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:
McCord Hospital Zoe-Life (ZL) and McCord Hospital (MH), in FY 2008, aimed to introduce a second test for
women who test negative at 36 weeks. This will be modified according to current KwaZuluNatal Department
of Health (DOH) guideline of repeat testing at 34 weeks.
ZL/MH will focus on pharmacy systems development to support initiating eligible pregnant women on
antiretroviral treatment (ART) at the clinic sites. This is currently not possible due to legislation and
municipal policy, which prohibit initiation of ART at clinics. In addition, the municipality pharmacy does not
receive drugs from the DOH's Provincial Medical Supply Centre (PMSC). Assisting the Municipality and the
DOH to develop a linked pharmacy system to procure ARV drugs from PMSC for the municipality pharmacy
and clinics will be a sustainability priority in COP 2009.
Strengthening follow-up of children will include ongoing support to mothers on infant feeding; careful infant
diagnosis processes which will begin at 6 weeks (PCR) and end at cessation of breastfeeding at 12-15
months; cotrimoxazole provision to HIV-exposed children from 6 weeks; TB screening of infants in follow-
up; and integration of child survival interventions linked to integrated management of childhood illness
(IMCI) including immunization and vitamin A provision.
NEW ACTIVITY: Linkages with community health workers to assist with tracking of pregnant women,
mother-child pairs, and implementation of community integrated management of childhood illness (CIMCI)
will be prioritized. Additional funding will be sought to implement a CIMCI & IMCI electronic data tool using a
personal digital assistant (PDA). This will simplify use in the community clinics, strengthen M&E, and
tracking mother-child pairs. Clinics do not use the IMCI system due to lack of relevant paper forms, but a
PDA will overcome this challenge, and it can be used for other program areas. A PDA electronic device can
be used as a clinical tool to guide diagnosis and treatment, and as an M&E tool in an integrated setting,
minimizing the need for many paper forms for many program areas.
MODIFIED ACTIVITY: Strengthening M&E will include developing a patient-linked health management
information system (HMIS) for mother-child pairs. This will assist with tracking and retention of mother-child
pairs, and strengthen the integration of the pairs into care and treatment programs. If the IMCI PDA system
works well, this may be expanded to the PMTCT services.
NEW ACTIVITIES:
1. ZL/MH will explore strengthening PMTCT in the private sector. Most private facilities do not offer a strong
PMTCT component and often do not follow best practices, even though clients often have the financial
resources. By offering technical support, resources, and training to obstetricians and midwives at a private
hospital in Durban, ZL/MH seeks to ensure that private sector PMTCT services are aligned with the HIV &
AIDS and STI Strategic Plan for South Africa, 2007-2011 (NSP), use best practices, and offer
comprehensive services, including psychosocial support and referral to appropriate providers for the
mother/infant post-delivery. In addition, obstetricians and midwives will be trained to provide pre-conception
and discordant couple counseling, and to encourage services to HIV-infected couples who would like to
have children (e.g., sperm washing and in vitro fertilization). Private pediatricians will be trained on the
diagnosis, care, and follow up of infected infants. This is an exploratory new activity and may not generate
excessive targets in the first year. However, it will provide a picture of the needs in the 'paying community'
of HIV-infected women, who do not generally use public health facilities, and may be a larger than expected
target group that is not receiving much technical assistance.
2. Increased partner testing and participation of partners to help manage maternal child pairs will address
male norms. Health-care workers will be trained in couple counseling, family-centered service provision and
active case finding. A focus group assessment will ascertain barriers to partner involvement in management
of maternal child couples. Results will be used to develop interventions to address male norms.
3. Women will receive support to prevent secondary infections during pregnancy and breastfeeding through
focused outcomes-based support groups, which will also address sexual coercion/ violence.
4. Linkages with schools will be strengthened to encourage healthy sexual choices, address sexual
coercion in young women, and increase access to PMTCT services for pregnant school-going women.
5. To date, MH's focus has been the reduction of HIV transmission 6 weeks postpartum with no assessment
on transmission after 6 weeks postpartum or clinical/health outcomes for mother/child. There has been no
assessment of infant feeding adherence post discharge. To address the high rates of postnatal lost to follow
up (LTFU), a follow up mother and baby wellness clinic was established to offer primary health-care
services and HIV-related care and treatment. This clinic will be evaluated to determine whether it is
successful in addressing LTFU. Concurrently the long-term clinical and health outcomes of the PMTCT
program intervention will also be evaluated.
--------------------------------
SUMMARY:The McCord Hospital/Zoe Life's overall activities relate to building capacity at four municipal
clinics in the Outer West area of Durban (KwaZulu-Natal) to provide a strengthened and integrated
prevention of mother-to-child transmission (PMTCT) service which is linked with tuberculosis (TB) and HIV
care and treatment. Activities that will strengthen services include provider-initiated (with the option to opt-
out) counseling and testing of all pregnant women attending the antenatal clinics, testing of partners and
children of the index patient where possible, TB screening of HIV-infected pregnant women with referral for
treatment where needed, antiretroviral (ARV) prophylaxis for HIV-infected women and newborns, maternal
nutrition and infant feeding counseling and infant follow-up. Emphasis areas include local organization
capacity development, strengthening of referral networks between PMTCT and other vertical programs,
including pediatric services; human resource development through training, mentorship and supervision of
PMTCT staff, quality assurance and improvement through supportive supervision, technical assistance and
mentoring during site visits and strategic information strengthening through development of a simple
integrated monitoring and evaluation system. The primary target populations are pregnant women, HIV-
infected pregnant women, and their infants.McCord Hospital currently receives funding for PMTCT and ARV
treatment through the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). This program described here
focuses on strengthening the capacity of public sector facilities, and it is distinct from the hospital-based
program funded by EGPAF.
Activity Narrative: With FY2008 reprogramming funds, and as part of the optimization of services, the McCord PMTCT hospital
-based program will be conducting a basic program evaluation which will feed directly back into the activities
implemented by McCord Hospital and Zoë-Life. Up until now, the McCord PMTCT program focus has
centred on whether HIV transmission occurs 6 weeks postpartum. However, there has been no assessment
as to whether transmission is occurring later than 6 weeks postpartum and what the clinical and health
outcomes of the PMTCT intervention are for mother and child. There has also been no way of determining
whether infant feeding decisions made on discharge are, in fact, being correctly practiced. In addition, in an
effort to address the high rates of postnatal lost to follow up that the Program had been experiencing, a
follow up mother and baby wellness clinic, located within the PMTCT program, was recently established.
This clinic offers primary health care services and HIV-related care and treatment to both mother and child.
As such, an evaluation of this clinic will be conducted to determine whether it is proving successful in
addressing the problem of lost to follow up. A concurrent evaluation of the long term clinical and health
outcomes of the PMTCT program intervention will also be performed. These lessons will be used to
strengthen both the hospital-based program and the clinic strengthening program.
BACKGROUND:The South African Government (SAG) recently published results of the PMTCT program
per province (2006 Antenatal HIV and Syphilis Prevalence Survey). Results of this survey show that
KwaZulu-Natal continues to have the highest antenatal prevalence of HIV at 39.1%. This is 10% higher than
the national prevalence of 29.1%. Current statistics at the four municipal clinics in the Outer West area of
Durban show suboptimal uptake of PMTCT and poor follow-up of infants from the PMTCT program. There
are currently no statistics to indicate the success of infant feeding interventions, infant follow-up rates or
involvement of partners. This is an ongoing activity designed to strengthen PMTCT services within the
framework of a decentralization and integration of HIV care and treatment program. This project is
supported by both municipal and provincial government. All protocols followed will be in line with the
Provincial Treatment Guidelines, and outcomes of the program will be reported to the eThekwini (Durban)
municipality as well as to the KwaZulu-Natal Department of Health. The implementing organizations,
McCord Hospital and Zoe-Life, will strengthen capacity of staff employed by the municipal government
(eThekwini Municipality) at the four clinics to optimize current PMTCT services. ACTIVITES AND
EXPECTED RESULTS:An emphasis on gender equity in this program area will focus on optimizing the
number of pregnant women who receive care, support and prophylaxis, as well as developing strategies to
include partners of pregnant women in decision-making and issues relating to PMTCT. Partners will be
encouraged to test for HIV, and infected partners or family members will be integrated into the HIV palliative
care and antiretroviral treatment (ART) services program areas. Access to couple counseling will be
increased, with focus areas around family planning, risk reduction, infant feeding choices and testing of
family members included in the counseling and support. ACTIVITY 1: Human Resources
StrengtheningPEPFAR-funded staff with PMTCT expertise will provide onsite mentorship and supervision of
staff of the PMTCT program at the four facilities to improve quality of PMTCT care; training and onsite
mentorship of counselors and clinical staff at the four facilities to increase skills in couple counseling and
integration of partners into PMTCT-related decision making; training of counselors and nurses in infant
feeding choices and maternal nutrition; and training of nurses to draw blood from infants to increase access
to infant testing.ACTIVITY 2: Monitoring and Evaluation This activity will focus on the development of a
monitoring and evaluation (M&E) system that can integrate data from ART, TB, palliative care and PMTCT
services. This M&E system will optimize the provincial PMTCT data protocols and ensure smooth referrals
into other vertical programs.ACTIVITY 3: Technical Support in Response to M&E ResultsPEPFAR-funded
staff will provide regular onsite technical support and training of staff to understand the outcomes of the
M&E to improve quality of care and to highlight areas where necessary.ACTIVITY 4: Follow-up of
InfantsThis activity will focus on the development of sustainable strategies to improve follow-up of infants
using M&E tools and optimization of routine infant clinic visits (e.g., for immunizations, weighing, etc.).NEW
ACTIVITIES:FY 2008 funding will go toward the following activities:(1) Counseling services will be
expanded to include pre-conception counseling, discordant couple counseling, extended family counseling
and establishment of relevant and appropriate psychosocial support interventions including focused
outcomes based support groups(2) Testing services will be expanded to include a second HIV test for all
women at 36 weeks gestation who tested negative at first booking. This will ensure that all women who may
have seroconverted during the pregnancy are able to participate in the PMTCT program.(3) Care and
Treatment services will be strengthened by improving early identification of women who require treatment,
and by offering these women referral and fast tracking into established ARV treatment program.(4) Follow
up of infants will be strengthened by establishment of child-friendly spaces within the clinics and through
sensitization of staff to improve case finding of all children attending the clinic and strengthening linkages
with community-based health workers and birth attendants where possible. (5) Linkages with the most
common hospital-based delivery sites will be strengthened with the aim of improving perinatal management
of the HIV infected women through staff training, technical support and strengthening of case finding
systems within the maternity unit.(6) Linkages with schools and educational services will be formed and a
program developed to sensitize young people to the realities of PMTCT and family planning. This activity
will link with the provision of counseling and testing services at these centers, and will link schools with the
clinics and NGOs that provide optimum PMTCT services.Sustainability is addressed through the capacity
building focus of this program area. PEPFAR-funded staff will not be permanently assigned to these clinics
but will lend support and build capacity until South African Government-funded staff are able to sustain the
program without assistance. The M&E system developed will be offered to the municipal and provincial
government if it is useful within this context.This program area expects to add quality and to increase uptake
of PMTCT services in four municipal clinics. Uptake of PMTCT services is expected to increase by 30-50%.
Zoe-Life and McCord Hospital expect to provide additional counseling services such as couple counseling,
partner counseling and testing, and maternal nutrition testing. A follow-up system for infants will be
developed which will capitalize on the routine immunization schedules, and an increase in infant and sibling
testing is expected. HIV-infected infants or children will be supported according to the provincial pediatric
treatment guidelines. Referral systems will be strengthened to ensure continuity of care. Infected infants will
be referred for initiation of treatment and referred back to the ARV services program area for ongoing care
once stabilized. This program area will thus increase access to treatment for infants and children.
New/Continuing Activity: Continuing Activity
Continuing Activity: 14006
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
14006 7906.08 HHS/Centers for McCord Hospital 6683 4625.08 $649,640
Disease Control &
Prevention
7906 7906.07 HHS/Centers for McCord Hospital 4625 4625.07 NEW APS 2006 $317,000
Emphasis Areas
Gender
* Addressing male norms and behaviors
* Reducing violence and coercion
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $26,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $1,000
and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $2,000
Economic Strengthening
Education
Water
Estimated amount of funding that is planned for Water $1,000
Table 3.3.01:
1. PAIN MANAGEMENT: Zoe-Life (ZL) will advocate for policy changes to enable PHCs to access drugs
currently only available at Hospital Level, such as amitriptyline for neuropathic pain. This will strengthen
integration of pain management.
2. CLINICAL SERVICES: ZL will strengthen follow-up of HIV-infected clients to include regular PAP smears,
TB screening and nutritional assessments.
3. COMMUNITY-BASED PSYCHOSOCIAL SUPPORT: ZL will create linkages with existing community-
based psychosocial support services such as support groups (SG), and provide technical support to
enhance the impact of SGs. This includes assisting SG facilitators to screen for TB, nutrition, mental health
(using validated community tools), alcohol, and appropriately refer. ZL promotes outcomes based SGs with
clearly identified care related goals.
4. MONITORING AND EVALUATION (M&E): Activities will focus on a paper based patient-linked system
for palliative care to maintain/assess quality of services, guide health care workers (HCWs) to provide a
basic package of care, and to track patients, improving patient retention. This health management
information system (HMIS) would ideally move from a paper-based system to an electronic system.Paper
systems are a good starting point, and should be piloted in at least one small clinic.As a scalable patient
record system it may not be appropriate for large patient numbers accessing palliative care services (and a
patient folder). Large numbers of paper folders are an implementation barrier for eThekwini municipality
(eTM) and the Department of Health (DOH). eTM does not hold patient records. Patient folders for only HIV-
infected clients may not be the best use of resources. ZL will explore collaborations with partners with
experience in electronic hand held devices to pilot new ways to manage patients, or to scale up piloted
technologies A hand-held device used by any HCW could provide an easier way to integrate services/ track
patients (if linked to GPS/SMS reminder systems).
5. REFUGEES: ZL will seek to understand the barriers to accessing care at public health services and
address these where possible. One intervention will be to provide a safe and culturally appropriate place to
receive care/support. The other will facilitate integration within public health facilities through provision of
educational materials in foreign languages, training of foreign HCWs to provide accurate information,
translation, patient advocacy and services at public facilities where refugees should ideally access services,
and facilitation of relationships with South African HCWs. ZL will partner with local organizations with
influence in this field.
6. SUSTAINABILITY: The current relationship and Service Level Agreement (SLA) between eTM and the
provincial Department of Health (PDOH) does not allow municipal sites to become accredited antiretroviral
(ARV) sites. This influences budget allocation from the provincial DOH to eTM, and implies that the
provincial DOH will not increase human resources, drug supply or other budget (M&E, patient records) to
sustain new HIV services at eTM clinics. This challenges sustainability. ZL will focus on strengthening the
relationship between eTM, the provincial DOH and the district DOH to address sustainability This will not
only benefit PEPFAR supported sites, but will have a broader impact at all eTM sites.
1. MENTAL HEALTH: ZL will train HCWs to conduct simple screening for mental health (depression,
anxiety, suicide risk, psychosis, dementia) and substance misuse (including alcohol). This will increase the
awareness of the impact of mental health/ substance misuse on adherence to care and treatment, as well
as on morbidity. ZL will develop a tool which will include referral/ management recommendations.
2. PSYCHOSOCIAL MENTORSHIP AND REFERRAL: ZL will explore development of linkages with local
tertiary institutions that train social workers/ psychologists. Students may be available to provide short-term
interventions as part of their practical training for clients with non-complicated mental health problems/
addictions including alcohol. This would be a sustainable way to address staff shortages and contribute to
human capacity development. ZL will develop linkages with the KwaZulu-Natal Community Psychiatric
services that have historically not been integrated into the HIV public health arena. This will strengthen the
support base for referrals.
3.HUMAN RESOURCES:
A.Workforce planning- ZL will monitor HCW human resource (HR) needs at PHCs providing a
comprehensive range of HIV services to analyze workforce needs to assist eTM management to forecast
HR and budget requirements as part of the SLA with the KwaZulu-Natal provincial DOH.
B.HR Management systems- ZL will develop a supportive supervision/ mentorship model for psychosocial
support services.
C.Quality- ZL will participate with other partners to develop standard operating procedures/ service
standards for palliative care. ZL will focus on psychosocial support and screening services, and include
these in accredited training curricula.
4.NUTRITION:
A.ZL will develop/implement a nutrition screening tool for use in SGs to ensure anthropometric assessment
and appropriate intervention.
B.ZL will provide technical support to access micronutrient supplementation for nutritionally compromised
clients enrolled in care.
C.ZL will develop guidelines for primary level and community-based HCWs as well as training and
resources for HCWs to provide integrated nutritional assessments and counseling for adults in care.
-----------------------
SUMMARY:
The McCord Hospital/Zoë-Life (MZL) activities in this area will build capacity in four municipal clinics, three
NGOs, and businesses in Durban, KwaZulu-Natal, to provide a comprehensive range of care and support
services for HIV-infected clients and their families. These services will be available to adults and children
Activity Narrative: from the time of CT, and will support sustained care services for clients not on ART as well as those
receiving treatment. Services will extend to end-of-life care with referral linkages to community-based care
services where available.
McCord Hospital receives funding for PMTCT and ARV treatment through the Elizabeth Glaser Pediatric
AIDS Foundation (EGPAF). This program focuses on strengthening the capacity of public sector facilities,
and is distinct from EGPAF's hospital-based program.
BACKGROUND:
This project seeks to address health seeking behavior by helping communities access comprehensive HIV
care proactively in a primary health setting, encouraging HIV-infected individuals and their family members
to access care as early as possible, and in so doing emphasize sustained wellness, quality of life and
productivity for as long as possible. Palliative care services offered by a multidisciplinary team will play an
integral part in this health behavior change model of care and improve palliative care services within the
context of both an HIV care program and ARV services. Clinical services will be nurse-led, with only
complex clinical issues referred to a clinician or secondary level facility. The emphasis on care services will
promote screening for pain and symptoms, prophylaxis and prompt treatment of opportunistic infections
(OIs), integration prevention services including prevention with positives, with well established systems for
tuberculosis (TB) screening and treatment. Psychosocial services are essential to promote early
engagement with health services, family-centered care, and the chronic health model. Increasing access to
care and treatment for men is a critical gender issue for the success of this program. This will be addressed
through access to couple counseling, family-centered services and mobile services offered in the workplace
to employed men (and women). This project is supported by both municipal and provincial government. All
protocols followed will be in line with the provincial treatment guidelines, and outcomes of the program will
be reported monthly and quarterly to the eThekwini municipality (Durban) as well as to the KwaZulu-Natal
Department of Health (KZNDOH).
ACTIVITES AND EXPECTED RESULTS:
The areas of legislative interest addressed in this program area are increasing gender equity as described
in the summary above, and increasing women's access to income and productive resources through
linkages with the three NGO income-generating programs.
ACTIVITY 1: Human Capacity Development
This activity will focus on training multidisciplinary teams in each site to provide comprehensive palliative
care services. Clinical staff will be trained to provide prophylaxis, screening and treatment for opportunistic
infections; training of counselors, community workers and spiritual supporters to provide augmented
counseling and support services to adults and children.
Clinical and psychosocial staff will support and mentor staff to develop skills and confidence to provide the
following services: couple counseling, psychosocial support for children, family-centered counseling,
wellness literacy for adults, children and caregivers, clinical care (including screening and prophylaxis of
OIs) and treatment of primary health level OIs.
ACTIVITY 2: Psychosocial services
MZL will establish community linkages to strengthen community referrals and to utilize existing community-
based psychosocial services (such as home-based care, church-based counseling and support groups).
MZL will develop and implement sustainable psychosocial support services, including a support group for
children at two clinics and one NGO site.
ACTIVITY 3: Monitoring and Evaluation
MZL will develop a monitoring and evaluation (M&E) system for palliative care services for use in quality
improvement and capacity building at local and provincial level.
ACTIVITY 4: Care services for refugee and asylum seekers
MZL will provide appropriate palliative care services for refugees and asylum seekers in the Durban central
area in collaboration with the United Nations High Commission for Refugees (UNHCR) and KHWEZI AIDS
Project. These services will be provided in French and Swahili. Palliative Care services for HIV-infected
clients and their families, adults and children from the time of testing, and will support sustained care for
clients not on ART as well as those receiving treatment, and includes: psychosocial support services
(patient HIV literacy, psychosocial assessments, augmented counseling, interventions and appropriate
referral); initial care screening: WHO staging, CD4 screening, TB screening, pregnancy tests; basic primary
health care: screening for pain and symptoms, prophylaxis and prompt treatment of opportunistic infections
(OIs), treatment with clinic level drugs from a limited formulary and referral for more complex medical
problems; care support: CD4 counts at regular, designated, appropriate intervals, support groups, spiritual
support, health education updates.
Services will extend to end-of-life care with referral linkages to community-based care services where
available.
ACTIVITY 5: Mobile services
A range of onsite palliative services will be provided for employees in industry who do not have access to
medical aid. PEPFAR will fund staff to provide mobile onsite services such as counseling, wellness literacy,
CD4 count monitoring, screening, prophylaxis and treatment for OIs where possible and integrated
prevention services including prevention with positives. Drugs and laboratory tests will be supplied by the
KZNDOH.
Sustainability at the municipal clinic sites will be addressed by assisting sites to become accredited with the
KZNDOH, and thus making all direct costs of maintaining a quality palliative care service the responsibility
of the KZNDOH. This project will build capacity in these sites to effectively manage the program without
Activity Narrative: ongoing technical assistance. The NGO sites will be assisted to build infrastructure and referral networks to
ensure sustainability of services. The long-term plan for the NGO sites is to build strong relationships with
nearby clinics with the intent of building clinical capacity to take over the clinical aspects of palliative care
services. This project will later build capacity with these institutions to become accredited sites. Staff will
assist the NGOs to source alternative funding. The services for workers in an industrial setting will be co-
funded by industry.
NEW ACTIVITIES for FY 2008:
1.Staff at the clinics and NGOs as well as community-based organizations will be trained to provide
nutritional assessments and counseling, and to link eligible clients with nutritional support. This entails
accessing nutritional supplementation available from the KZNDOH, as well as infant feeding
supplementation included in the PMTCT program.
2. Additional training will be provided at community level to assist with TB and other OI screening and
referral.
3. Linkages with social services, home-based care and community-based services will be strengthened to
ensure sustainable food security and follow up
PLHIV will receive at least one clinical and one other category of palliative care service. Palliative care to
family members of PLHIV or OVC will be provided in at least two or the five categories of palliative care
services.
With FY2008 reprogramming funds, MZL will undertake a basic program evaluation focused on expanded
HIV testing and linkage to care. While McCord has focused on retention in care of HIV-infected patients who
have already initiated ART, data suggests that substantial numbers of HIV-infected persons never reach
care following the HIV diagnosis. The currently proposed program evaluation will focus on determining the
success of linkage to care of patients along the pathway from being offered an HIV test to beginning and
maintaining care at McCord and St. Mary's Hospital (a collaborating partner). The evaluation will identify
socio-demographic and clinical factors that correlate with patients who are most likely not to be in care 12
months after a new HIV diagnosis. In addition, the two sites will also develop, pilot, and evaluate a
multifaceted, supportive intervention to improve linkage to HIV care for HIV-infected individuals at McCord
and St. Mary's. The pilot intervention will provide insight into the feasibility, efficacy, and cost of preventing
pre-treatment loss to care in these settings. Insights from this evaluation will enhance both the McCord
Hospital-based HIV testing program as well as strengthen linkage to HIV care at its primary clinic sites.
Continuing Activity: 14007
14007 7912.08 HHS/Centers for McCord Hospital 6683 4625.08 $729,180
7912 7912.07 HHS/Centers for McCord Hospital 4625 4625.07 NEW APS 2006 $380,000
Refugees/Internally Displaced Persons
Workplace Programs
Estimated amount of funding that is planned for Human Capacity Development $52,000
Estimated amount of funding that is planned for Public Health Evaluation $0
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $3,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $5,000
Estimated amount of funding that is planned for Water $2,000
Table 3.3.08:
McCord Hospital/Zoe-Life (MH/ZL) plan to continue to strengthen all activities mentioned in the FY 2008
COP narrative. Slow progress in this program area related to a variety of procurement, budget, and
pharmacy systems issues will continue to be addressed. Provision of antiretroviral therapy (ART) at primary
health settings will remain a priority within the context of a functional comprehensive primary health care
service.
1.NUTRTIONAL SUPPORT: ZL will develop and implement a nutrition screening tool for clinical use within
adult HIV care services, at patient literacy sessions and support groups to ensure anthropometric
assessment and appropriate interventions. Also, ZL will provide technical support to access micronutrient
supplementation for nutritionally compromised HIV-infected patients enrolled in the programs.
C.ZL will develop guidelines for primary level and community-based health-care workers (HCWs) as well as
training courses and resources for HCWs to provide integrated nutritional assessments and counseling for
adults on treatment, including guidelines for primary health nutrition management of patients with high BMI
and side effects.
2. GENDER: Access of ART to men will be addressed by assisting non-governmental organization sites to
offer ART services after work hours, as well as through provision of ART within the workplace program.
--------------------------------------
SUMMARY: The McCord Hospital/Zoe Life activities of this program area relate to strengthening capacity at
four municipal clinics and three non-governmental organizations (NGOs) to provide comprehensive
antiretroviral treatment (ART) services in a primary healthcare setting as part of a decentralization plan. A
mobile service will provide ART to infected workers as part of a workplace program. Emphasis areas are
development of referrals across vertical programs (CT, PMTCT, TB/HIV), community programs and to
secondary and tertiary facilities; local organization capacity building (major emphasis); quality assurance,
improvement and supportive supervision; strategic information; training; and workplace programs. The
primary target populations are the general population, people affected by HIV and AIDS, refugees and the
private sector (workers without health insurance).McCord Hospital receives funding for PMTCT and ARV
program funded by EGPAF.BACKGROUND:There are a number of constraints to the rapid rollout of ART in
the public sector. This is largely due to the lack of human and infrastructural resources, and that ART is
generally offered at secondary or tertiary care level. McCord Hospital has over 2,000 patients on ART, and
it is not sustainable to continue the follow-up of stable patients at this or any other hospital. This new activity
will be implemented by the McCord/Zoe Life team in partnership with the eThekwini Municipality (Durban),
three NGOs and participating corporate bodies. The project will build capacity at primary health care (PHC)
level to continue follow-up of down referred stable patients on ART (initiated at hospital level) and to
increase skill at PHC level to provide ART services (including initiation of ART in patients who are stable).
This project is supported by metropolitan and provincial health departments. provincial ART guidelines are
followed. Gender issues will be addressed through increasing access to ART in workers (assuming most
are men) in a workplace program, and by ensuring that a family-centered treatment approach is offered to
partners and family members via access to couple counseling, community-based referrals, provider-initiated
palliative care for partners and active case management of families.ACTIVITES AND EXPECTED
RESULTS:ACTIVITY 1: Site accreditationThis activity will support site accreditation at four metropolitan
clinics through negotiation with metropolitan and provincial health departments to ensure sustainability and
ongoing provision of staff and commodities for ART services.ACTIVITY 2: Human capacity
developmentNurse-led multidisciplinary teams at each site will be trained to provide comprehensive ARV
services at clinics. Training will include adult and pediatric clinical services, psychosocial support/adherence
counseling, pharmacy management and monitoring and evaluation (M&E). Teams will initially be trained to
follow up down referred patients on ART, and will later be supervised to initiate stable clients on ART.
Counselors will be trained to provide routine focused HIV prevention counseling to clients on ART. This will
also be included in routine treatment readiness training for patients. Staff will be trained to provide services
with a French/Swahili interpreter to increase access to refugees/asylum seekers.ACTIVITY 3: Pharmacy
systemsPharmacy systems will be strengthened to support drug chain management. Commodity
procurement will be largely the responsibility of the provincial government, and McCord Hospital has been
accredited as a KwaZulu-Natal Department of Health (KZNDOH) site, with the result that decentralized ARV
service sites will also fall under the KZNDOH. Provision of ARV drugs, test kits and labs will be supplied by
the DOH as a cost-share. ACTIVITY 4: Technical supportThese activities will build capacity through
technical support, mentorship and supervision to implement a comprehensive care and treatment program.
This project will provide experienced staff to each site on a weekly basis to ensure that ARV services are
seamlessly linked with wellness services, TB/HIV and PMTCT to strengthen continuity of care and patient
retention. This will be supported by development of referral tools and regular M&E feedback with problem
solving support.ACTIVITY 5: Pediatric ARTMcCord/Zoe Life will provide technical support to increase
provision of ART to children. Staff from the municipal and NGO sites will attend a preparatory workshop in
which an approach to increasing pediatric services will be formulated. Technical support will be offered to
integrate ARV services into current vertical services such as PMTCT, TB, children's clinic, immunization
services and community-based psychosocial services. Staff will be encouraged to implement routine testing
of children, and assistance will be given to develop effective systems which ensure referral of infected
children to voluntary counseling and testing, HIV care, and other programs. ACTIVITY 6:
ReferralsMcCord/Zoe Life will assist in strengthening referrals and linkages by establishing a system of up
referral for specialized or hospital-based care, and down referral from any accredited ARV site to the
municipal clinics and NGO sites for patients living in the area; and establish referrals for workers receiving
ART (workplace program).ACTIVITY 7: AdherenceA strong community-based family-centered adherence
component with existing and new role-players for continuity of care between facility and community will be
developed. Where possible, treatment readiness and adherence support programs will be decentralized
Activity Narrative: further into community facilities.ACTIVITY 8: M&EThe project will develop and implement a model of M&E
that can be integrated into, as well as strengthen the current data collection systems for partners across
both community and vertical programs and up to the secondary and tertiary level. This will improve quality,
ensure a multidisciplinary continuum of care and manage referral pathways.ACTIVITY 9: Staff
programsPartnerships will be developed to provide ARV services to employees who do not have access to
medical insurance. Sustainability at the municipal clinic sites is addressed by assisting sites to become
accredited with the KZNDOH. This project will build human capacity to effectively manage the program
without ongoing technical assistance. NGO sites will be assisted to build infrastructure and referral networks
to ensure sustainability of services. The long-term plan for the NGO sites is to build strong relationships with
nearby clinics where clinical capacity can be increased to take over clinical aspects of decentralized ART.
These institutions will be included in FY 2008 funding to become accredited sites. NGOs will be assisted to
source other funding. The workplace services will be co-funded by industry. Where possible, corporate
occupational health clinics will be assisted to become accredited KZNDOH sites. New activities:1. Linkages
with educational facilities and facilities housing orphan's or vulnerable children will be established and
counseling and testing services will be offered to these facilities in addition to linkages with care and
treatment services. Children found to be HIV-infected at these sites will either be referred to nearby
treatment centres (Either PEPFAR funded sites or referral sites, dependant on the severity of illness)2.Staff
at educational or facilities housing orphans or vulnerable children will be trained in basic ARV care
principles so that they will eventually be able to provide ongoing adherence support and monitor side effects
with appropriate referrals.3.Staff at sites will be trained in family counseling techniques. This counseling
approach encourages participation of al famil members including men (partners and fathers) and will assist
counselors to involve men in both decision making and caring processes. Where possible, counseling will
be offered at times that are suitable for employed men4.Patient retention will be strengthened through
strong patient tracking systems, community-based adherence support, psychosocial support services which
offer a comprehensive range of services, child friendly sites which encourage ongoing participation with the
services, and linkages with community-based organizations which offer other services which may appeal to
patients, such as art/drama, nutrition support, income generation.The McCord Hospital activities contribute
to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year Strategic Plan by strengthening the public
sector and expanding access to care and treatment.
New/Continuing Activity: New Activity
Continuing Activity:
* Increasing gender equity in HIV/AIDS programs
Table 3.3.09:
FY 2008 COP activities will be expanded to include:
-Strengthening of pediatric care and support services in the following areas: 1) training; 2) health systems
strengthening; 3) increased case findings; 4) technical support; 5) improved adolescent care; 6) improved
pediatric referral systems; and 7) improved monitoring and evaluation of pediatric services.
McCord/Zoe-Life (MZL) will build capacity in two municipal clinics and two NGOs in the eThekwini District to
provide a comprehensive primary health care/ support package for children with HIV. This will include
clinical and psychosocial support in line with integrated management of childhood illness (IMCI) and
community IMCI (CIMCI) goals and will ensure a family centered integrated model of care, both in primary
heath care settings as well as with strong community linkages
The South African Department of Health Antenatal HIV Seroprevalence Survey, 2007 estimated the
prevalence rate in KZN adults at 37.4%. Most recent estimates from the Actuarial Society of South Africa
(ASSA) model suggest that the overall prevalence of 1.2% in 2000 has almost doubled to 2.1% in 2006 for
children under the age of 18 years. The prevalence rates differ across age groups and it is clear that
younger children in the 0-5 year age group are most at risk of infection. The rate in the 0-5 year olds is 1.8
times more (almost double) than the overall rate for all children (0 - 17 years). The HIV prevalence rate in
the 0-5 year age group increased from 2.2% in 2000 to 3.6% in 2006. For children in the 6-12 year age
group, the prevalence increased from 0.1% to 1.0% during the same time period. The prevalence rate for
the 13-17 year age group stayed almost the same for this period - 1.0% in 2000 and 1.1% in 2006. Based
on the demographic statistics of 2005, approximately 215,000 children under the age of five years and close
to 55,000 children between the ages of six and 12 years are currently living with HIV infection. In total the
model estimates that approximately 360,000 children are living with HIV infection. According to UNAIDS,
there were around 280,000 children aged below 15 living with HIV in South Africa in 2007. Most of these are
undiagnosed. According to UNICEF, 260 children are born infected with HIV every day in South Africa. Most
die before their second birthday. The AIDS Law Project, based in Johannesburg, estimated that 50,000
children in South Africa were in need of antiretroviral drugs at the beginning of 2006, but that only around
10,000 were receiving them. UNAIDS estimates that at the end of 2005, children accounted for 8% of those
receiving antiretroviral drugs in South Africa. If the numbers of children requiring ARV therapy is so high,
then it follows that the numbers requiring care and support would be even higher. Challenges for pediatric
care at a primary health level include lack of sufficiently trained health care personnel and inadequate
facilities, the vertical nature of typical ART clinics, which make it difficult for children to be identified and
referred into appropriate care services. Challenges relating to services being offered to different family
members at different sites, poor linkages promoting the appropriate referral of children to HIV care and
treatment, lack of clarity regarding guardianship and authority over children accessing care and treatment,
slow movement of expanding care and treatment from tertiary level to secondary and primary health care
facilities (i.e. down-referrals), lack of confidence and hands on experience at primary care level, and lack of
onsite mentorship to build capacity in staff to move from a pediatrician led to nurse-driven model of care and
treatment to children are some of the challenges facing South African services The need for a more
integrated family care -orientated intervention at primary level as well as more efficient community-based
interventions is key in order to identify children and incorporate them into primary health level care without
compromising their quality of care or need for specialized care and support.
The McCord/Zoe-Life team (MZL) will implement this new program area. McCord (MH) will provide technical
support. Zoe-Life (ZL) will be the implementing partner. Other partners will include; iThemba Lethu (iTL) a
local NGO providing prevention skills at 4 nearby local schools as well as running 2 transition homes for
children abandoned or orphaned as a result of HIV (Orphans and vulnerable children-OVC); BigShoes (BS),
a Johannesburg-based organization which has started work in Durban and has a vision to improve the
medical care of orphaned and vulnerable children affected by HIV and AIDS both within the community of a
children's home and the wider community. BS provides both pediatric palliative care and specialist medical
pediatric services for orphaned and vulnerable children (OVC) including HIV testing, age assessments,
medical reports for adoption and anti-retroviral treatment. MZL will partner with BS to increase linkages with
OVC and to augment services provided by BS to ensure a comprehensive service. ZL will assist with
psychosocial support services for these children. ZL will partner with iTL to support case finding within the
schools, to offer testing, and to provide support to the Youth workers to provide psychosocial support to
infected and affected children. In the eTM clinics and NGOs, the aims of the program will be to identify HIV
exposed children as early as possible, to integrate them into a supported IMCI-based care program, and to
offer a comprehensive range of services which will ensure quality of life, optimal health and development,
and psychosocial support for themselves as well as their family members or care givers. Each NGO should
identify at least one school or avenue through which children can be identified and supported both clinically
and psychosocially, including strengthening referral systems, CIMCI capacity and implementing
psychosocial outcomes-based support groups.
ACTIVITIES AND EXPECTED RESULTS:
A technical support team focused on pediatric care will provide support for the following activities:
ACTIVITY 1: TRAINING
Counselors, nurses and community workers at supported sites will be trained in the following areas: a. Case
finding - early diagnosis of children and infants, optimizing entry points for case finding (immunization, IMCI,
PMTCT, TB clinic, community IMCI) use of dry blood spot (DBS) PCR tests, counseling children and their
caregivers with regard to testing b. Clinical care of the HIV-infected child (IMCI-based) c. Psychosocial care
of the HIV-infected child and their family (disclosure and stigma, dealing with chronic illness, trauma
Activity Narrative: counseling, using play and art as a counseling technique, developmental screening and referral, accessing
social assistance, care of the caregiver, incorporating healthy living into the family, bereavement and grief
counseling) ZL will explore the use of blended training to limit the amount of time HCW need to be absent
from the clinics. Training will be both off site and onsite and will be accompanied by ongoing technical
support.
ACTIVITY 2: IMPLEMENTATION SUPPORT-MENTORSHIP AND PRECEPTORSHIP
This is a key element to ensure sustained capacity onsite and to build HCW confidence. After being trained,
counselors, nurses and community workers at supported sites will engage in a mentorship program, where
they will be mentored closely in acquiring tangible technical skills and confidence to adequately prepare
them to provide pediatric HIV care. This will be achieved this by partnering with institutions such as
University of KwaZulu-Natal (UKZN) and MH. It may also include offering rotations for final year medical
students or Pediatrics registrars as part of a community level rotation.
ACTIVITY 3: HEALTH SYSTEMS STRENGTHENING
MZL will aim to address the regulatory environment to ensure that the statutes and regulations with regard
to pharmacy and nursing acts support a nurse driven model of care.
ACTIVITY 4: INCREASE CASE FINDING
The technical team, comprising a Pediatric Nurse, counselor and a part-time IMCI trained Pediatrician, will
provide onsite support to clinics and NGOs to set up sustainable systems within each site to identify HIV
exposed children at different entry points, including children of women in PMTCT programs, infants and
children being immunized, children with TB and symptomatic children identified through IMCI and
community IMCI. Linkages with OVC will be made where infected or vulnerable children from the OVC
community will be tested and linked with care and support offered at clinics and NGOs. This will take place
through the two partnering organizations, BS and iLT, as well as the NGOs and their linkages with local
schools, day care centers or other organizations that are identified in the communities.
ACTIVITY 5: TECHNICAL SUPPORT
Support will be given to nurses to take bloods from children and to use DBS-PCRs to test infants.
Resources and tools will be developed or sourced to assist health care workers (HCWs) to remember
diagnostic algorithms for children and infants.
ACTIVITY 6: ADOLESCENT CARE
Special attention will be given to identifying adolescents at risk, and to increase case finding in this
population. Outreaches to schools may be undertaken as a means to identify school going children at risk.
Partnerships with organizations already working with adolescents will be strengthened (such as iTL) NGOs
and clinics will be assisted to develop adolescent friendly services. Linkages with schools will be focused on
encouraging healthy sexual choices, addressing sexual coercion in young women and increasing access to
services for HIV-infected school-going children
ACTIVITY 7: REFERRALS
The technical team will strengthen referrals, both within facilities (TB, PMTCT, CARE, IMCI) and between
facilities (Primary care to ARV clinics/Pediatric facilities/ Specialist clinics) to ensure retention to care as well
as quality and completeness of care. Children found to be HIV-infected will be referred for psychosocial
support, and will be actively referred to a case manager within each clinic or NGO. Multidisciplinary team
meetings focusing on pediatric HIV will be initiated to ensure ownership of cases to reduce loss to follow up
and increase HCW accountability for tracking and care. Where possible, multiple referrals will be minimized
and as many services as possible offered at one site. A family centered model will be adopted so that
parents or siblings can also be cared for by the same HCW on the same day, to reduce costs and to
minimize loss to follow-up.
ACTIVITY 8.CLINICAL CARE
The Pediatric team will strengthen site capacity to provide a basic clinical care package for children, which
would include provision of cotrimoxazole for all HIV exposed children and infants, CD4% at time of
diagnosis and routinely thereafter, nutritional assessments and support, development assessments,
immunizations and early detection and treatment of OIs including TB. These activities would be achieved
within the broader goals of strengthening IMCI implementation and use at all sites. Systems will be
strengthened to support the regular procurement of multi-micronutrient supplementation
ACTIVITY 9: PSYCHOSOCIAL AND SPIRITUAL CARE
The MZL team will set up a child friendly area, either at the clinics, or at a community site nearby.
Psychosocial support will be offered to children and caregivers and will take the form of an outcomes-based
support group with a curriculum covering aspects of child development, disclosure, nutritional assessment
and support, adherence to care, healthy homes, clean water and accessing social services. The groups will
use play and art as a medium for the children. This will have an additional benefit in terms of cognitive and
motor development, and will assist with developmental screening. Sessions will also incorporate clinical
screening including TB screening, weighing and symptom screening and if needed ongoing CD4% bloods.
Psychological, emotional or developmental issues that cannot be addressed within the groups will be
referred appropriately. It is hoped that this safe forum will encourage children and caregivers to engage with
services and include their partners and other children. Caregiver support will also be provided. It is also the
aim that these groups can be moved into the community once children are well and stable, and therefore do
Activity Narrative: not need to come to the clinics regularly. This will ease the burden on the health system whilst keeping
children in care, and will also address infection control. Community IMCI programs (CHCWs or HBCs) can
also refer children to these groups. Linkages will be made with community-based organizations or churches
to participate in facilitating the groups, so that sustainability can start to be addressed, and community-
based continuity can be facilitated through these organizations providing home visit support. ZL will also
explore funding from the corporate sector through their corporate social investment funds to provide
ongoing resources for consumables (art, paper, play-dough) and possibly food. This again addresses
sustainability.
ACTIVITY 10: MONITORING AND TRACKING
ZL/MH would like to explore monitoring and evaluation systems for children at primary health level. The
current patient records for endorsed by the Department of Health were designed for use primarily for adult
HIV patient management. Children at eTM and most primary health facilities do not have a clinic held
record, and their progress is predominantly held on a road to health chart. The recommended IMCI forms
are not available at eTM sites or NGOs. A single user friendly yet accurate and reliable system needs to be
developed based on IMCI guidelines yet incorporating HIV care and tracking components for a primary
health setting. ZL/MH will engage with KZN-based pediatricians, the MCH team at the Provincial Health
Department and other organizations working on this issue to collaborate and develop tools, forms and a
system that will service the pediatric population. In addition to a paper-based system, ZL will engage with
other partners to look at electronic tools to assist with tracking and M E such as hand held devices and GPS
systems.
MZL will focus on the following activities which support gender: 1) encouraging fathers of children enrolled
in care and support to play an active role in both child rearing and the health of their children; 2) creating a
safe environment in which women and children can disclose their status to partners, and in which they are
able to disclose and deal with sexual coercion and sexual abuse; and 3) women caregivers of children in
the program will be assisted with family planning choices.
Estimated amount of funding that is planned for Human Capacity Development $13,000
Table 3.3.10:
McCord/Zoe-Life (MH/ZL) will build capacity in two eThekwini Municipality (eTM) clinics and two non-
governmental organizations (NGOs) in the eThekwini District to provide a comprehensive primary health
care and support package for children with HIV, including care of children on ART. This will include clinical
and psychosocial support in line with Integrated Management of Childhood Illness (IMCI) and Community
(CIMCI) goals and will ensure a family-centered integrated model of care, both in primary health care
settings as well as with strong community linkages.
The South African Department of Health Study 2007 estimated the prevalence rate in KwaZulu-Natal (KZN)
adults at 37.4%. Most recent estimates from the Actuarial Society of South Africa (ASSA) model suggest
that the overall prevalence of 1.2% in 2000 has almost doubled to 2.1% in 2006 for children under the age
of 18 years. The prevalence rates differ across age groups and it is clear that younger children in the 0 - 5-
year age group are most at risk of infection. The rate in the 0 - 5-year olds is 1.8 times more (almost double)
than the overall rate for all children (0 - 17 years). Based on the demographic statistics of 2005,
approximately 215,000 children under the age of five years and close to 55,000 children between the ages
of six and 12 years are currently living with HIV infection. In total the model estimates that approximately
360,000 children are living with HIV infection. According to UNAIDS, there were around 280,000 children
aged below 15 living with HIV in South Africa in 2007. Most of these are undiagnosed. According to
UNICEF, 260 children are born HIV-infected every day in South Africa. Most die before their second
birthday. The AIDS Law Project, based in Johannesburg, estimated that 50,000 children in South Africa
were in need of antiretroviral drugs at the beginning of 2006, but that only around 10,000 were receiving
them. UNAIDS estimates that at the end of 2005, children accounted for 8% of those receiving antiretroviral
drugs in South Africa.
Challenges for pediatric care at a primary health level include lack of sufficiently trained health care
personnel and facilities that are not child friendly. Health care workers (HCWs) at primary health care level
are not encouraged by pediatricians to care for children on antiretroviral therapy (ART) at these facilities -
this is reflected in the slow movement of expanding care and treatment from tertiary level to secondary and
primary health care facilities. Tertiary and secondary facilities do not provide support or mentorship to
increase confidence and hands-on experience at primary care level so that services can move from a
pediatrician led to nurse-driven model of care and treatment to children. The need for a more integrated
family care-orientated intervention at primary level as well as more efficient community-based interventions
is key in order to identify children and incorporate them into primary health level care without compromising
their quality of care or need for specialized care and support.
This new program area will be implemented by the McCord/Zoe-Life team. ZL will identify two interested
clinics and two NGOs that are interested in and suitable to care for children on ART. McCord Hospital (MH)
will provide technical support to care for the children and mentor staff. Zoe-Life will be the implementing
partner. Other partners may include CHIVA, a UK-based organization providing technical support in KZN,
iThemba Lethu (iTL) a local NGO providing prevention skills at four nearby local schools as well as running
two transition homes for children abandoned or orphaned as a result of HIV (OVC); and BigShoes (BS),a
Johannesburg-based organization which has started work in Durban and has a vision to improve the
children's home and the wider community. Bigshoes (BS) provides both pediatric palliative care and
specialist medical pediatric services for orphaned and vulnerable children including HIV testing, age
assessments, medical reports for adoption and antiretroviral treatment. (OVC). ZL will promote the
implementation of a family-centered treatment model and the initiation of children on ART at the sites.
Initially, children will be seen by a visiting clinician who would work closely with an IMCI-trained nurse on-
site who would eventually be able to initiate children under supportive supervision of the clinician. ZL will
train counselors and community health workers (CHWs) to assist with psychosocial support services for
these children and their caregivers, which would include treatment literacy and adherence support. Children
would be recruited into the treatment program via a range of entry points. The first would be to target
children of women attending prevention of mother-to-child (PMTCT) services. Infants attending well baby
follow-up programs and immunization visits will be targeted for testing and integration into care. Children
identified through IMCI services will be offered testing and CD4%. Children on ART at MH who are able to
be decentralized will also be included in the ART program. Lastly, children of adults in care and treatment
will be found through active case finding. The aims of the program will be to identify HIV-exposed children
as early as possible, to integrate them into a supported IMCI-based care program, and to offer a
comprehensive range of services including ART to those who qualify which will ensure quality of life, optimal
health and development, and psychosocial support for themselves as well as their family members or
caregivers.
Activity 1: TRAINING
Counselors, nurses and community workers at supported sites will be trained in the following areas: (a)
Case finding - early diagnosis of children and infants, optimizing entry points for case finding (immunization,
IMCI, PMTCT, TB clinic, community IMCI) use of dried blood spot (DBS) and polymerase chain reaction
(PCR) tests, counseling children and their caregivers with regard to testing (b) Clinical care of the HIV-
infected child on ART (c) Psychosocial care of the HIV-infected child on ART and their family (disclosure
and stigma, dealing with chronic illness, adherence counseling, using play and art as a counseling
technique). ZL will explore the use of blended training to limit the amount of time health-care workers
(HCWs) need to be absent from the clinics. Training will be both off-site and on-site and will be
accompanied by ongoing technical support
Activity Narrative: Activity 2: INCREASE CASE FINDING
The technical team, comprising a pediatric nurse, counselor and a part-time IMCI-trained pediatrician, will
provide on-site support to clinics and NGOs to set up sustainable systems within each site to identify HIV-
community IMCI. Linkages with orphans and vulnerable children (OVC) will be made where children from
the OVC community will be tested and linked with care and support offered at clinics and NGOs. This will
take place through the two partnering organizations, BS and iTL, as well as the non-governmental
organizations (NGOs) and their linkages with local schools, day care centers or other organizations that are
identified in the communities.
Activity 3: MENTORSHIP AND PRECEPTORSHIP
This is a key element to how ZL builds capacity within a site. After being trained, counselors, nurses and
community workers at supported sites will engage in a mentorship program with the ZL technical team,
where they will be mentored closely in acquiring tangible technical skills and confidence on site as to
adequately prepare them in providing pediatric HIV care.
Activity 4: TECHNICAL SUPPORT
Support will be given to nurses to take blood from children and to use DBS-PCRs to test infants. Laboratory
capacity will be strengthened through ensuring that HCWs are trained in specimen-taking, transport and
delivery of results. Resources and tools will be developed or sourced to assist HCWs to remember
diagnostic and treatment algorithms for children and infants.
Activity 5: ADOLESCENT CARE
Special attention will be given to identifying adolescents requiring ART, and to increase case finding in this
and clinics will be assisted to develop adolescent friendly services.
Activity 6: REFERRALS
The technical team will strengthen referrals, both within facilities (TB, PMTCT, Care, IMCI) and between
facilities, (Primary care to ARV clinics/Pediatric facilities/ Specialist clinics) to ensure retention of care as
well as quality and completeness of care. Children requiring ART will be referred appropriately depending
on severity of illness, either to a tertiary center or the site ART service. Children on ART on site will be
referred for psychosocial support, and will be actively referred to a case manager within each clinic or NGO.
Multidisciplinary team meetings focusing on Pediatric HIV will be initiated to ensure ownership of cases to
reduce loss to follow up and increase HCW accountability for tracking and care. Where possible, multiple
referrals will be minimized and as many services as possible offered at one site. A family-centered model
will be adopted so that parents or siblings can also be cared for by the same HCW on the same day
wherever possible, to reduce costs and to minimize loss to follow-up.
Activity 7: CLINICAL CARE
The Pediatric team will strengthen site capacity to provide a ART clinical care, which would include
provision of cotrimoxazole, regular CD4%and viral load nutritional assessments and support, and routine
and ongoing TB screening. These activities would be achieved within the broader goals of strengthening
IMCI implementation and use at all sites. Systems will be strengthened to support the regular procurement
of multi-micronutrient supplementation
Activity 8: PSYCHOSOCIAL AND SPIRITUAL CARE
The ZL team will set up a child friendly area, either at the clinics, or at a community site nearby.
Psychosocial support will be offered to children and caregivers and will take the form of an outcomes based
support group for children on ART and their caregivers. The curriculum will cover essential aspects of child
development, disclosure, nutritional assessment and support, adherence to care and treatment,
management of side effects, healthy homes, clean water and accessing social services. The groups will use
play and art as a medium for the children. This will have an additional benefit in terms of cognitive and
screening including TB screening, weighing and symptom screening and if needed ongoing CD4% bloods
and adherence monitoring. Psychological, emotional or developmental issues that cannot be addressed
within the groups will be referred appropriately. It is hoped that this safe forum will encourage children and
caregivers to engage with services and include their partners and other children. Caregiver support will also
be provided. It is also the aim that these groups can be moved into the community once children are well
and stable, and therefore do not need to come to the clinics regularly. This will ease the burden on the
health system whilst keeping children in care, and will also address infection control. Community IMCI
programs, CHWs or home-based carers (HBCs) can also refer children on ART to these groups. Linkages
will be made with community-based organizations or churches to participate in facilitating the groups, so
that sustainability can start to be addressed, and community-based continuity can be facilitated through
these organizations providing home visit adherence support. ZL will also explore funding from corporates
through their corporate social investment funds to provide ongoing resources for consumables (art, paper,
play dough) and possibly food. This again addresses sustainability.
Activity 9: MONITORING AND TRACKING
ZL/MH would like to explore monitoring and evaluation systems for children at primary health level. Current
patient records for HIV management endorsed by the Department of Health were designed for are used
primarily by adults. Children at eTM and most primary health facilities do not have a clinic held record, and
their progress is predominantly held on a road to health chart. IMCI forms which are recommended are not
available at eTM sites or NGOs. A single user-friendly yet accurate and reliable system needs to be
developed for both children in care and children on treatment, based on IMCI guidelines yet incorporating
HIV care, treatment and tracking components for a primary health setting. ZL/MH will engage with KZN
based pediatricians, the MCH team at the provincial Health Department and other organizations working on
this issue to collaborate and develop tools, forms and a system that will comprehensively service the
Activity Narrative: pediatric population. In addition to a paper based system, ZL will engage with other partners to look at
electronic tools to assist with tracking and M E such as hand held devices and GPS systems.
Activity 10: NUTRITIONAL SUPPORT
ZL will develop and implement a nutrition screening tool for clinical use within pediatric treatment services,
at pediatric psychosocial and education sessions and support groups to ensure anthropometric assessment
and appropriate interventions. ZL will provide technical support to access micronutrient supplementation for
nutritionally compromised HIV-infected children enrolled in the programs C.ZL will develop guidelines for
primary level and community-based HCWs as well as training courses and resources for HCWs to provide
integrated nutritional assessments and counseling for children on treatment.
Activity 11: GENDER
Gender related activities will include providing a safe environment for children especially adolescents to
discuss sexual aspirations with appropriate counsel. Fathers of children on ART will be actively encouraged
to participate in the health decision making processes of their children.
Some elements of pediatric treatment are also addressed in more details in other linked areas of the COP,
including Pediatric Care and Support, Counseling and Testing, ARV Drugs, and Adult Treatment.
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 $1,000
Table 3.3.11:
Since there is a high prevalence of TB in the communities, increasing the effectiveness of the community
home-based caregivers will assist in decreasing the number of undiagnosed TB cases and thus the spread
of TB in the community. Zoe-Life (ZL) will facilitate linkages between community home-based care and the
nearest clinics, share knowledge (symptom screening tools) with the existing community health groups, and
encourage the utilization and help with the procurement of existing information, communication and
education materials by the community.
NEW ACTIVITY: Scale up isoniazid preventive therapy (IPT): The recent National Department of Health
(NDOH) TB guidelines strongly recommend the implementation of IPT for HIV-infected people in all primary
health-care facilities. However, currently there is poor communication from NDOH to the eThekwini
Municipality (eTM) on protocols and implementation practices. In addition, eTM has a poor record of basic
TB program management with poor treatment completion rates. Together with policy uncertainties and poor
program management, the environment is not currently conducive to the implementation of IPT. Currently,
none of the ZL-supported sites are implementing this policy. (It is the belief of the author that no clinics in
the eThekwini district are implementing IPT.) ZL will ensure that the health environment is conducive to IPT
implementation through supporting best practice with regard to TB management, and supporting clinics to
strengthen and improve both case finding and treatment success. Thereafter, in collaboration with eTM
management, ZL will train the nurses from the 12 sites in applying the IPT, following the national guidelines.
Ongoing support and training follow up will be offered to the health-care providers to ensure correct
implementation of IPT. Procurement and a consistent supply of Isoniazid is vital for the effectiveness of this
policy, therefore ZL will assist in setting up efficient pharmacy systems at the sites level. Appropriate
linkages at all levels within pharmaceutical services will be strengthened.
MODIFIED ACTIVITY: Infection control: Currently, at ZL sites there is an insufficient TB infection control:
poor ventilation, inadequate TB patient flow, health-care workers lacking training and awareness, lack of
education and informative materials for patients on basic infection control (e.g., cough etiquette/hygiene).
ZL will support the clinics to implement a set of administrative control measures (i.e., early recognition of TB
suspects or confirmed cases through screening all clients entering the facility; separation of TB suspects
into separated and well ventilated waiting area; improved TB/HIV integration in the facility, particularly
screening of HIV clients at all clinic visits) and environmental control measures which will allow good natural
ventilation, thus reducing the risk of TB infection at the facility level. Training on TB infection control of all
clinic staff will be delivered, with emphasis on the NDOH's infection, prevention and control policy and
strategy. Facilities will be supported to develop an infection control plan and assessment tool.
NEW ACTIVITY: Pediatric TB/HIV care: ZL will support the sites to increase TB diagnosis, treatment and
prophylaxis for children. Clinic nurses will be trained to properly screen adult TB patients for identification of
under 5's contacts during history taking and provide prophylactic treatment to these children. Training on
existing pediatric TB protocols will be delivered with reinforcement of their implementation through an
intense mentorship support. Early diagnosis of TB in children at primary health-care clinics will be
strengthened through ensuring availability of the tuberculin skin test (TST) and training of the nurses in the
use and reading of the TST.
DOTS SUPPORT: There is currently a DOTS system in place at all clinics. This will be strengthened
through multidisciplinary case meetings and onsite training -- which will include the DOTS supporters -- in a
bid to strengthen case management, accountability and patient tracking through community and clinic
based case management.
GENDER: ZL will continue to address gender by ensuring that men have access to primary health
interventions, and particularly to TB/HIV screening. This will be achieved through increasing access in the
workplace, as well as by extending opening hours of facilities. One non-governmental organization currently
opens after hours and on weekends for this purpose. ZL will work with other sites to increase number of
sites that are open after hours.
-----------------------------------
McCord/Zoe Life activities will build capacity in four municipal clinics, three non-government organizations
(NGOs) and a corporate outreach program in Durban to provide proactive and integrated TB/HIV services
within the framework of a primary health decentralized HIV care and treatment program. Emphasis areas
include: development of referral systems between vertical HIV-related programs and other health services;
local organization capacity development; and development of a workplace program.
The prevalence of tuberculosis (TB) in KwaZulu-Natal (KZN) is high, with 60% of TB clients co-infected with
HIV. Local TB programs are vertical programs that do not integrate HIV and TB care. An outbreak of
multidrug-resistant tuberculosis (MDR-TB) along with poor treatment completion rates highlights the
challenges of TB management in KZN. The tools used for diagnosis of TB where an estimated 75% of
active TB is extrapulmonary and/or sputum negative pulmonary TB are limited to sputum microscopy for
AFB. Chest x-rays (CXR) do help with diagnosis, but is not confirmatory, and the CXR picture of pulmonary
TB in HIV is not the classic picture. Diagnosis is often complicated by other infections such as pneumocystis
carinii pneumonia (PCP). The yield on sputum culture for TB is higher, especially with sputum negative on
microscopy, and the yield of AFB on blood cultures in extrapulmonary and sputum negative TB is also fairly
high. The best tool at this stage, however, is the clinician with a high index of suspicion for TB. Effective
management of TB is one of the most important upcoming fields of care in South Africa. This new project
will be implemented by the McCord/Zoe Life team and seeks to integrate HIV and TB care using National
Department of Health (NDOH) guidelines and best practice models to provide a seamless continuum of
Activity Narrative: care to clients co-infected with TB and HIV. Gender will be addressed by increasing access to TB screening
in the workplace, increasing TB screening for women in PMTCT projects and in women's income generating
projects run through the NGOs. The project will also provide TB/HIV care to refugees.
ACTIVITY 1: Training
Counselors and clinical staff will be trained in provider-initiated CT, and this service will be offered to all TB-
infected clients accessing care at the municipal clinics, and to TB patients accessing services at NGO sites.
Counselors will be trained to enroll all HIV-infected clients into wellness/ARV services and to refer for CD4
screening. Counselors will be trained to screen for TB during any contact with an HIV-infected client and to
refer appropriately. Nurses working in prevention of mother-to-child transmission (PMTCT) or sexually
transmitted infections (STI) NGOs will be cross-trained to screen all HIV-infected clients at each contact and
to refer appropriately for quick diagnosis, treatment and CD4 monitoring. They will be trained to provide
focused wellness and adherence counseling to patients co-infected with TB and HIV. Staff working within
clinic-based TB programs will be trained in integrated TB/HIV management and reporting, including
provision of cotrimoxazole. Staff at NGOs will be trained to screen for TB in community settings and provide
community-based wellness training, dual testing for TB/HIV, and household adherence support for TB/HIV.
ACTIVITY 2: Increase screening of TB in all HIV-related settings including community
This activity will provide technical support for counselors, community workers and nurses to routinely screen
for TB in PMTCT, CT, palliative care and ARV services using a simple symptom-based screening tool.
ACTIVITY 3: Mentorship and supervision of staff
Mentorship and supervision of staff will provide integrated active case management of TB/HIV with
multidisciplinary service provision in palliative care and ARV services where required. Staff will be assisted
to integrate all patients with TB/HIV into comprehensive HIV management services with contact tracing,
screening and partner/family testing encouraged as standard of care. Sites will be assisted to provide
cotrimoxazole to all TB/HIV clients.
ACTIVITY 4: Linkages and referrals
McCord/Zoe Life will assist in strengthening linkages and referrals to ensure full range of HIV care and
treatment services (including extrapulmonary TB) are available without loss of continuity of care or patients
lost to follow-up.
ACTIVITY 5: Development of workplace program and mobile clinic
Staff and employees participating in the HIV workplace program will be trained to understand the link
between HIV and TB. Employees accessing the workplace CT services will be screened for TB by history
and symptom screening. Occupational nurses will be trained to screen for TB per protocol in the
management of HIV. Additional funding will be sought to equip a mobile clinic with a mobile x-ray machine
and microscopy. This unit will be used to provide TB and HIV screening and diagnosis to all workers
accessing the workplace wellness program. Funding will be sought through industry and international
funding to purchase this equipment which is vital to managing TB in the workplace. Until this is a reality,
linkages between workplace programs and referral centers for treatment will be established. Where
possible, TB treatment will be initiated onsite and TB rates reported to the district TB program.
ACTIVITY 6: Development and strengthening of M&E system
An M&E system should have the capacity to track HIV-infected clients receiving TB treatment, to ensure
tracking of visits, active case management and retrieval of TB patients. The system will require
strengthening of linkages between the municipal clinics, the Durban TB clinic and the DOTS workers. A
patient-held record for communication between health facilities will be used in conjunction with the
pharmacies and providers at the health facilities to ensure continuity of care in all services.
ACTIVITY 7: Sharing best-practices
McCord/Zoe Life will engage with provincial and district TB coordinating bodies to share best-practices to
improve services. This includes revisiting diagnostic algorithms, accessing funding to pilot better diagnostic
testing algorithms and expanding treatment centers.
ACTIVITY 8:
Staff will be trained and technical support provided to implement sustainable and affordable infection control
policies and measures within each environment.
Sustainability is addressed through development of integrated services within existing public health
facilities, establishment of linkages and referral pathways making access to diagnosis of TB easier, and
through cost sharing in workplace programs.
Through integrated TB/HIV services, McCord Hospital/Zoe Life expects to increase provider-initiated HIV
testing through the municipal TB services to all TB patients, expecting 40-60% of TB patients to be HIV
infected. Any HIV-infected client on TB treatment will be offered the full spectrum of palliative care services
and be referred to for ARV services according to provincial treatment guidelines. All HIV-infected clients will
be screened for TB. It is expected that 20% of all HIV-infected clients will require TB treatment. In the NGO
setting the goal is to increase community-based referral for TB screening, adherence support and
Activity Narrative: strengthening of referral systems. In the workplace, the goal is to increase workplace screening, diagnosis
and treatment of TB in the HIV workplace program through mobile onsite services.
The McCord Hospital activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year
Strategic Plan by strengthening the public sector and expanding access to care and treatment.
Continuing Activity: 14008
14008 7910.08 HHS/Centers for McCord Hospital 6683 4625.08 $167,810
7910 7910.07 HHS/Centers for McCord Hospital 4625 4625.07 NEW APS 2006 $144,000
Estimated amount of funding that is planned for Human Capacity Development $15,000
Table 3.3.12:
McCord Zoe-Life (MZL) activities will strengthen the linkages between sites that offer care and treatment,
and programs that offer traditional OVC services. The aim would be to integrate and streamline services,
and ensure that orphans and vulnerable children are tested for HIV in a timely manner and receive quality
care and treatment at the most appropriate facilities including the community. Emphasis areas include:
development of referral systems between traditional clinic-based programs and OVC services and local
organization capacity development.
A major challenge in HIV care and treatment is the very specialized and vertical manner in which children
and especially orphans and vulnerable children are managed. Organizations that predominantly support
care and treatment are often not aware of organizations focusing on OVC programs and vice versa. OVC
programs are often not aware of clinical and psychosocial best practice with regard to care and treatment,
nor are they equipped to advocate for the best quality services for OVC. Caregivers are often not kept up to
date with best practice and are often not emotionally or practically supported to provide the best quality care
to the children they support. Facility-based services do not link with the community or OVC programs very
effectively.
This is a new program area in which MZL will attempt to bridge services with an OVC focus to clinical and
psychosocial care. MZL would like to start working with 3 models: one clinic linking with Big Shoes
(children's home), one clinic or NGO linking with a curriculum-based OVC intervention (iThemba Lethu) and
one NGO supported by this funding, linking with its community OVC activities.
ACTIVITY 1:Case Finding
As part of case finding to engage infected children with care and support services, ZL will partner with two
local organizations that are involved with OVC activities. These are iThemba Lethu (iTL) and Big Shoes
(BS). iTL is a local organization which offers a curriculum-based prevention program in several local
schools. The focus is on HIV prevention, life choices, delay of sexual debut and community strengthening
through support of teachers, economic empowerment of parents and strengthening parenting skills,
particularly among men. ZL would seek to partner with iTL to provide testing to children within the school
context, provide training to iTL Youth Workers to equip them to provide appropriate referrals for care and
treatment, and to provide ongoing psychosocial support to children with HIV. BS operates within the context
of children's homes. ZL will partner with them to assist with case finding. ZL will also engage with OVC
programs which operate within close proximity to the NGOs and clinics which are supported by this funding
in order to support testing through either training to test or through direct testing of children.
ACTIVITY 2: Psychosocial Support
ZL will offer an outcomes-based psychosocial support program for HIV-infected children and their
caregivers at the clinics, children's home and community-based program. This will aim to link the clinic and
community-based programs. Linkages with OVC organizations that operate near the clinics or NGOs
supported by this grant will be created so that OVC facilitators and caregivers can be mentored to provide
similar psychosocial support within their programs or communities. The support program will offer
caregivers and volunteers quality updated information about the clinical care of HIV-infected children linked
with CIMCI goals, as well as psychosocial care which would include assistance to help with disclosure and
stigma, nutritional needs, understanding how to give medications, developmental screening and emotional
needs.
ACTIVITY 3: Increasing Caregiver Capacity
Caregivers of OVC attending the outcomes-based psychosocial support programs who are not able to read
will be linked with an adult literacy program (Operation Upgrade) which operates locally. This is essential as
caregivers are often not able to read medication labels, nor are they able to access the resources which
could assist them to provide quality care to the children. In addition, they are not able to read patient held
clinic records. Linkages with literacy programs will assist to ensure a better quality care and more consistent
clinical care from the caregivers. It will have a secondary effect on the cognitive development of the child as
the caregiver may be able to engage more actively in the schooling of the child. In addition to this, literacy
classes also address other issues such as clean water, starting small businesses, parenting, growing
vegetables, and reading to children. These all contribute to strengthening community-based responses and
leveraging additional resources to ensure that this happens.
ACTIVITY 4: Coordination of Care
ZL seeks to improve linkages, referral systems and case management of children between the clinics,
NGOs, and OVC partners. To facilitate this, a multidisciplinary team meeting will be encouraged at each
facility where a working partnership has been developed (clinic/NGO/OVC/Community) Infected children
should each be assigned a case manager to encourage accountability and quality of services. Cases will be
managed as a team, integrating facility-based recommendations with community-based recommendations.
Monitoring and Evaluation (M&E) methods will be developed that ensure tracking and geographical
mapping of children and their care pathways. Use of electronic hand-held devices to simplify M&E as well
as to access information about medications, referral centers and Community-Based Integrated
Management of Childhood Illness (CIMCI) goals will be explored as an integrated and simple way to
achieve service tracking, quality services and program M&E.
ACTIVITY 5: Mobile Services
Activity Narrative: Where possible and needed, the mobile clinic used predominantly by the Workplace program funded in this
grant may be used to provide clinical services to OVC in the community. This would be to optimize the use
of the mobile vehicle and to address OVC needs in the short term.
ACTIVITY 6: Nutritional Support
A. ZL will develop and implement a nutrition screening tool for use within OVC settings (psychosocial
support groups, school OVC programs and community OVC partners) to ensure anthropometric
assessment and appropriate interventions.
B. ZL will provide technical support to access micronutrient supplementation for nutritionally compromised
HIV-infected OVC patients where possible.
C. ZL will develop guidelines for OVC-based staff as well as training courses and resources to provide
integrated nutritional assessments and counseling for OVC.
ACTIVITY 7: Gender
Gender will be addressed by providing a safe environment for vulnerable girls to be given access to
accurate information and access to testing, care and PMTCT services where needed. Psychosocial support
groups will provide and environment in which boys and girls will be able to receive counsel around sexual
choices and to reinforce that girls have choices with regard to sexual coercion.
Estimated amount of funding that is planned for Human Capacity Development $2,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $2,000
Table 3.3.13:
Care and Treatment Scale-up: The stark reality, as one scales up counseling and testing (CT), is that there
are insufficient programs which offer care and support or antiretroviral (ART) to ensure that the HIV infected
clients access care. The greatest challenge is to ensure that, as testing increases, so does the capacity of
the facility to care for the clients and for the overburdened healthcare workers (HCWs). In an attempt to
increase access to care and treatment, Zoe Life (ZL) will increase support to more sites, with the intention of
supporting CT as a way to engage infected clients with quality care and support programs. ZL will not focus
on increasing numbers counseled and tested, to the detriment of the facility or the client, but will rather
assist facilities to identify the optimum numbers to be counseled and tested which can then be supported by
that facility and its staff. It is clear that not much thought has gone into workforce or spatial planning at
facilities, and sites will be assisted by ZL to determine the proportion of time which should be spent by
HCWs on CT in relation to the ongoing psychosocial and clinical support of those tested positive and their
families. This is important in workforce planning and budgeting. Lessons learned will be shared with district
and provincial managers. ZL will continue to strengthen care and support programs at non-governmental
organizations (NGOs), in the community and in the workplace to ensure that patients testing positive have
access to care and treatment.
Human Resource (HR) Policy Strengthening: Sustainability is a major focus for FY 2008 and FY 2009. The
relationship between the eThekwini Municipality (eTM) and the district/provincial government
(DDOH/PDOH) is currently a barrier to sustainable CT services. DDOH currently only provides one
counselor post per eTM clinic to support CT. This configuration creates productivity challenges as the DOH
counselors routinely do not come to work, and when they become ill or die, they do not get replaced by the
DOH due to a 16 month moratorium on all posts. HR management is a problem as DOH counselors do not
see the need to report to eTM staff, and reporting channels are unclear resulting in unsupervised
counselors. The use of ZL counselors in these sites was meant to augment current CT and to initiate new
psychosocial services such as partner testing, patient literacy, adherence counseling and other services.
However, DOH counselors have almost completely relegated their CT responsibilities to ZL/PEPFAR
funded counselors. This is a serious barrier to the scale-up of services/sustainability. However, as CT is the
entry point to care and treatment, ZL and McCord Hospital will continue to support a counselor salary at
each site as an interim measure to ensure continuity of service provision and to continue to engender a
sense of partnership. However a larger percentage of time will be spent strengthening the HR systems
between DOH and eTM, advocating for more counselors at sites, and engaging in dialogue that aims to
create more efficient methods of service provision.
Human Resource (HR) Management:
A. Psychosocial support services: ZL will start the process of developing clear standard operating
procedures and standards relating to service quality with particular attention paid to psychosocial services
within the clinic and non-governmental organization (NGO) environment. KZN province currently employs
more than 2,500 HIV counselors. Most of the services provided by the counselors have no standard
operating procedures or service standards. Neither the quality of services provided nor the program
outcomes are currently measured due to lack of standards or operating procedures/ best practices.
Counselor mentors employed to mentor and supervise onsite counselors have no guiding protocols or tools
to make their work meaningful. ZL has considerable expertise and experience in the provision of
comprehensive psychosocial support services, and will begin to develop standards and tools to measure
and improve services, to assess the productivity of counselors and effectiveness of the program, and to
guide the processes of supportive supervision by counselor mentors.
B. Supportive supervision and mentorship: The concepts of mentorships and supportive supervision are not
commonly understood in the South African public health environment. Nor are the benefits of this approach
accepted. In FY 2007, ZL started internal use of this system and has found that ZL staff struggle with the
concepts. This is due to both lack of exposure as well as lack of skills. In FY 2008, ZL will collaborate to
develop a locally appropriate training resource to develop skills and tools in supportive supervision and
mentorship. This will be piloted internally and with participating municipal clinic supervisors. ZL will work
closely with the provincial DOH and district mentors to ensure buy in and practical input during this process.
ZL will advocate for DOH budget to be allocated to training of all district mentors once the resource has
been developed.
Workplace Program: ZL would like to explore expanding its workplace program to other parts of the country.
This is one program that is not entirely dependent on geographical relationships being built. National
companies that have accessed our workplace program services have requested that services be offered in
other parts of the country. ZL has started developing relationships with organizations who could link with
the workplace program in the Western Cape. If this is financially viable, and referral linkages can be
ensured, ZL will explore this option further in discussion and with the approval of the activity manager.
Gender will be addressed by 1) increasing access to partner testing through offering CT services after hours
and increasing exposure to partner testing importance; 2) increasing access to working men through the
CT services offered as part of the workplace program; and 3) increasing disclosure counseling and couple
counseling as a part of CT.
--------------------------
McCord Hospital and Zoe Life (McCord/Zoe Life) aim to increase capacity to expand integrated counseling
and testing (CT) services within the framework of a comprehensive HIV care and treatment program in
seven sites: four municipal clinics and three non-governmental organizations (NGOs). Capacity will be
developed by (a) training voluntary lay counselors at the NGOs to provide best-practice services; (b)
mentorship of NGO and municipal counselors and clinical staff to provide integrated, provider-initiated CT
Activity Narrative: services; and (c) strengthening continuity of care post-CT through referral of HIV-infected clients by
counselors to the HIV care and treatment services. The emphasis areas are the development of referral
systems between vertical programs, human resource support, development of a training curriculum aimed
at CT of children, strengthening the local organizational capacity to increase CT services, quality
improvement, supportive supervision, and in-service training of staff. Specific target populations are the
general population, refugees and internally displaced persons (through the KHWEZI AIDS Project in central
Durban), and workers within the business community. Counseling and testing will be provided in French and
Swahili in the KHWEZI AIDS project to reach refugees and asylum seekers from Central and West Africa
who currently reside in the Durban area.
McCord Hospital receives funding for prevention of mother-to-child transmission (PMTCT) and antiretroviral
treatment (ART) treatment through the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). This program
described here focuses on strengthening the capacity of public sector facilities, and it is distinct from the
hospital-based program funded by EGPAF.
Counseling and testing is the entry point to prevention, care, treatment and support of HIV-infected persons.
If access to care and treatment is to be accelerated, then access to CT should be aggressively pursued. In
KwaZulu-Natal, lay counselors in municipal and local health authorities have traditionally provided a stand-
alone vertical service to persons requesting HIV testing. Uptake of CT services has largely been a result of
the PMTCT program, with referral from other programs (sexually transmitted infections (STI) and
tuberculosis (TB)) and self-referral contributing a small percentage to the uptake of CT. In the NGO setting,
patients are largely referred for CT from community health workers who suspect advanced HIV disease.
Thus, apart from PMTCT where CT is provider-initiated, clients who are already symptomatic with AIDS and
who require a definitive diagnosis and ARV treatment request the bulk of CT services.
The emphasis of this new project would be to shift the trend of voluntary counseling and testing (CT) to a
universal, provider-initiated opt-out service designed to increase uptake of services and to promote early
diagnosis of HIV while patients are still well enough to access wellness and health promotion services. This
project would also emphasize increasing opportunities to counsel and test children. In addition to increasing
uptake of CT, this project seeks to ensure that clients who learn of their HIV status will be seamlessly
integrated into care, support and treatment services. Lastly, this project seeks to take CT into the business
community to workers who would not otherwise have an opportunity to be counseled and tested. The
KwaZulu-Natal Department of Health (KZNDOH) supports these activities. Activities within the municipal
clinics will be undertaken with the support of the eThekwini (Durban) Municipality. Gender issues will be
addressed by taking CT services into the business community, where many employed men have no access
to services. In addition, counselors will proactively encourage partners of women tested in PMTCT services
to access testing. Where possible, the technical support team will investigate the possibilities of extended
hours of CT services to include weekends or evenings.
McCord/Zoe Life will work with three NGOs currently providing psychosocial support to HIV-infected clients
in their communities using voluntary lay counselors. These voluntary lay counselors have been trained by a
variety of organizations. In order to standardize the quality of counseling which will be offered through this
project, McCord will train all participating lay counselors. Training will be conducted over 10 days according
to the South African national counseling guidelines (minimum standard). Lay counselors employed by the
four municipal clinics will have benefited from the 10-day training course as a pre-employment requirement
and will not require further training in CT. Staff from all seven sites will be trained in CT of children to
increase confidence and skill in this area. Counselors will be trained to conduct pre- and post-test
counseling with caregivers and children where appropriate. Clinical staff will be trained in testing of children,
which includes skills to draw blood from small children or babies. This is currently a barrier to widespread
testing of small children outside of a hospital setting. Counselors who have not already had exposure to
training in couple counseling will be trained and urged to encourage partner or family attendance at clinic or
NGO activities with the view of encouraging testing and other palliative care services.
