV activities include the ongoing provision of TB

clinical services and the expansion of referral networks and service integration in a deprived inner city area

of Johannesburg, South Africa. In addition, in KwaZulu-Natal (KZN), the RHRU is supporting

implementation of ARV services at two TB hospitals (Don McKenzie & Charles James, where over 80% of

TB patients are coinfected with HIV. Lastly, RHRU will pilot a program to provide a health screening

program to health care workers in the inner city of Johannesburg, to ensure a healthy workforce and early

referral and management of chronic disease. Emphasis areas include human capacity development and

local organization capacity building. Target populations include PLHIV, adults and children.

BACKGROUND:

RHRU, a unit of the University of the Witwatersrand in Johannesburg, currently provides technical support

to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South

Africa, which includes the national ARV rollout. Under PEPFAR funding since FY 2004, RHRU has provided

regular on-site support, direct treatment, training and quality improvement to DOH sites in 3 provinces. They

will continue these activities, which include inner city, district wide and rural programs focusing on providing

support to complete up and down treatment referral networks. In addition, RHRU will continue the provision

of counseling and testing (CT), palliative care, and prevention services. RHRU continues to develop models

of service delivery that can be replicated and expanded, and produces findings from lessons learned and

targeted evaluations to disseminate and share with others. It should be noted that the success of ARV

treatment scale-up depends on the comprehensive approach detailed in other program areas. In particular,

the strengthening of referral from other primary healthcare programs such as TB, family planning,

antenatal/postnatal and STI treatment is critical. Basic Health Care and Support is an integral part of this

system, and the RHRU will focus this part of its program on PLHIV, in impoverished areas such as the

Hillbrow neighborhood in Johannesburg, and at PHC clinics in Durban, and rural areas of the North West

province by delivering high quality palliative care, psychosocial support, and intensive training of doctors,

nurses, and other health care professionals. Furthermore, RHRU will continue to develop strategies to

address underserved communities affected by HIV, such as couples, high risk groups such as adolescents,

and gender-based interventions with women at risk, including pregnant women, sex workers, and men.

Although approximately 58% of TB patients in South Africa are HIV infected, published data have shown

that a low number of patients are referred from surrounding TB sites to ARV services. A large percentage of

these patients will qualify for immediate ARV treatment, and represent an untapped population requiring

immediate access to ARVs. RHRU has been working with health authorities to provide TB clinical services

and training, with the support of Emergency Plan-funding. RHRU has integrated TB into general palliative

care training, and trained thousands of health providers in these areas in previous years. In addition, RHRU

programs assist in treating HIV-infected people for TB. In FY 2008, RHRU will build on this program by

continuing to train health care providers, and continuing to emphasize TB and HIV integration as part of on-

site technical support to ARV treatment sites and primary health care clinics and their referral facilities.

ACTIVITIES AND EXPECTED RESULTS:

RHRU 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. RHRU 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. RHRU 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. RHRU 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.

ACTIVITY 1: TB Treatment Support & Integration

Tuberculosis treatment represents an ideal opportunity for entry in to an ARV program. Patients being

treated for TB have to deal with the public health system entry, daily adherence, drug toxicity, and regular

follow-up evaluation, all of which are key components of the ARV program. Ensuring that health care

workers understand that referral from TB sites should be seamless, and encouraging patients to test for HIV

through the DOH program, will ensure a constant stream of well-prepared co-infected patients entering the

system.

ACTIVITY 2: TB Referral & Staging

RHRU's teams will continue to work within the existing TB services in 3 provinces to expand CT, CD4

staging, initiation of opportunistic infection prophylaxis (cotrimoxazole) and preliminary ARV adherence

advice. RHRU will also facilitate direct referral of correctly staged patients into ARV treatment sites, and

ensure that other patients accessing ARVs in RHRU sites in the 2 provinces are referred for TB treatment

where necessary. Additionally, in the case of very immuno-compromised patients with TB who require

ARVs relatively quickly in terms of national guidelines, RHRU will train health care workers to recognize this

urgency and refer accordingly, while working with accepting ARV sites to similarly treat these cases with

urgency.

ACTIVITY 3: Human Capacity Development

RHRU will continue to develop and scale up TB/HIV training programs for TB service providers operating at

all levels of facilities in the provinces in which RHRU works. The primary focus will be on increasing access

to ARV services from TB services through continual training and engagement with TB managers. RHRU

anticipates that this approach will maintain a steady stream of patients into their ARV programs (see ARV

Services section for more information).

ACTIVITY 4: Health Maintenance Program for Health Care Workers

RHRU will continue to provide screening for TB, HIV and chronic diseases among health care workers in

Activity Narrative: City of Johannesburg health facilities, to ensure the preservation of human capacity and to determine the

risk of TB infection among this important group. In FY 2008, RHRU will continue to undertake M&E activities

to inform and develop quality TB/HIV care. RHRU will be in a position to conduct Public Health Evaluations

(PHE) of some of its TB-HIV related projects in FY 2008-2009. For each PHE, a detailed proposal will be

developed and submitted to PEPFAR for review and funding approval. This activity will contribute to both

the vision outlined in South Africa's 5 Year Strategy and to the 2-7-10 goals by identifying and directing

more people to ART, and by increasing access to care.

SUMMARY:

The Reproductive Health and HIV Research Unit's (RHRU) PEPFAR-funded program, subsequently

referred to as the "Follow-on to the RHRU Program" (FRP), was re-competed through an Annual Program

Statement (APS) in 2007, and awarded to the RHRU. PEPFAR funds will support the FRP to continue to

provide counseling and testing (CT) services, and to expand services tailored to target groups such as

couples, pregnant women, young people, children, and families, as part of an integrated prevention, care

and treatment program. FRP will also provide training and mentoring in voluntary counseling and testing to

Department of Health (DOH) staff, to ensure the implementation of provider-initiated testing and counseling

(PITC) in TB, STI, antenatal/postnatal and contraceptive services at all levels. Major emphasis in this

program area is on quality assurance and supportive supervision, with additional emphasis on the

development of network/linkages/referral systems, human resources, and training. These activities target

HIV-affected families (children, youth, and adults), sex workers, men, pregnant women, discordant couples,

and public health workers.

BACKGROUND:

RHRU, a unit of the University of the Witwatersrand in Johannesburg, currently provides technical support

to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South

Africa, which includes the national antiretroviral (ARV) roll-out strategy. Under PEPFAR funding since FY

2004, RHRU has provided regular on-site support, direct treatment, training, and quality improvement to

DOH sites in three provinces (Gauteng, KwaZulu-Natal and North West). The FRP will continue these

activities, which include inner city, district wide and rural programs focusing on providing support to a

complete up and down treatment referral network. In addition, FRP will continue the provision of counseling

and testing (CT), palliative care, and prevention services. FRP will seek to develop models of service

delivery that can be replicated and expanded, and produces findings from lessons learned and targeted

evaluations to disseminate and share with others. It should be noted that the success of ARV treatment

scale-up depends on the comprehensive approach detailed in other program areas. In particular, the

strengthening of referral from other primary healthcare programs such as TB, family planning,

antenatal/postnatal and STI services is critical.

In FY 2007, FRP will continue to focus on further strengthening DOH adult and pediatric treatment, and on

continuing the development of a family-based approach to HIV care and treatment in the public sector.

Furthermore, FRP will continue to develop strategies to address underserved communities affected by HIV,

such as couples, high-risk groups such as adolescents, and gender-based interventions with women at risk,

including pregnant women and sex workers, and men. FRP places strong emphasis on quality assurance

for all interventions supporting CT and will draw on the tools that have a proven track record in terms of

improving quality of care, such as pocket reminders for counselors, wall charts with trigger messages for

clients and counselors, and routine performance assessments.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Counseling and Testing

PEPFAR funds will support FRP to continue to directly provide CT services at multiple sites, and to expand

services tailored to target groups such as couples, family planning clients, children, families, men, pregnant

women, and sex workers as part of an integrated prevention, care and treatment program. Discordant

couples will be targeted for prevention education, and concordant couples can benefit from referral to a

wellness program. Both groups will benefit from fertility and family planning advice. FRP will work closely

with the national DOH and will ensure that CT is integrated into other health programs at all levels. In

addition, FRP will focus on integrating provider-initiated testing and counseling (PITC) into TB, STI,

antenatal/postnatal and family planning services as recommended in the HIV & AIDS and STI Strategic

Plan for South Africa, 2007 - 2011.

ACTIVITY 1.1: Gender-based Voluntary Counseling and Testing

Approximately 70% of individuals currently accessing antiretroviral treatment (ART) are women. FRP will

continue to develop services that aim to address this gender inequality, and to increase the number of men

who obtain HIV care. This will be done through the development of male-friendly CT methods, such as

family-centered counseling and testing, and interventions to encourage health-seeking behaviors. This

program will contribute towards increasing gender equity in HIV and AIDS programs.

ACTIVITY 1.2: Family-Centered Testing

Children and families have special needs that will be addressed in the program. Previous work in antenatal

clinics and in pediatric treatment will have given FRP the opportunity to promote family testing to DOH staff

and community social workers, and to develop approaches to this activity. A youth-friendly CT model will

continue to be developed and implemented in the inner city of Johannesburg and Durban. Mobile CT units

will be utilized to increase access to CT for families at weekends and to other hard-to-reach groups. Age-

appropriate counseling and testing techniques will be developed, and opportunities to scale-up counseling

and testing of this group will be identified and interventions implemented accordingly.

ACTIVITY 2: Human Capacity Development

FRP will train counselors, doctors, nurses, and other healthcare workers to provide comprehensive and

appropriate CT services, in line with South African guidelines. This includes appropriate referral, and

updates on new practices and current debates in an evolving field. In addition, FRP staff will provide

mentoring to local NGOs, lay counselors, and DOH staff in the public sector facilities in which they work,

through weekly supportive supervision sessions with all counselors and regular meetings to discuss the

development and application of new practices.

In FY 2008, RHRU will continue to undertake monitoring and evaluation activities to inform and develop

quality HIV care. RHRU will be in a position to conduct targeted evaluations (TE) and Public Health

Evaluations (PHEs) of some of its counseling and testing projects in FY 2008 and FY 2009. For each PHE,

a detailed proposal will be developed and submitted to PEPFAR for review and funding approval.

Activity Narrative:

These activities expand CT services to important high-risk populations, and serve as a critical entry point

into HIV care and treatment programs, thus contributing to the 2-7-10 goals by enabling access to treatment

and prevention for those who test.

SUMMARY:

The Reproductive Health and HIV Research Unit's (RHRU) will provide ARV rollout support services with

Department of Health (DOH) partners in over 30 facilities in 4 provinces. The emphasis areas are

renovation, human capacity development, and wrap-around programs. Services target people living with

HIV (PLHIV) and their families, including children, pregnant women, caregivers, doctors, nurses, traditional

healers, and other healthcare workers.

BACKGROUND:

RHRU currently provides technical support to the South African Government (SAG) that includes the

national ARV rollout. With PEPFAR funding since FY 2004, RHRU has provided regular onsite support,

direct treatment, training and quality improvement to provincial departments of health (DOH) sites in

Gauteng, North West, Limpopo and KwaZulu-Natal (KZN). RHRU will continue these activities as well as an

inner city program in Johannesburg. Up and down treatment referral systems are being improved in all

provinces. In addition, RHRU will continue the provision of counseling and testing (CT), palliative care, and

prevention services. RHRU will develop service delivery models that can be replicated and expanded, and

produces lessons learned to share with others.

An effective, sustainable ARV treatment (ART) program is founded on strong partnerships with local public

sector treatment sites. The needs of each facility vary, and successful incorporation of ARV services at

facilities requires a thorough facility-based situational analyses. RHRU's aim is to deliver decentralized HIV

care or up and down referral between hospitals and related primary care clinics. ARV clients will be

identified, screened, prepared and initiated on ARV treatment with access to future care at up or down

referral sites. This system reduces congestion at primary treatment sites and improves patient access to

care.

As of June 2007 RHRU-assisted sites were treating over 28,000 people with ART, and over 2,000 health

providers had been trained in ART. RHRU will continue assistance in existing sites and expand services to

several new sites. Pediatric support as well as ART for pregnant women will be expanded. In addition,

RHRU will continue an HIV Maternal Health Outreach Service, and provide planning, training and technical

assistance (TA) to two primary healthcare clinic (PHC) networks in Gauteng and KZN. This will enable

these clinics to receive down-referred patients, and initiate new patients in selected sites. Nurse-based

services will be promoted whenever feasible.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Treatment Support

Specialist HIV treatment teams will support urban and rural ARV sites for adults (including pregnant women)

and pediatrics. They will provide TA to new sites, and will develop and facilitate referral networks. Teams

include a doctor, nurse, management specialist and counselor and will rotate among a cluster of treatment

facilities providing onsite training and management support. In most cases, these teams will be anchored at

each site by a permanent quality improvement nurse and a patient tracker to reduce the number of patients

lost-to-follow-up and lost to initiation. The continuum of care will be emphasized including: prevention,

healthy lifestyle, responsible behavior, nutrition advice, opportunistic infection prevention/treatment,

palliative care, and ART. Materials previously developed to educate healthcare workers and HIV clients

about HIV care will be utilized. Outreach teams will provide ARV and referral clinics with TA on up and down

referral models. The teams will assist local clinic staff to improve practice, integrate and expand services

(including TB, see TB section), and maximize referral for CT, palliative care and ART. As part of this, clinic

renovations and provision of park homes, to maximize quality service delivery, may be necessary in

selected sites. RHRU will also explore the possibility of linking with the private health sector to access and

refer indigent populations into public sector care through low salaried family members on basic medical aid

plans. Furthermore, senior staff will provide TA to national and provincial government in the development of

policies and guidelines. ARV treatment and HIV care for perinatal women will provide outreach in maternal

services. Family-based and gender-specific services for underserved groups such as men and high-risk

women will also continue to be expanded.

ACTIVITY 2: Human Capacity Development

Insufficient skills in HIV care and program management have been a barrier to scale-up of site support.

RHRU will develop an internal site-based training program to enhance staff skills. RHRU also offers a

structured program for young doctors interested in pursuing a career in HIV. All RHRU staff involved in the

PEPFAR program will become skilled HIV clinicians and program implementers, benefiting the program in

the short term, and improving the South African skill base in public health in the longer term.

RHRU will provide DOH staff in ARV sites with expert capacity and TA to develop models of effective

service delivery using existing infrastructure and resources. It will emphasize clinical training and promotion

of quality improvement techniques that can be applied by the DOH staff to develop local solutions to local

problems. The teams will provide onsite support to clinical management, referral, patient flow and data

management.

Through the PHC and decentralized care projects, RHRU will assist PHC sites to integrate HIV care into

routine service delivery and will support sites with ARV accreditation if appropriate. Nurses will lead these

services, with doctor support when necessary (task shifting). RHRU will conduct formal training courses

including foundation courses in adult and pediatric ART for healthcare providers and traditional healers, and

HIV management for nurses and doctors.

ACTIVITY 3: Pediatrics

RHRU and its partners will expand pediatric and services for young people to additional provinces based on

a review of needs and requests from provincial authorities. The pediatric clinical support teams will rotate

through DOH sites, capacitating and strengthening clinical skills, and supporting the development of referral

networks. They will aid collaborations between healthcare facilities and local FBOs, NGOs and CBOs to

Activity Narrative: provide holistic care for children on ART. RHRU will play a pivotal role in initiating pediatric ARV services at

facilities where no pediatric services exist. Innovative methods of improving pediatric and adolescent

adherence to ART will be investigated.

The National Adolescent Friendly Clinic Initiative (NAFCI) supports the public sector to provide quality

services geared to youth, and are developing a referral system for HIV-infected adolescents to receive

ongoing care and provision of ART. RHRU will support services at NAFCI sites in proximity to HIV treatment

facilities in Soweto.

ACTIVITY 4: Referral Networks

RHRU will provide training, mentoring, management support and consultants across 4 provinces, to assist

DOH ART sites with referral processes. This includes increasing referral capacity at secondary sites to

channel and monitor stable patients at peripheral sites closer to patient's homes. This mechanism will

reduce congestion at primary sites, enable clinics to see more patients, reduce patient transportation costs

and increase adherence. RHRU will aid capacity development and training of local organizations, as well as

develop linkages, referral systems, human resources, information, education and communication (IEC),

needs assessments, policy and guidelines and strategic information.

ACTIVITY 5: Nutrition

RHRU will support several ART sites including TB hospitals in Johannesburg and Durban by employing

dieticians to provide TA, coordinate supplies of nutritional supplements from the district health office to

facilities for pediatric and TB/HIV-infected clients, provide nutrition information and counseling support and

develop IEC materials. RHRU will provide TA to national and provincial DOH about appropriate nutrition

interventions at different stages of disease in people infected with HIV and TB.

ACTIVITY 6: Monitoring and Evaluation

In FY 2008, RHRU will continue to undertake M&E activities to inform and develop quality HIV care.

These activities directly contribute to PEPFAR's goal of 2 million people on treatment. RHRU will support

the South Africa 5 year strategy by expanding access to HIV services, improving ARV service delivery, and

increasing the demand for and acceptance of ART.