SUMMARY:

Pathfinder will implement activities aimed at equipping clinics to offer prevention of mother-to-child

transmission (PMTCT) services, train nurses in the provision of PMTCT services and train peer educators in

case finding and supporting groups. The emphasis areas for these activities are human capacity

development and local organizational capacity development. The target population is women between the

ages of 15-24 years.

BACKGROUND:

Pathfinder International is a new PEPFAR partner and all activities related to this project will be initiated in

FY 2008. The objective under this program area is to improve access to youth-friendly PMTCT services,

including the prevention of unwanted pregnancies and protection/treatment of the pregnant women. All

activities will be implemented by Planned Parenthood Association of South Africa (PPASA) and services will

be made available in PPASA youth-friendly service (YFS) clinics in KwaZulu-Natal, Gauteng, North West,

and the Eastern Cape. Antenatal Care (ANC) comprises a large percentage of services delivered in YFS

clinics. With demand for ANC among young people increasing, the YFS clinics are well positioned to offer

the continuum of PMTCT services in the selected sites. The establishment of PMTCT services will have a

two-pronged approach: increasing PMTCT services at YFS clinics and encouraging community

support/mobilization for these services. The clinics will provide ANC, VCT, infant feeding and psychosocial

counseling, ART, family planning in the context of HIV and referrals for optimal obstetric care, newborn care

(including infant feeding options), and well-child/well-mother follow-ups. The community (through existing

networks of peer educators and local NGOs) can be organized, trained and be supported to identify cases;

support young women during pregnancy and home-birth; encourage facility delivery; provide information on

PMTCT; and promote safer breastfeeding. These elements of service provision must be carefully linked and

coordinated to guarantee the even flow along the continuum of care for the young woman and family at risk.

A two-way referral system, training of facility-based providers and peer educators, and sensitization of

facility-based staff and community leaders are all part of establishing this two-pronged approach. This effort

to integrate PMTCT services into existing YFS clinics will utilize and strengthen the existing infrastructure

and systems in the selected sites to ensure sustainability in preventing new infections.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: PMTCT Continuum of Services

PMTCT services for young people will go beyond the usual focus on pregnant women to engage partners,

family members and the community in institutionalizing the services and reducing the stigma associated

with them. VCT is an important entry point for PMTCT services, starting with primary prevention for couples

intending to have children and then promoting VCT early in pregnancy to minimize chances of MTCT. VCT,

as a routine part of ANC, is the cornerstone of PMTCT. Consistent and correct condom use after

pregnancy, as well as early postpartum care will be encouraged through counseling on family planning.

Family planning and dual protection for young mothers will be reinforced in PMTCT training of service

providers. Nurses will also be trained in the provision of youth friendly PMTCT services. Pathfinder will also

conduct monthly supervision and refresher training meetings with nurses providing PMTCT. The project will

train peer educators to find young pregnant women in the community and encourage them to use youth-

friendly PMTCT services. The project will also establish a two-way referral system between providers and

peer educators. The peer educators will refer young pregnant women from the community to the YFS clinic

and the nurses will refer the pregnant women who test positive to the peer educators for ongoing support

during their pregnancy.

ACTIVITY 2: Guidelines for PMTCT

The project will follow the National PMTCT guidelines and will expand them by adding best practices and

practical guidelines on PMTCT services for young people. Pathfinder will adapt these guidelines to be more

youth-focused and use the national training curriculum on PMTCT, complemented by Pathfinder's PMTCT

curriculum developed in Kenya, to train doctors and nurses specifically on issues relating to youth and

PMTCT. It is also crucial that providers be trained in YFS and counseling for pre- and post-testing, as well

as to provide support throughout the PMTCT continuum.

ACTIVITY 3: Behavior Change Communication (BCC) Interventions for PMTCT

The BCC campaign will increase knowledge about and motivation for the use of PMTCT services. Aside

from gaps in service delivery that will be addressed through the project, cultural barriers to testing for

pregnant women (such as stigma, denial, and lack of partner, familial or community support) will be

addressed through a PMTCT BCC intervention. Because the PMTCT services will be offered through

existing youth-friendly clinics providing an array of services, including ANC, the common stigma associated

with seeking PMTCT services will be reduced and young women will be able to seek the services

confidentially at the clinics. The project will benefit from lessons learned from Pathfinder's PEPFAR-funded

PMTCT work in Botswana and in Kenya, as well as the Ndola demonstration project run by AED in Zambia.

These successful BCC messages will be adapted to focus on youth for the South African setting. The first

BCC priority will be to develop materials for young clinic clients and providers. Community outreach efforts

to increase awareness of services will be coordinated with other HIV and AIDS awareness activities,

especially those under this project on VCT and community home-based care (CHBC). BCC efforts will also

encourage young expecting couples/partners to utilize services at YFS clinics to prevent MTCT. Finally,

information campaigns on PMTCT will be carried out by peer educators in the waiting areas of clinics.

Pregnant clients waiting for services will be informed that PMTCT services are available and will learn of the

importance of protecting their own health and the health of their child.

These results contribute to the PEPFAR 2-7-10 goals by improving access to and quality of PMTCT

services in order to identify HIV-infected pregnant women and increase the number of pregnant women

receiving ARV services.

SUMMARY:

Pathfinder will conduct a situational analysis and select communities for implementation of community and

home-based care (CHBC) services according to availability of referral sites, such as hospitals and other

facilities offering treatment of opportunistic infections (OIs) and ART. Peer educators will also be trained and

peer supervisors in CHBC and establish linkages with programs providing nutritional support to people living

with HIV (PLHIV) and OVC. The objective under this program area is to improve the quality of life for young

PLHIV and their families through expanded access and improved quality of CHBC services. All activities will

be implemented by Planned Parenthood of South Africa (PPASA) and services will be made available in

PPASA youth clinics in KwaZulu-Natal, Gauteng, North West, and the Eastern Cape. The emphasis areas

for these activities are human capacity development and local organizational capacity development.

Specific target populations include young people between the ages of 15-24 years and their families around

the clinic catchment areas.

BACKGROUND:

As the number PLHIV increases in South Africa, the gap continues to widen between the supply and

demand for health care services. Relying on the strengths of community networks, community home-based

care has emerged as an effective method of providing compassionate care to those infected and affected

by HIV and AIDS. Since the 1980s, Pathfinder has been a leader in managing successful CHBC programs

in a number of countries, including Uganda, Kenya, Tanzania, and Ethiopia, as well as a new youth CHBC

program in Mozambique. Pathfinder will transfer this experience to better meet the needs of PLHIV --

particularly youth infected or affected by HIV and AIDS in South Africa. This is a new partner for FY 2008.

CHBC will be implemented by NGOs, Community-Based Organizations (CBOs), volunteers, and youth

organizations with technical oversight provided by Pathfinder/PPASA. Youth CHBC volunteers will provide

an important link between PLHIV, community services and the youth-friendly clinics providing HIV and AIDS

care and support services. They will identify potential barriers to ART adherence and ensuring treatment

compliance for PLHIV on ART.

ACTIVITY 1: CHBC Networks

CHBC programs provide clients and family members with practical nursing skills such as how to treat bed

sores, pain and symptom management, how to treat opportunistic infections etc., psychosocial support and

linkages to other community services, such as income generation, food, and orphan support. CHBC relies

on networks of community health workers who are attached to local CBOs; they regularly visit homes of

those who are affected and teach caretakers how to provide emotional support and physical care to

household members living with HIV and AIDS. In addition, community health workers play a major role in

prevention, stigma reduction and social mobilization within their communities. CHBC programs strengthen

linkages with nearby health facilities, such as hospitals and PMTCT sites, establishing two-way referral

systems between these facilities and community health workers. CHBC is a critical element in the

continuum of HIV and AIDS prevention, care and support. CHBC programs will expand their focus on

palliative care to include adherence support, community engagement, prevention with positives, and

nutritional support. Through this project, Pathfinder will facilitate CHBC services in selected communities

around the four youth-friendly clinics upgraded to provide HIV and AIDS care and support services under

this project. The project will build upon existing relationships with the Provincial Departments of Health,

(PDOH) as well as with youth NGOs and youth associations currently providing community outreach

services. CHBC will be implemented by NGOs, CBOs, and youth organizations, with technical oversight

provided by Pathfinder/PPASA. Under the coordination of PDOH, Pathfinder/PPASA and project

stakeholders will select communities for CHBC during project start-up. Criteria for selection will include

proximity to a youth-friendly clinic, referral facilities, and existence of appropriate youth NGOs, CBOs or

associations that have the capacity to carry out such activities. Pathfinder will conduct situational analysis

and select communities for CHBC services based on the above criteria. Peer Educator Supervisors will be

selected in each of the communities, where peer educators will receive training in CHBC and subsequently

become Youth CHBC Activists. The Youth CHBC Activists will be trained to provide palliative care and

training for primary caregivers and especially to youth affected by HIV/AIDS in their communities. From its

long history of implementing CHBC programs and working with youth, Pathfinder recognizes the need for

effective and frequent supervision and mentoring of Youth CHBC Activists. These Activists will be given the

emotional support they need to do their jobs, which are often demanding and difficult. Supervisors will

conduct monthly meetings with them to track progress and provide updates, as well as provide a forum for

the health workers to support one another and discuss difficulties and solutions as a group.

ACTIVITY 2: Community Support and Mobilization

Community support and mobilization are key to CHBC. Peer Educator Supervisors and Youth CHBC

Activists will be trained on social mobilization as a part of basic CHBC training. Peer educators will be

trained as Youth CHBC Activists to provide palliative care and training for primary caregivers and especially

to youth affected by HIV and AIDS in their communities. The Youth CHBC Activists will identify and follow

up with young pregnant women for PMTCT services and promote VCT among community members

(especially youth). They will facilitate anti-AIDS clubs and support groups for youth infected or affected by

HIV and AIDS, and identify and link orphans and vulnerable children (OVC) to available services, such as

nutritional support and support for payment of school fees. In those families with a PLHIV receiving ART,

Youth CHBC Activists will provide adherence support, follow-up, and linkages to referral centers. Youth

CHBC Activists will be trained on the referral systems, and will refer clients appropriately. Activists will play

a key role in community sensitization and stigma reduction around HIV and AIDS, working to introduce

CHBC services in their communities and garner the support of local leaders, faith-based groups, and other

youth organizations. Pathfinder together with PPASA will conduct community sensitization meetings to

introduce CHBC services and garner support for program and youth community health workers. Health

workers will be supplied with basic home-based care kits, containing gloves, swabs, disinfectant, and basic

medicines such as paracetamol and hydrocortisone cream to assist in their work. A communication strategy

will be designed to help Youth CHBC Activists to facilitate dialogue and collective action in their

communities.

ACTIVITY 3: Gender Issues

Activity Narrative: Gender and sexuality are significant factors in the sexual transmission of HIV and they influence access to

treatment, care, and support. Pathfinder will facilitate adaptation of the DOH HBC curriculum to be more

gender sensitive and responsive, especially in regard to gender roles and norms among young people to

improve gender-sensitive training for Youth CHBC Activists and Supervisors. Pathfinder will also add youth,

gender, human rights and social mobilization components to national HBC training curriculum. Pathfinder

will ensure appropriate representation of male and female Youth CHBC Activists and ensure that the

number of families and young people reached with CHBC is proportionate with the number of young males

and females in need in each community. Special attention will be given to young women infected or affected

by HIV/AIDS to ensure that care and support services are available and that schooling continues whenever

possible.

ACTIVITY 4: BCC and social mobilization: Participation of young people and community members in social

mobilization processes will be valued as a goal. To start this process, community members need clear

values in relation to young people, especially those living with HIV and AIDS. They must believe that living

conditions of these young people ought to change. Through dialogue and establishment of prevention clubs,

community members will collectively evaluate the social consequences of those living conditions and

elaborate a different future, free of stigma and discrimination. Materials explaining the purpose of CHBC

and helping PLHIV to "live positively," as well as those that build treatment literacy will be sourced and

disseminated by the Youth CHBC Activists. Addressing prevention with HIV-infected individuals is an

important part of this comprehensive care strategy. Through healthy living and reduction of risk behaviors,

these prevention with positives interventions can substantially improve quality of life and reduce rates of HIV

transmission.

These results contribute to the PEPFAR 2-7-10 goals by improving the quality of life for young PLHIV and

their families through expanded access and improved quality of CHBC services.

SUMMARY:

Pathfinder/Planned Parenthood Association of South Africa (PPASA) will train PPASA nurses and public

sector service providers from four existing clinics and the public sector facilities in the PPASA clinic

catchments areas to provide youth-friendly voluntary counseling and testing (CT) services to young people

ages 15-24. This project will train nurses on pre- and post-test counseling, testing procedures and record

keeping related to CT. A comprehensive community-based behavior change communication (BCC) and

social mobilization strategy involving youth networks and community groups will promote CT and access to

care and treatment services. The emphasis areas for these activities are human capacity development and

local organizational capacity development. Specific target populations include young people between the

ages of 15-24 years.

BACKGROUND:

All activities related to this project will be initiated in FY 2008. The objective under this program area is to

improve access to and utilization of CT by youth by strengthening the capacity of PPASA youth-friendly

clinics to provide CT services in four clinics. All activities will be implemented by PPASA and services will be

made available in PPASA youth clinics in KwaZulu-Natal, Gauteng, North West, and the Eastern Cape. CT

is both a preventive service, to provide information and support for those who are negative, as well as an

entry point to care and support services for those who test positive. CT is a necessary component of

comprehensive HIV and AIDS services and further provides the opportunity to screen for other opportunistic

infections, such as TB and STIs. High HIV prevalence among young people indicates that there remains a

significant unmet need for care and support services. In order to meet the needs of these youth, quality

youth-friendly CT services must be available and age-appropriate, ensuring that services adhere to basic

rights for privacy and confidentiality and that there are adequate staff and facilities to ensure real access.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training of Providers and Social Mobilization

Pathfinder/PPASA propose to train PPASA nurses and public sector service providers from six existing

clinics and the public sector facilities in the PPASA clinic catchments areas to provide youth-friendly CT

services which will emphasize elements such as respect for youth, confidentiality and privacy for young

people ages 15-24. This project will provide refresher training for nurses on pre- and post-test counseling,

testing procedures and record keeping.

ACTIVITY 2: Behavior Change Communication

A comprehensive community-based BCC and social mobilization strategy involving youth networks and

community groups will promote CT, and access to care and treatment services. The BCC and social

marketing interventions will focus on barriers that influence youths' willingness to seek services, particularly

misinformation about benefits, perceptions about poor confidentiality and provider bias, and stigma and

discrimination in the community and in the facilities. The BCC strategy implemented through community

clinics and peer educators will promote the availability of youth-friendly, confidential CT services. Emphasis

will shift from the transmission of information to dialogue, debate, and negotiation on issues that resonate

with youth and members of the community. In order to support acceptability, young people and communities

should know that youth-friendly CT services offer confidentiality and psychological support before and after

testing. CT clients will be encouraged to recruit their peers to be tested. Dialogue, debates, and other

communication activities through print and audio-visual materials will inform young people about the

importance of CT. These materials will be disseminated through youth networks, community groups, clubs

etc.

ACTIVITY 3: CT Service Provision to Youth

As a starting point, the project will conduct thorough HIV and AIDS clinical care needs assessment of clinics

and upgrade facilities as needed. During general visits to the clinic, providers will offer CT to all clients, and

provide crucial information on STIs and HIV and AIDS. Counselors will stress the importance of testing for

clients and their partners, provide information on use of condoms for dual protection against STIs/HIV and

pregnancy, and discuss primary and secondary abstinence and being mutually faithful in relationships.

Service providers will conduct post-test counseling with all clients, as per South African Government

standards, and will provide referrals to other adolescent sexual and reproductive health (ASRH) services

and care and support services within a facility, as needed. All young people testing positive will be referred

and offered enrolment in the clinic's ambulatory care program. Youth testing positive for HIV will also be

referred to community resources, such as community home-based care (CHBC) programs. The project will

also establish linkages with CT, prevention of mother-to-child transmission and antiretroviral treatment

national programs so that youth-friendly sites are under national programs.

Young men and women differ in the decision-making that leads to the use of CT services. Males tend to

seek testing independently of others, in part because they fear isolation and abandonment by their peers,

who are likely to consider this an example of "male weakness." Young women usually feel compelled to

discuss testing with their partners, friends or relatives before accessing the service, thereby creating a

potential access barrier since they might be discouraged from taking an HIV test. To increase access to

testing, attention to gender issues will be improved in health providers' training, as well as in routine

activities and promotion of CT services carried out by peer educators.

These results contribute to the PEPFAR 2-7-10 goals by improving access to and quality of CT services for

young people.

This is a new activity in FY 2008.

SUMMARY:

Pathfinder/Planned Parenthood Association of South Africa (PPASA) is a new PEPFAR partner (starting in

FY 2008) that will expand access to youth-friendly ARV service delivery, including diagnosis and treatment

of opportunistic infections and administration and monitoring of ART. Providers will help young clients

become treatment literate and young people beginning ART will be linked to youth community home-based

care (CHBC) activists to provide ongoing support for adherence. The emphasis areas for these activities are

human capacity development, gender and local organizational capacity development. Specific target

populations include young people between the ages of 15-24 years. All activities will be implemented by

PPASA and services will be made available in PPASA youth clinics in KwaZulu-Natal, Gauteng, North

West, and the Eastern Cape. All activities related to this project will be initiated in FY 2008.

BACKGROUND:

This project aims to relieve the over-burdened, understaffed hospitals by (1) providing care and support

services through the PPASA youth clinics, and by (2) building the capacity of more PPASA service

providers to offer HIV and AIDS care and treatment services. This initiative proposes to provide expanded,

comprehensive HIV and AIDS clinical care and linkages to young people at four existing Youth-Friendly

Services (YFS) sites. All the sites currently provide quality YFS, including treatment of sexually transmitted

infections (STIs), which will continue in this project. For youth receiving ART, youth-friendly service

providers will facilitate monitoring of illness stages with CD4 counts, adherence and drug resistance.

Providers will help young clients become treatment literate, and young people beginning ART will be linked

to youth CHBC activists for DOTS.

ACTIVITY 1: Training of Health Care Providers on Youth-Friendly HIV and AIDS Care and Treatment

Nurses from the PPASA youth clinics will be trained in HIV and AIDS care and support including treatment

of opportunistic infections and ART. To avoid creating parallel training programs, the project will form

linkages with the existing Department of Health (DOH) training programs.

ACTIVITY 2: ART Service Delivery for Youth

The project will conduct a thorough HIV and AIDS clinical care needs assessment of YFS clinics with the

DOH and will equip clinics to offer services as needed (for example, partitioning and equipping additional

treatment rooms). Regular counseling sessions and check-ups at the youth-friendly clinic will be

encouraged for all youth living with HIV and AIDS. Counseling sessions will address psychosocial issues

around coping with HIV and AIDS, including the person's conception and understanding of her/his illness

and stage of illness; cultural beliefs around HIV and AIDS; other services utilized by the patient (e.g.,

traditional medicine); the client's living situation, support systems, and financial needs; occupational and

legal concerns; and stigma (both self-stigma and perceived stigma of others). Young clients will be

counseled on "living positively" with HIV and AIDS. For youth receiving ART, youth-friendly service

providers will facilitate monitoring of illness stages, adherence and drug resistance. Providers will help

young clients become treatment literate and those beginning ART will be linked to youth CHBC activists for

DOTS. Young clients living with HIV and AIDS will be encouraged to visit the YFS clinic regularly and will

also be linked to support groups and encouraged to become regular members. The project will also

establish linkages between youth-friendly service points and referral hospitals and laboratories, as well as

other referral facilities. In addition, service provider monthly supervision meetings will be conducted to follow

up the providers to ensure that youth friendly approach is being practiced and also to avoid burnout.

Periodic refresh trainings will also be conducted for the providers.

Adherence support groups, where young people can exchange experiences and solutions, will be

conducted at each of the four clinics. They will focus on: difficulties in taking ARVs (pills, frequency, time

charts, food); difficulties in adhering to the services (tests, distance, financial resources and others);

presentation and discussion of side effects of the drugs used; discussion on secondary prevention and

reproductive counseling; the impact of stigma and discrimination and coping strategies; and nutrition and

positive living. The project will assist these groups in building linkages with CHBC, income-generating

activities (IGA), and nutrition support.

ACTIVITY 3: Addressing Gender Issues

Service providers will receive training on gender issues related to young men and women's sexuality and

sexual rights so they feel comfortable when accessing HIV and AIDS services. Training will include sound

gender-based communication skills valued by youth of both sexes, such as confidentiality and an open-

minded approach to questions instead of making pre-conceived judgments. Additional gender differences to

be addressed include: sexually active young women and/or girls living with HIV must not be stigmatized by

health providers who blame them for being too young to seek services. Because of their social and

biological vulnerability to STIs and HIV, young women account for more new HIV infections than young men

in South Africa - and thus are proportionately in greater need of care and support services. Yet, they are

often denied access due to power differentials, financial constraints, lack of education, and/or stigma.

Special care will be taken to provide youth-friendly, gender-sensitive services to these young people,

including counseling, partner involvement and testing and stigma reduction. Efforts will be made to ensure

that the number of male and female clients seeking HIV and AIDS care and treatment services is

proportionate with the number in need, based on prevalence studies and VCT service statistics for young

males and females. The female community peer educators will play an important role in this case, and

equal numbers of male and female the peer educators will be recruited. In addition, peer educators will be

encouraged to increase their participation in public events. Pathfinder's experience in Mozambique has

shown that it is useful to recruit a group of girls who were friends before and that involvement of the parents

during the process of recruitment and training will increase peer education participation and retention.

ACTIVITY 4: Behavior Change Communication and Social Mobilization

The project will also train youth CHBC activists and key individuals on advocacy for the availability of ART

Activity Narrative: drugs for all PLHIV, and especially for youth. Printed materials will be adapted to increase the demand for

YFS and VCT and support treatment, such as a diary for young clients to record treatment protocols,

dosages and side effects, as well as clinic appointments.

These results contribute to the PEPFAR 2-7-10 goals by improving access to and quality of HIV/AIDS

services and care for young people.