PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
ACTIVITY HAS BEEN MODIFED IN THE FOLLOWING WAYS:
FY 2009 funds will be used to expand prevention of mother-to-child (PMTCT) program-strengthening
activities to the Ehlanzeni district of Mpumalanga.
ACTIVITY 1: Program Strengthening in Enhlazini District, Mpumalanga
The Human Sciences Research Council (HSRC) will promote the use of health facilities for delivery among
pregnant women and their families. All pregnant women attending the 120 antenatal clinics in the Ehlanzeni
district will be encouraged to undergo confidential counseling and testing (CT) for HIV infection during
pregnancy. Women who test HIV positive will be referred to the nearest accredited antiretroviral treatment
(ART) site for staging and initiation of ART, if indicated (according to the national ART guidelines) and will
be referred to support services. HIV-infected pregnant women will be counseled about disclosure, and
encouraged to refer their partners for HIV testing. Women identified as HIV-infected during pregnancy (and
who do not have long-term ART initiated prior to delivery), and their infants, will be provided with a complete
course of dual antiretroviral prophylaxis in a PMTCT setting. HIV-exposed infants will be tested using
polymerase chain reaction (PCR) at 6 weeks and at 6 months. HIV-infected infants will be referred to the
local health services for follow-up, monitoring and initiation of treatment if eligible. Staff already employed by
district health services will do most of the programmatic work.
Activities will also include PMTCT program integration with family planning, reproductive health, ART
services, and positive prevention interventions for HIV-infected women in Ehlanzeni district.
FY 2009 PEPFAR funds will be used to employ additional staff to strengthen PMTCT programs in the
Ehlanzeni district. The Mpumalanga Department of Health and Social Services has agreed to take over the
funding of these positions after the initial phase of program strengthening.
ACTIVITY 2: Technical Assistance
HSRC will provide technical assistance to strengthen monitoring and evaluation (M&E) systems and will
seek to coordinate the M&E and PEPFAR-related reporting activities with routine district health M&E
activities in order to minimize any unnecessary duplication of work. At the clinic level this will be paper-
based. HSRC will employ a dedicated M&E specialist, a community engagement and outreach specialist,
and a data manager. HSRC will mobilize community leaders, faith- and community-based organizations,
district councils, traditional leaders and traditional birth attendants in the region to support PMTCT
interventions. Training activities will include basic education about PMTCT and its benefits, infant feeding
options (ensuring women make informed choices around infant feeding), risk-reduction counseling, the
benefits of ART, disclosure counseling and encouraging partner testing, training to address HIV-related
stigma, M&E, and positive prevention interventions.
Specific activities will include:
a. Conducting PMTCT community awareness activities such as clinic days, training of clinic committees,
etc.;
b. Promoting disclosure of HIV status among women tested as part of PMTCT programs, and encouraging
partner testing, thus increasing gender equity in HIV and AIDS programs;
c. Training professional nurses on PMTCT and voluntary counseling and testing (VCT);
d. Training lay counselors on VCT and PMTCT;
e. Training traditional health practitioners and traditional birth attendants on HIV and PMTCT;
f. Training professional staff on M & E;
g. Training other professionals (nutritionists, pharmacists, social workers) on PMTCT;
h. Establishing support groups for HIV-infected women; and
i. Assisting with PMTCT program evaluation.
---------------------------
SUMMARY:
The Human Sciences Research Council (HSRC) will provide technical support, including ongoing
monitoring and evaluation (M&E) to prevention of mother-to-child transmission (PMTCT) activities in 50
antenatal care clinics (ANCs) and surrounding communities in the Eastern Cape and Mpumalanga. Once
the PMTCT program in the Eastern Cape is running smoothly, HSRC will embark on similar activities in an
underserved district in Mpumalanga. The District in Mpumalanga is still to be determined and will be
determined in consultation with the provincial department of health. The major emphasis area will include
quality assurance and supportive supervision, with community mobilization, local organization capacity
development, strategic information, and training as minor emphases. The primary target populations include
pregnant women, people living with HIV and AIDS (PLHIV), families affected by HIV and AIDS, public and
private healthcare workers, community-based organizations (CBOs) and non-governmental organizations
(NGOs).
BACKGROUND:
This project will contribute to the PEPFAR objective of preventing HIV infections in the PMTCT priority area.
The project was in the FY 2006 and FY 2007 COPs, but is currently in the early stages of implementation
because funding was awarded late. At the request of the provincial government, the district was changed
and it took longer to establish partnerships with provincial and local health authorities than anticipated.
HSRC will provide technical support for the implementation of PMTCT services according to national
guidelines, and will seek to actively engage communities served by the specified ANCs. HSRC will also
seek to establish partnerships with relevant CBOs and NGOs conducting HIV-related work in the area,
develop reciprocal referral networks and strengthen peer support group systems to enhance family support
(especially husbands, partners, mothers and mothers-in-law) and support from traditional birth attendants
(TBAs) for the PMTCT program.
Activity Narrative: ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Rapid Assessment
Using FY 2006 funding, a baseline assessment is currently underway to identify gaps and challenges to
PMTCT implementation in the district. The assessment will identify program elements that are in need of
strengthening, and provide a baseline measure by which to assess the success of systems strengthening
activities.
ACTIVITY 2: Systems Strengthening
Once the baseline assessment has been completed, program strengthening activities will commence.
HSRC will promote the use of health facilities for newborn delivery among pregnant women and their
families. All pregnant women attending the 26 antenatal clinics in the Kouga Local Service Area (LSA) of
the Eastern Cape will be encouraged to have confidential counseling and testing (CT) for HIV infection
during pregnancy. Women who test HIV-positive will be referred to the nearest accredited ART site for
clinical staging, a CD4 count, and initiation of ART, if indicated (according to the national ART guidelines).
Women who do not meet the criteria for initiation of ART will be referred to a wellness program and/or
relevant social support services. HIV-infected pregnant women will be counseled about disclosure, and
who do not have long-term ART initiated prior to delivery), and their infants, will be given a short course of
ART prophylaxis at delivery for PMTCT. This regimen will be adapted once the dual therapy protocol
becomes policy in the Eastern Cape province. HIV exposed infants will be tested using PCR, and at 15 to
18 months using appropriate tests to determine their HIV infection status. Infants found to be infected will be
referred to the local health services for follow-up, monitoring and initiation of treatment if eligible. Most of the
programmatic work will be done by staff already employed by district health services, or by traditional birth
attendants in the target communities. FY 2008 PEPFAR funds will be used to employ additional staff to
strengthen PMTCT programs in the Kouga area. The Eastern Cape Department of Health has agreed to
take over the funding of these positions after the initial phase of system strengthening.
ACTIVITY 3: Technical Assistance
HSRC will provide technical assistance to strengthen M&E systems and will seek to coordinate the M&E
and PEPFAR-related reporting activities with routine district health M&E activities to minimize any
unnecessary duplication of work. At the clinic level this will be paper-based. HSRC will employ a dedicated
M&E specialist, a community engagement and outreach activity specialist, and a data manager. HSRC will
mobilize community leaders, FBOs, CBOs, district councils, traditional leaders and traditional birth
attendants in the region to support PMTCT interventions.
ACTIVITY 4: Expansion
Activities will be expanded with FY 2008 funding to include:
PMTCT program integration (wraparound) with family planning, reproductive health, and ART services, and
positive prevention interventions for HIV-infected women in the Kouga Local Service Area (LSA). The
impact of the project on the PMTCT delivery system in the Kouga LSA will be monitored, and when service
delivery quality is satisfactory, support will gradually phase out (based on service delivery indicators and
achievement of more than 80% PMTCT uptake in the district), and similar program implementation and
support service activities will be initiated in a new geographic region in an underserved area of Mpumalanga
province. The area will be selected in consultation with the provincial department of health and the CDC,
and an analysis of key PMTCT indicators by district. The district with the most need will be selected. This
activity will increase gender equity in HIV and AIDS programs by increasing women's access to HIV
information, treatment, care and support.
The HSRC PMTCT Program contributes to the PEPFAR 2-7-10 goals and objectives by strengthening
PMTCT service delivery, increasing uptake of PMTCT and decreasing the number of new infections.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13968
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13968 3553.08 HHS/Centers for Human Science 6671 2813.08 HSRC $1,649,000
Disease Control & Research Council
Prevention of South Africa
7315 3553.07 HHS/Centers for Human Science 4375 2813.07 HSRC $1,250,000
3553 3553.06 HHS/Centers for Human Science 2813 2813.06 HSRC $700,000
Emphasis Areas
Gender
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Safe Motherhood
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $247,350
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
FY 2009 funds will be used to implement the healthy relationships group-based positive-prevention
intervention in the OR Tambo District of the Eastern Cape, and to conduct a rapid assessment of the
Phaphama-2 one-on-one positive-prevention intervention at four clinics/voluntary counseling and testing
(VCT) sites in the Cape Town Metropole.
ACTIVITY 1: Implementation of the Healthy Relationships Intervention
In the OR Tambo District, four trainers/quality assurance (QA) specialists will train two local health authority
staff in each of the six local service areas as trainers of the healthy relationships intervention. These 12
trainers will then collectively train approximately 60 group facilitators, recruited from local non-governmental
organizations (NGOs), community-based organizations (CBOs) and treatment sites throughout the OR
Tambo District, to conduct the healthy relationship intervention. Group facilitators will work in pairs to
provide the healthy relationships intervention to support groups for PLHIV. The four QA specialists will
conduct monitoring and QA to ensure that the healthy relationships intervention is given as intended.
ACTIVITY 2: Rapid Assessment of the Phaphama-2 Intervention
HSRC will conduct a rapid assessment of the Phaphama-2 intervention at four clinics/VCT sites in Cape
Town. The Phaphama-2 intervention is a brief risk-reduction intervention against sexually transmitted
infection (STI)/HIV risk and alcohol misuse delivered by counselors to clients in a single 1-hour individual
session. It is currently being evaluated for its effectiveness/generalizability in a study currently being carried
out among 1800 STI patients in three clinics in South Africa, under carefully controlled research conditions.
The intervention is also being evaluated for its efficacy among PLHIV in a sub-study at one of the three
clinics in the Ekurhuleni (East Rand) Metro. The rapid assessment will seek to assess the effect of this
intervention under the "real world" conditions among PLHIV attending STI clinics or VCT sites. Clients will
be asked by one of the project staff (not involved in delivering the intervention) to complete a brief
questionnaire about demographic characteristics and risk behavior prior to participating in the intervention.
After receiving the intervention, clients will be asked to complete a brief qualitative exit interview giving their
opinion of the intervention, its relevance to their own circumstances, and any changes that they intend to
make to modify their own risk. Two people will be trained as trainers/evaluators of the Phaphama-2
intervention. They will train two counselors from each of the four clinic sites to deliver the intervention.
These eight counselors will each deliver the intervention to an average of two clients per week. The rapid
assessment will take place over a six-month period, or until approximately 400 clients have completed the
intervention and at least 200 of these clients have also completed the assessment (pre- and post-
intervention questionnaires).
-----------------------
The HSRC is using PEPFAR funds to implement and determine the effectiveness of two prevention-with-
positives interventions to reduce HIV transmission risks for their partners.
The prevention-with-positives (PwP) activity will adapt and pilot an existing CDC intervention for promoting
HIV status disclosure and behavioral risk-reduction strategies among people living with HIV (PLHIV). This
intervention is known as Healthy Relationships. It is a support-group-based intervention designed to reduce
HIV transmission risks for PLHIV and their partners using an interactive approach that includes educational,
motivational, and behavioral skill building components. Once this intervention has been piloted, a second
individualized intervention will be developed and pilot-tested for effectiveness. Both interventions will include
messages on condom use for PLHIV. The major emphasis area for the activity is gender and human
capacity development. Target populations include men and women of childbearing age, National AIDS
Control Program staff, HIV-infected pregnant women and health care workers, doctors, nurses, CBOs,
FBOs and NGOs.