In addition, staff will be trained and supported to provide family centered counseling aimed at increasing
retention and improving case finding within families. Also, training will be provided to increase skills to
counsel and test children and adolescents in both the clinical and community/educational settings.
ACTIVITY 2: Workshop in Provider-Initiated Counseling and Testing Within a Multidisciplinary Team
All staff who participate in this project will attend a preparatory workshop on the concept, advantages and
implementation challenges of provider-initiated or opt-out CT services. During this workshop, the seven
sites will be assisted in formulating an approach to implementing provider-initiated CT or opt-out counseling
as an augmentation to their current services, which would include PMTCT, STI, TB, children's clinic,
immunization services. Staff will be assisted to include lay counselors into a multidisciplinary team that will
span across vertical programs. Staff will be assisted to develop referral systems that are effective and
ensure continuity of care between CT, HIV care and treatment and the other programs. Special attention will
be paid to increasing confidence in counseling and testing of children.
ACTIVITY 3: Technical Support to Implement Provider-Initiated or Opt-Out CT
All sites will be supported technically to implement provider-initiated or opt-out CT through weekly
mentorship of counselors and clinical staff, facilitation of multidisciplinary and inter-program referrals, and
problem solving. McCord/Zoe Life will assist sites to strengthen monitoring and evaluation systems linked to
CT. Information relating to the implementation of CT services will be reviewed and fed back to staff at the
Activity Narrative: sites for ongoing quality control and problem solving. Counselor mentors will monitor quality of counseling,
assist with complex cases and strengthen referrals. Clinical support will be given to staff that require
assistance with testing of children.
ACTIVITY 4: Human Resource Augmentation
In sites where uptake of CT exceeds the staff capacity, PEPFAR-funded counselors will be employed to
increase capacity whilst the organization motivates for increasing human resources from the KZNDOH or
from other funding sources.
ACTIVITY 5: Mobile CT
Mobile counseling and testing services will be offered to at risk populations or difficult to reach populations
such as unemployed, migrant or displaced peoples. These services will be provided as an outreach service
linked to the current sites. Sites' staff will be used to link population at risk or in difficulty with appropriate
ACTIVITY 6: Increase CT for OVC
Linkages with educational facilities and facilities housing orphans and vulnerable children will be
established and counseling and testing services will be offered to these facilities, either on site, or in
conjunction with the Zoe-Life/McCord sites, in addition to linkages with care and treatment services.
The McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa
Five-Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.
Estimated amount of funding that is planned for Human Capacity Development $6,000
Table 3.3.14:
MODIFIED ACTIVITY: Site Accreditation: Due to the relationship between eThekwini Municipality (eTM)
and the Department of Health (DOH), there is currently no service level agreement to support the
accreditation of eTM sites. This is also due to the fact that eTM does not procure chronic medications
through the DOH Provincial Medical Supply Centre (PMSC). Current accreditation criteria could never apply
to eTM sites due to the absence of pharmacies at eTM sites, as well as eTM policy issues. Zoe-Life (ZL)
and McCord Hospital (MH) will explore new accreditation criteria for eTM sites. This will not only enable
sites to initiate antiretrovirals (ARVs), but will also lay a foundation from which other local governments in
the country can base their accreditation criteria.
NEW ACTIVITY: Procurement planning:
MH will work closely with the DOH, PMSC and the Financial Director of HIV AIDS STD and TB Unit (HAST)
to assist with budgeting relating to decentralization. Provincial and District budgeting with regard to
provision of ARVs has been poor, resulting in capping of ARV budgets for many hospitals. This is a real
barrier to sustainability and scale up of decentralization. Through regular contact, feedback, training and
relationship building at provincial and district level, MH will ensure that adequate budget is allocated to the
decentralization processes.
NEW ACTIVITY: TRAINING - Dispensing Licenses:
As new sites become ready to provide ARV treatment, nurses will not only require clinical skills, but also
dispensing licenses according to legal requirements. This was not taken into account in COP 2008 due to
unclear legislation. All nurses involved in ART provision at the primary care level supported by this program
will require a dispensing license, which requires training at an approved institution.
GENDER: ZL will ensure that men in the workplace have access to ARV drugs through addressing policy
regulation that would allow provision of ART through the workplace program. Access for women will be
expanded through prevention of mother-to-child transmission (PMTCT) and through supporting the systems
to provide ART at non-governmental organizations in the communities
------------------------------------
McCord Hospital and its implementing partner, Zoe Life (McCord/Zoe Life) will support and provide
technical assistance in the delivery of antiretroviral drugs (ARVs) to patients at seven sites - four municipal
clinics and three non-governmental organizations (NGOs). The activity will also extend to participating
industry sites for workers without medical insurance in Durban, KwaZulu-Natal.The emphasis areas are
human capacity development, local organization capacity building, and workplace programs. The primary
target populations are the general population, refugees and asylum seekers, and business community.
Refugees and asylum seekers are an important target group, as they cannot access free antiretroviral
treatment in the public sector.McCord Hospital receives funding for prevention of mother-to-child
transmission (PMTCT) and antiretroviral treatment (ART) through the Elizabeth Glaser Pediatric AIDS
Foundation (EGPAF). The program described here focuses on strengthening the capacity of public sector
and NGO facilities, and it is distinct from the hospital-based program funded by EGPAF. Note: EGPAF will
also be supporting a similar program in three Department of Health (DOH) clinics in the northern sub-district
of Durban.
This new project will be implemented by the McCord/Zoe Life team in partnership with the eThekwini
Municipality (Durban), three NGOs and private sector sites, to decentralize antiretroviral treatment (ART)
provision to primary healthcare settings. Stable patients initiated on ART at local hospitals will be referred to
the above sites for ongoing follow-up and for monthly ART dispensing. New stable patients will be initiated
on ART at the decentralized sites and continue follow-up and ART dispensing at these sites.McCord
Hospital currently dispenses ART to approximately 2,000 patients, and has now become an accredited site
with the KwaZulu-Natal Department of Health (KZNDOH), which will ensure long-term sustainability of ARV
drug supplies. The KZNDOH is committed to increasing the number of patients provided with ART in the
province. The project described here to support public sector and NGO sites is supported by the
metropolitan and provincial health departments. KZNDOH ARV guidelines will be used in the provision of
ARVs wherever appropriate. Gender issues will be addressed through increasing access to ART in workers
(assuming most are men) in a workplace program, and by ensuring that a family-centered treatment
approach is offered to partners and family members of index patients via access to couple counseling,
community-based referrals, provider-initiated palliative care for partners and active case management of
families. The project will also increase access to ART for refugees.There will be links between ARV use
data and laboratory and clinical data for overall program improvement.
ACTIVITY 1: Site Accreditation
McCord/Zoe Life will support a process of site accreditation at four metropolitan clinics through negotiation
with the metropolitan and provincial health departments to ensure sustainability and ongoing provision of
ART drugs to these sites. Once the sites are accredited, they would be able to access ARVs through the
ACTIVITY 2: Accreditation Guidelines
McCord/Zoe Life will assist the KZNDOH to develop accreditation guidelines for NGOs and workplace
programs to ensure ongoing provision of ART to these sites.
Activity Narrative: ACTIVITY 3: ART to Decentralized Sites
This activity will support and strengthen systems on site to provide ART efficiently at decentralized sites.
This will be done through meetings with various stakeholders, particularly the provincial and district
pharmaceutical services, to look at the logistics and processes required to supply ARVs sustainably to
community-based sites.The McCord hospital pharmacy currently manages the ART supply chain for more
than 2,000 patients. This project will hire staff to expand this service to decentralized sites and to strengthen
current systems. ARVs will be selected from national regimens according to trends from previous
forecasting. Drugs will be procured, stored and regulated by the McCord Hospital Dispensary which is
registered as a hospital pharmacy, where necessary. Systems will be developed to procure ARVs for the
municipal clinics from their nearest ARV initiating hospital (RK Khan). As McCord Hospital is accredited with
the KZNDOH, ARVs will be ordered from and supplied by the central Department of Health Pharmacy. Two
month's buffer stock is stored.All drugs received by the pharmacist will be stored in the McCord Hospital
dispensary under the care of the pharmacists who adhere to good pharmacy practice conditions. Drugs will
be ordered twice a month. Systems are in place to select, procure, store, track and distribute the drugs
privately from alternative sources if there are stock-outs. Monitoring of purchases and distribution is done
both manually and electronically. If stock-outs (less than five days) occur, stock will be purchased from an
alternative source. Discussions will be held with the DOH pharmaceutical services as well as the local DOH
District office to evaluate the logistics required for ARVs to be supplied to clinics from DOH facilities - from
either the closest district hospital or a community health center, following the same process by which other
chronic drugs are supplied.A PEPFAR-funded pharmacist will liaise with the pharmacists at municipal, NGO
and industry sites to forecast ARV needs on a weekly basis. ARVs will be prepackaged for the
decentralized sites and delivered weekly to each site. Pediatric formulations will also be delivered to sites
weekly. The McCord/Zoe Life team will provide technical support to ensure that onsite storage and
dispensing systems are in place before ARVs are dispensed. Scripts will be written by dispensing nurses at
the decentralized sites and kept in a register in the pharmacy. In clinics without a pharmacy, drugs will be
stored in a secure cupboard. A register of scripts and drugs dispensed will be maintained at each clinic by a
senior dispensing nurse. Records will be captured in the logistics database on a weekly basis. Excess or
expired medicines are disposed of through a waste management company.Sustainability is addressed at
provincial level through accreditation of municipal sites and development of accreditation policies for NGO
and corporate sites.Human capacity development is strengthened through technical support and mentorship
of pharmacists and senior nursing staff at the sites to improve logistics management regarding ARV supply.
Staff will be trained in monitoring and evaluation to strengthen the efficiency of the systems, and to optimize
tracking of missed drug pick up, liaising with the multidisciplinary team who will follow up these clients.The
McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-
Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.
With FY2008 reprogramming funds, McCord/Zoë-Life will purchase additional antiretroviral drugs due to a
shortfall in the allocation from the KwaZulu-Natal Department of Health (KZNDOH) for drug procurement.
This is as a result of overspending by the KZNDOH in the 2007 fiscal year for HIV services; including
treatment (demand exceeded the funding available). This is an interim measure, and it is expected that the
full budget will be restored in the KZN 2009/10 fiscal year.
Estimated amount of funding that is planned for Human Capacity Development $11,000
Table 3.3.15:
McCord Hospital (MH) and Zoe-Life (ZL) will strengthen strategic information systems at both facility level
and health management level at eThekwini municipality (eTM) clinics, at 5 non -governmental
organizations, at organizations working with orphans and vulnerable children (OVC) linking with services
supported by MH/ZL, and in workplace programs. Emphasis areas are development of strategic information
systems which support data collection, patient tracking and referrals across vertical programs (CT, PMTCT,
TB/HIV), community programs and to secondary and tertiary facilities; local organization capacity building
(major emphasis); strategic information systems to support quality assurance, improvement and supportive
supervision; strategic information support to training programs; and strategic information systems to report
on and manage workplace programs. The primary target populations are the general population, people
affected by HIV and AIDS, refugees and the private sector (workers without health insurance).
Until recently, public health utilized strategic information at a very high level using aggregated data which
was not often used at facility or patient level. The HIV pandemic has highlighted the need for robust
strategic information systems to not only be in place, but to be used for policy making, systems
improvement, program management, workforce planning and indeed, individual patient management. The
millennium goals of the five ones carry a consistent theme of one monitoring and evaluation system which
will support the strengthening of services. In developing countries with no patient linked strategic
information systems, and outdated facility-based health management information systems (HMIS), it is
evident that there are multiple layers of strategic information development required in order to fill the data
gaps which are evident. Many of the data elements and source documents required for comprehensive HIV
care and treatment are available at hospital level and are functioning relatively well in an environment where
audit and technology are available and expected. At primary health level however, a different environment
exists where individual patient care is not the norm and technology or even paper-based systems to support
the HMIS required for comprehensive HIV management is not available. In addition, primary health
standards and procedures are not yet standardized for adults. Primary health care standards for children
with HIV have not linked with the integrated management of childhood illness (IMCI) strategic information
systems to form a combined HMIS. Without these systems in place at primary health care level,
comprehensive integrated management of people with HIV at community level will continue to be of
substandard quality and decentralization will cause more harm than good.
This project seeks to work on some of the strategic information gaps at primary health level and to develop
simple user friendly methods of integrating and using data.
SI will continue to be a focus for FY 2009. The following elements will be integral to the program:
ACTIVITY 1.
Program level data: ZL will continue to develop and implement an SI system within the eTM clinics which
will enable them to monitor and evaluate the implementation of new HIV services at their clinics. This data
will be in line with National Department of Health (NDOH) requirements. ZL will continue to feed data back
to eTM management for decision-making purposes. New in FY 2009 will be engaging eTM management in
the analysis and presentation of data. This is key to sustainability. It is vital that the eTM management own
the data, rather than the data being collected and presented by ZL. ZL will increasingly hand over
responsibility of the data collection, analysis and use to the eTM management so that they can start to
make program related decisions, including cost analyses and workforce planning. This will strengthen their
appeal to the NDOH for increased budget for HR and other requirements relating to implementation of HIV
ACTIVITY 2.
HMIS: Implementation of a paper-based HMIS at all facilities will be a priority in FY 2009. Lessons learned
during implementation will be documented, analyzed, and presented to both eTM and District/Provincial
Information Officers to assist with the District/Provincial scale up, as well as to encourage eTM to implement
in all their other clinics. If practical and appropriate, ZL will work with other stakeholders to develop an
electronic version of the HMIS.
ACTIVITY 3.
Other technologies: ZL will start to develop ideas and engage other stakeholders/partners with the idea of
developing an HMIS which integrates Adult, Pediatric integrated management of childhood illnesses (IMCI)
and TB care algorithms and M&E onto a hand-held PDA which can be used both in the clinics and NGOs as
well as in the community with GPS and GPRS functionality. The aim of the PDA would be to integrate care
and support prompts, patient tracking and scheduling, family coordination and data collection into a simple
tool which has internet connectivity for web-based data collection, text message reminders to clients, lab
connectivity for real time results, drug dispensing and ordering options and blended learning capacity. This
would be a significant intervention that would require a different funding source. However, lessons learned
during the implementation of the pediatric care and support, adult services, and HMIS scale-up will inform
the needs and possibilities with regard to this proposal and will be further explored in FY 2009.
ACTIVITY 4.
Psychosocial support services monitoring and evaluation (M&E): ZL will continue to develop standards,
procedures, tools and measurement protocols to bring qualitative measurement to psychosocial services
offered at facility and community level. Currently there are few measurement tools or indicators to measure
Activity Narrative: the effectiveness of the psychosocial support services, the program productivity or impact on client well
being and adherence to care/treatment. ZL will continue to develop this aspect of monitoring and evaluation
together with the District and Provincial Department of Health and other psychosocial providers. This, in
turn, will strengthen the health services through establishing a professional standard with regard to HIV
counselors and psychosocial service providers and will strengthen the case for a professional body for HIV
psychosocial service providers. The data which can be gathered from these tools and standards will assist
in workforce planning and budgeting at all levels.
ACTIVITY 5:
GENDER: Currently programming around gender has not been well informed by supportive evidence. ZL
will incorporate gender indicators into all aspects of M&E to inform program improvement and intervention
design. This will include trends relating to access of care by men, improvement in partner testing, and
reporting of sexual coercion by girls attending psychosocial support services.
FY 2009 will see a more significant drive towards eTM management taking over all data related activities
from ZL. This will require mentorship and training at a management level, advocating for budget from the
NDOH for eTM to employ data capturers at all eTM clinics, and integration of the eTM data systems with the
NDOH reporting systems for HIV. There will also be a need to strengthen IT support at the eTM. ZL will
provide IT training in Microsoft Excel and Access to equip eTM management to use data more effectively.
This strengthening will be to prepare for the possible use of an electronic HMIS used to enhance the paper-
based HMIS. ZL will explore the development of an electronic HMIS, or will use whatever electronic HMIS
that has been developed by the provincial Department of Health for use in HIV patient management.
Estimated amount of funding that is planned for Human Capacity Development $22,000
Table 3.3.17:
McCord Hospital (MH) and Zoe-Life (ZL) plan to leverage lessons learned, networking and internal
experiences to inform and strengthen the capacity of the South African government as well as leverage
other learning opportunities for non-governmental organization (NGO) service providers, to more effectively
provide increasing access to quality care and treatment services for adults and children. This will be
achieved through advocacy, management and leadership strengthening; human resource strengthening,
(supportive supervision, blended learning, quality assurance, and training); and organizational development
at the levels of local government (eThekwini Municipality-eTM), district Department of Health (DDOH) and
provincial Department of Health (PDOH). This strategy capitalizes on the strong relationships built over time
at each level of influence.
South Africa has emerged as a fledgling democracy in the wake of an explosive epidemic. Systems and
structures required to support this epidemic are still under reconstruction post-apartheid, and are dependant
on fully functional organizations with specialized human resource expertise to drive a consolidated and
efficient response to HIV/AIDS. The reality of the health system is that at no level is it able to contain or
manage the epidemic. Not from an infrastructural, organizational, human resource or political perspective.
In order to provide contained and effective management of patients within a crumbling reforming health
system, considerable planning, effort and resource is required to stabilize and equip the health system to
provide all the supporting and systemic services required to manage the epidemic. With a skills shortage at
all levels and financial and infrastructural constraints, it is important to capitalize on lessons learned, both in
the practical implementation of HIV programs and in other sectors that enable the health system and the
fragile state of human resources to remain intact and retain expertise into the future. This addresses the
critical question of sustainability of services, particularly with respect to the systems and staff required to
manage ever increasing numbers of HIV-infected patients entering the health system.
MH has a long history of service within KwaZulu-Natal (KZN) province, and has strong relationships with
many organizations and facilities providing services. These relationships and shared learning between
organizations will be harnessed. ZL has a strong innovative and implementation background, which drives
the desire to do things better, to improve or change systems, and to innovate solutions to the many
challenges of HIV care. ZL believes that sharing best practices, improving skills and strengthening systems
happens most effectively in an environment of strong relationships, ongoing support, and practical technical
assistance and training. In addition, ZL believes in setting service and performance standards which are
achievable and that can be monitored for the purposes of ongoing improvements.
In FY 2009, ZL/MH will continue to build on the foundations of good relationships, shared learning,
innovation, blended learning and performance appraisal to find the interventions, tools, skills and resources
that will make the biggest impact to service delivery at the organizational, facility, and community levels, as
well as at the level of defining strategic policy.
ZL/MH will carry out eight separate activities in this program area.
ACTIVITY 1: Advocacy
There are multiple levels of advocacy required which have been highlighted in each activity area. These
include pharmacy (discrepancies between pharmacy and nursing responsibilities with regard to dispensing
of drugs at the primary health level), counseling and testing (counselors being able to perform finger
pricking), human resource and sustainability (task shifting, provision of human resources by provincial
Department of Health to eThekwini municipality to support HIV services at sites). ZL/MH will work closely
with the provincial and district units as well as the eThekwini municipality and other stakeholders to assist
with this aspect of health systems strengthening.
ACTIVITY 2: NGO Organizational Development:
ZL will engage with local and international organizations to assist the PEPFAR funded NGOs to strengthen
their leadership and management capacity and build sustainability. ZL will work with the NGOs on a three-
year sustainability plan which will include financial and human resource sustainability as well as service
sustainability. This will be achieved through providing tools, skills training (HR, management, fundraising,
financial management) as well as facilitating linkages with potential supporters and sponsors. Currently
relationships are being built with SANGONET and Frank Julie, who are leading organizational development
specialists in South Africa, as well as ukuZwana Project Management Solutions.
ACTIVITY 3: Management and Leadership Strengthening
ZL will focus on relationship building at the management level within the eTM, district and provincial health
departments to ensure credibility. ZL will explore partnerships with organizations that provide management,
leadership support and training in order to leverage expertise to support leadership and management
through mentorship or training. Relationships are being established with Willowcreek and ukuZwana Project
Management Solutions, which will start to input in this area. The ZL training department will provide at least
one training opportunity in FY 2009 to eTM, district or provincial managers in collaboration with external
organizations. In addition, ZL will provide at least one training opportunity in teamwork and management to
all clinic and NGO leadership.
ACTIVITY 4: Human Resource Strengthening
During FY 2008 and FY 2009 ZL will continue the process of defining an expanded scope of practice of
Activity Narrative: healthcare workers (HCWs). This will start with HIV counselors and counselor-mentors and will extend to
enrolled nurses and community workers involved in HIV care. It will also include data capturers to support
career progression in the M&E field. This process will entail clear job progression and understanding the
expanded scope of practice, which includes task shifting.
ACTIVITY 5: Blended Learning
ZL recognizes the impracticality of traditional training with regard to HIV care and management. In order to
implement effective programs, training cannot occur as a once-off event. Training must be linked with
specific site needs and must be driven by the particular goals of service implementation, available human
resources, and individual training needs. Training must include regular implementation support and must
include integrated and practical components of M&E and management and change methodology. Whilst
ongoing training and onsite support is so vital, human capacity is limited. As a sustainability and resource
management priority, ZL will develop the concept of blended learning at four sites and attempt to source
funding for development and implementation. If funding allows, interactive materials will be developed for
use by all HCWs at sites. Training will be initiated with a short didactic component, which will also include
the use of the onsite training approach. Each site will be provided with a computer in a cubicle. Training will
be provided on a DVD. HCWs will be able to go through modules on site. Pre- and post-module
questionnaires can be completed onsite and stored on the computer for retrieval and analysis by ZL data
supporters. A training data base will be developed to monitor progress and inform support requirements.
Sites have the option of requesting specific support, and the ZL training team will be able to ascertain
whether this support can be offered via interactive onsite training modules, or requires a visit by a technical
support staff member. ZL will seek professional collaborations with institutions that have used blended
learning in order to share best practices. In this way, ZL seeks to minimize time away from work and
maximize the impact of onsite training, which should not be focusing on transfer of information, but on
supportive supervision and practical skills strengthening.
ACTIVITY 6: Quality Assurance/Psychosocial Support Services
Linked to human resource strengthening as described above, ZL will start the process of developing clear
standard operating procedures and standards relating to service quality, with particular attention paid to
psychosocial services within the clinic and NGO environment. KZN province currently employs more than
2,500 HIV counselors. Most of the services provided by the lay counselors have no standard operating
procedures or service standards. Neither the quality of services provided, nor the program outcomes are
currently measured, due to lack of standards and operating procedures. Counselor-mentors employed to
mentor and supervise onsite counselors have no guiding protocols or tools to make their work meaningful.
ZL has considerable expertise and experience in the provision of comprehensive psychosocial support
services, and will begin to develop standards and tools to measure and improve services and to assess the
productivity of counselors and the effectiveness of the program. It will also guide the processes of
supportive supervision by counselor-mentors.
ACTIVITY 7: Supportive Supervision and Mentorship
The concepts of mentorship and supportive supervision are not commonly understood in the South African
public health environment, nor are the benefits of this approach accepted. In FY 2007, ZL started internal
use of this system and has found that ZL staff struggle with the concepts. This is due to both lack of
exposure as well as lack of skills. In FY 2009, ZL will collaborate to develop a locally appropriate training
resource to develop skills and tools in supportive supervision and mentorship. This will be piloted internally
and with participating municipal clinic supervisors. ZL will work closely with the provincial HIV/AIDS/STI/TB
(HAST) unit and district mentors to ensure buy-in and practical input during this process. ZL will advocate
for DOH budget to be allocated to training of all District Mentors once the resource has been developed.
ACTIVITY 8: Workplace Wellness
- HIV Human Resources (HR) Policy: A representative proportion of ZL staff is HIV-infected. ZL has
grappled with the HR inefficiencies that do not allow for HIV-infected workers with low CD4 counts to
prioritize health seeking without losing sick and annual leave benefits. ZL will explore ways to improve HR
policy around management of HIV-infected staff with low CD4 counts to maximize employees' health
improvement rate without compromising productivity. This is a huge issue within the workplace environment
that requires urgent revision at a policy level. ZL will develop and implement an internal policy which can be
used as a pilot to inform legislation and companies seeking advice as part of the PEPFAR-funded
workplace program.
- Compassion Fatigue: In FY 2007 ZL began to look at baseline assessments with regard to compassion
fatigue in the clinics. In FY 2009 ZL will begin to develop interventions to address compassion fatigue and
will assess their success based on the baseline assessments. This will then serve as the basis for further
implementation in FY 2010.
- Quality Assurance and Career Progression Psychosocial Support Services: Once standards have been
developed for all psychosocial support services, ZL will develop an outcomes-based accredited curriculum
for counselors which will be accredited by the Council for Higher Education and provide an entry into an
undergraduate degree related to HIV. The modules will be developed to be integrated into the first year
subjects of either a degree in social work, psychology or education. This is a retention and integration
strategy and would ensure that if counselors left their posts to study further, that they would enter another
career with a strong HIV service background which would enhance the cross-cutting integration of HIV
- Supportive Supervision and Mentorship: After piloting a training resource and tools, ZL will advocate for
training to be provided to all KZN District Mentors and Mentor coordinators. ZL will also seek additional
funding to ensure that this takes place.
- Blended Learning: ZL will continue to seek opportunities, collaborations and funding to develop the critical
strategy of blended learning and to pilot this in a variety of settings.
- Workplace Wellness: Based on the results of the internal HR HIV policy, ZL will share lessons learned
Activity Narrative: and, if appropriate, engage in policy revision activities with relevant stakeholders.
All ZL activities will integrate gender by encouraging men to be responsible in child rearing and to respect
women. This will come through all trainings, particularly those focusing on leadership and management, as
well as in supportive mentorship messages. Workplace wellness activities will integrate gender by placing
special attention on women with children who need to access care and treatment services.
These activities contribute to the overall PEPFAR 2-7-10 goals through strengthening the health system and
the human resource element to provide quality health care management for individuals on treatment, to
avert infections and to provide services for people in care.
Estimated amount of funding that is planned for Human Capacity Development $39,000
Table 3.3.18:
