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: 2007 2008 2009
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
Medical Care Development International - South Africa (MCDI-SA) has modified ACTIVITY 1 in the
following way: All PMTCT training will be based on the new 2008 National Department of Health prevention
of mother-to-child (PMTCT) guidelines, including the protocols for dual therapy.
ACTIVITY 2 has been modified in the following way: Pre- and post-natal support through HIV-infected
mothers' support groups and Birth Companions programs will be continued as a child survival and safe
motherhood wraparound program funded by UNICEF. PEPFAR funds originally allocated for these activities
will be used to focus solely on facility-based support for improved PMTCT service delivery and referral. This
activity will include training and refresher training of nurses on (a) the new South African PMTCT guidelines,
including the dual therapy protocol; (b) routine offering of counseling and testing; (c) routine voluntary
referral to TB screening, family planning and ANC services; (d) correct data recording and reporting; (e)
effective patient communication; and (f) referral to available PMTCT support groups and Family
Companions. Training will be followed with one-on-one mentoring and an annual quality and service
assessment, including an annual client satisfaction survey and targeted one-on-one mentoring of facilities
with poor indicator results as determined by service assessment results. Two nurses will be hired to train
and mentor facility nurses on PMTCT, based on the current PMTCT protocol developed in consultation with
the KwaZulu-Natal Department of Health. These MCDI-SA staffers will also be responsible for regular
collection of PMTCT statistics from health facilities.
To increase health service uptake and community linkages, MCDI-SA will continue training and refresher
training of community health workers, home-based caregivers, traditional health practitioners and other
community leaders on community PMTCT. Training messages will include support for adherence to PMTCT
infant feeding choices, basics of dual therapy; the need for TB screening; anti-stigma advocacy;
involvement of men in care; and how to provide psychosocial support and promote adherence to treatment.
This will include a particular focus on training of traditional health practitioners in the rural and deep rural
areas, a previously neglected yet highly influential group of health workers, and will emphasize referral and
linkage of these practitioners with South African government health facility services and personnel.
In setting target numbers for training, MCDI-SA has expanded the definition of health worker from facility
nurses to include traditional health practitioners (THP). To date, 25 THPs have been trained. MCDI-SA will
therefore expand the 2009 target to 660, including 2 nurses in each of 30 facilities (60), 10 community
health facilitators, 400 community health workers, 50 THPs, and 120 home-based caregivers.
ADDITIONAL ACTIVITY: MCDI-SA will use PEPFAR funds to pilot Infant Feeding Corners (IFC) in five
health facilities. The primary purpose of the IFCs is to introduce the sipping cup as a method of formula
feeding that replaces the risks affiliated with bottle-feeding, and that is endorsed by the World Health
Organization and UNICEF. Staffed by trained Family Companions, IFCs will be offered as a service to all
pregnant women to provide thorough, individualized training and to assist pregnant women to make an
informed infant feeding choice that decreases and removes the risk of transmission and supports the health
of mother and child. PEPFAR funds will cover IFC materials and the transport needs of Corner staff.
(Family Companions will be given a regular stipend from UNICEF funds for their time staffing the IFC.)
ADDITIONAL ACTIVITY: MCDI-SA will purchase and pilot the use of the LifeStraw Family Instant
Microbiological Purifier (a low-cost household water purifying system approved for use in PEPFAR projects)
in households of PMTCT clients, piloting the effort with women who are participating in PMTCT support
groups co-facilitated by MCDI-SA (a wraparound program funded by UNICEF). The majority of households
in deep rural areas of Maphumulo, Mandeni and Ndwedwe sub-districts rely on often contaminated surface
water from local streams and rivers for their regular drinking water supply, leading to child and adult
diarrhea and other water-borne illnesses, especially among those who are immuno-suppressed. MCDI-SA
will select the households based on agreed-upon criteria with the Department of Health, train household
members on proper use and maintenance of the LifeStraw device, and provide follow-up supervision and
data collection to measure any implied effect on reducing diarrhea incidence among household members.
---------------------------------
SUMMARY:
Medical Care Development International - South Africa (MCDI-SA) is a US-based private voluntary
organization (PVO) that is registered as a Section 21 company (NGO) in South Africa. MCDI-SA has been
successfully implementing community public-health and social support projects in KwaZulu-Natal, South
Africa, since 1995. Prior to PEPFAR funding, projects have incorporated activities focusing on traditional
Child Survival (CS) interventions, reducing HIV and AIDS through prevention among youth and
adolescents, assisting with CT/PMTCT site establishment, strengthening the government healthcare
system's provision of services to and creating support groups for HIV-infected and TB-affected individuals,
and supporting other health-supportive community-based initiatives. MCDI-SA seeks to prevent mother-to-
child transmission (MTCT) through a comprehensive training and support program. Target populations
include men and women of reproductive age, pregnant women, and people living with HIV and AIDS, and
children under five. The major emphasis areas are all gender-related issues (addressing male norms and
behaviors, increasing gender equity in HIV and AIDS programs, increasing women's access to income and
productive resources, increasing women's legal rights, and reducing violence and coercion), Human
Capacity Development (in-service training and retention strategy), Local Organization Capacity Building,
and include Child Survival and Safe Motherhood Wraparound Programs.
BACKGROUND:
FY 2008 PEPFAR funding will be used to expand MCDI-SA's ongoing PMTCT initiatives in rural Ndwedwe
sub-district to the three remaining sub-districts of Ilembe District Municipality in KwaZulu-Natal province.