Among adults, the predominant mode of HIV transmission in South Africa is through heterosexual
intercourse. PLHIV are an important group to target for HIV prevention activities (both to prevent re-infection
with other HIV strains, and to prevent transmission to others), but to date prevention in this group has
received little attention. Behavioral risk-reduction interventions targeting PLHIV will reduce new HIV
infections and will complement behavior change prevention, including condom usage, efforts currently
targeting uninfected people. Until now, people who knew they were infected with HIV had been largely
ignored by HIV risk-reduction strategies in South Africa. There is an urgent need to develop behavioral and
other supportive interventions to assist PLHIV to manage sexual situations, avoid acquiring new sexually
transmitted infections, and to prevent the transmission of HIV to uninfected sexual partners. For behavioral
risk-reduction to be successful among PLHIV, de-stigmatization must be an integral part of the intervention.
Although there is also a need for broad-based stigma-reduction interventions at a community/population
level, interventions for PLHIV can assist in managing the adverse effects of HIV-related stigma, including
the hazards of disclosure of their HIV-infected status. The Healthy Relationships intervention is a small
(support) group-based intervention which has been packaged and disseminated as part of CDC's
Replication Project (REP). It has been implemented successfully in several U.S. states as part of an
initiative by the CDC to provide HIV prevention interventions for PLHIV. This intervention has been adapted
for local conditions and materials have been translated into isiXhosa, the predominant local language in the
Eastern Cape. A second individualized intervention is being considered as many PLHIV have not yet
reached a point when they are willing to disclose their status to others (including other PLHIV). The second
intervention will focus on individual (one-on-one) positive prevention activities.
This activity was in the FY 2006 COP and FY 2007 COP but implementation has been delayed due to late
receipt of funds. The HSRC will use PEPFAR funding to adapt and implement the Healthy Relationships
Program in the area around Mthatha in South Africa's Eastern Cape province. Funds will be used to employ
ten support group facilitators and an administrative staff person to undertake formative evaluations at
baseline and at one, three and six months after enrollment, and to develop or purchase training materials
and videos. Each group of ten PLHIV participating in the Healthy Relationships intervention will attend five
sessions of two hours each over a 1 to 2 month period. The effects of the intervention will be evaluated
using before and after comparisons, and by comparisons to PLHIV who have not yet taken part in the
intervention. A process evaluation will also be conducted.
The project will establish how well these interventions work in a rural under-resourced South African setting
and will also determine the feasibility of scaling-up these interventions in other rural areas with a high HIV
prevalence. The interventions will be framed by the challenges PLHIV face in establishing and maintaining
satisfying relationships, with special emphasis on strategies for disclosing HIV-infected status to a sex
partner (reducing violence and coercion, key legislative issue). Skills for making effective HIV disclosure
decisions will be taught for disclosing HIV status to non-sex partners, particularly family members, friends,
and employers (stigma and discrimination, key legislative issue). The interventions will also address building
skills for reducing HIV transmission risk through behavior change with a particular focus on one of the key
legislative issues: male norms and behavior. Risk-reduction strategies arise naturally in the context of
disclosing HIV status, with different implications for practicing protected and unprotected sex with HIV-
infected partners, HIV-negative partners, and partners of unknown HIV status. An advocacy component will
be incorporated to train participants to advocate for HIV testing and risk behavior reduction among partners,
family members, and friends. In this way, the impact of the intervention will be spread among their social
and sexual networks, and hence increasing gender equity in HIV and AIDS programs. Participants in both
field tests will be assessed at baseline, immediately post-intervention, and at one, three and six months
after completion of the intervention. Once the evaluation of these two interventions has been completed,
they will be further adapted if necessary and expanded to other parts of the Eastern Cape, including the
Kouga LSA. The HSRC will train an additional 50 lay counselors and other healthcare workers working in
the public sector or for local NGOs, community-based organizations or faith-based organizations, in the
delivery of positive prevention interventions, and will undertake monitoring and evaluation of the program.
FY 2008 COP activities will be expanded to include:
The development and adaptation of another PwP intervention, to be delivered as an individual intervention
by community health workers. Individual PwP interventions are needed because issues of stigma and fear
to disclose one's HIV serostatus may serve as barriers to participation in group-based PwP interventions.
The one-on-one intervention will be based on the Options for Health PwP intervention developed by Fisher
et al. This intervention will be adapted for use in a rural South African setting, and adapted for delivery by
community health workers instead of clinicians (task-shifting). Following a formative phase to adapt the
existing intervention in consultation with service providers and PLHIV in Region E of the Eastern Cape,
training materials will be modified and translated into the local language (isiXhosa). This new intervention
will be implemented and evaluated among 400 PLHIV participating in ART programs or wellness programs
in Region E of the Eastern Cape. This individual intervention is likely to consist of 3 one-hour individual
sessions with a lay counselor delivered over a 1-month period. Both process and outcome evaluations will
be conducted. Participants will be interviewed at baseline, at the end of the intervention, and at 3 and 6
months from the start of the intervention to assess the impact of the intervention on risk behavior, and
disclosure.
In addition, the Healthy Relationships PwP intervention will be expanded to another geographic region in
the Eastern Cape, most likely the Kouga LSA ensuring linkages with the HSRC PMTCT program activities
being implemented in that same geographic region. HIV-infected pregnant women will be targeted for this
PwP activity. The main purpose of these new activities is to increase the range of evaluated PwP
interventions available to accommodate the varying needs of PLHIV and to expand the types of settings for
providing PWP interventions, and to scale-up the coverage of PwP programs in South Africa.
These activities will contribute to the PEPFAR goals by developing prevention strategies for PLHIV and their
partners, thus having an impact on prevention of new infections. This activity will also contribute to the
National Strategic Plan (NSP) goal of halving the incidence of new HIV infections by 2011.
Continuing Activity: 13970
13970 3552.08 HHS/Centers for Human Science 6671 2813.08 HSRC $824,500
7314 3552.07 HHS/Centers for Human Science 4375 2813.07 HSRC $500,000
3552 3552.06 HHS/Centers for Human Science 2813 2813.06 HSRC $300,000
* Addressing male norms and behaviors
* Increasing women's legal rights
Estimated amount of funding that is planned for Human Capacity Development $70,083
Table 3.3.03:
NO FY 2009 FUNDING IS REQUESTED FOR THIS ACTIVITY:
This activity was approved in the FY 2008 COP, is funded with FY 2008 PEPFAR funds, and is included
here to provide complete information for reviewers. No FY 2009 funding is requested for this activity. The
Human Science Research Council (HSRC) requested FY 2008 funding to conduct a situational analysis of
adult treatment and HIV service delivery in South Africa. This activity will be completed with the allocation of
FY 2008 funding. Therefore there is no need to continue funding this activity with FY 2009 COP funds.
New/Continuing Activity: New Activity
Continuing Activity:
Table 3.3.09:
orphans and vulnerable children and HIV service delivery in South Africa. This activity will be completed
with the allocation of FY 2008 funding. Therefore there is no need to continue funding this activity with FY
2009 COP funds.
Continuing Activity: 13974
13974 13974.08 HHS/Centers for Human Science 6671 2813.08 HSRC $200,000
Table 3.3.13:
counseling and testing services in South Africa. This activity will be completed with the allocation of FY
2008 funding. Therefore there is no need to continue funding this activity with FY 2009 COP funds.
Continuing Activity: 13971
13971 8276.08 HHS/Centers for Human Science 6671 2813.08 HSRC $300,000
8276 8276.07 HHS/Centers for Human Science 4375 2813.07 HSRC $300,000
Table 3.3.14:
In FY 2009, second generation HIV surveillance will continue to be the main focus of Strategic Information
(SI) activities. FY 2009 funds will be used to:
(1) Conduct analyses of trends in HIV and risk behavior using surveillance information from past national
household HIV surveys conducted in 2002, 2005, and 2008;
(2) Conducting training and preparatory work for the 2011 national household HIV survey (a NEW activity);
(3) Developing and enhancing M&E capacity; and
(4) Work with SAG partners to harmonize health management information systems (HMIS) (a NEW activity).
ACTIVITY 1: 2008 HIV Prevalence Survey
No FY 2009 funds will be used for the 2008 national household HIV survey because fieldwork and primary
analyses will have been completed. A portion of FY 2009 funds will be used to conduct analyses of trends in
HIV and risk behavior using surveillance information from past national household HIV surveys conducted in
2002, 2005, and 2008.
ACTIVITY 2: Surveillance of HIV and Risk Behavior Among men who have sex with men (MSM)
No FY 2009 funds will be used for this activity because FY 2008 funds are sufficient to complete this
activity.
ACTIVITY 3: Surveillance of Discordant Couples and Assessment of HIV Prevention Strategies and Support
Needs
A portion of FY 2009 funds will be used to support this activity because the scope has increased. A
population-based survey will be conducted to identify HIV serodiscordant couples. In order to estimate the
prevalence of HIV discordance with a 4% margin of error, an estimated 7,200 households will need to be
visited in order to obtain 2,880 eligible couples. Preparation for this study (protocol development and
approval) and preliminary fieldwork will be done using FY 2008 funds. However the bulk of the household
survey activities and analysis and write-up of results will be done using FY 2009 funds.
ACTIVITY 6: Preparation for the 2011 national HIV household survey
This is a NEW activity that will start in FY 2009. FY 2009 funds will be used for preparatory activities for the
2011 national household HIV survey including:
1. Formative research using qualitative methods (e.g. focus group discussions) to collect in-depth
information on survey-relevant topics in preparation for the 2011 national household HIV survey;
2. Development and pre-testing of questionnaires and survey instruments in preparation for the 2011
national household HIV survey;
3. Recruitment and training of fieldworkers and survey staff in preparation for the 2011 national household
HIV survey;
4. Conducting studies to assess the feasibility of providing participants with HIV test results in the 2011
national household HIV survey, and to devise practical methods for providing participants in the 2011
survey with voluntary counseling and testing (VCT) under the field conditions and methods used in previous
national household HIV surveys. (The provision of VCT in the 2011 national household survey will be a
departure from previous national household HIV surveys where anonymous unlinked HIV testing (UAT) has
been used, in keeping with WHO and UNAIDS guidelines for HIV testing in population-based surveys.)
The methods used for preparatory activities for the 2011 national household HIV survey will be modeled on
those used in preparation for previous national household HIV surveys.
ACTIVITY 7: M&E capacity enhancement and M&E support for the national strategic plan (NSP)
Some of the core indicators specified in the NSP, required for effective M&E of the HIV epidemic in South
Africa, are not currently available from routine information sources. Measures will be taken to ensure that
information is obtained for all critical indicators required by the NSP.
The HSRC will use FY 2009 funds to provide ongoing technical support and training to enhance M&E
capacity within the South African National AIDS Council (SANAC). The HSRC will provide technical support
to the deputy-chairperson of SANAC, as well as research advice, scientific reviews, and expert input to
SANAC through the Research Sector. Training will be provided to HSRC/South Africa staff, SANAC staff,
and relevant government officials in the analysis and use of strategic information, and ongoing mentoring
will be provided.
ACTIVITY 8: Harmonization of HMIS
This is a NEW activity that will start in FY 2009. The HSRC will partner with Statistics South Africa
(StatsSA), the NDOH, and other relevant organizations, to ensure the availability and optimal use of data
obtained in previous national surveys. This activity will ensure that key national HIV data are properly
archived and are made available to a wide range of stakeholders. This will assist with the development of a
coordinated national M&E system and will support the dissemination of data.
-------------------------
The Human Sciences Research Council (HSRC) will use PEPFAR funding to support the South African
national population-based HIV prevalence and behavioral risk survey in 2008. Data will be used to enhance
Activity Narrative: national HIV and AIDS program indicators and to compare South Africa's HIV epidemic to the global
pandemic. FY 2008 COP activities are expanded to include surveillance activities among most-at-risk
populations (MARPs) including C (MSM), discordant couples, and refugees, as well as an evaluation of the
impact of the national antiretroviral treatment (ART) rollout.
The following section provides background for the listed activities.
1) The HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011 (NSP) assigns the HSRC the task of
conducting national HIV prevalence and behavioral surveys every two to five years. The results of the
previous two surveys have succeeded in drawing attention to gender inequalities in the HIV epidemic in
South Africa. Preparatory activities will take place in 2007 and the fieldwork will begin in early 2008. The
Nelson Mandela Foundation, the Nelson Mandela Children's Fund, the Swiss Agency for Development and
Cooperation, and the HSRC funded the surveys conducted in 2002 and 2005. The HSRC received support
from PEPFAR and the National Institute for Communicable Diseases to conduct HIV incidence testing on
dried blood spot samples (using the BED assay) in the 2005 survey. HIV incidence could be estimated for
the first time in a national population-based sample of the general population. HSRC plans to seek co-
funders for the 2008 survey.
HSRC is considering a couples sub-study as part of the 2008 national household survey to obtain an
estimate of the prevalence, patterns, and factors associated with discordant HIV serostatus among people
in established sexual partnerships. This sub-study is contingent on mobilizing adequate funding and human
resources, and devising a sampling strategy that does not compromise the main survey.
2) During the 1980s, the South African HIV epidemic was largely confined to MSM and people who had
received contaminated blood products. The epidemic became generalized in the early 1990s, and attention
shifted away from MSM. HIV prevention programs generally do not include messages or interventions
targeting MSM. The gap in knowledge about HIV in MSM and services for this group is a priority area in the
NSP.
3) Information on the number and characteristics of serodiscordant couples in South Africa, and the
strategies they use to prevent HIV transmission to the uninfected partner, is lacking. As people in long-term
partnerships tend to have unprotected sex, and the majority of people living with HIV (PLHIV) in South
Africa are unaware of their status, it is probable that a substantial portion of new HIV infections are acquired
from primary (as opposed to casual) sexual partners. The uninfected partners constitute an important but
neglected MARP, and current HIV prevention programs do not address the needs of discordant couples.
4) Refugees face many challenges in accessing HIV prevention treatment and care services. Specific
challenges include poverty, migration, a lack of social support, language barriers, xenophobia and
discrimination. Political and economic upheaval in several African countries has led to dramatic increase in
the number of refugees (both legal and illegal) in recent years. Although accurate statistics are unavailable,
it is believed that South Africa has one of the largest refugee populations.
5) South Africa currently has the largest number of people receiving ART, as well as the largest number of
people needing ART (but not currently receiving treatment). Since the national ART rollout in 2004, the
number of people receiving ART has expanded rapidly, but falls short of the goal, in part because resource
constraints have not been able to keep up with demand. Task shifting of treatment provision to less
specialized health workers (nurses instead of doctors), and making use of primary health-care centers
rather than hospitals have been used to try to meet the demand. One of the two key goals of the NSP is to
ensure that 80% of those needing ART have access to ART by 2011. To date a number of evaluations of
local programs and programs of specific providers (e.g. workplace programs provided by the Anglo group of
companies) have been conducted, but there has been no broad-based national evaluation of the national
ART program.
ACTIVITIES AND EXPECTED RESULTS:
HSRC will use PEPFAR funds to conduct the 2008 national population-based HIV prevalence survey in
South Africa. The survey will include children, youth, and adults of all ages. The survey will include children
under the age of two for the first time (UNICEF will partially fund this). A large portion of funding will be
devoted to HIV antibody testing and other related tests at an accredited national laboratory. Funds will also
be used to support the analysis and the publication of a report, scheduled for release on World AIDS Day.
Results will be analyzed by gender, thus providing information for increasing gender equity in HIV and AIDS
programs. In addition, HSRC will conduct a detailed risk assessment on a sample of youth, which will
provide information on male norms and behaviors. Following the publication of the report, additional
secondary analyses will be conducted including an assessment of trends using data from the 2002, 2005
and 2008 surveys. The 2008 survey will be the third survey to conduct population-based HIV surveillance
combined with behavioral surveillance on a national level and this will provide new knowledge and will
provide a benchmark for the M&E objectives of the NSP. In addition, qualitative methods (e.g. focus group
discussions) may be used to collect in-depth information on select topics to provide a better understanding
of the findings of the national household survey. Lastly, as part of the survey, HSV-2 behavioral questions
and biologic markers will be obtained for seroprevalence, behavioral and demographic data on HSV-2 and
HSV-2/HIV co-infection, allowing for the monitoring of trends, and for the development of the evidence base
for improving HIV prevention programs and local and national guidelines and policies.
ACTIVITY 2: Surveillance of HIV and Risk Behavior Among MSM
HSRC will conduct an assessment of the prevalence of HIV and risk behavior among MSM. This activity will
Activity Narrative: complement the surveillance information on the general population, and will provide strategic information
about MSM as identified in the NSP. This evaluation will be conducted in nine or ten large South African
cities. MSM aged 18 years and older will be recruited by means of respondent-driven sampling (RDS). RDS
is the best method of recruiting a representative (generalizable) sample of MSM because no sampling
frame exists, and other methods are more prone to sampling bias. As RDS is only suitable for use in urban
areas and no satisfactory method is known for recruiting MSM from rural areas, rural MSM will not be
included. Participants will be tested anonymously for HIV, provided with voluntary counseling and testing
and asked questions about sexual and other risk behavior using a structured questionnaire, based on the
one used to collect demographic and behavioral surveillance information on youth and adults in the national
household survey. Additional questions, specific to MSM will be added. Semi-structured interviews will be
conducted with MSM recruited through gay organizations, including HIV-infected MSM, and key informants
in order to assess the HIV prevention, treatment, care and support needs of MSM in South Africa. The
results of this activity will help meet the objectives of the NSP and will be used to develop recommendations
for addressing current program deficiencies and barriers to accessing services among MSM.
This project aims to estimate the number of PLHIV whose primary sexual partner is HIV-negative, and to
ascertain the demographic and social characteristics of discordant couples. HSRC will assess barriers and
facilitators to disclosure of HIV-serostatus to one's primary partner, and strategies that discordant couples
are using to prevent HIV transmission to the uninfected partner. A combination of qualitative and
quantitative methods will be used, and interviews will be conducted with couples, as well as individual
interviews with both HIV-infected and uninfected people. This activity will address an important gap in
strategic information, as outlined above. The results will be used to raise awareness of discordant couples
among the general population (including people who are unaware that they are in discordant partnerships)
and among policymakers, and will inform the development of prevention programs for discordant couples.
ACTIVITY 4: Assessment of HIV and Risk Behavior Among Refugees
A small exploratory study will assess the prevalence of HIV and risk behavior among a sample of registered
refugees. Refugees will be recruited using information from the United Nations High Commission for
Refugees (UNHCR) database. Methods of measuring HIV and risk behavior will be similar to those used in
the national household survey. This activity may be expanded to include a larger number of refugees and
illegal immigrants in subsequent years.
ACTIVITY 5: Assessment of the Impact of the National ART Roll-out
An evaluation will be conducted by means of a retrospective cohort study of a selection of patients from
government-accredited ART sites in all provinces. Information will be collected by means of individual
interviews with patients receiving ART, and patients who have discontinued ART, and by means of reviews
of medical records (including the records of persons who have died).
Continuing Activity: 13972
13972 3343.08 HHS/Centers for Human Science 6671 2813.08 HSRC $2,348,000
7313 3343.07 HHS/Centers for Human Science 4375 2813.07 HSRC $2,850,000
3343 3343.06 HHS/Centers for Human Science 2813 2813.06 HSRC $1,550,000
Estimated amount of funding that is planned for Human Capacity Development $292,000
Table 3.3.17:
