SUMMARY:

Columbia University International Center for AIDS Care and Treatment Program (ICAP) will use FY 2008

funding to apply its PMTCT capacity building activities in 30 sites located in Limpopo, Northwest, Gauteng,

Mpumalanga, Northern Cape, and Western Cape provinces. ICAP's capacity building model is based on its

support of the South-to-South Partnership for Comprehensive Pediatric HIV and AIDS Care and Treatment

Training Initiative (S2S) in the Western Cape, which emphasizes site level training; namely, continuous and

supportive onsite presence, onsite dynamic skills-building events such as on-the-job training, clinical

mentoring, modeling and site implementation workshops and case-based learning. The core activity for FY

2008 involves designing and implementing PMTCT performance action plans and establishing long-term

monitoring systems so that increased quality of service delivery can be sustained over the long term. This

activity will be implemented in collaboration with the Foundation for Professional Development (FPD),

BroadReach Healthcare and Right to Care.

BACKGROUND:

A main focus of ICAP support on the site level is to build provider and system capacity with a focus on

continuous quality improvement. Shortages of health care workers are exacerbated by the gap between the

knowledge and skills required to provide HIV and AIDS services. Additionally, poor design of facility

systems and services, lack of patient scheduling systems, inefficient provider placement and scheduling

and irregular supervision by senior management continue to weaken already stressed HIV services. ICAP's

site level support is dynamic and continuously customized to consider site attributes and existing resources.

During FY 2008 this capacity building model will support the continuation and expansion of the S2S

Partnership with Tygerberg Children's Hospital-Stellenbosch University in the Western Cape. The S2S

program, experiences and materials will support the activities within this initiative aimed at supporting

pediatric HIV and AIDS.

ACTIVITIES and EXPECTED RESULTS:

ACTIVITY 1: Basic Capacity Building Model

While the technical support and capacity building focus varies according to site attributes, all sites benefit

from ICAP support to: (1) jointly develop or review/revise existing site specific work-plans (with clear

benchmarks, targets, and activities) to outline action steps on how to achieve related goals, including setting

site specific benchmarks and targets (in close collaboration with USAID-SA partners); (2) leverage and

maximize efficiency of existing site and regional level human and commodity resources; (3) deliver a quality

package of PMTCT-Plus and family-centered HIV services to clients; (4) implement active referrals and

linkage systems; (5) efficiently operate with an integrated approach to caring for the HIV-infected pregnant

woman/mother and her family; (6) facilitate and lead site level system improvements that improve quality of

care, support optimal patient flow, and decrease patient wait time; and (7) initiate a multidisciplinary

approach to service delivery.

ACTIVITY 2: Exposed Infant Follow-up/Care and Pediatric HIV Care and Treatment

ICAP will continue to support pediatric activities in close collaboration with the S2S program to rapidly

expand access to HIV care and treatment for infants and children. Through its basic capacity building model

ICAP will support the implementation of comprehensive care services for the HIV-exposed child at all sites,

including growth monitoring, neuro-developmental screening, and cotrimoxazole prophylaxis. ICAP will

capitalize on IMCI, EPI, and under-5 services to identify infants at peripheral sites that should be referred for

HIV testing, and use aggressive pediatric case finding by supporting clinical/immunological presumptive

diagnosis and/or early infant diagnosis services. The ICAP model will be used when appropriate to expand

provider-initiated in-patient testing in pediatric wards, and to assist in the implementation of routine

pediatric psychosocial assessments to appraise readiness and support needs prior to initiating treatment.

ACTIVITY 3: Expansion of Early Infant Diagnosis (EID)

The ICAP capacity building approach will support implementation and expansion of EID services. This

includes the improvement of follow-up services, including improving counseling to ensure that caregivers

understand the importance of returning for services and developing mechanisms to identify and trace

caregivers who have not returned for follow-up and test results.

ACTIVITY 4: HIV-infected Women of Childbearing Age and their Partners

ICAP plans to strengthen the quality of the clinical and psychosocial services available to women of

childbearing age and males (especially partners) enrolled in care and treatment services. This activity

Includes supporting facilities to offer services and referrals to counsel HIV-infected women and partners,

specifically on family planning.

By strengthening PMTCT services, these activities contribute to PEPFAR 2-7-10 goals, averting new

infections among infants exposed to HIV as well as increasing access to treatment care and support for HIV

-infected women and their infants.

PEPFAR funds were allocated to Columbia University for OVC activities during the final FY 2007

reprogramming round. In actuality, however, this is a treatment activity so USAID will reprogram the FY

2007 funds for OVC to the treatment services program area. Therefore there is no need to fund this activity

with FY 2008 COP funds.

This is a new activity in FY 2008.

SUMMARY:

Columbia University is a Track 1 care and treatment partner in South Africa, implementing site-level

activities in the Eastern Cape and KwaZulu-Natal with CDC funding. Since FY 2007, Columbia University's

office in Western Cape has received funding from USAID to support treatment partners in Limpopo, North

West, Gauteng, Mpumalanga and Western Cape to improve linkages with prevention of mother-to-child

transmission (PMTCT) and pediatric antiretroviral treatment (ART). This is achieved by providing technical

assistance, training, and mentoring in public and non-governmental (NGO) facilities. The emphasis areas

are human capacity development and local organization capacity building.

FY 2008 funds will support the continuation and expansion of the South-to-South Partnership for

Comprehensive Pediatric HIV/AIDS Care and Treatment Training Initiative (S2S), a pediatric HIV and AIDS

training program implemented in partnership with Tygerberg Children's Hospital and the Stellenbosch

University in the Western Cape. The S2S program's experience and materials will support the activities

within this initiative.

BACKGROUND:

Columbia University's International Center for AIDS Care and Treatment Program (ICAP) supports sites to

build provider and system capacity with a focus on continuous quality improvement. Poor facility

systems/services design, lack of patient scheduling systems, inefficient provider placement/scheduling and

irregular supervision by senior management continue to weaken already stressed HIV services. ICAP's site

level support is dynamic and continuously customized to consider site attributes and existing resources.

While the technical support and capacity-building activities vary according to site attribute, all sites benefit

from ICAP support, including assistance to (1) jointly develop or revise existing site specific work plans to

outline action steps on how to achieve PMTCT and pediatric ART goals, including setting site specific

benchmarks and targets (in close collaboration with USAID-SA partners); (2) leverage and maximize

efficiency of existing site and regional human and commodity resources; (3) deliver a quality package of

PMTCT and family-centered HIV services to clients; (4) implement active referrals and linkage systems; (e)

operate efficiently with an integrated approach to caring for the HIV-infected pregnant woman/mother and

her family; (5) facilitate and lead site level system improvements that improve quality of care, support

optimal patient flow, and decreases patient wait time; and (6) initiate a multidisciplinary approach to service

delivery.

Site level systems improvement and skills-building activities will be conducted routinely on an individual and

group basis to introduce new competencies and activities as well as to reinforce specific areas of need with

emphasis on the skills providers' and teams' need for appropriate care of families. All improvement activities

are conducted on the site level and are generally targeted towards rapidly enhancing site performance and

strengthening program implementation and include a blend of didactic, modeling, clinical

implementation/preceptorship, negotiation and case study activities. ICAP will support stakeholders to (1)

assess and identify missing service components, performance gaps, and systems failures to providing

quality care and treatment services; (2) identify action steps and activities to support root causes of

problems; and (3) support the management team to monitor the resulting affect and ensure positive

enabling factors to improve or initiate that service component.

ACTIVITY 1: On-site Skills Building, Task Shifting and Clinical Mentoring

The critical conduits for system implementation are the healthcare workers. ICAP will work with site staff

and partners to implement a supportive supervision model that combines capacity-building elements such

as (1) supportive and regular on-site presence; (2) on-site dynamic skills-building events that directly link to

implementation and program improvement such as (a) clinical mentoring and modeling to promote the rapid

application of in-service learning to the clinical settings and to improve the quality of clinical care and patient

outcomes; and (b) on-the-job training to provide necessary knowledge and hands-on practice of skills

needed to perform job tasks; and (3) structured training interventions that employ multiple skills building and

transfer of learning strategies to reinforce and emphasize key PMTCT and pediatric ART content. Training

interventions include instructional (didactic) activities that include case-based learning, group-discussions,

problem solving exercises; one-on-one and small team clinical mentoring activities (across/within cadre)

with responsive/dynamic coaching and modeling activities; and case study activities.

ACTIVITY 2: Utilize a Multidisciplinary Approach

ICAP will promote the strengthening of a comprehensive approach to patient care at each facility. This

includes instituting distinct clinical reasoning skills among cadres, emphasizing collaborative decision

making and recognizing the important contributions of all members of the team. Activities to support this will

include routine and regular management meetings to discuss service delivery and patient cases, onsite

skills building activities and implementation workshops.

ACTIVITY 3: Performance Support

ICAP will provide technical support to partners and site staff to develop content for simple tools, resources,

and performance aids that will help providers to correctly perform tasks and make decisions. This includes

the development of protocols, decision trees, flip charts and posters for clinical and counseling related

services.

ACTIVITY 4: Improve Service Quality and Standards of Care

ICAP will support the adaptation and implementation of a simple standards of care (SOC) tool designed to

help the staff rapidly monitor the quality and depth of PMTCT, pediatric and adult ART services being

offered at a facility level. ICAP will do so in collaboration with facility staff and partners.

The approaches noted above will be applied to focus areas outlined below.

Activity Narrative:

(1) Prioritizing ART for eligible pregnant woman: ICAP will build on existing PMTCT services to ensure that

all HIV-infected pregnant women are assessed for ART eligibility. Eligible women will be fast-tracked to

initiate ART regardless of point of entry. Depending on site attributes, ICAP will work with sites and partners

to ensure the following: (a) HIV-infected pregnant women receive CD4 testing the same day they receive

their HIV test results; (b) women accessing maternal and child health (MCH) services initiate ART at the

nearest ART site and be given coordinated visits to ensure that both MCH and HIV and AIDS needs are

met; and (c) development of additional service models that increase access to care and treatment services

for families including family days at care and treatment clinics, weekend and afternoon care and treatment

clinics.

(2) HIV-infected women of childbearing age and their partners: ICAP will continue to strengthen the quality

of the clinical and psychosocial services available to HIV-infected women of childbearing age and males

(especially partners) enrolled in care and treatment services. This includes supporting facilities to offer

services and referrals to counsel HIV-infected women and partners intending to become pregnant.

(3) Ongoing support for PMTCT clients on ART: ICAP will support sites to improve clinical management of

pregnant women and families on ART. The support will include assessing (a) clients for treatment failure;

(b) ARV contraindication and adverse reaction; and (c) administration of appropriate drug substitution or

regimen change.

(4) Psychosocial and Adherence Support (P&AS): Quality adherence and psychosocial support is the

cornerstone of successful HIV care and treatment services and having healthier HIV-infected pregnant

woman. ICAP will provide individual P&AS through (a) developing and routine implementation of

psychosocial assessments to assess ART readiness during pregnancy and post-natal period; and (b)

establishing support groups at sites to initiate or strengthen support groups for PMTCT clients. ICAP will

also strengthen the roles of the Implementation Team to support P&AS programs. The Implementation

Team will include pharmacists and nurses. This activity aims to ensure that facility staff understand the roles

and responsibilities of each cadre and acquire the necessary skills to provide those services as part of the

multidisciplinary team.

(5) Patient Follow-up: ICAP will develop a mechanism to track and trace patients that have discontinued

services or missed appointments. Specifically, this includes (a) setting up a system for tracking no-shows

and discontinuers; (b) implementing a follow-up system to reach out to clients soon after they fail to return to

the clinic; and (c) developing strong linkages with community-based organizations and community health

workers to support patients who have discontinued services.