The MCDI-SA PMTCT program is part of the Ndwedwe Integrated TB and HIV and AIDS program
(NITHAP), funded by the USAID Child Survival Program, as well as Ilembe District Child Survival Project
Activity Narrative: and UNICEF. Proposed activities are consistent with the South African Government's mission of preventing
the spread of HIV. The main partner in this activity area is Ilembe District Department of Health. Other
partners include South African non-governmental organizations (NGO) such as The Valley Trust and
National Association of People Living With HIV and AIDS (NAPWA) as well as the Campus Law Clinic at
the University of KwaZulu-Natal (UKZN). Activities in this area will provide the means to empower women of
reproductive age in general to protect the health and well-being of their children and themselves and will
provide pregnant women and HIV-infected pregnant women and mothers expanded access to counseling
and testing (CT), PMTCT and antiretroviral (ARV) services.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Capacity Building
MCDI-SA will continue to improve the capacity of local government-supported and volunteer-community
health workers to provide quality CT, traditional VCT and PMTCT; services, and to educate the community
on the importance of CT and PMTCT. Community Health Workers (CHWs), home-based care volunteers
(HBCV), and other community influencers, such as traditional healers, religious and traditional leaders, will
ensure that HIV-infected pregnant women and mothers adhere to PMTCT treatment and feeding protocols,
i.e. taking nevirapine at the onset of labor, either on arrival at the health facility for delivery, or at home in a
community setting (assisted by a birth companion) and adhering to exclusive infant feeding practices until
appropriate weaning commences.
Training of health providers and community outreach workers will include the following: (1) Training of sub-
district trainers, Community Health Facilitators (CHF) and health facility personnel on PMTCT/VCT and
household and community integrated management of childhood illnesses (C/HH IMCI) by MCDI-SA and
The Valley Trust; (2) CHFs will provide training to CHWs, HBCVs, Traditional Birth Attendants (TBAs), and
Traditional Healers (THs) on C/HH-IMCI and Community PMTCT; (3) Households and communities as well
as traditional healers and community and religious leaders will be reached by community workers and
provided with information about Community and Household Integrated Management of Childhood Illnesses
(C/HH-IMCI) and PMTCT. All training activities are based on the South African Government (SAG) PMTCT
protocols. In addition, community workers will be provided with sound knowledge of C/HH-IMCI and
community PMTCT and will serve as community advocates for CT and PMTCT to pregnant women in the
area. Community awareness is a key to increasing access to PMTCT services and adherence to
government healthcare and treatment protocols.
Training formats will be either small workshops held over one or more days or one-on-one mentoring and
will be conducted by qualified nurses and/or South African Qualification Authority (SAQA)-accredited
trainers. Training quality assurance will be measured through pre- and post-training evaluations as well as
periodic follow up evaluations whenever feasible.
ACTIVITY 2: Pre- and Post-Natal Support Through HIV-infected Mothers Support Groups and Birth
Companion Programs
MCDI-SA will continue its current efforts in providing HIV-infected women with psychosocial and other
support as part of the PMTCT program. With FY 2008 funding, MCDI-SA will establish HIV-infected Mothers
Support Groups in collaboration with the local National Association of People living With AIDS (NAPWA)
affiliate. Locally recruited lay counselors trained by MCDI-SA and NAPWA will offer additional educational
and psychological support to mothers support groups, and legal support will be provided through a
partnership with the UKZN Campus Law Clinic. These support groups will: (1) guide new mothers on
appropriate feeding practices; (2) assist new mothers in developing income generation and public
awareness/anti-stigma projects; and (3) encourage information sharing on accessing and adhering to
antiretroviral treatment (ART), childhood illness prevention, detection and treatment, accessing social
grants, involving men in maternal and child care, and addressing and reducing domestic violence. HIV-
infected mothers' support groups will be used as linkages between communities and health facility
PMTCT/CT and ART services. Groups also will be mentored in how to register themselves as community-
based organization who can receive funding for their own organized activities. Furthermore, birth
companions will be identified and trained by MCDI-SA and NAPWA trainers to accompany pregnant women
in all stages of the antenatal and postnatal periods. They will foster best practices in antenatal care, child
bearing, and infant feeding and care, including ensuring that HIV-infected mothers adhere to PMTCT
protocols related to self-administration of nevirapine in the home, when delivery does not take place in a
facility. In addition, Birth Companions will promote referral to the two ARV service centers in Ilembe sub-
district. The Support Group Facilitators will work with the district Department of Health Community Health
Facilitators, traditional birth attendants (TBAs), HBCVs and CHWs to identify Birth Companions among the
community, family members or volunteers.
ACTIVITY 3: Facility PMTCT Service Quality Assessments
Using an assessment tool developed in conjunction with the Ilembe District DOH under the current TB-HIV
service integration project, MCDI-SA will conduct annual assessments of PMTCT services at the facility
level. This tool is similar in format to the District Rapid Assessment Tool (DRAT) that was developed to
evaluate TB services in the Eastern Cape for the Equity Project, which has been adapted and expanded for
use in Ndwedwe under our TB-HIV project, NITHAP. This tool, which provides a more in-depth
understanding of service provision than current DoH data vehicles are able to collect and present, has
proven to be effective for TB services, and will be adapted to address PMTCT service quality. Each
assessment will evaluate the quality of PMTCT service provision in terms of number, training and tenure of
personnel; adequacy of physical space, supplies and equipment; integration with ANC, VCT, and TB
services; consistency of recording and reporting; and other key service points in compliance with NDOH
PMTCT guidelines. Results and recommendations will be discussed on-site with the service providers as
well as compiled and presented to the Ilembe District Health Management Team. DOH PMTCT program
managers will be trained on use of the tool and provided with electronic copies of the tool for their ongoing
Activity Narrative: use.
This project contributes to PEPFAR 2-7-10 goals by improving uptake and access of PMTCT services at
public health facilities, facilitating the linkages between PMTCT and ART services, and providing
psychosocial support to HIV-infected pregnant women and mothers, ensuring better adherence to PMTCT
protocols and reducing the number of new infant infections.
New/Continuing Activity: Continuing Activity
Continuing Activity: 14015
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
14015 7903.08 U.S. Agency for Medical Care 6685 4624.08 $224,000
International Development
Development International
7903 7903.07 U.S. Agency for Medical Care 4624 4624.07 NEW APS 2006 $200,000
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Child Survival Activities
* Family Planning
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $3,500
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $1,200
and Service Delivery
Food and Nutrition: Commodities
Economic Strengthening
Education
Water
Estimated amount of funding that is planned for Water $5,000
Table 3.3.01:
In response to OGAC's review of the PEPFAR South Africa FY 2009 Country Operational Plan, the
Prevention Steering Committee directed the country team to reprogram 20-30% of the PEPFAR South
Africa sexual prevention portfolio
organization that is registered as a Section 21 company (NGO) in South Africa. MCDI-SA has been
successfully implementing community public health and social support projects in KwaZulu-Natal, South
Africa, since 1995.
MCDI-SA will expand their PEPFAR funded programs to include abstinence and being faithful (AB) among
youth. All MCDI-SA activities are based on the goals, guiding principles and strategies developed and
published in the HIV & AIDS and STI National Strategic Plan, 2007-2011, and are in ongoing collaboration
with the Ilembe District Department of Health and KwaZulu-Natal Department of Health. A major emphasis
of the activities under this project area for in- and out-of school youth will be messaging on the importance
of gender equality as well as prevention of teenage pregnancy to encourage confidence and self-
determination among girls and increased understanding among boys of the respect that all women and men
deserve equally. This is especially critical in the context of the prevailing traditional Zulu cultural influence in
the rural areas that support males as the dominant gender in all social contexts.
ACTIVITY 1: Expansion of Youth HIV and AIDS Education and Advocacy through High School Health
Groups and Out-of-School Youth Clubs
MCDI will expand its previously successful program of participatory youth education on HIV and AIDS and
abstinence, sexually transmitted infections (STIs), and teenage pregnancy prevention to 10 iLembe District
high schools through its partnership with Royal Falcon Education Initiative, a South African non-
governmental organization. This organization uses dramatic methods including acting and role-playing,
which are very appealing to youth, to increase knowledge and awareness of HIV and AIDS while building
the skills and confidence necessary for the practice of safe sexual behaviors, specifically abstinence and
faithfulness, to prevent new infections and reduce stigma and discrimination. Due to MCDI's previous
success in two Ndwedwe sub-district high schools, it has been able to secure support from the iLembe
District Department of Education for this activity, as well as commitment from school principals. Special
efforts will be made to involve 10-14 years to instill abstinence messages.
In order to reach out-of-school youths, the established school-based health groups will be supported to
establish out-of-school youth clubs within their local community. The clubs are encouraged to call bimonthly
meetings to deliver education on HIV and AIDS, STI and teenage pregnancy prevention, specifically
through AB and through dramatic methods. These out-of-school youth clubs will be significantly more
successful at identifying and encouraging the participation of out-of-school youth than efforts from outside
the community. The school-based health groups will deliver the same education messages through
dramatic methods delivered in schools. Initiating clubs in this manner assures easy scalability into any
number of other districts and provinces. These clubs will then be linked with the prevention of mother-to-
child HIV transmission and voluntary counseling and testing support groups that have already been
established by MCDI. The clubs will interact for mutual benefit, including participatory education and
available venues for meetings.
In the first year, MCDI-SA will target eight schools with an estimated 1,000 students each for a total of
8,000.
This activity will be preceded by a standardized Knowledge, Attitude and Practice (KAP) study that will be
repeated annually. The frequency and content of messages will be established by Royal Falcon and will be
reflected in their work plan.
ACTIVITY 2: Behavior Change through Educating Community Role Models
MCDI will reinforce youth behavior change and communication, specifically through AB, delivered through
the school-based health groups and out-of-school youth clubs by training influential community members
who are central to community spheres of influence. Having influential community members trained to deliver
HIV-related education will also combat HIV-related stigma and discrimination within communities. The need
for this is particularly substantial in iLembe District where HIV-related stigma and discrimination are
widespread.
ACTIVITY 3: Radio Messages to Promote Abstinence and Faithfulness
Previous community surveys done by MCDI have shown that about a third of the general population rely on
radio messages for health information. Using community radio stations in iLembe District and eThekwini, as
well as Ukhozi Radio, a mainstream radio station with the highest listenership in southern KwaZulu-Natal,
MCDI will develop and produce a series of Zulu-language radio messages communicating AB messages
targeted to youth as well as to the general population. These messages will be based on the Youth
Enrichment Program training manual developed by Royal Falcon.
Continuing Activity: 21164
21164 21164.08 U.S. Agency for Medical Care 6685 4624.08 $250,000
* Reducing violence and coercion
Estimated amount of funding that is planned for Human Capacity Development $5,500
Table 3.3.02:
MCDI-SA will expand their PEPFAR funded programs to other sexual prevention activities. All MCDI-SA
activities are based on the goals, guiding principles and strategies developed and published in the HIV &
AIDS and STI National Strategic Plan, 2007-2011, and are in ongoing collaboration with the Ilembe District
Department of Health and KwaZulu-Natal Department of Health.
ACTIVITY 1: HIV Positive Youth Support Groups
To support youths receiving a positive HIV test result, the current PEPFAR-funded project will establish nine
HIV Positive Youth Support Groups, three in the Ndwedwe, Maphumulo, and Mandeni sub-districts. The
groups will be community rather than clinic-based, an approach found to be successful with Medical Care
Development International (MCDI)-established and UNICEF-funded prevention of mother-to-child
transmission (PMTCT) and voluntary counseling and testing (VCT) support groups in these areas. Each HIV
Positive Youth Support Group will include an HIV-infected facilitator trained to educate on prevention
behaviors, focusing on the abstinence/be faithful (ABC) approach, as well as 'Positive Living' and other
relevant HIV-related skills and information necessary for maintaining health, nutrition, and overall well-
being.
ACTIVITY 2: Mobile HIV/AIDS Education Unit
Because iLembe District comprises widely dispersed households and community clusters, MCDI will
organize a mobile education unit to reach poorer, more remote areas that are underserved. The mobile unit
will travel between traditional authorities to educate youths and their communities. This will raise knowledge
and awareness on HIV/AIDS/STIs and TB (HAST), the location of VCT facilities, stigma, discrimination and
sexual abuse. It will use low-cost movies locally produced by Art for Development as a platform for a
participatory method of action and reflection. Information, education and communication (IEC) materials
with information on abstinence, faithfulness, correct and consistent use of condoms, promotion of VCT,
adherence to antiretroviral (ARV) and tuberculosis (TB) treatment, as well as anti-stigma, anti-discrimination
and anti-violence messages, will be developed, distributed and discussed in the local language, Zulu. The
Mobile Education Unit will provide up to 90 annual visits within three sub-districts aiming to increase
knowledge on safe sexual behavior, the importance of ARV and TB drug adherence, and increase voluntary
counseling and testing (VCT) uptake among the traditionally underserved.
ACTIVITY 3: Radio Messages to Promote Correct Condom Use
Previous community surveys done by MCDI have discovered that about a third of the general population
relies on radio messages for health information. Using community radio stations in iLembe District and
eThekwini, as well as Ukhozi Radio, a mainstream radio station with the highest listenership in southern
KwaZulu Natal, MCDI will develop and produce a series of Zulu-language radio messages communicating
prevention messages, including correct use of condoms, targeted to the general population.
ACTIVITY 4: Support Groups for Parents
Working through groups of local religious leaders, MCDI will facilitate the establishment of parents groups,
in which parents can discuss and support each other in talking about sex and prevention of HIV and
sexually transmitted infections (STIs) with their children. In local culture, it is considered taboo for parents to
discuss anything of a sexual nature with children. Working with a trained MCDI facilitator and MCDI-trained
religious leaders, this will provide concerned parents with an outlet to air their concerns about the spread of
HIV and AIDS and to practice ways to discuss safe sexual behaviors effectively with their children.
ACTIVITY 5: Training of School Nurses
For additional support to youths, MCDI will provide training and support to all 19 school nurses in iLembe
District to include HIV/AIDS, other STI and teenage prevention education in their everyday work. In biannual
workshops, nurses will be trained in behavior change and communication methods. Training school nurses
allows the school system to serve as a sustainable source for youth prevention education and referral to
treatment and care services.
Continuing Activity: 21163
21163 21163.08 U.S. Agency for Medical Care 6685 4624.08 $250,000
Estimated amount of funding that is planned for Human Capacity Development $4,500
Estimated amount of funding that is planned for Economic Strengthening $1,200
Table 3.3.03:
Revision to Activity 1: At the beginning of 2008, the iLembe District Department of Health endorsed Medical
Care Development South Africa (MCDI-SA) as the primary referral organization to provide technical and
other organizational support to the community-based organizations (CBOs) funded by the department to
give stipends to and supervise home-based carers (HBCs) to promote the delivery of quality, holistic, family-
centered care, including clinical/physical care, psychological care, spiritual care, social care, integrated
prevention services and referrals including family-planning counseling and referral, according to South
African Government (SAG) guidelines on home-based care (HBC). MCDI-SA now works directly with these
organizations and their carers to train, mentor and otherwise support their ongoing work. MCDI-SA has
taken as its mandate the support of the current SAG-provided stipend system for home-based carers to
ensure its success and sustainability in iLembe District by providing technical support and guidance. MCDI-
SA holds monthly meetings with CBO leadership to discuss training needs, share technical information, field
questions on quality care, and assist with data collection and reporting to the Department of Health. In
addition, MCDI-SA has set a series of technical training workshops for CBOs and their carers, focusing on
provision of palliative care to clients and family members, with particular emphasis on the Basic Care
Package; TB-HIV integration (cross-testing, co-treatment protocols); TB signs and symptoms; TB and ART
treatment adherence and directly observed treatment (DOT) support; prevention of mother-to-child
transmission and the new dual therapy; HIV and AIDS counseling; healthy lifestyles; positive prevention for
TB and HIV-infected people, and more.
Additional activity: MCDI-SA will supplement HBC kit supplies as the Department of Health has had budget
cuts and is unable to provide adequate supplies of kit items.
Additional activity: Due to rising food and fuel costs, many households in the project area have become
food insecure, which is exacerbated when HIV-infected household members become ill and are unable to
work or a caregiver must stay home to look after a sick child. MCDI-SA will pilot a community garden
project, managed by a local resident, to grow, maintain and distribute parcels of fresh vegetables to HIV-
and AIDS-affected households serviced by HBCs.
Additional activity: MCDI-SA is undertaking a community mapping exercise, beginning in Maphumulo sub-
district, to identify and map using GIS technology all community-based resources available to people living
with HIV in those communities, from health care facilities to food schemes to support groups. This activity is
in support of the Local AIDS Councils and will produce a map of resources to be posted at health facilities,
traditional courts, and at other high-visibility public locations throughout the area.
-----------------------
Medical Care Development South Africa (MCDI-SA) will carry out activities to support expansion of holistic,
comprehensive community HIV and AIDS and TB care and support from Ndwedwe sub-district to the other
sub-districts of Ilembe District in KwaZulu-Natal province. FY 2007 and FY 2008 PEPFAR funding will be
used to expand the primary activities of training, support and supervision of home-based care volunteers
(HBCVs) and Directly Observed Treatment, Short-course (DOTS) providers, as well as the introduction of
software to monitor home-based patient care. This will help to improve quality of care and treatment
adherence for those on TB medication and/or ART; facilitate linkages between HIV and AIDS and TB-
related community-based projects with the local health facilities; and build capacity among relevant
community-based organizations (CBOs).
The emphasis areas include human capacity development (Pre- and In-service training, Retention strategy),
local organization capacity building, and are extended through Child Survival and Safe Motherhood
Wraparound Programs. The target populations are children, adolescents and adults, discordant couples,
pregnant women, people living with HIV and AIDS, and orphans and vulnerable children.
MCDI-SA is a US-based private voluntary organization (PVO) that is registered as a Section 21 company
(NGO) in South Africa. MCDI-SA has been successfully implementing community public health and social
support projects in KwaZulu-Natal, South Africa, since 1995. Prior to PEPFAR funding, projects have
incorporated activities focusing on traditional Child Survival (CS) interventions, reducing HIV and AIDS
through prevention among youth and adolescents, assisting with CT/PMTCT site establishment,
strengthening the government healthcare system's provision of services to and creating support groups for
HIV-infected and TB-affected individuals, and supporting other health-supportive community-based
initiatives.
The activities proposed are expansions of those previously implemented by MCDI-SA in Ndwedwe sub-
district and are in line with the PEPFAR and SAG objective of providing quality palliative care for HIV-
infected and -affected individuals. The key program partner is the South African National Department of
Health (NDOH), whose current policies on HIV and TB care and gender equity inform all project objectives,
and whose representatives are actively engaged in the design and implementation of activities to promote
consistency and long-term sustainability. The NDOH has agreed to provide staff and financial support for
project activities, as needed. Other project partners include The Valley Trust, the National Association of
People With AIDS (NAPWA), and Strengthening Pharmaceutical Systems (SPS).
ACTIVITES AND EXPECTED RESULTS:
ACTIVITY 1: Training, Support and Supervision of HBCVs
Due to the large distances between households and health facilities throughout the Ilembe District, HBCVs
Activity Narrative: are a crucial part of a comprehensive system of care for people living with HIV and AIDS (PLHIV) and
people living with TB (PLWTB) and play a significant role in their day-to-day treatment. As part of its
ongoing USAID-funded Child Survival Project and the ongoing Ndwedwe Integrated HIV/AIDS Tuberculosis
Project, MCDI-SA will broaden its existing integrated home-based care (HBC) program in Ndwedwe sub-
district to the three other sub-districts of the Ilembe District: Maphumulo, Mandeni and KwaDukuza.
PEPFAR funds will be used to train new HBCVs in comprehensive home-based care skills during a three-
week course on providing quality care for community members, including elements of the preventive care
package, pain and symptom management and other palliative care services for PLHIV and PLWTB.
Trainers from The Valley Trust will assist with this activity. Supervisory training and checklists will be
provided, also in collaboration with The Valley Trust. Ilembe District community health facilitators (CHFs),
who are responsible for overseeing HBCV activities in the District, and previously trained HBCV will be
provided with refresher training in comprehensive home-based care skills for patients and their families.
Distinctions between the needs of adults and children will be emphasized, as well as gender-specific issues
such as integrating males into household care practices; increasing male knowledge of effective HIV
prevention measures; increasing women's and girls' use of healthcare services; and recognizing and
addressing domestic abuse against women and girls. Monthly meetings will be held between HBCVs and
facility staff members to promote consistent quality care. Trained HBCVs will also become eligible for
registration with the NDOH and to receive a government stipend for their work. Community-based
organizations (CBOs) will be identified and supported to serve as supervisors of HBCVs. CBOs will also
distribute HBCV supply kits, provide care for caregivers, assist with training, and arrange for HBCVs to
receive recognition for their work at community gatherings. MCDI-SA will provide participating HBCVs with
regular incentives, such as cell phone airtime, so that they will have the means to remain in contact with the
supervising CBOs, clients and health facilities. Supervised by MCDI-SA, the CBOs will work in collaboration
with CHFs to monitor and maintain the quality of services provided.
ACTIVITY 2: Introduction of Software to Monitor HBC Visits
Once HBCVs are trained, supported and supervised, and strong linkages are established with facility staff, it
will be important to monitor HBCVs activities. Consequently, the introduction of software to monitor HBC
visits is proposed. The Outreach Home-Based Care Database Software Program will be installed on DOH
computers to tracks HBC monthly visit rates, activities during visits, client conditions, and the number of
OVC in target communities. The system includes paper forms that are filled out by HBCV and their CBO
supervisors, and the data is then captured and analyzed at the District level. As part of its collaboration with
MCDI-SA, the RPM Plus project has agreed to collaborate with MCDI-SA to help institute this system as a
pilot test of the concept. MCDI-SA will collect and analyze the data initially and will train Ilembe District
health information officers to continue using the system to monitor the performance of its ongoing HBC
program with potential scale-up to the KwaZulu-Natal provincial level. This system will strengthen the
capacity of the District Health Office in monitoring health events at the community level and provide data to
show the breakdown by gender of those receiving care services. The data also will be used to monitor the
project's HBCV activities and inform project management decisions. The ultimate focus of this tool is to
provide feedback to service providers with a focus on quality improvement.
These results contribute to the PEPFAR 2-7-10 goals by improving access to and quality of care and
support for PLHIV and their families.
Continuing Activity: 14016
14016 7904.08 U.S. Agency for Medical Care 6685 4624.08 $224,000
7904 7904.07 U.S. Agency for Medical Care 4624 4624.07 NEW APS 2006 $200,000
* Increasing women's access to income and productive resources
Estimated amount of funding that is planned for Human Capacity Development $4,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $5,000
Table 3.3.08:
Medical Care Development South Africa (MCDI-SA) will carry out OVC activities to support expansion of
holistic, comprehensive community HIV and AIDS and TB care and support from Ndwedwe sub-district to
the other sub-districts of Ilembe District in KwaZulu-Natal province. FY 2007 and FY 2008 PEPFAR funding
will be used to expand the primary activities of training, support and supervision of home-based care
volunteers (HBCVs) and Directly Observed Treatment, Short-course (DOTS) providers, as well as the
introduction of software to monitor home-based patient care. This will help to improve quality of care and
treatment adherence for those on TB medication and/or ART; facilitate linkages between HIV and AIDS and
TB-related community-based projects with the local health facilities; and build capacity among relevant
Wraparound Programs.
incorporated activities focusing on traditional Child Survival (CS) interventions, reducing HIV/AIDS through
prevention among youth and adolescents, assisting with CT/PMTCT site establishment, strengthening the
government healthcare system's provision of services to and creating support groups for HIV-infected and
TB-affected individuals, and supporting other health-supportive community-based initiatives.
The proposed OVC activities are part of the new and expanded activities from the previously implemented
by MCDI-SA in Ndwedwe sub-district and are in line with the PEPFAR and SAG objective of providing
quality care and support programs for children affected, orphaned and left in vulnerable situations. The key
program partner is the South African National Department of Social Development (DOSD), whose current
policies on HIV and TB care and gender equity inform all project objectives, and whose representatives are
actively engaged in the design and implementation of activities to promote consistency and long-term
sustainability. The DOSD has agreed to provide staff and financial support for project activities, as needed.
ACTIVITY 1: Expand Model Creche Framework
Based on the success of the Mavela Model Creche previously established by MCDI-SA in the Ndwedwe
Sub-district of iLembe District, which has been functioning with very minimal support from MCDI funding for
more than two years, MCDI-SA will use PEPFAR funds to expand this integrated approach to improve
health, education and psychosocial well-being with input from the DOSD to four already identified creches
(or day care centers) in iLembe District over a 2-year period. For the FY 2009 COP, MCDI will expand this
activity to 2 creches in Maphumulo and Mandeni sub-districts. Working within this existing local capacity
reduces initial investment and accelerates service delivery. To assure high quality and sustainable creches
beyond the life of the project, minor improvements will be made to facilities, including minor upgrading of
infrastructure and the planting of vegetable gardens as a food supply and an income-generating activity.
Additionally, the model includes training creche teachers and principals to identify danger signs of need for
urgent care per Community and Household Integrated Management of Childhood Illnesses (C/HH IMCI)
guidelines, encourage parents to seek timely and appropriate care for their children, and use a health
monitoring tool called the "Road to Health" card, which monitors growth and immunization status and
ensures that any treatment regimens are adhered to. Support for good nutritional status will be provided
through a balanced, calorie-dense lunch for each child using funds provided by the DOSD.
In addition, LifeStraw drinking water purifier units will be installed and creche staff trained on their use and
maintenance. The majority of households in rural areas rely at least partially on local streams and rivers for
drinking water, which are also used for sewage and other purposes that render them rich with disease-
causing pathogens. Diarrhea remains one of the leading causes of illness and death among young children
in iLembe, especially those who are HIV-infected.
As an additional public-private alliance, MCDI will partner with Vestergaard Fransden, manufacturer of the
innovative and inexpensive LifeStraw units, to place units in model creches and make additional LifeStraw
units available to households of OVC as a means of reducing incidence of diarrhea and other life-
threatening water-borne diseases. Creche staff will be trained on use and maintenance of the LifeStraw
units so they in turn can train household caregivers. For the sustainability of the project, our strategy is to
link the OVC sites with community, government, private and faith-based resources. MCDI-SA will also
advocate with the Department of Health to purchase LifeStraw units for free or low-cost distribution to need-
identified households.
ACTIVITY 2: Educational and Social Support for OVC
MCDI will partner with Training and Resources in Early Education (TREE) to provide children in model
creche communities with educational and social supports through an established relationship with the
network of Early Childhood Education (ECD) sites. Originally established by the KZN Department of
Education, ECD sites are designed to support the needs of children in poverty and are currently active in
most communities. Functioning ECD sites can become important resources for OVC and their caretakers by
offering improved educational opportunities, an emotionally safe environment, and information and support
for caretakers to access basic social services such as accessing social grant, and referrals to PMTCT and
treatment sites as necessary.
ACTIVITY 3: Psychosocial Support for Caretakers and OVC
Activity Narrative: MCDI-SA will facilitate psychosocial support to OVC and their caretakers in collaboration with two
partnership organizations using a variety of activities. While there are several programs addressing the
material needs of OVC, there is less availability of psychosocial support services to help children cope with
the trauma associated with the progressive deterioration and deaths of parents and other household
members. The impact of this trauma begins even before children become orphans because of AIDS. MCDI-
SA will partner with the KZN Interfaith Forum (eKhaya Project) and the Department of Psychology of
University of KZN to provide support services to OVC and their caretakers under the direction of an MCDI-
SA Social Worker and Social Work Assistant. Methods found to be successful include art, play, music
therapy, narrative theatre, spiritual and psychosocial support groups, and individual counseling. The eKhaya
Project provides age-appropriate support services to all household members. Successful activities have
included after school groups and weekend activities for older siblings, including those who head child-
headed households. MCDI will build on the experience of collaborating with the eKhaya Project on other
projects to provide increased psychosocial support. Including caretakers in support activities helps ensure
that vulnerable children maintain good mental health and are brought up in an emotionally safe home.
ACTIVITY 4: Legal Support for OVC and their Caretakers through Legal Desks
MCDI-SA will provide legal support to OVC and their caretakers, which will have a significant impact on their
current and future economic well-being. Protecting and promoting the inheritance rights of OVC and fighting
against disinheritance is crucial to comprehensive care and support of these children. MCDI-SA will partner
with the Campus Law Clinic at the University of KwaZulu-Natal to provide legal/paralegal services for OVC
and their caretakers to protect the legal rights of OVC. The most critical issues include property grabbing,
inheritance rights, government social grants and the preparation of wills. Two types of activities are needed.
Orphaned children and their caretakers will be assisted to access educational and government childcare
grants. HIV-infected parents will be assisted in making end of life plans to ensure that the child is cared in
the event of their death, including instructions for legal guardianship or adoption. Parents and other
caregivers will also be assisted in creating a file for their child consisting of essential legal documents and
including birth certificates, instructions for acquiring death certificates, an appointed guardian, a will, and
information on property and asset transfer.
Moreover, parents and caregivers will be advised on their legal rights to combat employment discrimination
and the available adjudication channels should their rights be violated. Legal desks will be established in the
Municipal Office or Traditional Courts in each sub-district, which are already being provided some legal
support related to other legal aspects of HIV/AIDS.
Continuing Activity: 21165
21165 21165.08 U.S. Agency for Medical Care 6685 4624.08 $250,000
Construction/Renovation
Estimated amount of funding that is planned for Human Capacity Development $1,500
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $4,000
Table 3.3.13:
Revision to Activity 1: Training will include special emphasis on counseling and communicating with males
to get tested for HIV.
Revision to Activity 2: Male-only support groups will be established in addition to mixed-gender groups to
encourage men and teenage boys to get tested for HIV and follow through with treatment, healthy lifestyle,
and to become advocates in the community for other males to do the same.
Revision to Activity 4: Due to the positive response and demand for their services, 8-10 additional facility-
patient liaisons will be identified, trained and placed in health facilities in iLembe District. Liaisons will be
trained to expand their role to provide HIV/AIDS counseling in homes and assist with disclosure to family
members.
Additional activity: Because of the relatively low rate of voluntary counseling and testing uptake among
males, Medical Care Development International (MCDI) will sponsor a series of male-oriented community
events to raise awareness of the importance of testing and the potential for living a positive life as a person
living with HIV/AIDS. Events will be organized in conjunction with local male leaders, the Department of
Health, local male traditional health practitioners, and other influential community members and
organizations that are focused on positive health actions among community males. The program will focus
on the facts of HIV transmission, encouraging responsible sexual behavior and respect for women's well-
being, reduction of sexual violence and coercion, and male participation in raising and caring for children.
------------------------
Medical Care Development International - South Africa (MCDI-SA) is a U.S.-based private voluntary
organization (PVO) that is registered as a Section 21 company or non-governmental organization (NGO) in
South Africa. MCDI-SA has been successfully implementing community public health and social support
projects in KwaZulu Natal, South Africa, since 1995. Prior to PEPFAR support, projects focused on
traditional Child Survival (CS) interventions, reducing HIV through prevention among youth and
adolescents, assisting with counseling and testing (CT) and prevention of mother-to-child transmission
(PMTCT) site establishment, strengthening the government healthcare system's provision of services to and
creating support groups for HIV-infected and TB-affected individuals, and supporting other health-related
community-based initiatives.
Building on its USAID child survival program, MCDI-SA will use PEPFAR funding to carry out activities to
support the KwaZulu-Natal Department of Health's (KZNDOH) efforts to improve and increase use of the CT
services. These activities consist of three components: (a) training local health workers to provide
comprehensive counseling and testing services; (b) strengthening the capacity of HIV support groups for
networking with CT centers and communities for the reduction of stigma and discrimination; and (c)
incorporating community-based, youth-focused, home-based care, outreach and other approaches to
promote CT uptake. Target populations children under 5 years, children aged 5-9, adolescents aged 15-24,
and adults 25 and over, people living with HIV (PLHIV), and orphans and vulnerable children. The major
emphasis areas include gender-related issues (addressing male norms and behaviors, increasing gender
equity in HIV and AIDS programs, increasing women's access to income and productive resources,
increasing women's legal rights, and reducing violence and coercion), human capacity development
(training and retention strategy), local organization capacity building, and child survival and safe
motherhood wraparound programs.
This project will expand on and strengthen activities that MCDI-SA has been working on in KwaZulu-Natal
(KZN) for the last 10 years through funding from USAID's Health and Child Survival Grants Program. CT
will be promoted by (1) training health workers and lay counselors to provide pre-test counseling and CT
services for youth and adults in HIV and STI prevention; (2) promoting CT through community outreach,
education and advocacy; (3) strengthening the capacity of HIV support groups to become eligible for
registration as cooperatives; (4) training HIV support groups to promote HIV counseling and testing in CT
and PMTCT sites and in communities with an emphasis on reducing stigma and discrimination; and (5)
establishing youth clubs for girls and boys in-school and out-of-school for promotion of CT. Partners include
the KZNDOH, The Valley Trust (TVT), the National Association of People Living with HIV and AIDS
(NAPWA) and Community Health Committees (CHC).
ACTIVITY 1: Training Healthcare Workers
MCDI-SA will continue to improve the capacity of local health workers to provide quality CT services and to
educate the community on the importance of CT in preventing HIV transmission and as an entry point for
treatment and care. A core team of sub-district trainers will be trained on CT, home-based-care, anti-
retroviral (ARV) and TB treatment adherence. In turn, they will train facility nurses on National Department
of Health (NDOH) CT and TB/HIV protocols, so that each primary healthcare facility will have at least two
nurses trained on current NDOH CT and TB-HIV protocols. This activity will also include training on provider
-initiated testing and counseling (PITC).
ACTIVITY 2: Establishing and Strengthening Support Groups
MCDI-SA has demonstrated that the provision of easy access to HIV and AIDS support groups is one key
way of combating stigma and discrimination in health facilities and in communities. Existing support groups
Activity Narrative: in Ndwedwe sub-district will be strengthened to become eligible for registration as cooperatives. Sub-
districts will work closely with other organizations in a self-sustainable and self-sufficient entity. MCDI-SA
will also identify viable CT and PMTCT sites in other sub-districts of Ilembe District to establish additional
HIV and AIDS support groups, with the goal of strengthening their capacity to become sustainable
registered cooperatives. Support groups members will receive training and education on counseling and
advocacy.
ACTIVITY 3: Information, Education and Communication
A mobile education unit, staffed by two trained HIV-infected individuals from NAPWA's support groups, will
travel to tribal authorities to conduct information and education campaigns at, and in close proximity to, CT
sites. This will assist to (1) raise knowledge and awareness about CT services for HIV, STIs and TB
patients; and (2) explain how stigma, discrimination and sexual abuse are undermining the health and well-
being of their families, friends and neighbors. MCDI-SA will enlist and train members from community
church groups, traditional healers, and traditional leaders to participate in these information, education and
communication campaigns. Based on successful workshops conducted in Ndwedwe sub-district as part of a
previous project, MCDI-SA will hold additional workshops for influential community members to educate
them on CT services and the harmful effects of stigma and discrimination. Support group members will be
included in the training to discuss their own experiences with stigma and discrimination and the benefits of
using CT services.
ACTIVITY 4: HBC Facility Patient Liaison
Qualified home-based caregivers (HBCs) will be trained by MCDI-SA and placed in each of the seven
government hospitals and community health centers in the district to act as a liaison between CT, TB and
ARV patients and to educate and counsel TB/HIV clients and suspects in cross-testing, treatment literacy
and family directly observed treatment (DOT) support. The liaisons will increase the quality of services
provided to patients while facilitating provision of education and counseling services in facilities with high
patient headcounts and inadequate staffing.
ACTIVITY 5: Facility CT Service Quality Assessments
Using an assessment tool developed in conjunction with the Ilembe District Department of Health under the
current TB/HIV service integration project, MCDI-SA will conduct annual assessments of CT services at the
facility level. Each assessment will evaluate the quality of service provision in terms of number, training and
tenure of personnel; adequacy of physical space, supplies and equipment; integration with antenatal care,
PMTCT, and TB services; consistency of recording and reporting; and other key service points in
compliance with NDOH CT guidelines. Results and recommendations will be discussed on site with the
service providers and will be compiled and presented to the Ilembe District Health Management Team.
Department of Health CT program managers will be trained to use the assessment tool and will be provided
with electronic copies of the tool for their ongoing use.
These activities contribute to the PEPFAR 2-7-10 goals by improving access to, and quality of counseling
and testing services in order to identify HIV-infected persons and to increase the number of persons
receiving antiretroviral services.
Continuing Activity: 14017
14017 7905.08 U.S. Agency for Medical Care 6685 4624.08 $224,000
7905 7905.07 U.S. Agency for Medical Care 4624 4624.07 NEW APS 2006 $200,000
* Safe Motherhood
Estimated amount of funding that is planned for Human Capacity Development $2,000
Estimated amount of funding that is planned for Economic Strengthening $10,000
Table 3.3.14:
