Detailed Mechanism Funding and Narrative

Years of mechanism: 2008 2009

Details for Mechanism ID: 271
Country/Region: South Africa
Year: 2009
Main Partner: Right to Care
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $36,120,762

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $493,190

SUMMARY:

The success of Right to Care's (RTC) delivery of the antiretroviral treatment (ART) program activities and

particularly with down referral has led the Department of Health to request support for implementation of

prevention of mother-to-child transmission (PMTCT) activities at all RTC-supported sites. These sites

include government, non-governmental and private sector ART programs that operate in partnership with

primary care providers and workplace programs. RTC will use FY 2009 funds to accelerate the

implementation of the South African government's national Comprehensive Care Management and

Treatment (CCMT) program at government sites in partnership with the provincial Departments of Health

(DOH). This includes the scale up of prevention and PMTCT services at 16 sites in 5 provinces, namely

Gauteng, Mpumalanga, Northern Cape, Limpopo and Free State. PMTCT activity at these sites will be

integrated into existing prevention education, counseling and testing, and ART activities. Emphasis will be

placed on child survival, increasing gender equity, family planning and TB screening. Target populations

will include women, infants, family planning clients, and people living with HIV.

BACKGROUND:

RTC has not been funded for PMTCT programs prior to FY 2008. It subsequently applied for funding

because the organization upholds the importance that successful ART programs be integrated with

prevention, and especially PMTCT programs. A recent change in the National Department of Health

PMTCT guidelines, including the guidelines on dual therapy, has necessitated additional support to sites at

which these guidelines must be implemented.

RTC will focus on expanding PMTCT services using family-centered models developed in FY 2008 at all

supported sites. Since this is a new area of focus for RTC, a lot of training and implementation advice will

be sought from other PEPFAR partners who are already providing this service (e.g., Perinatal HIV Research

Unit, Mothers to Mothers and South to South). The major areas of focus as requested by the provincial HIV

& AIDS and STI and TB directorates are human resources and training.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: PMTCT Coordinator and National PMTCT Guidelines

RTC is appointing a PMTCT Coordinator in COP 2008 to support a family-centered model of PMTCT

according to the national guidelines. The Coordinator would provide technical assistance, coordinating

infrastructure support in the form of renovations to buildings (may be necessary for the pharmacies to store

AZT), training and quality assurance. This post will be filled by an experienced senior registered nurse, with

expertise and experience to conduct site evaluations and to identify training and technical support needs for

PMTCT. During FY 2008 and extending into FY 2009, the Coordinator will be responsible for the

implementation of national PMTCT guidelines and policy-specific training program for PMTCT. Currently a

one-day training program aimed at the development and enhancement of effective and successful

implementation of the current South African national PMTCT policy and guidelines is being conducted and

will be expanded in FY 2008 and FY 2009. RTC will establish a provincial team in each province to conduct

site assessment, monitoring evaluation and continuous quality assurance, particularly as the program

grows. Technical assistance will be provided to sites to address any limitations that hamper scale up of the

program. In some sites, the lack of qualified personnel may be addressed through the hiring and

secondment of personnel, particularly for rural underserved sites and populations.

ACTIVITY 2: Quality Assessment

The aim of the PMTCT program in FY 2009 is to consolidate the work done in FY 2008. The PMTCT

Coordinator will continue to implement the PMTCT training program; this will be done together with training

coordinators for the districts as well as in partnership with the regional training centers. Continuous quality

assurance is a priority in order to assess the standards of PMTCT at each RTC-supported site and to

provide continuous quality improvements where necessary. Program quality assurance will focus on the

provision of dual therapy, supply chain management, implementation of the guidelines, quality of

counseling, proportion of pregnant women taking up PMTCT (target >80%) and incidence of new pediatric

infection (reduced to <5%). Additional staff may be deployed to provide expert on-site training and

mentoring. Community education, mobilization and improved access to health-care will be supported.

Community organizations may be supported to provide lay counseling, in an adapted model, similar to

Mothers to Mothers.

ACTIVITY 3: PMTCT Program

Essential activities using FY 2009 funds to scale up of the PMTCT program at all levels of care, especially

primary health care, include:

a. Integration of the PMTCT program with on-site provider-initiated HIV testing and counseling, aimed at

providing all pregnant women with HIV testing at their first antenatal care (ANC) appointment. As RTC only

operates in high prevalence sites (15-33% ANC HIV prevalence) in the public sector, repeat testing will be

provided in the third trimester and at the time of delivery. Women presenting in labor who have not been

tested during the ANC period will be tested at time of labor and will receive single dose nevirapine and post-

partum AZT. All women will be encouraged to know her status prior to delivery but she will have the right to

refuse the test. Women attending ANC will be encouraged to come with their partners and couple

counseling will be available. Postpartum voluntary counseling and testing will also be available in the post

delivery wards.

b. All counseling and testing activities will be linked to prevention in the context of pregnancy through

ongoing risk reduction sexual behavior education, the provision of condoms and referral to family planning

clinics. Partners of pregnant women will be invited to test. There will also be a strong focus on tracking and

tracing for transition to care to minimize missed opportunities for prophylaxis and treatment.

c. Early and fast track referral of all pregnant women either for PMTCT with dual therapy or if the CD4 <200

Activity Narrative: for the initiation of highly active antiretroviral therapy (HAART), in accordance with the national guidelines

will be provided. As the program grows, HAART initiations may be conducted as part of the ANC service.

d. Patients will be screening for TB, with health-care workers using with symptom questionnaires. This may

result in increased case detection, and the provision of prophylaxis for opportunistic infections and TB to

HIV-infected pregnant women. Women will be linked to nutritional support services that will improve

maternal health.

e. Infant diagnosis using polymerase chain reaction testing will be used to ensure early ART of infants born

HIV positive. RTC will encourage exclusive breast-feeding for infants who are confirmed HIV positive, and

will continue to provide prophylaxis for infants found to be HIV positive. A major focus of the 2009 COP will

on the support of sustained infant feeding choices.

f. Linkages to family planning programs will be established at each of the sites.

g. Through the support of RTC an overall strengthening of the Maternal and Child Health services is

anticipated, this will encourage women to bring children from previous pregnancies for testing. These

services will also provide advice on safe disclosures, which help to reduce gender-based violence.

h. Community Engagement in PMTCT will be promoted.

i. RTC's PMTCT program will address maternal nutritional support, to reduce the maternal death rate during

breast-feeding by approximately 10%, and the provision of information to enable informed choice support

for either exclusive breast-feeding or infant formula feeding. Emphasis will be placed on lactating women

and those with a BMI <16.5.

j. RTC will establish the required monitoring and evaluation (M&E) and quality assurance program to enable

reporting of PEPFAR and South African Department of Health targets, as well as to provide continuous

assessment and technical assistance to sites. The M&E system will be implemented in FY 2009.

RTC is responsible for supporting more than 20 government treatment district and referral hospitals sites in

three provinces. Initially, PMTCT activities will be supported at 8 of these sites in FY 2008 and this number

will increase to 16 in FY 2009. At each of these 16 sites, targets will be set at 80% uptake of counseling and

testing, and for HIV-infected women, an 80% uptake of PMTCT to reduce the infant infection rate to less

than 5%. Improved maternal and child health service quality and better integration of PMTCT into existing

HIV services will be an outcome of FY 2009 RTC activities.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Construction/Renovation

Gender

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* Family Planning

* Safe Motherhood

* TB

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $250,970

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $130,624

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $50,234

Economic Strengthening

Education

Water

Table 3.3.01:

Funding for Care: Adult Care and Support (HBHC): $3,725,358

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

SUMMARY:

Following the National Strategic Plan (NSP), Right to Care (RTC) will use FY 2009 funds to accelerate the

scale up of family-centered approaches to adult and pediatric treatment, care and support. The specific aim

is to increase the access to care support to 80% of individuals infected with HIV, in accordance with the

NSP and the technical considerations for the FY 2009 COP. Focus for the adult care and support program

will be to scale up TB and antiretroviral (ARV) activity at all Department of Health, Comprehensive HIV and

AIDS Care, Management and Treatment (CCMT) sites, supported by RTC. At the request of the provincial

DOH and implemented according to the memorandums of understanding (MOUs) with each province, RTC

will continue to support the activity and budget for family centered treatment, care and support.

BACKGROUND:

RTC provides mentorship and technical assistance to over 18 sub-recipients. These are ongoing programs

expanded with NDOH coordination and private sector support. By providing training and support to these

sites, RTC leverages NDOH resources to reach an increasing number of patients. RTC supports these sites

with infrastructure, staff, training, equipment and data management. In addition, the NDOH has recognized

the successes of RTC supported NGO/FBO sites and has been accrediting these sites and taking over the

provision of ARV drugs, laboratory monitoring and some staff salaries, thus enabling RTC to shift funds to

other sites in need of support.

ACTIVITIES AND EXPECTED RESULTS

FY 2009 funds will be used for human capacity development and salaries at all care and support (C&S)

providers; (1) non-governmental (NGO) and faith-based (FBO) clinics/organizations receive sub-awards

earmarked for doctors, nurses, counselors and other healthcare workers; (2) RTC will provide support to

South African Government (SAG) staff through the salaries of health care providers seconded to DOH

facilities; and (3) a capitation fee-for-service arrangement exists with a network of private sector service

providers for the Thusong program with wellness support to indigent HIV-infected individuals.

ONGOING ACTIVITIES

PEPFAR funds will also be used to maintain RTC's mobile clinics. NGO and FBO clinics also use PEPFAR

funds for laboratory monitoring of HIV patients and for the procurement of health commodities such as

medical equipment, ARVs, drugs for opportunistic infections, counseling and testing kits, and home-based

care kits. RTC supports all the C&S providers by disseminating policies and guidelines and providing quality

assurance through sharing best practices. With FY 2009 funding RTC will provide ongoing training and

continued medical education to assure that staff is aware of the latest treatment norms.

Public-private partnerships (PPPs) have also been formed. These include those with the provincial DOH,

where value is seen by the government in accrediting specific NGO clinics in order to provide ARVs and

pathology monitoring thereby reducing the overall cost on one donor. RTC will continue to work hand in

hand with the SAG to ensure sustainability of the service delivery though a human resource development

plan where value has also been seen when the government takes over certain positions initially paid for by

PEPFAR.

Down referral of stable patients from hospitals to community health centers and local clinics will be

strengthened further with FY 2009 funding, which will ensure that people receive comprehensive care closer

to their homes and thus improve patient retention. The major areas of focus for the down referral process

are human resources, training, infrastructure, data management and support with drug distribution even

though the drugs are not funded by PEPFAR. Up-referral mechanisms linking primary sites to tertiary sites

for complicated patients have been integrated into the RTC network of sites.

HIV-infected women, with or without antiretroviral therapy, are at high risk for the development of cervical

cancer. Cervical cancer screening in HIV-infected individuals has been initiated as an integrated wellness

service for all women attending the Helen Joseph Hospital, Themba Lethu Clinic. Results of the initial period

under review demonstrate that approx. 55% of HIV-infected individuals have abnormal pap smears with

over 30% of those demonstrating high grade pre-cancerous lesions (Ref: Firnhaber et al submitted July

2008). HPV testing conducted in a sub-set of these patients (funding source NIH CFAR) demonstrate that

all samples with abnormality have multiple oncogenic HPV types. Campaigns to increase the uptake of

cervical screening at all treatment and wellness sites supported by RTC will be undertaken.

RTC will continue strengthen links between counseling and testing and care within and between facilities.

For those testing positive a tracer system will reduce loss to treatment initiation. Those who test positive will

be tracked so that they benefit from wellness services and are tested every six months for their CD4 counts

to ensure that they commence ART as soon as they become eligible.

AREAS OF EMPHASIS

RTC will emphasize an increase in activities to meet the objectives of the technical considerations in the

following areas:

a. Cotrimoxazole prophylaxis - RTC sites report a high utilization of cotrimoxazole for patients with a CD4

<200. An increase in training and implementation is required for the discontinuation of cotrimoxazole in

patients with a CD4 count greater than 200 at two sequential time points. This is in line with the

comprehensive care guidelines for South Africa.

b. Palliative care - RTC will continue to emphasize the training for palliative care, with training courses

provided to all counselors, nurses and doctors. Home-based care will continue in remote districts. Palliative

education and training will be undertaken for family members.

Activity Narrative: c.Transition to care and retention in care will be emphasized using call center support for all patients

undergoing HIV testing, inclusion of CD4 testing for staging for all who are tested HIV-positive, site specified

referral to care at the time of CT, and follow-up of patients who do not reach the referral point. RTC uses the

TherapyEdge-VCT module which enables tracking of all these processes.

d. Enhancement of the basic care package for all wellness, pre-HAART patients will include access to

Isoniazid Prevention Treatment (IPT);

e. Positive prevention will continue to be emphasized including provider \-initiated counseling and testing for

family and household members; engagement of disclosure of HIV status for sexual partners; condom

distribution; assessment and diagnosis of both symptomatic and asymptomatic sexually transmitted

infections.

f. All women will be provided with access to cervical dysplasia screening. Treatment will follow the South

African guidelines for cervical cancer screening.

------------------------

SUMMARY:

Right to Care's PEPFAR program was recompeted through an Annual Program Statement (APS) in 2007

and was a successful applicant. RTC will continue to use PEPFAR funds to strengthen the capacity of

healthcare providers to deliver Care and Support (C&S) services to HIV-infected individuals, and to improve

the overall quality of clinical and community-based health care services in five provinces.

BACKGROUND:

RTC's C&S services will expand from the current levels achieved using PEPFAR funds. The integrated

program of education, counseling and testing, care and ARV treatment has been implemented in five focus

areas: (1) The employed sector, where RTC is currently providing HIV services to >130,000 employees in

>32 companies; (2) FBO/NGO clinics which target underserved populations in rural areas, industrial areas,

and informal housing sectors as well as targeted gender-specific support groups and family-centered

approaches; (3) Thusong, a private practitioner program for indigent patients; (4) Small, Medium, and Micro-

Enterprise, including farm employees, with mobile treatment units; and (5) In partnership with the National

Department of Health (NDOH), capacity support for national comprehensive HIV and AIDS care,

management and treatment sites. RTC provides mentorship and technical assistance to over 15 sub-

recipients and manages their sub-agreements. These are ongoing programs expanded with NDOH

coordination and private sector support. By providing training and support to these sites RTC leverages

NDOH resources to reach an increasing number of patients. RTC has supported these sites with

infrastructure, staff, training, equipment and data management. In addition, the NDOH has recognized the

successes of RTC NGO/FBO sites and has been accrediting these sites to enable the provision of ARV

drugs and laboratory monitoring.

ACTIVITIES AND EXPECTED RESULTS:

RTC will build on past successes by consolidating and expanding its support for government sites, NGO

and FBO clinics/organizations and private sector programs. FY 2008 PEPFAR funds will be used for human

capacity development and salaries at all C&S providers; (1) NGO and FBO clinics/organizations receive sub

-awards earmarked for doctors, nurses, counselors and other healthcare workers; (2) RTC will not provide

salary support to SAG staff, but rather the salaries of health care providers seconded to DOH facilities

including support for doctors, nurses, data managers, and counselors; and (3) a capitation fee-for-service

arrangement exists with a network of private sector service providers for the Thusong and Direct AIDS

Intervention (DAI) programs.

PEPFAR funds will also be used to maintain RTC's mobile clinics. NGO and FBO clinics also use PEPFAR

funds for laboratory monitoring of HIV patients and for the procurement of health commodities such as

medical equipment, ARVs, drugs for opportunistic infections including cotrimoxazole, counseling and testing

kits, and home-based care kits.

RTC supports all the C&S providers by disseminating policies and guidelines and providing quality

assurance through sharing best practices. With FY 2008 funding RTC will provide ongoing training and

continued medical education to assure that staff is aware of the latest treatment norms.

RTC will ensure that each HIV patient at RTC-supported facilities receives a comprehensive minimum

package of C&S services and preventive care, including clinic, community and home-based services. This

minimum package includes clinical and pathology monitoring, management and treatment of opportunistic

infections, psychosocial counseling, healthy living education, prevention with positives services, nutritional

counseling, assessment, monitoring and referral, home-based care, advice and assistance on welfare

issues and applications for welfare grants, and hospice and end-of-life care for terminally-ill patients.

Emphasis will be placed on increasing the number of HIV-infected children and pregnant women in care. A

number of NGO sites are doing nutritional counseling at community level and refer for nutritional

assessment and monitoring. Examples of non USG-funded community activities include food gardens and

income generating programs in order to support patients that are on ART. In addition, sites supported by the

NDOH have dieticians for ARV-treated patients.

PEPFAR funds facilitate partner linkages and a referral system between treatment sites-based care, and

other non-medical C&S services. At each site RTC will identify a community-based care organization to add

to the counseling capacity of the site. Peer counselors complement the NDOH appointed clinic staff. The

Thusong program is linked with a national network of care organizations. The expansion of the strategic mix

of clinic, home and community-based C&S will bring more C&S services to the doorstep of impoverished

populations such as farm workers, rural communities and residents of informal settlements.

Activity Narrative: Public-private partnerships (PPPs) have also been formed to ensure longer term sustainability. These

include, for example, those with the provincial DOH, where value is seen by the government in accrediting

specific clinics in order to provide ARVs and pathology monitoring thereby reducing the overall cost on one

donor. In addition PPPs are being explored with a number of organizations to provide holistic and

comprehensive care and treatment services to HIV-infected patients.

NGO clinics also receive cooperative funding from donors and patient fees. Knowledge sharing between

treatment sites and networks is being facilitated by Value-based. Referral mechanisms linking primary sites

to tertiary sites for complicated patients have been integrated into the RTC network of sites.

A number of NGO clinics also have gender-specific C&S programs. For example, the ACTS (AIDS Care

Training and Support) clinic has a series of comprehensive monthly support groups aimed at young men or

young women who are HIV-infected. Support group members meet to discuss challenges and problems and

provide each other with support and guidance. These programs include family-centered approaches.

Expansion of gender-specific activities with FY 2008 PEPFAR funding is planned.

Right to Care will continue to use PEPFAR funds to strengthen capacity of healthcare providers to deliver

C&S services to HIV-infected individuals and to improve quality of clinical and community-based health care

services in five provinces. RTC will strengthen links between counseling and testing and care. For those

testing positive a tracer system will reduce loss to treatment registration. Those who test positive will be

tracked so that they benefit from wellness services and are tested every six months for their CD4 counts to

ensure that they commence ART as soon as they become eligible.

By reaching patients with care and support services at various outlets, RTC will contribute to the PEPFAR

goal of providing services to 10 million HIV-infected and affected individuals. In addition, RTC activities will

support the USG Five-Year Strategy for South Africa by training health care workers in care and support

services, significantly expanding access to and quality of palliative care services.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13793

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13793 2975.08 U.S. Agency for Right To Care, 6612 271.08 $1,022,000

International South Africa

Development

7547 2975.07 U.S. Agency for Right To Care, 4460 271.07 $0

International South Africa

Development

2975 2975.06 U.S. Agency for Right To Care, 2652 271.06 $2,200,000

International South Africa

Development

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Family Planning

* TB

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $3,130,397

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.08:

Funding for Care: Adult Care and Support (HBHC): $430,307

This is a new PHE for FY09 that has been approved for $430,307.

PHE tracking number: ZA.09.0265

Title: Validation of HPV, cytology and visual inspection for cervical cancer screening in HIV-positive women.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Human Capacity Development

Public Health Evaluation

Estimated amount of funding that is planned for Public Health Evaluation $430,307

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.08:

Funding for Treatment: Adult Treatment (HTXS): $19,341,122

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

ART treatment sites receive the following package of support from Right to Care (RTC):

-RTC conducts an initial needs assessment at all treatment sites, including the epidemiology of HIV and

AIDS in the target population served by the treatment site. During this period, RTC also establishes the

priorities of the district and provincial department of health (DOH) for the health care facility.

-Technical assistance is provided to establish the policies and procedures at the site. This includes

supporting the health care facility to ensure the most efficient workflow processes, task shifting, interaction

with local non-governmental organizations (NGOs), pharmacy supply chain management for facilities, data

system strengthening and quality assurance assessments.

-Training is provided to all health care workers. This provides both on-site mentorship programs, as well as

didactic training courses. Retention of staff and career development are emphasized.

-RTC is focused on the recruitment and retention of staff for treatment sites, particularly in rural and under-

served or hard-to-reach populations. Where possible RTC will fill existing DOH positions, or alternatively if a

position needs to be supported until the DOH can establish new positions, RTC will employ and second

staff to sites. RTC has supported down referral from the overloaded and successful Comprehensive Care

Management and Treatment (CCMT) sites of patients stable on ART. Such down referral is conducted with

an emphasis on transfer not only of the patient, but also the data record. In addition to internal HAART

treatment reviews, quality assurance activities will include the following: (1) review of all counselors at site

to ensure consistent treatment adherence education and counseling (2) review of the use of treatment

protocols at site including pharmacy and laboratory resource utilization (3) review of management of toxicity

e.g. Nevirapine dose escalation and rash or hepatotoxicity, (4) individual clinician level performance review

to ensure management is according to training, policies and guidelines, (5) monitoring the quality of care

provided by down referral sites and maintenance of down referral guidelines, (6) monitoring prescription,

dispensing and supply management of pharmaceutical supplies, (7) provision of cotromoxazole and

isoniazid prophylaxis, (8) management of opportunistic infections.

ACTIVITIES AND EXPECTED RESULTS:

RTC will use PEPFAR funds to accelerate the implementation of the National Strategic Plan (NSP) CCMT

program at DOH sites. Through memorandums of understanding (MOUs) in the five provinces, RTC plans

to enhance the ART services by developing network coverage of the CCMT and primary health care

facilities in each district. This may include additional CCMT treatment sites as requested by the DOH. More

emphasis is however placed on the improved efficiency of each of the sites, and the integration of CCMT

sites into the primary health care facilities through down referral. FY 2009 funds will be used to expand

access to treatment with a special focus on the following target areas:

-Improved management of patients according to the treatment guidelines focused on safe, effective ART

treatment to reduce HIV and AIDS associated morbidity and mortality.

-Integration of ART with prevention of mother-to-child (PMTCT) activities with Highly Active ART (HAART)

provided to all eligible pregnant women.

-Improved follow-up of patients in pre-HAART wellness clinics through the provision of care and support

activities at these clinics, strengthening the scope of non-ART services including but not limited to, HIV

counseling and testing (CT), HIV primary care, opportunistic infection management, family planning,

nutritional counseling, linkages to in-patient care, home-based care, and secondary prevention, and OVC

and social services.

-Increased CT for ART access, and transition to care by linking CT activities to referral treatment sites. CT

is provided to couples, to reach the partners and family members of individuals already in care.

-Focused activities to the current gender imbalance focused on reaching more men (approx. 65% of ART

patients are women).

-Inclusion of pediatric patients in family-focused clinics

-Expansion of the successful down referral model to 18 sites in four provinces Mpumlanga, Free State,

Gauteng and Northern Cape as requested by those provincial DOH. By the end of FY 2009 RTC will have

over 20,000 patients will be treated at down referral sites.

- RTC will support the early diagnosis of TB, improved TB treatment, access to TB culture and polymerase

chain reaction (PCR) testing for drug resistance, HIV testing in TB, and provision of ART to TB patients.

Linkage between ART treatment sites and TB hospitals will facilitate care for patients diagnosed with

multi/extensively drug resistant TB. Isoniazid prophylaxis will be introduced and expanded in all RTC-

supported CCMT sites, in accordance with the national and provincial treatment guidelines.

-RTC will continue to support capacity development for pharmacy services, in particular the training of

pharmacy assistants, integration of pharmacy supply chain IT systems chosen in each province with HIV

data systems, and overall reporting of outcomes according to SAG and PEPFAR requirements.

-RTC will increase the access to data management systems enabling clinics to monitor quality assurance

including CD4 percentage increases, viral load, disease stage, side-effects, adverse events and outcomes

at annual intervals.

In order to complement clinic-based ARV services, support is provided to at least one community-based

care organization to partner with each treatment site. This team is tasked with monitoring patients'

adherence, providing support such as nutrition, wellness and welfare services, encouraging patients to

remain on treatment, tracking patients that are lost to follow up and providing home-based care services for

those that are terminally ill. The Clinical Mentorship Program will continue to enhance the provision of HIV

care by transferring skills, using local and international clinical mentors. Implemented in rural sites and hard

to reach populations, with human capacity development and skills transfer, increased numbers of people in

hard to reach populations will receive quality care and treatment services. To address gender imbalances,

RTC anticipates opening a male-only clinic in partnership with the Clinical HIV Research Unit (CHRU) at

Wits University. This clinic will focus on recruiting adult males from local industries dominated by males in

the private sector as well as males from indigent populations.

-------------------------------

SUMMARY:

Right to Care (RTC) will use FY 2008 PEPFAR funds to strengthen the capacity of healthcare providers to

deliver ARV treatment (ART) services to eligible HIV-infected individuals in five provinces. Emphasis will be

placed on increasing the number of HIV-infected children and pregnant women on ART. The emphasis

areas are renovation, gender, human capacity development, and local organization capacity building. The

Activity Narrative: primary target populations are people living with HIV (PLHIV), public and private healthcare providers.

BACKGROUND:

RTC's ARV Treatment (ART) services are a continuation of activities, which have been USG-funded since

2002. Originally initiated as a holistic education, testing, care and treatment program for the employed

sector (called the Direct AIDS Intervention (DAI) program), RTC's ART activities have expanded their reach

through a range of partnerships with government sites, private sector providers and NGO and FBO clinics

and organizations. RTC is now reaching substantial numbers of people from predominantly vulnerable

populations in five provinces. RTC's ART activities consists largely of support for the ART services of all of

RTC's treatment partners, including its Thusong network of private practitioners, many government sites

and NGO and FBO clinics and organizations. In addition, RTC itself implements the ART components of the

DAI and other partnership workplace programs. ART training is conducted by RTC's Training Unit as well as

by several sub-partners. With FY 2008 funding, RTC will expand its pediatric treatment, expand into a male-

only clinic and increase its focus on reducing stigma and encouraging disclosure. RTC will consolidate and

expand its support for government sites, NGO and FBO clinics and organizations and private sector

programs, and build on past successes (over 22,500 people reached with ART by the third quarter of FY

2007).

ACTIVITIES AND EXPECTED RESULTS:

RTC will use PEPFAR funds to accelerate the implementation of the national rollout plan at government

sites in partnership with the National Department of Health (NDOH). As the procurement of ARV drugs and

lab services is undertaken by government in these sites, PEPFAR funds will be used to expand access to

treatment. RTC has successfully negotiated for the NDOH to supply certain NGO and FBO sites with ARVs

and laboratory services, freeing PEPFAR funds to support new treatment sites.

PEPFAR funds will be used for: (1) human capacity development and salaries (consultant and part-time

healthcare workers) at all ART facilities: NGO and FBO clinics and organizations receive sub-awards for

doctors, nurses, pharmacists and counselors, and a fee-for-service arrangement exists with the network of

private sector service providers for the Thusong and private programs; (2) developing a training program for

pharmacy assistants as human capacity development for the distribution of ARVs and HIV services; (3)

addressing minor infrastructure needs where necessary at NGO, FBO and government sites, and to

maintain RTC's mobile clinics; (4) NGO and FBO clinics use PEPFAR funds for the laboratory monitoring of

HIV patients, as well as for the procurement of health commodities; and (5) covering the costs of labs for

the new mobile clinic treatment program servicing remote communities in Mpumalanga, in collaboration with

another PEPFAR-funded partner, FHI.

Down referral sites will be established with the Department of Health in Gauteng and Mpumalanga in FY

2007 for stable patients. Human capacity, minor infrastructure and training will be provided to these sites. A

'smart card' system is being developed with Therapy Edge and Supply Chain Management Service to track

transfer of patient data.

RTC supports its ART providers by disseminating policies and guidelines and sharing best practices.

Ongoing quality assurance and supportive supervision is undertaken by centralized treatment experts. RTC

and several of its sub-partners will also provide training in ART services for health workers. In the delivery of

medical ART services, doctors are given ongoing support in clinical decision-making, prescribing and case

management by RTC's team of medical HIV experts, through RTC's Expert Treatment Program (ETP). The

ETP management model enables primary healthcare providers to communicate directly with HIV experts.

ETP uses a sophisticated web-based IT tool in the form of TherapyEdge, licensed to RTC, which enables

the effective management of patients and includes a secure patient database. The Clinical Mentorship and

Preceptorship Program (CMPP) will continue to enhance the provision of HIV care and clinical expertise

across the intermediate levels of health care within the overburdened public healthcare system. Through

human capacity development, increased numbers of people will receive care, support and treatment. The

anticipated benefit of the mentorship program is the dissemination of training and knowledge gained by

healthcare personnel in the urban academic site to rural and smaller sites around the country.

A new PPP, the AIDS Treatment Institute (ATI), is proposed with Vodacom and the DOH. Vodacom will

provide all infrastructure requirements for a HIV care and treatment centre for indigent patients, with the

DOH supplying all ARV and covering lab costs. PEPFAR funds will be used for training, human capacity

development of necessary health care workers, and ongoing technical assistance. This clinic is targeted to

provide treatment for 10,000 patients, care and support to 15,000 patients, CT to 40,000 individuals and

prevention education to 100,000 in FY 2008. Vodacom, other private sector organizations and DOH will

provide over 90% of support for this program, and PEPFAR funds will provide less than 10% of the PPP

budget.

RTC will ensure that each ART patient at RTC-supported facilities receives a minimum package of ART

services, including clinical and pathology monitoring, adherence counseling and support, and follow-up of

defaulting ART patients. Adherence activities will include a focus on reducing stigma and encouraging

disclosure in order to enhance drug compliance and to improve patient retention. Emphasis will be placed

on increasing the number of HIV-infected children and pregnant women on ARVs according to the national

treatment guidelines. Mobile clinics are used to bring ART services to farm workers and other vulnerable

populations in rural areas of the Northern Cape and Mpumalanga.

To support the implementation of ART, adherence counseling and support is implemented through

individual counseling, support groups and direct observed therapy, either clinic-based or community-based.

In order to complement clinic staff, support is provided to at least one community-based care organization to

partner with each treatment site. This team is tasked with monitoring patients' adherence, providing support

such as nutrition, wellness and welfare services, and providing home-based care services for those that are

terminally ill. The team also provides referral services to clinics and in some cases, arranges transport or

hospice services. RTC anticipates opening a male-only clinic in partnership with the Clinical HIV Research

Activity Narrative: Unit (CHRU) at Wits University. This clinic will focus on recruiting adult males from local industries

dominated by males in the private sector as well as males from indigent populations. Patients in this clinic

will receive ART services, clinical and pathology monitoring, with specific adherence and other support

designed to meet the needs of men. Best practices on adherence and support as well as clinical care from

this clinic will be shared with other RTC partners. In FY 2008, RTC will contribute to increased patients on

ART at various sites towards the PEPFAR treatment target of 2 million patients, and will train healthcare

workers in ART services. RTC will support the PEPFAR vision outlined in the Five-Year Strategy for South

Africa by expanding access to ART services for adults and children, building capacity for ART service

delivery, and increasing the demand for and acceptance of ARV treatment.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13797

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13797 9453.08 U.S. Agency for Right To Care, 6612 271.08 $29,554,000

International South Africa

Development

9453 9453.07 U.S. Agency for Right To Care, 4460 271.07 $0

International South Africa

Development

Emphasis Areas

Construction/Renovation

Gender

* Addressing male norms and behaviors

Health-related Wraparound Programs

* TB

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $17,367,031

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $493,661

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $194,470

Economic Strengthening

Education

Water

Table 3.3.09:

Funding for Care: Pediatric Care and Support (PDCS): $943,309

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

FY 2008 COP activities will be expanded to include:

-PEPFAR funds will also be used to structurally improve and maintain all RTC supported clinics;

-PEPFAR funds will be used for human capacity development and salaries at all pediatric care and support

providers; and

-Using FY 2009 funds RTC will consolidate provincial centers of pediatric ART expertise established in FY

2008.

SUMMARY:

Following the emphasis in the National Strategic Plan 2007-2011, RTC will use FY 2009 PEPFAR funds to

accelerate the scale-up of family-centered approaches to pediatric treatment, care and support. The specific

aim is to increase the access to antiretroviral therapy for pediatrics from the current 7% of patients treated

to 15%, in accordance with the National Strategic Plan (NSP) and the technical considerations for the FY

2009. Focus for the Pediatric treatment program will be to integrate into the adult treatment at all

Department of Health, Comprehensive HIV/AIDS Care, Management and Treatment (CCMT) sites,

supported by Right to Care. At the request of the provincial Department of Health (DOH) and implemented

according to the memorandums of understanding (MOUs) with each province, RTC has increased the

activity and budget emphasis towards pediatric treatment, care and support. The implementation is

conducted in collaboration with the Hospital, District, Provincial and National Departments of Health (DOH).

The guidelines that are available for the care and support of HIV exposed and HIV-infected children will be

followed at all RTC supported sites.

BACKGROUND:

The Right to Care Pediatric Program was established in March 2008. Prior to this date, pediatric treatment

was supported at all sites, with training and preceptorship received from ECHO. It became apparent that the

scale of Right to Care program required a dedicated training and mentorship program within the

organization. Dr. Leon Levin was recruited from private practice to join the organization as a full-time

employee. Dr. Levin is one of only eight Pediatricians in South Africa who are experts in HIV treatment,

antiretroviral therapy and infectious Diseases. Dr. Levin has been involved in HIV treatment with

antiretroviral therapy for over 10 years; has established the largest cohort of patients on treatment in private

practice; and established a specialized referral clinic for complex pediatric HIV cases on the East Rand of

Johannesburg. PEPFAR funds are used to support access to this referral site for indigent public sector

pediatric patients.

The major initial aim of this program was to increase the number of pediatric patients on antiretroviral

therapy (ART) at all Right to Care assisted ART sites. According to December 2007 statistics, children

under 14 years only represent about 7-8% of all patients on ART at Right to Care. The National Department

of Health has called on all HIV and AIDS/STI/TB (HAST) directorates to ensure that at least 15% of all

patients receiving ART are children.

The integrated program of pediatric and adolescent education, counseling and testing, care & support and

ARV treatment will continue to be implemented using RTCs existing models of care:

1) In partnership with the National Department of Health (NDOH), capacity support for pediatric care and

support at CCMT sites in five provinces i.e. Gauteng, Mpumalanga, Northern Cape, Limpopo, and Free

State;

2) Strengthening the pediatric care component of FBO/NGO clinics, which target underserved populations

in rural areas, industrial areas, and informal housing sectors;

3) Thusong, a private practitioner program for indigent patients where pediatric care is emphasized is the

treatment model used in areas where there are no government systems in place. The Thusong pediatric

program is not planned for expansion, patients have started to be transitioned into the government program

and this will continue in FY 2008 and FY 2009. However, this program will remain operational to allow RTC

to treat under this program where necessary; and

4) The employed sector, where RTC is providing HIV disease management services to >130,000

employees in >30 companies and pediatric dependents who are HIV exposed or infected are encouraged to

enroll onto the workplace care and support program.

Since March 2008, the pediatric team has conducted needs assessments for pediatrics at 10 sites

throughout the provinces. Training programs have been finalized for implementation and have been

conducted on 3 occasions with 120 health care workers (HCWs) attending. The training provided includes

the following broad areas of emphasis:

Since March 2008, the pediatric team has conducted needs assessments for pediatrics at 10 sites

throughout the provinces. Training programs have been finalized for implementation and have been

conducted on 3 occasions with 120 HCW attending. The training provided includes the following broad

areas of emphasis:

a. Diagnosis of HIV in infants and children

b. Diagnosis and treatment of TB and other common opportunistic infections

c. Laboratory monitoring of HIV disease in children

d. Treatment initiation in children

e. Pharmacology, dosing, formulation of ARVs in children

f. Treatment adherence in children

g. Adolescent counseling and adherence to treatment

h. Family centered approach to ARVs including linkages to nutritional support program

Activity Narrative: Dr. Levin, Dr MacDonald and others have established mentoring support of treatment sites, with on-site

management of patients supported by pediatric experience clinicians. Mentoring pediatricians are sent to

sites throughout the network at regular intervals, providing both didactic continuing medical education, and

practical bedside teaching. Ongoing support is provided with access to a mobile call-line for clinicians to

receive specific advice from the treatment experts. This line is now available to all clinicians in RTC sites,

with utilization increasing to 6 calls per day. In FY 2008 linkage will be established to the FPD supported

HCW call center.

The pediatric program is linked to an increase in the activities under RTCs PMTCT program at sites

throughout the five supported provinces. Particular emphasis is placed on the provision of infant PCR

diagnosis to all infants exposed to HIV, and early treatment initiation for all children, to reduce early infant

mortality. As the effectiveness of the PMTCT program is enhanced, with transmission of HIV reduced to

less than 5%, children requiring treatment will decrease.

Through the development of treatment sites emphasis is placed on the family centered approach, with

improved pre and post-natal care and mothers, their partners and children treated in the same clinic, this is

in line with safe motherhood. Clinician training is focused on medical officer and primary health care nurse

prescribed HIV treatment.

By providing pediatric training and implementation support to these sites RTC leverages NDOH resources

to reach an increasing number of children. RTC supports these sites with infrastructure especially focus on

renovating the facilities and making them child and adolescent friendly as well as support with staff, training,

equipment and data management.

Through the provision of technical assistance, RTC has established a number of pediatric specific IT

solutions, which will be ready for beta testing within RTC sites in October 2008. Particular emphasis in

TherapyEdge-Pediatrics (TE-Peds) is the provision of treatment guidelines specific to children, yet

accessible as part of the real-time integration of the data system at all sites, to all clinicians. TherapyEdge-

Pediatrics improves disease management through guideline directed, expert systems and pediatric specific

therapeutic intervention. The system provides enhanced clinic management, with the development of

workflow processes that define roles and responsibilities enabling shifting, yet ensuring quality assurance.

Through interfacing with the NHLS, Toga Laboratories, Lancet Laboratories and others, direct provision of

laboratory results into the data system will enable real-time laboratory alerting. The data system provides

overall health system strengthening with integration of guidelines and data collection according to IMCI

WHO standard. RTC has already demonstrated that the use of TherapyEdge-HIV (TE-HIV) in adult patients

has led to: (1) enhanced efficiencies in clinics with reduced waiting periods to <2hours in the largest HIV

clinic in South Africa, Helen Joseph Hospital; (2) improvements in patient retention with a reduction in LTFU

from 21% to 4%; (3) improvement in clinical quality with response to toxicity, virologic failure, dosing errors,

drug interactions and TB diagnosis demonstrated (4) overall mortality, morbidity and viral load suppression

rates have improved; (5) staffing: patient ratios required by Helen Joseph Hospital are approx. 25% of the

ratios recommended by the DOH, due to the ability to shift and efficiencies of the clinic. Through enhanced

guideline driven decision support, RTC will demonstrate the benefits of TE-Peds, in particular the more

accurate prescription of drugs according rapidly changing weight, body surface area, and BMI in children

growing with antiretroviral therapy. RTC continues to support the pharmacovigilance program of the

Medicine Control Council for antiviral therapy in pediatric patients, through the provision of data from all of

our sites.

ACTIVITIES AND EXPECTED RESULTS

RTC will use COP 09 funds to build on consolidating and expanding its support for pediatric care at

government sites, NGO and FBO clinics/organizations and private sector programs. NGO and FBO clinics

also use PEPFAR funds for laboratory monitoring of HIV pediatric and adolescent patients and for the

procurement of health commodities such as medical equipment, ARVs, drugs for opportunistic infections,

counseling and testing kits, and home-based care kits. RTC supports all pediatric care and support (C&S)

providers by disseminating policies and guidelines and providing quality assurance through sharing best

practices.

FY 2009 PEPFAR funds will be used for human capacity development and salaries at all C&S providers; (1)

NGO and FBO clinics/organizations receive sub-awards earmarked for doctors, nurses, counselors and

other healthcare workers; (2) RTC will not provide salary support to SAG staff, but rather the salaries of

health care providers seconded to DOH facilities including support for doctors, nurses, data managers ,

counselors; and (3) a capitation fee-for-service arrangement exists with a network of private sector service

providers for the Thusong program.

The program of pediatric care will have strong emphasis on diagnosing infants and children with HIV early

and national guidelines on PCR testing will be followed. Family members, usually female caregivers, who

require care will also be identified during this process and pregnant caregivers will be referred into PMTCT

services. Couples counseling will be offered to parents who bring children to the clinics together and this will

help to promote the testing of men. RTC will continue getting the children into care as soon as possible and

starting them on ART early, especially young infants who are at high risk of dying. RTC support at the sites

will ensure that a comprehensive package of preventive care is available to all HIV exposed infants and

infected children and ensure that they receive CTX prophylaxis in a timely manner and that they are

appropriately referred for immunizations according to the national guidelines. The staff who will be hired for

the pediatric program will conduct nutritional assessments, nutritional counseling and refer appropriately for

support, an important area of focus will also be TB screening, TB treatment and IPT for those under 5 who

do not have active disease. This will include the clinical management of common opportunistic infections

and other conditions affecting children with HIV and their management. Emphasis will be placed on quality

assurance and assessing and improving the programs already in place.

PEPFAR funds will also be used to structurally improve and maintain all RTC supported clinics and these

Activity Narrative: will offer clinical and psychological and services to HIV-infected and affected children and their families with

strong links to available social and spiritual services. PEPFAR funds will be used to facilitate partner

linkages and a referral system between treatment sites-based care, and other non-medical C&S services.

At each site RTC will identify a community-based care organization to add value to the counseling and

testing program by tracking and tracing pregnant moms who are lost to initiation and PMTCT and by finding

the babies of these mothers to assess them and ensure that they benefit from care. The care and support

NGOs will also help to minimize the pediatric loss to follow up rate.

Using FY 2009 funds RTC will consolidate provincial centers of pediatric ART expertise established in FY

2008 in each province in order to allow staff from other sites to rotate through the centre of excellence and

learn to treat and care for pediatric patients under supervision. In so doing staff from other clinics will

acquire expertise in pediatric care and support and then take that expertise back to their own clinics where

service delivery will be sustainable.

We would expect the number of pediatric patients on ART to increase at all RTC sites and reach the

required15% pediatric patients on ART to be achieved by the end of the FY 2009. In addition, the quality of

pediatric care would continue to improve in FY 2009.By reaching patients with care and support services at

various outlets, RTC will contribute to the PEPFAR goal of providing services to 10 million HIV-affected

individuals.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Construction/Renovation

Gender

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* TB

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $801,489

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.10:

Funding for Treatment: Pediatric Treatment (PDTX): $3,262,506

SUMMARY:

Following the emphasis in the National Strategic Plan 2007-2011 (NSP), Right to Care (RTC) will use FY

2009 COP PEPFAR funds to accelerate the scale up of family-centered approaches to pediatric treatment,

care and support. The specific aim is to increase the access to antiretroviral therapy for pediatrics from the

current 7% of patients treated to 15%, in accordance with the NSP and the technical considerations for the

FY 2009 COP. Focus for the pediatric treatment program will be to integrate into the adult treatment at all

Department of Health (DOH), Comprehensive HIV and AIDS Care, Management and Treatment (CCMT)

sites, supported by Right to Care. At the request of the provincial DOH and implemented according to the

Memoranda of Understanding (MOU) with each province, RTC has increased the activity and budget

emphasis towards pediatric treatment, care and support. The implementation is conducted in collaboration

with the hospital, district, provincial and national Departments of Health. The guidelines that are available

for the care and support of HIV-exposed and HIV-infected children will be followed at all RTC supported

sites.

BACKGROUND:

The Right to Care Pediatric Programme was established in March 2008. Prior to this date, pediatric

treatment was supported at all sites, with training and preceptorship received from Enhancing Children's

HIV Outcomes (ECHO). It became apparent that the scale of the Right to Care program required a

dedicated training and mentorship program within the organization. Dr Leon Levin was recruited from

private practice to join the organization as a full-time employee. Dr Levin is one of only eight pediatricians

in South Africa who are experts in HIV treatment, antiretroviral therapy and infectious diseases. Dr Levin

has been involved in HIV treatment with antiretroviral therapy for over 10 years, has established the largest

cohort of patients on treatment in private practice, and established a specialized referral clinic for complex

pediatric HIV cases on the East Rand of Johannesburg. PEPFAR funds are used to support access to this

referral site for indigent public sector pediatric patients.

The major initial aim of this program was to increase the number of pediatric patients on antiretroviral

therapy (ART) at all Right to Care-assisted ART sites. According to December 2007 statistics, children

under 14 years only represent about 7-8% of all patients on ART at Right to Care. The National Department

of Health has called on all HAST directorates to ensure that at least 15% of all patients receiving ART are

children.

The integrated program of pediatric and adolescent education, counseling and testing, care and support

and ARV treatment will continue to be implemented using RTC's existing models of care:

(1) In partnership with the National Department of Health (NDOH), capacity support for pediatric care and

support at CCMT sites in five provinces i.e. Gauteng, Mpumalanga, Northern Cape and Free State.

(2) Strengthening the pediatric care component of Faith-Based Organization (FBO) and Non-governmental

organization (NGO) clinics which target underserved populations in rural areas, industrial areas, and

informal housing sectors.

(3) Thusong, a private practitioner program for indigent patients where pediatric care is emphasized is the

treatment model used in areas where there are no government systems in place. The Thusong pediatric

program is not planned for expansion, patients have started to be transitioned into the government program

and this will continue in FY 2008 and FY 2009. However, this program will remain operational to allow RTC

to treat under this program where necessary.

(4) The employed sector, where RTC is providing HIV disease management services to >130,000

employees in >30 companies and pediatric dependents who are HIV-exposed or infected are encouraged to

enroll onto the care program.

Since March 2008, the pediatric team has conducted needs assessments for children at 10 sites throughout

the provinces. Training programs have been finalized for implementation and have been conducted on

three occasions with 120 HCW attending. The training provided includes the following broad areas of

emphasis:

a. Diagnosis of HIV in infants and children

b. Diagnosis and treatment of common opportunistic infections

c. Laboratory monitoring of HIV disease in children

d. Treatment initiation in children

e. Pharmacology, dosing, formulation of ARVs in children

f. Treatment adherence in children

g. Adolescent counseling and adherence to treatment

h. Family-centered approach to ARVs

Dr Levin, Dr MacDonald and others have established mentoring support of treatment sites, with on-site

management of patients supported by pediatric experience clinicians. Mentoring pediatricians are sent to

sites throughout the network at regular intervals, providing both didactic continuing medical education, and

practical bedside teaching. Ongoing support is provided with access to a mobile call-line for clinicians to

receive specific advice from the treatment experts. This line is now available to all clinicians in RTC sites,

with utilization increasing to six calls per day. In FY 2008, linkages will be established to the FPD supported

HCW call center.

The pediatric program is linked to an increase in the activities under RTC's Prevention of Mother-to-Child

(PMTCT) program at sites throughout the five supported provinces. Particular emphasis is placed on the

provision of infant Polymerase Chain Reaction (PCR) testing to all infants exposed to HIV, and early

treatment initiation for all children, to reduce early infant mortality. As the effectiveness of the PMTCT

program is enhanced, with transmission of HIV reduced to less than 5%, children requiring treatment will

decrease.

Activity Narrative: Through the development of treatment sites emphasis is placed on the family-centered approach, with

mothers, their partners, and children treated in the same clinic. Clinician training is focused on medical

officer and primary health care nurse prescribed HIV treatment.

By providing pediatric training and implementation support to these sites RTC leverages NDOH resources

to reach an increasing number of children. RTC supports these sites with infrastructure, including staff,

training, equipment, data management, and making the facilities child- and adolescent-friendly.

Through the provision of technical assistance, RTC has established a number of pediatric-specific IT

solutions, which will be ready for beta testing within RTC sites in October 2008. Particular emphasis in

TherapyEdge-Paediatrics (TE-Paeds) is the provision of treatment guidelines specific to children, yet

accessible as part of the live real-time integration of the data system at all sites, to all clinicians.

TherapyEdge-Paediatrics improves disease management through guideline-directed, expert systems and

pediatric-specific therapeutic intervention. The system provides enhanced clinic management, with the

development of workflow processes that define roles and responsibilities enabling task shifting yet ensuring

quality assurance. Through interfacing with the NHLS, Toga Laboratories, Lancet Laboratories and others,

direct provision of laboratory results into the data system will enable real-time laboratory alerting. The data

system provides overall health system strengthening with integration of guidelines and data collection

according to IMCI WHO standard. RTC has already demonstrated that the use of TE-HIV in adult patients

has led to: (1) enhanced efficiencies in clinics with reduced waiting periods to less than two hours in the

largest HIV clinic in South Africa, Helen Joseph Hospital; (2) improvements in patient retention with a

reduction in loss-to-follow-up (LTFU) from 21% to 4%; (3) improvement in clinical quality with response to

toxicity, virologic failure, dosing errors, drug interactions and TB diagnosis demonstrated (4) overall

mortality, morbidity and viral load suppression rates have improved; (5) staff-to-patient ratios required by

Helen Joseph Hospital are approximately 25% of the ratios recommended by the DOH, due to the ability to

task shift and efficiencies of the clinic. Through enhanced guideline-driven decision support, RTC will

demonstrate the benefits of TE-Paeds. In particular, the more accurate prescription of drugs according

rapidly changing weight, body surface area, and BMI in children growing with antiretroviral therapy. RTC

continues to support the pharmaco-vigilance program of the Medicine Control Council for antiviral therapy in

pediatric patients, through the provision of data from all of our sites.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Increasing Access to Pediatric Support, Care and Treatment

RTC will use FY 2009 COP funds to build on consolidating and expanding its support for pediatric care at

government sites, NGO and FBO clinics/organizations and private sector programs. RTC currently supports

five provinces. At the request of the DOH in the provinces Gauteng, Mpumalanga, Northern Cape, Free

State, and Limpopo, both funding and activity emphasis will be placed on increasing access to pediatric

support, care and treatment at each of these sites.

NGO and FBO clinics also use PEPFAR funds for laboratory monitoring of HIV pediatric and adolescent

patients and for the procurement of health commodities such as medical equipment, ARVs, drugs for

opportunistic infections, counseling and testing kits, and home-based care kits. RTC supports all the Care

and Support (C&S) providers by disseminating policies and guidelines and providing quality assurance

through sharing best practices.

The program of pediatric care and treatment, through linkages with the PMTCT program, will have strong

emphasis on diagnosing infants and children with HIV early and national guidelines on PCR testing will be

followed. Family members who require care, including fathers, will also be identified during this process and

pregnant caregivers will be referred into PMTCT and care services resulting in the promotion safe

motherhood. RTC will continue getting the children into care as soon as possible and starting on ART early,

especially in young infants who are at high risk of dying. RTC supports the roll-out of the Children with HIV

Early Antiretroviral Therapy (CHER) study results demonstrating a reduction in early mortality in children

initiated on ART at or after six weeks of age. RTC support at the sites will ensure that a comprehensive

package of preventive care is available to all HIV-exposed infants and infected children and ensure that

they receive cotrimoxazole prophylaxis and that they are appropriately referred for immunizations according

to the national guidelines thereby increasing child survival. The staff who are hired for the pediatric program

will conduct nutritional assessments, nutritional counseling and refer appropriately for support, an important

area of focus will also be TB screening, treatment and prophylaxis for those under five who do not have

active disease. This will include the clinical management of common opportunistic infections and other

conditions affecting children with HIV and their management. Emphasis will be placed on quality assurance

and assessing and program monitoring in order to improve the programs already in place.

ACTIVITY 2: Infrastructure and Human Capacity Development

FY 2009 PEPFAR funds will be used for infrastructure, human capacity development and salaries at all

C&S providers; (1) NGO and FBO clinics/organizations receive sub-awards earmarked for doctors, nurses,

counselors and other health-care workers; (2) RTC will not provide salary support to SAG staff, but rather

the salaries of health care providers seconded to DOH facilities including support for doctors, nurses, data

managers, counselors; and (3) a capitation fee-for-service arrangement exists with a network of private

sector service providers for the Thusong program.

Using FY 2009 COP funds, RTC will consolidate already-established provincial centers of pediatric ART

expertise, maintained within family clinics, in order to allow staff from other sites to rotate through the centre

of excellence and learn to treat and care for pediatric patients under supervision. In so doing staff from other

clinics will acquire expertise in pediatric care and support and then take that expertise back to their own

clinics where service delivery will be sustainable.

PEPFAR funds will also be used to maintain the infrastructure of all RTC-supported clinics, which will offer

clinical and psychological and services to HIV-infected and affected children and their families with strong

links to available social and spiritual services. NGO and FBO clinics also use PEPFAR funds for laboratory

Activity Narrative: monitoring of HIV-infected and exposed pediatric patients and for the procurement of health commodities

such as medical equipment, ARVs, drugs for opportunistic infections.

ACTIVITY 3: Linkages and Referrals

PEPFAR funds will be used to facilitate partner linkages and a referral system between treatment sites-

based care, and other non-medical C&S services. At each site, RTC will identify a community-based care

organization to add value to the counseling and testing program by tracking and tracing pregnant moms

who are lost to initiation and PMTCT and by finding the babies of these mothers to assess them and ensure

that they benefit from care. The care and support NGOs will also help to minimize the pediatric loss to follow

up rate.

We would expect the number of pediatric patients on ART to increase at all RTC sites and reach the

required 15% pediatric patients on ART to be achieved by the end of FY 2010. In addition, the quality of

pediatric care would continue to improve in FY 2010. By reaching patients with care and support services

at various outlets, RTC will contribute to the PEPFAR goal of providing services to 10 million HIV-affected

individuals.

New/Continuing Activity: New Activity

Continuing Activity:

Emphasis Areas

Construction/Renovation

Gender

* Increasing gender equity in HIV/AIDS programs

Health-related Wraparound Programs

* Child Survival Activities

* Safe Motherhood

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $2,659,301

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $160,570

and Service Delivery

Food and Nutrition: Commodities

Estimated amount of funding that is planned for Food and Nutrition: Commodities $90,241

Economic Strengthening

Education

Water

Table 3.3.11:

Funding for Care: TB/HIV (HVTB): $3,348,032

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

Right to Care (RTC), in support of the South African government's TB program and the World Health

Organization's policy on collaborative TB/HIV activities, has developed and implemented a model of TB/HIV

integration through TB focal point activities at provincial and district hospitals, and at local primary care

clinics. At the request of the Department of Health (DOH) RTC will help the government to expand the

TB/HIV integration model in FY 2009.

In FY 2009, RTC will scale up the TB/HIV integrated package to all sites in the six provinces. This will

include: (a) enhanced uptake of Isoniazid Preventative Therapy; (b) evaluating and implementing improved

infection control practices at all antiretroviral and TB facilities to prevent nosocomial transmission of TB; (c)

support the development of drug-resistant TB treatment at Sizwe Hospital; (d) improve data collection and

system linkages between treatment points and the laboratory; and (e) strengthen laboratory services to

implement the TB/HIV program.

TB Focal Point Scale-up: The DOH has asked RTC to expand TB Focal Point in sites in six provinces.

Scaled up activities will include (1) increased access to HIV counseling and testing for patients with TB; (2)

intensified case finding through TB symptom screening at all points of contact with patients; (3) improved

access to induced sputum for TB diagnosis in HIV-infected individuals through specialized sputum induction

rooms that comply with occupational and environment safety standards, thus enhancing infection control

and increasing the sensitivity of sputum testing; (4) improved linkages between the HIV and TB programs at

each of the sites through referral, notification and follow-up; (5) infrastructure support to develop TB sputum

induction rooms with appropriate infection control procedures to prevent the transmission of TB; and (6)

targeting faith-based and non-governmental clinics focusing on underserved populations in rural areas,

industrial areas and informal housing sectors. The programs will promote sustainability through training of

health care-workers and partnerships with the National Department of Health (NDOH) to fund the ongoing

running cost and staff components. PEPFAR funds will enable long-term sustainability through training,

human capacity development and infrastructure support at all RTC-supported TB/HIV clinics.

RTC will focus on improving monitoring and evaluation (M&E) methods and data collection tools to

demonstrate the integration outcomes of TB/HIV integration. A successful RTC technical assistance team

has been established to continue to expand the activities from the key sites, to include all sites in the RTC

network.

Pediatric TB/HIV Care: An experienced pediatrician leads the RTC pediatric care and support program.

Training health-care workers (HCW) to enhance the diagnosis and treatment of TB in children will be

focused upon. In addition, training will include skills to improve clinical recognition of TB, specimen

collection and treatment with both TB and antiretroviral treatment.

Implementation of the DOH government policy and guideline for Isoniazid Preventative Therapy: RTC will

provide appropriate training to HCWs and family members, aimed at increasing the delivery of IPT and

treatment adherence. Duration of IPT will follow the NDOH guidelines.

Improved Infection Control: To prevent nosocomial infection of TB in clinical facilities supported by RTC, an

emphasis will be on introducing best practices for infection control. This will focus on urgent referral of TB

suspects out of the clinic to prevent transmission, ventilation, ultra-violet lights, masks and regular staff

screening for TB.

Drug-resistant TB: At the request of the Gauteng DOH, Sizwe, the provincial MDR/XDR-TB referral hospital,

is supported by RTC. RTC will continue activities at Sizwe. The DOH has requested support for a second

MDR/XDR-TB hospital. The planned activities include: (1) continuing to contribute to the overall activities at

Sizwe linked to the development of new treatment options for MDR/XDR-TB. Research is funded by the

pharmaceutical industry, National Institutes of Health and European Union (e.g., TMC207-TiDP13 phase 2

clinical trial currently underway at Sizwe); (2) supporting a prospective trial to evaluate the use of line-probe

assay PCR testing to monitor patients on MDR/XDR-TB treatment with the aim of reducing hospital stay; (3)

improving data collection (using DOH staffed vehicles) and linkages with laboratories to facilitate rapid

referral of MDR/XDR-TB patients; (4) adhering to the TB Strategic Plan for South Africa 2007-2011, where

emphasis will be placed on occupational development and income generation projects for patients admitted

to MDR/XDR-TB facilities; (5) enhancing data collection and linkages to facilitate tracing contacts of

MDR/XDR-TB patients; and (6) examining the feasibility of community-based treatment of MDR-TB with

strong DOT support as was successfully implemented in Lima, Peru. FY 2009 activities will pursue the

development of such a model and a potential demonstration project in one of the townships of South Africa.

Strengthening Laboratory Services: RTC will, in line with recent NDOH guidelines, support the line-probe

assay using PCR methods on all culture positive specimens. This will facilitate the rapid diagnosis of TB

and early diagnosis of M/XDR-TB. As on the South African incidence of drug resistant TB increases, further

expansion of the laboratory infrastructure is required to meet the demand for PCR services. RTC aims to

strengthen access to PCR testing through the central laboratory services of the Department of Molecular

Biology, Contract Laboratory Services, and Wits Health Consortium. Activities will establish the laboratory

infrastructure, provide technical assistance, training of laboratory personnel, and disseminate the DOH and

NHLS guidelines for PCR testing. The sustainability of the laboratory including staffing, pathologist support,

and laboratory consumables will be provided by the NHLS and clinical treatment sites. Linking laboratory

results to patients is critically important. FY 2009 funds will be used to enhance the quality and quantity of

TB diagnosis, including rapid turn-around time for sputum samples to less than three hours, use of LED

microscopy and fluorescent staining methods, and linkage of results to the patient. Throughout the process,

from specimen collection to the final culture result, enhanced attention will be paid to improved infection

control and biosafety standards for TB.

---------------------------------------

Activity Narrative: SUMMARY:

Right to Care (RTC) will use FY 2008 PEPFAR funds in five provinces to strengthen the capacity of

healthcare providers to deliver TB/HIV services, identify TB and HIV co-infected individuals, and improve

the overall quality of clinical and community-based healthcare services. The major areas of emphasis are

human capacity development and local organization capacity building. Target populations include people

infected with TB/HIV, public health care providers and local organizations.

BACKGROUND:

Throughout South Africa, active TB incidence rates are rising, reaching 608 per 100,000 per annum. HIV-

infected patients are at significant risk for developing TB, and 58% of patients attending TB clinics have

been identified as HIV-infected. Of primary importance is the identification of TB in HIV infected individuals,

with over 60 percent of co-infected patients being sputum negative. Improved and early diagnosis of TB in

HIV-infected individuals improves outcomes of morbidity and mortality. Co-infected individuals need to be

initiated on antiretroviral therapy, according to standard treatment guidelines, to ensure improvement in

mortality, morbidity and TB cure rates. RTC will support the South African government's TB program and

the World Health Organization's policy on collaborative TB/HIV activities.

Since FY 2006 RTC has received funding for TB/HIV and plans to integrate the services for TB/HIV for all

co-infected patients at sites throughout the RTC network with the FY 2008 funding. The additional activities

at each of the sites will be: (1) access to HIV counseling and testing for patients with TB, (2) improved

access to induced sputum for TB diagnosis in HIV-infected individuals, (3) improved linkages between the

HIV and TB programs at each of the sites through referral, notification and follow-up; (4) infrastructure

support to develop TB sputum rooms with appropriate infection control procedures to prevent the

transmission of TB. Activities are currently limited by budget to the sites at Themba Lethu Clinic, Sizwe

Hospital, Kimberley Hospital, Shongwe and 4 NGO sites. (5) FBO/NGO clinics focusing on underserved

populations in rural areas, industrial areas and informal housing sectors as well as targeted gender specific

support groups and family centered approaches will be targeted. The programs will promote sustainability

through training of health care workers and partnerships with the National Department of Health (NDOH) to

partially fund the ongoing running cost and staff components, over time.

ACTIVITIES AND EXPECTED RESULTS:

RTC 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. RTC 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. RTC 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. RTC 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.

With FY 2008 funding, the program will be expanded to all sites in the RTC network. RTC support to

government sites will include infrastructure, human capacity development, salaries and training. Technical

assistance will be provided to improve the integration of TB and HIV services and referral between the sites

treating each of the diseases. In all cases where RTC provides salary support an agreement is made with

the facility where positions will be created and funded by provinces in due course. Oftentimes a government

position has been created, but not filled, and RTC supports a consultant to fill the position until such time as

the province successfully recruits for it.

PEPFAR funds will enable long-term sustainability through support of, salaries, training and human capacity

development at all RTC-supported TB/HIV clinics, in the form of sub-awards for NGO and FBO clinics and

direct salary support for government sites. PEPFAR funds will also be used to adapt existing training

materials to specific TB/HIV issues, and address infrastructure needs, such as HIV counseling rooms in TB

clinics and specialized sputum induction rooms that comply with occupational and environmental safety

standards. This will enhance both safety of obtaining sputum samples and increase sensitivity for positive

sputum test.

At TB/HIV treatment sites, emphasis will be placed on identification of co-infected individuals, through

promoting routine HIV counseling and testing for TB patients and TB screening of HIV patients who present

with risk factors. Co-infected patients will be evaluated for correct application of ARVs and TB medications.

Those on combined ARV and TB treatment will be monitored for the development of Immune Reconstitution

Inflammatory Syndrome. Emphasis is placed on adherence support to address the increased risk of non-

compliance due to high pill burden, and overlapping toxicities, particularly hepatotoxicity. Human capacity

development in the management of anticipated drug interactions and shared adverse effects is an additional

expected result. Family and community support network will be educated and trained in basic TB knowledge

to help support the client with his/her treatment to improve compliance.

In addition to sputum collection, the implementation of low-cost, high through-put, digital, mobile chest x-ray

technology, access to screening x-rays will be improved at rural, distant sites and in underserved

populations. FY 2008 PEPFAR funding will be used to purchase and equip one mobile x-ray facility to assist

the program in rural Northern Cape and Mpumalanga provinces. While x-ray is not a microbiological

diagnosis, it is a simple method to augment diagnosis. TB bactecs and bone marrow procedures are not

planned for the sites at present.

Although the current government policy includes access to INH for primary TB prophylaxis, most clinics do

not have the required capacity or experience to provide this. INH is provided to Helen Joseph by the

provincial government. RTC will evaluate INH prophylaxis at the Helen Joseph Hospital using evidence-

Activity Narrative: based locally relevant data collected within the unit. In collaboration with the local National Health

Laboratory Services ongoing monitoring of the evolution of mycobacterial resistance and effect on incidence

of TB at the hospital will be undertaken. PEPFAR funds will be used for human capacity development,

consultant and sessional salaries and infrastructure, but not for the purchase of INH prophylaxis.

RTC and several of its sub-partners will also continue to incorporate TB/HIV training in ART courses for

doctors, nurses and lay counselors to ensure quality of care.

Through induced sputum and chest x-ray, this program will improve TB case finding, improved sputum

diagnosis and early TB treatment initiation. Through improved adherence to TB treatment, and improved

notification and referral, the aim is to improve TB cure rates. Through improved HIV counseling and testing

and referral to ARV treatment, overall TB cure rates and mortality outcomes are anticipated.

Overall the planned activities include monitoring and evaluating the outcomes of the integration of TB and

HIV services on patients' outcomes, hospital stays, and mycobacterial outcomes of cure and resistance.

By reaching patients with TB/HIV therapy at various outlets, RTC will contribute to the PEPFAR goal of

providing services to 10 million HIV-affected individuals. In addition, the activities support the USG Five-

Year Strategy for South Africa by training health care workers in TB/HIV services, significantly strengthening

these services and their integration into HIV and primary health care services.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13794

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13794 3276.08 U.S. Agency for Right To Care, 6612 271.08 $3,395,000

International South Africa

Development

7548 3276.07 U.S. Agency for Right To Care, 4460 271.07 $0

International South Africa

Development

3276 3276.06 U.S. Agency for Right To Care, 2652 271.06 $350,000

International South Africa

Development

Emphasis Areas

Construction/Renovation

Health-related Wraparound Programs

* TB

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $2,840,296

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.12:

Funding for Prevention: HIV Testing and Counseling (HVCT): $2,046,401

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

SUMMARY: Right to Care (RTC) is one of the most successful counseling and testing (CT) partners of the

South African PEPFAR program, using leveraged funds to provide access to the Proudly Tested program.

In FY 2009, PEPFAR funds will emphasize provider initiated HIV testing at all antiretroviral treatment (ART)

sites, and, through direct community-based access to CT in all nine provinces of South Africa.

BACKGROUND: RTCs CT services are a continuation of ongoing activities. The point of care testing is

conducted using an opt-in policy of the Department of Health (DOH) and is provided with streamlined post-

test counseling for risk reduction. Couples CT and improving the testing of males and home-based HIV

testing have been successfully implemented by RTC. Sexually transmitted infection (STI) assessments and

tuberculosis (TB) symptom screenings are included in CT activities. The CT activities of RTC now exceed

100,000 clients annually from predominantly vulnerable populations.

RTC implements workplace programs and collaborates with employers to extend the HIV testing funded by

the employer to the temporary or contractors workers and/or community. This workplace program is

currently contracted to 130,000 employees of 38 companies. After three years of the program, >80% of

employees volunteer to go for CT. All RTC CT initiatives are coordinated through the Proudly Tested

campaign. This campaign, a registered trademark under RTC, is intended to create a brand that promotes

regular CT for individuals and groups in all social levels. RTC has implemented a unique mobile data

system, encompassing biometric consent, to enable both the collection of data and improved transition to

care through reporting and referral.The data systems have been developed on an open-source code

platform and can be made available to other CT partners.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Scaling of access to CT through provider initiated CT

FY 2009 funds will support the continuation of assistance to government sites, non-governmental and faith-

based organization (NGO), and faith-based organization (FBO) clinics, as well as to private practitioners to

ensure the widespread availability of CT services. PEPFAR funds will largely be used for human capacity

development including: (a) salaries for consultants and part-time healthcare workers at all CT providers, (b)

sub-grants for NGO and FBO clinics and organizations that are partially earmarked for nurses and lay

counselors, (c) direct salary support for lay counselors and nurses at government sites, (d) providing direct

CT support to all TB sites supported by RTC to ensure that all TB patients are tested for HIV, and (e)

scaling up the PMTCT testing of pregnant women, their partners through the use of rapid testing methods

for point of care diagnosis of HIV, and infant PCR diagnosis for children born of HIV-infected mothers.

PEPFAR funds will also be utilized to address minor infrastructure needs such as for the delivery of CT

services at NGO, FBO and government sites.

ACTIVITY 2: Support for CT Providers

RTC will support all its CT providers by disseminating guidelines on CT, by providing quality assurance

through sharing best practices and supportive supervision, and by offering guidance on monitoring and

reporting of results. RTC and several of its sub-partners will also provide ongoing training in CT services for

lay counselors and nurses (either employed by RTC or its partners, or external health workers) to ensure

strict adherence to CT protocols and high quality counseling. RTC will also support healthcare providers in

public health facilities to implement provider-initiated counseling and testing (PICT) as recommended in the

HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011.

ACTIVITY 3: Community-based CT

The strategic mix of clinic-based and community-based CT will see further expansion of activities which will

bring CT services to the doorstep of impoverished populations and high-risk, male dominated groups such

as truck drivers, farm workers, small and medium enterprise (SME) employees, Direct AIDS Intervention

(DAI) contract/temporary workers, tertiary students, rural communities and residents of informal settlements.

Mobile and rural clinics, home-based CT in partnership with the Home Loan Guarantee Company, and clinic

-linked units will be established in vulnerable communities.

ACTIVITY 4: Prevention and Behavior Change

In FY 2009, RTC will support a partnership with Cell-life to develop a cell phone program focused on the

provision of prevention education messaging using mobile technologies. This program will be a public

private partnership with the Vodacom Foundation (committed to providing 1:1 funding to Cell-life) for the

expansion of the use of mobile platforms for HIV prevention and transition to care. Content for messaging

has already been developed. This same platform will be used to manage all appointments scheduling for

patients who are found to be HIV-infected at the time of CT, and through TxtAlert provide patient reminders

for medical appointments.

ACTIVITY 5: Strengthening Expansion of Referral Networks and Increasing Initiation to Treatment

Linkages with community mobilization and outreach activities will be continued to promote the uptake of CT

services and to normalize CT-seeking behavior using community lay counselors and educators. These

linkages and capacity building with indigenous organizations will affect long-term sustainability. Prior to all

CT activities, referral linkages will be established for direct referral at the time of CT.

ACTIVITY 6: Large Scale Mass Media CT Promotion

In collaboration with other CT providers, RTC is participating in the annual national HIV testing week

promoted through Khomanani and will include enhanced testing at mobile and facility-based sites and other

Activity Narrative: non-traditional testing sites. The entire network of RTC nurses will be available at treatment sites.

------------------------------

INTEGRATED ACTIVITY FLAG:

SUMMARY: Right to Care's PEPFAR program will be recompeted through an Annual Program Statement

(APS) in 2008. Right to Care (RTC) will use FY 2008 PEPFAR funds to identify HIV-infected individuals by

supporting selected antiretroviral treatment (ART) sites and through direct community-based access to

counseling and testing (CT) in seven provinces, namely KwaZulu-Natal, Free State, Eastern Cape,

Limpopo, Mpumalanga, Western Cape and Northern Cape. CT is used as a prevention mechanism to

promote abstinence, be faithful and condoms, as well as an entry-point into care, support and ART. It is also

an essential tool for fighting stigma and discrimination. The major area of emphasis is human resources.

Minor areas of emphasis include community mobilization/participation, training and workplace program.

Specific target populations include university students, adults, pregnant women, HIV-infected infants,

truckers, and public and private sector healthcare providers.

BACKGROUND: RTC's CT services are a continuation of ongoing activities. CT was originally part of RTC's

holistic education, testing, care and treatment program for the employed sector, known as the Direct AIDS

Intervention (DAI) program. RTC's CT activities have since expanded their reach through a range of

partnerships with government sites, private sector providers and non-governmental and faith-based clinics

and organizations, and are now reaching substantial numbers of clients from predominantly vulnerable

populations, through clinic-based and mobile CT services.

RTC is currently implementing a program of CT for vulnerable populations. Testing is conducted by nurse

networks, General Practitioner (GP) networks, mobile CT clinics or by sub-partner non-governmental

organizations (NGOs). RTC implements workplace programs and often collaborates with a private sectorr

partner, Alexander Forbes' Comprehensive Health and Wellness Solutions.

Uptake of on-site CT is reaching high proportions. Almost 90% of employees volunteer to go for CT. RTC

supports the Access CT activities of treatment partners, including the Thusong network of private

practitioners, several government sites, and non-governmental and faith-based organization sites. CT

training is conducted by RTC's Training Unit as well as by several of RTC's sub-partners.

All RTC CT initiatives are coordinated through the Proudly Tested campaign. This campaign, a registered

trade mark under RTC, is intended to create a brand that promotes regular CT for individuals and groups in

all social levels. High-profile leaders within communities will promote this brand and strategy to create

increased social acceptance of CT. The Proudly Tested activities will also include commercial CT, which will

receive technical support through PEPFAR funds.

ACTIVITIES AND EXPECTED RESULTS:

RTC used FY 2008 funds to consolidate and expand its existing activities; building on past successes. RTC

tested more than 52,000 clients, and trained 180 healthcare workers and lay counselors in the first three

quarters of FY 2007.

ACTIVITY 1: Assistance to South African Government Sites

FY 2008 funds will support the continuation of assistance to government sites, NGO, and FBO clinics as

well as to private practitioners to ensure the widespread availability of CT services. PEPFAR funds will

largely be used for human capacity development including (a) salaries for consultants and part-time

healthcare workers at all CT providers; (b) sub-grants for NGO and FBO clinics and organizations that are

partially earmarked for nurses and lay counselors; (c) direct salary support for lay counselors and nurses at

government sites; and (d) support for a fee-for-service arrangement with private contractors such as the

private and Access CT programs and a network of private practitioners for the Thusong program. PEPFAR

funds will also be utilized to address minor infrastructure needs such as for the delivery of CT services at

NGO, FBO and government sites, for the maintenance of RTC's mobile clinics, and for the procurement and

distribution of HIV test kits for NGO and FBO clinics.

ACTIVITY 2: Support for CT Providers

RTC will support all its CT providers by disseminating guidelines on CT, by providing quality assurance

through sharing best practices and supportive supervision, and by offering guidance on monitoring and

reporting of results. RTC and several of its sub-partners will also provide ongoing training in CT services for

lay counselors and nurses (either employed by RTC or its partners, or external health workers) to ensure

strict adherence to CT protocols and high quality counseling. RTC will also support healthcare providers in

public health facilities to implement provider-initiated testing and counseling (PITC) as recommended in the

HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011. Providers will be trained on PITC as well

as on conducting HIV rapid tests. This activity will include internal and external quality assurance around

rapid testing.

ACTIVITY 3: Prevention and Behavior Change

The success of CT as a prevention activity should include promoting prevention and behavior change

including "abstinence, be faithful and condom use", reducing stigma, encouraging disclosure and couple

counseling. HIV-infected individuals are referred from CT to care services. RTC's counselors are trained to

provide counseling services in all prevention areas. In FY 2007 RTC will maintain models of increasing

transition to care including the use of CD4 count testing at the time of CT to encourage early patient staging

for referral. Access to a 24-hour call center for post-test counseling has also proven to be beneficial.

Activity Narrative: ACTIVITY 4: Strengthening Expansion of Referral Networks and Increasing Initiation to Treatment

The strengthening and expansion of referral networks and linkages with care and treatment services for

clients identified as HIV-infected remains one of the central focus areas of RTC's CT activities. Linkages

with community mobilization and outreach activities will be continued to promote the uptake of CT services

and to normalize CT-seeking behavior using community lay counselors and educators. These linkages and

capacity building with indigenous organizations will affect long-term sustainability. Prior to all CT activities,

referral linkages will be established for direct referral at the time of CT. A CT module through Therapy Edge,

an electronic patient database system, is being developed to track all positive CT clients, for call center

counselors to follow-up and direct referral and regular CD4 test.

ACTIVITY 5: Community-based CT

The strategic mix of clinic-based and community-based CT will see further expansion of activities which will

bring CT services to the doorstep of impoverished populations and high-risk, male dominated groups such

as truck drivers, farm workers, small and medium enterprise (SME) employees, DAI contract/temporary

workers, tertiary students, rural communities and residents of informal settlements. Mobile and rural clinics,

home-based CT in partnership with the Home Loan Guarantee Company, and clinic-linked units will be

established in vulnerable communities. Through a public-private partnership, RTC will increase CT uptake

in a cost-sharing model with commercial companies. PEPFAR funds will be used for technical support,

training and CT kits, while the commercial partner will cover the substantial direct cost of nurses, facilities

and other direct activities. This cost-sharing model will enable CT of contract workers, employees and

unemployed persons.

Emphasis will be placed on consolidating and expanding CT services for couples, infants and children, and

cross-testing (testing STI and TB patients for HIV and vice versa, and testing of pregnant women).

FY 2008 funds for counseling and testing will be used by Right to Care to expand services in government

sites, NGO and FBO clinics as well as to private practitioners to ensure the widespread availability of CT

services. The organization will assist the National Department of Health and the provincial Departments of

Health in Gauteng, Northern Cape, and Mpumalanga with activities for National Testing Week. The South

African National Testing Week will include enhanced testing at mobile and facility-based sites and other non

-traditional testing sites. Right to Care will also focus on improving provider-initiated testing and counseling.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13795

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13795 2972.08 U.S. Agency for Right To Care, 6612 271.08 $1,616,000

International South Africa

Development

7544 2972.07 U.S. Agency for Right To Care, 4460 271.07 $0

International South Africa

Development

2972 2972.06 U.S. Agency for Right To Care, 2652 271.06 $1,100,000

International South Africa

Development

Emphasis Areas

Gender

* Addressing male norms and behaviors

Health-related Wraparound Programs

* TB

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $1,997,027

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Estimated amount of funding that is planned for Education $60,893

Water

Table 3.3.14:

Funding for Treatment: ARV Drugs (HTXD): $2,530,537

ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:

SUMMARY:

Right to Care (RTC) supports the South African Government in the implementation of the HIV and AIDS

Program. However, in areas where health systems are weak and there are no ARV services, NGO

treatment sites are capacitated by RTC as requested by government to provide comprehensive HIV and

AIDS services. These sites which are earmarked for accreditation as government sites once governments

budget becomes available serve a large number of very poor individuals who are mostly based in rural

settings and cannot afford to access health care services. FY 2009 funding for ARV drugs will be used to

only expand government requested assistance in developing non-governmental (NGO), faith-based

organization (FBO), and community-based organization (CBO) clinics. Thusong, a private practitioner

program for indigent patients is the treatment model used in areas where there are no government systems

in place. The Thusong program is not planned for expansion, patients have started to be transitioned into

the government program and this will continue in FY 2008 and FY 2009. However,, this program will remain

operational to allow RTC to treat patients under this program where necessary. No new NGO treatment

sites will be started without the support and commitment of government. The areas of emphasis where

PEPFAR funds are used include: human resources (direct salary support for government seconded

pharmacists, pharmacist assistants and therapeutic counselors and sub grants for NGOs), human capacity

development, drug and commodity procurement and distribution, quality assurance, supportive supervision,

infrastructure, and training. All of the government sites that RTC supports receive its drugs through internal

government systems and the drugs are not procured using PEPFAR funds.

ACTIVITIES AND EXPECTED RESULTS:

In FY 2009, pharmaceutical procurement and supply will continue to be managed by RTCs partnership with

Rightmed Pharmacy, this partnership has enabled all RTC supported facilities to have no stock-outs to date

on any drugs despite global shortages of stavudine and lamivudine.

PROCUREMENT AND STORAGE:

The wholesalers deliver medicines to Rightmed and these are signed for by a pharmacist, the medication is

checked against the invoice and stored at Rightmed under temperature-controlled conditions which are

monitored and recorded daily.

PRESCRIPTIONS:

Prescriptions from the NGO treatment sites are either couriered or faxed daily (with follow up originals to be

couriered weekly) to Rightmed and are dispensed as they are received and then batched for courier

collection with the drug arriving at the sites within 48hours depending on the area of the site. All

prescriptions must contain the patient's weight and site identifier as well as all information required by the

South African Pharmacy and Medical Regulations. All prescriptions are checked to ensure all regimens and

dosages conform to SA HIV treatment guidelines.

DISTRIBUTION AND DISPENSING:

A pharmacist or a qualified post basic pharmacist assistant is responsible for retrieving, labeling and

packing the ordered medicine. The medication is individually labeled using labels printed by the

Pharmassist software program. The labels will show the following information: the date the prescription was

processed, drug trade name, drug strength, drug quantity, directions of use, prescription number, patient

initials and surname, dispenser name and telephone number, prescriber name, pharmacy address and

contact details. Patient details and treatment history are stored in an electronic dispensing program, which

assigns prescription numbers to all prescriptions and chronologically stores all the prescription details. A

second pharmacist quality assures the shipment by verifying that the correct drug was dispensed to the

correct patient as well as all other dispensing and shipping details. It is highly unlikely that the patients need

come to the pharmacy but they may, they may also call the pharmacy and speak to the pharmacist at any

time during office hours or call the 24-hour toll-free line for after hours advice. All the pharmacy staff that

work at Rightmed are highly trained and experienced in the field of HIV treatment. The expertise from

Rightmed Pharmacy will continue to be used for training and mentorship for various government and NGO

sites.

ACCOUNTABILITY:

A Complete Drug Accountability Record is kept at Rightmed with the following information: drug description

(name and strength), batch number, expiry date, prescription number (which holds all script details), number

of containers dispensed, and dispenser initials. The medication is packed into a carton and shipments are

processed one shipment at a time. A packing list is sent with every shipment. Once the medication arrives

at the site, the site checks the medication, signs the packing list and faxes it back to Rightmed. Drugs are

then securely stored at the site and are issued to the patients on a monthly basis, in remote areas where it

is hard to attract and retain scarce skills like pharmacists; this model removes the requirement to have a

pharmacist on site because the drugs have already been dispensed at Rightmed. As the patient numbers

grow and where the sites are able to harness the capacity of a pharmacist, direct procurement is facilitated.

The medication is issued to patients by the site clinician who counsels the patient and ensures that the

patient understands the directions. All the staff at the RTC supported sites is offered comprehensive HIV,

TB and counseling training courses free of charge. The patients receive their drugs at no cost as this is

funded by Right to care. Any unused medicine is returned to Rightmed for incineration or destroyed at site

level using the services of a medical waste disposal company. At any one time a three-month buffer supply

of stock is held at Rightmed so as to ensure uninterrupted drug supply to the patients. If there are any

transferred or deceased patients, the site managers inform Rightmed so that pharmacy records are

updated.

Activity Narrative: Following DOH accreditation of the NGO and CBO clinics, government takes over the costs of the drugs,

labs and some staff salaries and the funding which was used for that is re-channeled to other areas that still

need strengthening within the site or to other sites that need support. RTC is working with each site to

ensure that there is a plan in place for the government to take over these salaries as soon as feasible and a

RTC hand over to government has already occurred in the Mpumalanga province. In an effort to support the

government to address the chronic shortage of pharmacists, RTC has embarked on a program to train

pharmacist assistants in partnership with government using PEPFAR funding. This crucial training program

will continue to be supported as the learners are earmarked for placement government sites once they are

qualified. With the graduation of NGO sites and the training of pharmacist assistants sustainability is

addressed. RTC will also expand the current pharmacist expertise in pediatric treatment. The provision of

additional staff that are trained and the clinical infrastructural improvements contribute to the improvement

of quality treatment outcomes.

With FY 2009 funding, RTC will continue to use PEPFAR funds for direct salary support for pharmacists and

pharmacy assistants at government treatment sites to enhance the widespread and sustainable availability

of ARV drug services. Subject to government requests, PEPFAR funds may be used to upgrade

infrastructure and equipment needs at government sites and at NGO and FBO clinics. RTC will also expand

the current pharmacist expertise in pediatric care and procurement.

With FY 2009 funding, RTC will procure and supply ARV drugs to RTC-supported treatment programs and

sites, directly contributing to the 2-7-10 goal of two million people treated. RTC will support the PEPFAR

vision outlined in the Five-Year Strategy for South Africa by expanding access to ART services for adults

and children, building capacity for ART service delivery, and increasing the demand for and acceptance of

ARV treatment.

---------------------------------------

SUMMARY:

Right to Care (RTC) will use FY 2008 PEPFAR funds to procure and distribute antiretroviral (ARV) drugs to

partner antiretroviral treatment (ART) sites and programs in five provinces to expand ART for eligible HIV-

infected individuals. Funds are used to procure ARV drugs used in non-governmental and faith-based

organizations (NGOs, FBOs), and remote treatment sites. RTC will continue to refer HIV-infected individuals

identified through counseling and testing (CT), care, and support services, when indicated, into ART

services. The emphasis areas are human capacity development, renovation, and local organization capacity

building. Populations to be targeted include people living with HIV (PLHIV) and pharmacists.

BACKGROUND:

Since 2005 PEPFAR funds have been used for human capacity development and for consultant and

sessional salaries for employees that augment NGO clinics and government sites. Pharmacists are

employed at each site as it grows and as numbers of patients on treatment rise above 500. RTC will

continue ARV drug activities, which have been PEPFAR-funded since 2004, when RTC began supporting

the purchase of ARV drugs for patients treated through NGOs, FBOs, and the Clinical HIV Research Unit

(CHRU). Pharmaceutical procurement and supply is managed by Rightmed Pharmacy, an independent

pharmacy established that meet the South African pharmacy regulations.

ACTIVITIES AND EXPECTED RESULTS:

With FY 2008 funding, RTC will consolidate and expand its existing activities, building on past successes in

procuring and supplying ARV drugs to its treatment sites/programs. RTC sites have had no stock-outs to

date on any drugs despite global shortages in stavudine and lamivudine. All RTC-supported government

sites receive drugs through internal government systems.

PEPFAR funds will continue to be used for the procurement and distribution of ARV drugs via Rightmed

Pharmacy for the current NGO and FBO clinics as well as for the Thusong program. The Thusong program

provides ART to those unable to access care through Department of Health (DOH) sites. ARV scripts are

forwarded to Rightmed, which handles all the procurement, logistical and pharmaceutical management,

dispensing and distribution of ARVs. The drugs are delivered to the treatment sites via an independent

courier company on a weekly basis. Treatment sites receive batches of drugs for multiple patients, with

drugs labeled and dispensed on a patient-named basis. Drugs are then securely stored at the site and

dispensed to the patient on a monthly basis. Where sites are able to harness the capacity of a pharmacist,

direct procurement is facilitated. Sub-awards for clinics will also include funding for pharmacy staff.

Following DOH accreditation of the NGO and FBO clinics, the South African government will take over the

costs of the drugs and labs. RTC will re-channel funds that were allocated to ARVs and labs to supporting

additional staff, human capacity development and minor infrastructure adjustments. Additional staff,

including dieticians and social workers, may be hired to meet the full staff complement for an accredited

ARV clinic as defined by government. RTC is working with each site to ensure that the South African

government takes responsibility for these salaries at accredited sites as soon as feasible. With government

taking over the cost of ARVs, and the increased number of pharmacists receiving training, sustainability is

addressed. The provision of additional staff that are trained and the clinical space adjustments will

contribute to the improvement of quality treatment outcomes.

In FY 2008, RTC will use PEPFAR funds for direct salary support for pharmacists and pharmacy assistants

at government treatment sites to enhance the widespread and sustainable availability of ARV drug services.

Subject to needs assessments, PEPFAR funds may be used to upgrade infrastructure and equipment

needs at government sites and at NGO and FBO clinics. RTC will also expand the current pharmacist

expertise in pediatric care and procurement. Expertise from Rightmed Pharmacy will be used in training and

mentorship at various government and NGO sites.

Activity Narrative: In FY 2008, RTC will procure and supply ARV drugs to RTC-supported treatment programs and sites,

directly contributing to the 2-7-10 goal of two million people treated. RTC will support the PEPFAR vision

outlined in the Five-Year Strategy for South Africa by expanding access to ART services for adults and

children, building capacity for ART service delivery, and increasing the demand for and acceptance of ARV

treatment.

New/Continuing Activity: Continuing Activity

Continuing Activity: 13796

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

13796 2974.08 U.S. Agency for Right To Care, 6612 271.08 $1,173,000

International South Africa

Development

7546 2974.07 U.S. Agency for Right To Care, 4460 271.07 $0

International South Africa

Development

2974 2974.06 U.S. Agency for Right To Care, 2652 271.06 $5,321,000

International South Africa

Development

Emphasis Areas

Construction/Renovation

Workplace Programs

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $1,905,277

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.15:

Subpartners Total: $10,554,905
Refilwe Christian Clinic: $41,266
CARE International: $234,137
Friends for Life: $38,982
Ndlovu Medical Trust: $1,981,599
Vuselela: $43,737
Alexandra Clinic: $1,031,558
ACTS Community Clinic: $1,621,305
Witkoppen Health And Welfare Centre: $710,218
Clinical HIV Research Unit: $1,211,477
Alberton Methodist Care and Relief Enterprise: $161,627
Emthonjeni Christian Centre: $40,565
Hoedspruit Training Trust: $160,853
Keimoes Diocese: $41,226
Ndlovu Care Group Bhubezi: $1,981,599
Thembalitsha Foundation: $309,920
Topsy Foundation: $855,647
Hospice West Rand: $89,189
Cross Cutting Budget Categories and Known Amounts Total: $32,562,788
Human Resources for Health $250,970
Food and Nutrition: Policy, Tools, and Service Delivery $130,624
Food and Nutrition: Commodities $50,234
Human Resources for Health $3,130,397
Public Health Evaluation $430,307
Human Resources for Health $17,367,031
Food and Nutrition: Policy, Tools, and Service Delivery $493,661
Food and Nutrition: Commodities $194,470
Human Resources for Health $801,489
Human Resources for Health $2,659,301
Food and Nutrition: Policy, Tools, and Service Delivery $160,570
Food and Nutrition: Commodities $90,241
Human Resources for Health $2,840,296
Human Resources for Health $1,997,027
Education $60,893
Human Resources for Health $1,905,277