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:
Activities started in FY 2008 will continue in FY 2009. This includes the implementation of the new dual
therapy South African National PMTCT Guidelines, started in FY 2008 when the new policy was instituted.
Modifications Plans to Activity 3 in FY 2009:
There will be a focus on creating stronger referral links and support between St. Mary's Hospital and the
referral community clinics. The groundwork for this has already commenced as the hospital has initiated
partnerships with various non-governmental organizations (NGOs) and community-based organizations
(CBOs) and counselors in the community. This focus will also encourage mothers to attend antenatal clinic
support before or by 20 weeks. The hospital will make use of current therapeutic counselors and links with
NGOs and CBOs, and the school nurse in the community to achieve this objective. Antiretroviral treatment
(ART) for treatment-eligible pregnant women will be emphasized at community clinic level and if possible,
these patients will be referred to the hospital as soon as possible. It is important for the pregnant woman to
receive at least 4 to 6 weeks of treatment prior to delivery. This will be addressed in the training modules
for PMTCT staff at the hospital and the referral clinics. Education to encourage mother-to-mother support
and integrated management of childhood illnesses (IMCI) health education will be addressed at clinic
referral level. Greater emphasis will be placed on provider-initiated testing and counseling (PITC) to all
mothers attending the antenatal clinic at St. Mary's Hospital as well as in the referral clinics to increase the
number of pregnant HIV-infected mothers choosing dual therapy. A greater emphasis will be placed on
nutrition and micronutrient supplementation, at all referral clinics and at hospital level.
Human Capacity Development:
Funding will be allocated in FY 2009 to train PMTCT staff at referral clinic level to encourage mother-to-
mother support and peer group counseling. There will be a focus on nutrition, partner testing and
counseling, routine PITC, but more specifically health education in IMCI for therapeutic counselors and the
Department of Health community health-care workers. The objective will be for these trained counselors to
encourage health management of children in the community. St. Mary's has five nurses who are IMCI
trained and these nurses will be used in this capacity training.
----------------------------------------
SUMMARY:
St. Mary's Hospital in Durban, KwaZulu-Natal will aggressively address the need to prevent the
transmission of HIV from mother-to-child. St. Mary's is ideally situated and offers a wide range of services to
'capture' the target group to ensure success. This will be achieved through the integration of maternal
services at the primary health care facility. The activities will encompass human resources, laboratory tests
and medical supplies. The emphasis area of this activity is to provide counseling and testing to the family
unit and in particular there will be a focus on couple counseling. The ultimate aim is to reduce the number of
new infections from mother-to-child and to refer the mother into treatment programs when required. The
target groups for this activity are people living with HIV, pregnant women, and their infants.
BACKGROUND:
This is a new program activity funded in FY 2008, although St. Mary's has received previous PEPFAR
funding as a sub-partner to Catholic Relief Services (CRS). This activity is linked in with the counseling and
testing activity program. The program is supported by the South African Government as St. Mary's Hospital
has a service level agreement with the KwaZulu-Natal Provincial Department of Health and the Hospital is
in partnership with the District Office of the Department of Health to provide HIV and AIDS training to all
clinical staff over the next two years.
ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Routine HIV testing and counseling
The PMTCT program is based in the primary health care (PHC) facility that has an antenatal clinic. This is
the first point of entry for a pregnant mother (not in labor) to the hospital. It is at this point that the pregnant
mother will be counseled and tested using same-day rapid test results to establish her status. Provider-
initiated Testing and Counseling is currently the standard practice for testing in the entire facility. Women
who initially test negative will be offered a repeat HIV test during the last trimester in the pregnancy, and if
the mother is not tested at the PHC facility then the mother will be tested at the hospital when the mother is
in labor. Linkages and referral to the PMTCT program will occur at the primary health care facility as well as
from the midwifery and obstetrics unit in hospital. The overall objective of this activity is to routinely counsel
and test as many pregnant mothers as possible so preventative prophylaxis will be offered to the women
and their infants. Counseling and testing in hospital at labor and delivery will also be a focus as some
mothers are referred from community clinics and have not attended the antenatal clinics sessions on site.
Partner counseling and testing will also occur at the primary health care facility as well as in the hospital. In
addition attention on TB screening will occur at all levels of health care for the mother. A group of six
PMTCT counselors based at the PHC facility and in the hospital will be trained extensively in PMTCT and
pediatric ART to ensure that the goals of this activity are achieved. Government counseling and testing
protocols will be adhered to. The expected results of this activity are to: (a) create a culture in which all
people regularly seek counseling and testing for HIV; (b) provide preventative treatment to mothers for their
unborn child; and (c) the subsequent follow up and support for the family unit post-delivery.
ACTIVITY 2: The provision of ARV prophylaxis and post-delivery support
The provision of ARV prophylaxis dependent on the CD4 count of the mother will be in line with the South
African Guidelines, which currently include single-dose nevirapine (SDNVP). However, when the guidelines
Activity Narrative: change to include dual therapy, St. Mary's will change its protocols. Single-dose nevirapine will be provided
to pregnant mothers that have a CD4 count of 200 and above and HAART to pregnant mothers that have a
CD4 count of below 200. ARV prophylaxis will be provided to pregnant mothers who test positive during
labor and who have not previously entered the PMTCT program at the PHC facility. PCR testing is
conducted at 6 weeks post-delivery and if these infants are born positive to mothers who entered the
PMTCT program, the children will be referred to the pediatric ARV program. This is an extension of the
PMTCT program. Similarly, the mother and partner will be referred post-delivery if necessary. Subsequent
PCR testing is conducted 6 weeks after cessation of exclusively breastfed babies, and formula fed infants
will be re-tested at 18 months to determine HIV status. Home-based visits will occur through the counseling
and testing activity program. St. Mary's Hospital is accredited as a baby-friendly hospital and the hospital
promotes exclusive breast feeding; however, other feeding options are discussed in the extensive infant
feeding counseling that is provided. A PMTCT therapeutic counselor will provide nutritional support and
counseling to the mother, mother-in-law and father of the baby. Infant formula is available through the PHC
facility on site as well as at the community clinic level. This is a service from the Department of Health. In
addition, one of the treatment activity plans is for the dietician/nutritional expert to provide ongoing
education to communities at clinic level. This educational support will be expanded to include pregnant
mothers and mothers post-delivery. In addition, the therapeutic counselors will visit mothers in the home
setting which is addressed as a counseling and testing activity program. Extensive counseling on feeding
options will be provided in the home setting.
The expected results of this activity are: (1) Prevent the transmission of HIV from mother to child; (2)
Effective referral and access to treatment programs if the child is born positive; (3) The referral and access
to treatment programs for HIV or TB for the mother and partner if necessary; (4) Additional home-based
support if required to the family unit to limit loss to follow-up, especially to those mothers that did not enter
the PMTCT program at the PHC facility; (5) Address referral links for care and treatment to St. Mary's
Hospital or other treatment centers.
ACTIVITY 3: Provision of support and guidance to referral clinics
The PMTCT program based at St. Mary's Hospital will work extensively with referral clinics in the area to
ensure that pregnant mothers from referral clinics will be afforded the same service as if they had attended
the PMTCT program at St. Mary's. The PMTCT training that will be afforded to the staff at St. Mary's
Hospital will be extended to the referral clinics to the PHC facility on site. This will be included in the
treatment activity plan.
These activities contribute directly to the overall PEPFAR 2-7-10 goals as HIV-infected pregnant mothers
will be identified, appropriately treated, cared for and supported. Family members affected will benefit
directly from counseling and support within the hospital environment as well as within the community setting
during home visits.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13831
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13831 12240.08 HHS/Centers for St. Mary's Hospital 6626 4760.08 $388,000
Disease Control &
Prevention
12240 12240.07 HHS/Centers for St. Mary's Hospital 4760 4760.07 New APS 2006 $300,000
Emphasis Areas
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $7,143
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $2,857
Economic Strengthening
Education
Water
Table 3.3.01:
St. Mary's Hospital in Durban, KwaZulu-Natal will attempt to address a prevention strategy through the
WHO/UNAIDS circumcision policy in adult males. St. Mary's is ideally situated as it is a hospital and the add
-on service of this medical procedure will not incur major costs. This procedure will be highlighted in the
ARV treatment clinic, discussions with partners of pregnant women in the antenatal clinic, the primary
health care clinic as well as through the school nurse visiting schools. The activities will encompass human
resources, consumables and medical supplies. The target group for this activity is adult men.
This is a new program activity funded in FY 2009. This activity is linked in with the counseling and testing
activity program. Currently the WHO/UNAIDS male circumcision policy has not received South African
government (SAG) approval, but is being reviewed. The hospital has a doctor who has been trained in male
circumcision with an accredited service provider. Once SAG policy is in place and approval granted (in a
letter from the Department of Health), activities will commence.
ACTIVITY 1: Counseling
Therapeutic counselors and counselors based in-hospital and at out-patient and primary health care clinic
levels will advocate circumcision as a preventative measure together with other preventative methods. This
will focus on emphasizing that male circumcision is not a "replacement" for other prevention interventions,
including correct and consistent condoms use; reducing multiple concurrent partnerships; and fidelity to a
single partner. The school nurse will also address this preventative method in schools. A men's clinic will be
open one day every two weeks at the hospital. General education regarding circumcision will be supported
to mothers in the PMTCT clinic setting as well as in children's ward which is in-hospital and at the primary
health care facility.
ACTIVITY 2: Medical Procedure
Medical procedures will be made available for those interested at the male clinic. A trained medical doctor
and a nurse will be available for the procedures. This will only be conducted once approval from the
Department of Health is received.
This activity contributes to the overall PEPFAR 2-7-10 goals in the prevention arena.
New/Continuing Activity: New Activity
Continuing Activity:
Program Budget Code: 08 - HBHC Care: Adult Care and Support
Total Planned Funding for Program Budget Code: $45,418,157
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
The vision for the PEPFAR South Africa Team for Adult Care and Treatment Team is to support the South African Government
(SAG) policies and programs to provide comprehensive HIV care and treatment services to all those in need. It is estimated that
currently 5.7 million people in South Africa are HIV-infected and that 1.7 million are in need of treatment.
The 2003 Comprehensive Plan for HIV and AIDS Care, Management and Treatment (Comprehensive Plan) states that its primary
aim is comprehensive prevention, care, and treatment for all in need with the target of universal access to antiretroviral treatment
(ART) over a five-year implementation period (2004-2009). The goals of this plan are reiterated in the new South African National
Strategic Plan for HIV & AIDS and STI, 2007-2011 (NSP).
The USG has contributed significantly to these goals and targets, and with the support of the PEPFAR program 550,000 people
are currently on ART in South Africa, and more than 1.4 million people receive appropriate care and support, including palliative
care. South Africa has exceeded its PEPFAR treatment target of 500,000 set for September 2009 one year early and continues
progress to meeting the care and support targets. The PEPFAR-funded treatment programs have maintained excellent retention
since implementation in 2004. Cumulatively, only 15% of patients started on ART have died, stopped ART, or were lost to follow-
up. Treatment and care partners are progressively improving their capacity to measure outcomes.
Only 13.7% of South Africans have access to medical insurance. The estimated 1.2 million people still in need of ART are
primarily dependent on the public sector for care and treatment services. The number in need will continue to rise, especially in
light of revised national guidelines raising the threshold for ART eligibility from a CD4 of 200 to 250.
Much more needs to be done to ensure that the ART coverage (currently estimated at 30%) comes closer to the targets set by the
SAG. Maintaining the estimated 550,000 people on treatment and reaching the additional 1.2 million who need ART requires
continuous investment in treatment services in South Africa.
The National Department of Health (NDOH) has allocated approximately $410 million USD for the implementation of the
Comprehensive Plan in FY 2009 (prevention, care, and treatment), mainly through conditional grants to the nine provinces.
According to the NSP Costing Plan, the total need for funding for ART alone in 2009 is $710 million for adults and an additional
$128 million for children (total $838 million), clearly indicating the need for additional funding and support to the SAG and civil
society. Much of this funding is directed to the purchase of antiretroviral (ARV) drugs, since all drugs for the public sector ART
program are procured and supplied by the SAG. The SAG also provides, in some instances, the ARV drugs for non-governmental
and private sector programs with PEPFAR funding other service components. The USG is ideally positioned to support the
implementation of the NSP by ensuring equitable access to quality HIV care and treatment through support to the SAG by
PEPFAR-funded partners. Other contributing donors to the care and treatment program include CIDA, Ireland DCI, DFID, EU, The
Global Fund, The Elton John Foundation, and several public-private partnerships. The USG meets with the major donors several
times per year in various fora to discuss activities, explore collaborations, and minimize duplication of effort.
Challenges are even greater for Care and Support (C&S), as the majority of SAG funding for HIV & AIDS is for ART-related
services. With the transition to a newly elected government in South Africa in FY 2009, it is envisioned that even greater
cooperation between the USG and SAG will allow for collaboration on key issues, including accelerating accreditation of facilities,
decentralizing care and treatment services to nurse-driven clinic level, and establishing better monitoring and evaluation indicators
and systems in the public sector.
In FY 2009, the USG will continue to use a minimum requirement for someone having received C&S, including palliative care,
which reflects a minimum standard of HIV-related services, aligning the program more closely to WHO standards. An HIV-infected
individual must have received at least one form of clinical and one other type of non-clinical care. For HIV-affected family
members, the minimum requirement would be that the individual receive services in at least two of the five categories of clinical,
psychological, social and spiritual care, and prevention services. While quality is very difficult to measure through routine
indicators, this reinforces the message that PEPFAR is not simply interested in counting the number of people reached, but trying
to reach individuals with appropriate and quality care.
South Africa has a generalized mature HIV epidemic, and HIV care and treatment services are required across the entire
population, though population-based data has shown that the highest burden of HIV is in urban and peri-urban areas. The USG
utilizes prevalence information to direct its assistance to areas of greatest need, especially to ensure equitable access to ART for
lower-density rural populations. C&S is delivered at all levels including hospitals, clinics, workplaces, hospices, and home-based
programs in communities.
The key treatment priorities for the USG in FY 2009 are: 1) developing human capacity, especially at primary healthcare level; 2)
strengthening decentralization of HIV care and treatment, including building capacity for nurse-initiated ART; 3) improving
pediatric HIV care and treatment; 4) encouraging early identification of those in need for HIV care and treatment services (e.g.
provider-initiated counseling and testing (CT)); 5) CD4 testing for those that test positive and dried blood spot PCR; 6) integrating
TB care for HIV-infected clients, including screening and treatment; 7) continuing to strengthen the integration of treatment
programs within other health interventions (e.g., PMTCT, cervical cancer screening and reproductive health); and 8) reducing loss
to initiation of treatment of people that test HIV positive and loss-to-follow-up once on ART.
The key C&S priorities for the USG in FY 2009 are to strengthen quality HIV and AIDS palliative care service delivery and
implement standards of care. PEPFAR will support this effort by: 1) strengthening the integration of the basic care package and
family-centered services across all care and treatment programs for adults and children living with HIV; 2) increasing the number
of trained formal and informal healthcare providers, building multidisciplinary teams to deliver quality care with pain and symptom
control, and improving human resource strategies; 3) building active referral systems between community home-based caregivers
(CHBC) and facility services; 4) developing quality assurance mechanisms, including integration of supervision systems and
standardization of services and training; and 5) translating national policy, quality standards, and guidelines into action,
particularly national adoption of the basic care package. PEPFAR partners will advocate for new national guidelines to improve
access to pain management including the authority for nurse prescription. In collaboration with SAG, FY 2009 funds will scale up
direct delivery of quality palliative care services.
All PEPFAR-funded care and treatment partners follow SAG standards, policies, and guidelines. The majority of care and
treatment partners are local entities, and in addition, the three Track 1 treatment partners will start to transition to local
implementing partners in FY 2009. The USG program continues to strengthen comprehensive high quality care for HIV-infected
and affected people by: 1) scaling up existing effective programs and best practice models in approximately 900 public, private,
and NGO sites in all 9 provinces; 2) providing direct care and treatment services through prime partners and their sub-partners; 3)
increasing the capacity of the SAG to develop, manage, and evaluate care and/or treatment programs, including recruiting
additional health staff, training and mentoring health workers, improving information systems, conducting public health
evaluations, and infrastructure assistance; 4) increasing demand for and acceptance of ART through community mobilization; 5)
ensuring integration of ART programs within palliative care, TB, reproductive health, STI, and PMTCT services; and 6) assisting in
the accreditation of facilities for ART initiation.
Key linkages are made with prevention and wellness programs, which provide ongoing support for patients once they have tested
positive for HIV, including opportunistic infection (OI) management, cotrimoxazole prophylaxis, and prevention with HIV-infected
individuals. Care and treatment services are an ideal setting for formulating prevention messaging to HIV-infected clients and their
families. Wellness programs are linked to strong community programs, notably home-based care networks that extend care from
the facility level to the home.
Support for communications programs to improve demand for treatment and to improve treatment literacy remains an important
focus in FY 2009. These programs address health-seeking behavior among men and youth and strengthen prevention messages,
especially on concurrent relationships. The USG ascribes the high rates of adherence and retention in treatment programs to the
focus on treatment literacy and active community tracking and support.
Proposed care and treatment activities for FY 2009 include patient information systems logistic support for commodities and
pharmaceuticals and public-private partnerships to deliver ARV services at workplace settings and through private practitioners
serving the uninsured in remote areas. A significant contribution of PEPFAR-funded care and treatment partners to strengthen the
health system is to address the human resource needs in the public sector through different strategies, including consultancies
and secondments, national and international fellowships, internship and mentorship programs, and comprehensive clinical and
management training.
The USG supports a holistic, family-centered approach to HIV and AIDS care that begins at the onset of HIV diagnosis,
throughout the course of chronic illness, to end-of-life care. In order to ensure that all HIV-infected clients have access to basic
care services and to minimize loss to initiation (currently at about 70%), PEPFAR partners will provide a basic package of services
for all HIV-infected individuals. This package will include acceptance of status, disclosure, partner counseling and testing,
prevention with positives (PwP), psychosocial support, nutrition counseling, pain assessment and referral, treatment literacy and
adherence counseling, and outreach services to trace clients who have defaulted from the program. Emphasis will be placed on
ensuring that HIV-infected individuals, who are eligible, receive cotrimoxazole as per national guidelines. This package of services
will be offered at community level through support groups. These support groups (primarily run by PLHIV) will serve as a link
between the health facilities and the community to ensure a continuum of care. Counseling and testing sites will refer all clients
testing positive for HIV to the support group in their area.
Human capacity in the health-care system is under strain, and coordination between public and private sectors and facility and
community-based care remains fragmented. FY 2009 investments will result in an improved continuum of clinical, psychological,
spiritual and social care, and prevention services for PLHIV. The NDOH leads and coordinates national efforts to advance
palliative care. Partnering with the NDOH at all levels, the PEPFAR partners will continue to support the integration of
standardized quality palliative care services into primary healthcare and build HIV-related care services into CT, TB, ART,
PMTCT, and prevention programs, as well as reproductive health services, STI sites, workplaces, and CHBC sites, including for
OVC. This will build on previous investments in supportive care to improve access to preventive care and basic clinical care
services for PLHIV at the community level.
The minimum care standard for facilities includes the following elements of the preventive care package and other essential care
interventions, including: 1) prophylaxis and treatment for OIs, per national guidelines, cotrimoxazole prophylaxis for stage III-IV
disease, CD4<200 or HIV-exposed/infected children; TB screening and management; isoniazid preventive therapy in selected
sites, and candidiasis screening and management where the Diflucan/Flucanozale partnership exists; 2) CT to partners and family
members; 3) nutrition counseling, clinical measurement and monitoring, micronutrient support according to WHO guidelines, and
wrap-around support; 4) STI care; 5) routine screening and management of pain and symptoms; 6) child survival interventions for
HIV-infected children (e.g., immunizations, growth monitoring, and infant/young child nutrition); 7) integrated PwP strategies
including messaging, condoms, support for disclosure, referral for family planning, PMTCT services, ART adherence education,
leading healthy lives, reduction of risk behaviors, and reduced rates of HIV transmission; 8) provision of at least one element of
psychological, social, or spiritual care, or prevention services; and 9) referrals for other services.
The minimum standard for services at CHBC levels include messaging, mobilization, and referral (with follow-up) for the above
mentioned services plus routine screening of all PLHIV and their family members (including OVC) for OI, TB, symptoms and pain,
prevention messaging and condom provision, personal hygiene strategies to reduce diarrheal disease, and distribution of
insecticide treated nets where appropriate. Home and community settings often facilitate delivery of a more comprehensive
response including the provision of bereavement care, household support, and community group meetings. PEPFAR partners will
continue to strengthen adherence to national standards with emphasis on relief of pain and symptoms and the provision of
culturally appropriate end-of-life care. The package of services at facility and community levels also includes medication
adherence support for ART, TB, and OI. At all levels, attention will be given to increasing gender equity in accessing HIV and
AIDS programs, increasing male involvement in community programs, reaching pediatric patients, addressing stigma and
discrimination, and building partnerships with local non-governmental and faith- and community-based organizations.
Table 3.3.08:
Activity 1:
St. Mary's will take a more focused approach to the training of therapeutic counselors (TCs) to assist in the
community with clinical staging of patients requiring care, support and possible treatment. Training will also
be provided to non-government organizations (NGOs) and community-based organizations (CBOs) to
provide ongoing support in the home and referral to the hospital if and when required.
A family-centered approach will allow for early identification of infected and affected adults and children in
need of care and support. Retention of patients in care and support services is essential and TCs,
counselors and community healthcare workers will be made aware of their role and responsibility to
continuously support and if required refer patients to clinics or St. Mary's Hospital.
TCs will be trained in basic palliative care and TB screening, which will also allow for a more efficient up and
down referral system between the hospital and the community clinics, as well as enhance the support
service offered to the patient in the community. There will be a need to integrate services with other service
providers that have been identified and trained to offer other services that the TCs may not be able to
continue with. The need to establish support groups at community clinics churches or with NGOs and CBOs
will be important as the basic care package has to be provided in order to retain the patient for antiretroviral
(ARV) treatment in the future. Preventative interventions such as testing of sex partners and the children of
those HIV patients in care, disclosure of HIV status to sex partners, adherence interventions will be
emphasized when patients are visited in the home.
Activity 2:
There will be no emphasis on the caesarian birth budget in this programmatic area, but this will be
addressed in a limited way in the Prevention of Mother-to-Child Transmission (PMTCT) programmatic area.
There will be an aggressive focus on the use of cotrimoxazole for all HIV-infected patients. There is
currently a national shortage of cotrimoxazole but children, HIV patients with a CD4 count under 100 and
HIV-infected patients that are co-infected with TB will receive preferential treatment. The patients would
continue with this treatment until the patient has reached two consecutive CD4 results above 200. Should
this national shortage persist, this strategy will also apply in FY 2009. Nutritional support will be provided to
those in-patients requiring this support.
Special attention will be given to the integration of pain assessment and management within care and
support to all patients receiving palliative care.
-------------------------
St. Mary's Hospital in Durban, KwaZulu-Natal will implement palliative care activities that encompass human
resources, training and consumables. A dedicated palliative care team will identify and provide clinical,
spiritual, psychosocial, social and preventive support to the HIV-infected client and family. A hospital-wide
education program will be initiated to enhance knowledge of palliative care practice. In addition a number of
consumable items will be purchased to assist in managing pain and symptoms related to HIV and AIDS and
ensuring comfort of people living with HIV (PLHIV). The emphasis areas of the project are related in
particular to human resource support for the palliative care team, training, commodity procurement and the
development of networks/linkages/referral systems. The primary target population is pregnant mothers,
children, adults infected with HIV and AIDS; family members affected by HIV and AIDS and healthcare
workers.
This is a new program funded since FY 2007, although St. Mary's has received previous PEPFAR funding
as a sub-partner to another PEPFAR partner, Catholic Relief Services. The project is an expansion of the
current palliative care program that functions at St. Mary's Hospital. The hospital, established in 1927,
serves a peri-urban/rural community of 750,000 people, a third of which are HIV-infected. The community
has a high unemployment rate of around 60% and an estimated 25,000 people in the community require
ART. On an annual basis approximately 3,000 of St. Mary's inpatients require palliative care support,
35,000 require palliative care, and over 2,500 patients are currently in HIV care at the hospital, who by
definition fall into the category of people requiring palliative care including ART adherence support.
ACTIVITY 1: Dedicated Palliative Care Team and Trained personnel to Ensure Delivery of Quality Services
The overall objective of this activity is to ensure that patients who require palliative care and their affected
families are adequately supported in the hospital and in their surrounding communities; including clinical,
spiritual, psychological, social, and prevention support. Patients and families requiring palliative care will be
identified in the inpatient, maternity section, outpatient and ART clinic and hospice care settings. The need
to expand to the wards dedicated to pregnant mothers is due to a high maternal death rate as a result of
HIV and AIDS. The Hospital's caesarian rate is increasing due to HIV and averages around 29%. It is
estimated that around 68% of the births at St. Mary's Hospital are from HIV-infected mothers. Activities to
address this are described elsewhere in the COP. The HIV-related services offered by the hospital and its
hospice service is based on the belief that the palliative care activity is central and automatically provides a
network of services, from counseling and testing, stigma reduction, integrated preventions services,
including prevention with positives, ART and adherence, counseling and support to the individual and
Activity Narrative: family, end of life care, referral to other organizations and continuous education and support thereafter to all
concerned. The palliative care team will work with other facility-based health providers to ensure that HIV-
infected adults and children in all facility settings are either provided or referred (with follow-up) for evidence
-based preventive care interventions which include the following: OI screening and prophylaxis (including
cotrimoxazole, TB screening/management), counseling and testing for clients and family members, safe
water and personal hygiene strategies to reduce diarrheal disease, HIV prevention counseling, including
prevention with positives, provision of condoms, referral for family planning services for HIV-infected
women, appropriate child survival interventions for HIV-infected children and nutrition counseling, clinical
measurement, nutrition monitoring and targeted support based on WHO criteria for severely malnourished
PLHIV. The package of services also includes basic pain and symptom management and facility-based
support for adherence to OI medications (including cotrimoxazole prophylaxis and TB treatment) and
antiretroviral therapy (ART). Community and home-based psychological support, stigma reduction
strategies and adherence support for OI medications and ART will be provided by therapeutic counselors
who are trained PLHIV, employed by the hospital that visit the patients and their families in the community.
Attention will be given to increasing the gender equity in the HIV and AIDS programs, increasing male
involvement in the program, addressing stigma and discrimination, and partnerships with local NGOs, FBOs
and CBOs. In addition to care for PLHIV, therapeutic counselors and hospital staff will also expand their
provision of psychological, spiritual and social support of affected family members. A complex referral
network to a number of organizations, inter alia the KwaZulu-Natal Department of Health, the Ethekwini
Metropolitan (Durban), other NGOs, the Highway Hospice, and the Dream Centre exists and is used on a
proactive basis. A dedicated palliative care professional nurse and pastoral care worker will manage this
activity, with additional involvement of other members of the palliative care multi-disciplinary team including
hospital doctors and nurses, a social worker and the community outreach coordinator. The palliative care
program is managed and administered via the organizational arrangements pertaining to the hospital itself
and relies on a multi-disciplinary team approach for service delivery.
Training & Volunteer Engagement: The program relies on both volunteer and fulltime qualified and
registered healthcare professionals who require technical support and training. St. Mary's hospice care
program is a member of the PEPFAR-funded Hospice Palliative Care Association (HPCA) who is supporting
St. Mary's with critical areas including staff training and clinical protocols so St. Mary's may meet the HPCA
accreditation requirements essential to providing holistic quality health care to patients. In FY 2007, St.
Mary's will scale up its palliative care training for all health professionals, volunteers and PLHIV therapeutic
counselors involved in palliative care service delivery with training materials from HPCA and from the World
Health Organization's (WHO) Integrated Management of Adolescent Illnesses (IMAI) program. All modules
of IMAI will be utilized, however, the IMAI module on palliative care which will be made available to all the
nursing students and staff at St. Mary's who will be directly involved in palliative care. Clinical protocols
designed and approved by the HPCA are used for support and clinical services for opportunistic infections
and pain assessment and management. St. Mary's has a number of partnerships with US universities and
interest and support from US-based volunteers. On average, four to six U.S. volunteers will be
accommodated by St. Mary's on a monthly basis (supported with non-PEPFAR funds). A relationship is
currently being explored to link in with an active OVC program in the area that cares for children at drop-in
centers in and around the community. St. Mary's will offer testing; counseling and treatment services; and
the OVC program will provide the ongoing adherence support for the children. All palliative care support
services will be offered by St. Mary's Hospital to children in care at the relevant drop-in centers
ACTIVITY 2: Commodity Procurement
Provision has been made for palliative care medications and commodities which directly improve the
comfort of PLHIV, including medications for appropriate pain and symptom control (additional morphine for
pain control, syringe drivers, anti-nausea medications, cotrimoxazole and other drugs for symptom control).
Provision for such palliative medications and supplies are included in this activity and are vital to the overall
success of the program. In addition there is a need to address some of the theatre requirements and
consumables associated with caesarian section births at the Hospital. Almost 30% of all the births (150
births per month) in hospital are non elective caesarian sectional births. The primary reason for this high
rate is due to the impact of HIV and AIDS in pregnant mothers. There is a steady increase in the number of
maternal deaths due to HIV and very sick mothers are too weak to deliver naturally. The affect of this is the
long stay of many mothers and their premature babies in the high care nurseries and palliative care medical
wards, post delivery.
These activities contribute directly to the overall PEPFAR objectives of 2-7-10 as HIV-infected people will be
identified, appropriately treated, cared for and supported. Family members affected will benefit directly from
counseling and support within the hospital environment as well as within the community setting during home
visits.
Continuing Activity: 13832
13832 8262.08 HHS/Centers for St. Mary's Hospital 6626 4760.08 $611,100
8262 8262.07 HHS/Centers for St. Mary's Hospital 4760 4760.07 New APS 2006 $500,000
Estimated amount of funding that is planned for Human Capacity Development $5,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $2,204
In FY 2009, the support and clinic capacitation for efficient down referral and transfer to community clinics
will be a priority. Together with other PEPFAR-supported capacitation programs in the area (RHRU and
McCord Hospital), St. Mary's Hospital has established a defined geographical area that the hospital has
committed to capacitate in order to address the down referral process. This geographical area consists of
eight referral clinics, one of which St. Mary's will assist to obtain full accreditation to initiate patients on
antiretroviral therapy (ART) in FY 2009. St. Mary's will ensure that clinics adopt a family approach to ARV
treatment and care addressing partner and family member identification and testing. Children and couple
counseling and testing (CT) training will be provided to staff in the clinic to assist with this approach to ART
in the community.
As in FY 2008, two therapeutic counselors (TCs) will be located in each of the clinics and have been trained
by St. Mary's in ART and CT. These TCs will ensure adequate support to patients referred to the
community clinics and will transfer skills to clinic staff. The TC's role is also to support the patient in the
home care setting, which includes screening for TB, offering CT to other family members, implement
integrated management of childhood illness (IMCI) strategies and adherence. At least three clinics require
additional clinical and counseling space and three park homes will be procured for these sites.
Screening for TB will be a priority, as well as the need for clinics to integrate TB and HIV care, and the
provision of TB prophylaxis where indicated, and the promotion of cotrimoxazole prophylaxis if available. If
the clinics are unable to provide adequate TB treatment and support, these patients will be referred to either
St. Mary's Hospital or other institutions supporting TB care and treatment. Healthcare workers in the
community clinics may require additional training and this will be linked into the training that St. Mary's
Hospital healthcare workers will receive.
The challenge is to enroll those patients that are not ready/eligible for ART into a wellness program for
periodic follow-up. Computer monitoring systems are currently being investigated by Catholic Relief
Services (CRS), a PEPFAR partner, to assist with the tracking of all patients, "pre-ART" and for those on
treatment. Data capturers to manage this system will also be located in each of the clinics.
Experience in FY 2007 highlighted that clinics require assistance in terms of personnel. Locum budgets for
nursing and a rotating doctor will be allocated to cover for shortage of staff when clinic staff are in training.
St. Mary's will assist one clinic to obtain accreditation for ARV initiation, and there will be a need to assist
with health care personnel (doctor, pharmacist, nurse) in order to ensure that the accreditation is obtained.
The DOH will assume responsibility for these personnel costs beyond FY 2011.
Activity 4: Procurement of ARV Drugs
St. Mary's Hospital will be responsible for the procurement of ARV drugs for the patients that will be down
referred to the community clinics; until such time that the referral clinic is accredited as an ARV initiation
site. These drugs will be packaged at St. Mary's and distributed to down referred patients at the community
clinic level.
Activity 5: Possible establishment of a laboratory service at clinic level
There are concerns that the National Health Laboratory Services (NHLS) may not be able to cope with the
demand for laboratory services at a clinic level. There may be some need to establish a TOGA tainer at
clinic points to assist with this demand. Discussions have not been held with the NHLS or with the DOH,
but some discussion has occurred with TOGA Laboratories (a PEPFAR partner).
Modification to Activity 3 in FY 2009:
The hospital will focus less on patient care in-hospital and rehabilitation services and more on the support of
the clinics in a more direct manner.
The activities will also directly address the Ethekwini district plans to have additional primary health care
facilities providing ARVs by 2009/2010. The service provider recommended by the Department of Health is
the provider contracted by the hospital for this support.
-----------------------------
The proposed St. Mary's Hospital project addresses comprehensive and holistic HIV care and treatment,
including antiretroviral treatment (ART) within a hospital setting, with a large focus on training at a
community clinic level to ensure that stable patients, once down-referred from the hospital can be treated on
a continuous basis at a community level. The major emphasis area for this project is human capacity and
the development thereof both in the community as well as in the hospital. The expansion plans for FY 2008
is to provide holistic treatment and care to patients that are experiencing side-effects of ART as well as
babies born to mothers that are HIV-infected (described elsewhere in the COP). The care and treatment is
extended to the rehabilitation department for adults and children. Some focus will be on community
participation, national media campaigns addressing preventative educational messages in partnership with
other donors (also described elsewhere in the COP), linkages with other sectors, and the capacity
development of local organizations. The primary target populations will be the general population, people
affected by HIV and AIDS, discordant couples in special populations, the community, the South African
Government (SAG), healthcare providers and other groups, pregnant women and children, partners of
pregnant women and people infected with HIV and on treatment as well as children with rehabilitation needs
that were born to HIV-infected mothers.
Activity Narrative: Since 2003 St. Mary's hospital has successfully implemented an ART program based on holistic and
comprehensive treatment of HIV and AIDS patients. This program was funded through another PEPFAR
partner, Catholic Relief Services (CRS) as part of their Track 1 program. Since FY 2005, the USG has
added additional funding to St. Mary's Hospital to focus on pregnant women.
Successful treatment of HIV and AIDS requires that patients maintain adherence to medication,
incorporating overall wellbeing, including nutrition. The early stages of the treatment program allowed St.
Mary's to maintain an average adherence rate of around 90%, which was largely due to a patient-centered
model of care. However as the patient numbers have increased St. Mary's has realized that there is a
greater need to provide patient support both in the community and to the community clinics. St. Mary's will
aggressively address loss-to-follow-up, and ensure a more efficient down referral process of patients from
the hospital setting to the community clinics. In the district that St. Mary's serves, it is estimated that 25,000
patients require immediate treatment. Just over 2,500 patients are currently in HIV care and just over 2,200
patients are on antiretroviral treatment at the hospital.
It has been noted that many patients on treatment are experiencing neurological side-effects to treatment
that require services associated with rehabilitation both on an inpatient and outpatient basis. In addition
there is a need to provide rehabilitation support to HIV-infected patients that are experiencing complications
due to opportunistic infections. It is estimated that 60% of the patients attended to by the rehabilitation
department are HIV-infected and require extensive rehabilitation support. The hospital delivers
approximately 500 babies per month and many of these babies are to HIV-infected mothers resulting in the
need for rehabilitation services to mother and infant at a ward and outpatients level. Follow-up is provided to
the mother and child upon discharge from the hospital at weekly support clinics held at the PHC facility.
Activity 1: Human Resource Capacity Training.
As an accredited SAG antiretroviral (ARV) rollout site and as an extension of the service level agreement
the Hospital has with the Department of Health, St. Mary's will contribute to the success of the SAG ARV
rollout plan through this project. The funding allows St. Mary's to continue to initiate patients on ART, and
once stable, down refer them to the community clinics in the area. St. Mary's will assist with the training of
health workers at clinic level to facilitate this. St. Mary's has identified local partners as well as the World
Health Organization's Integrated Management of Adult Illnesses (IMAI) training toolkit as a vehicle for
training. The toolkit makes use of people living with HIV (PLHIV) as expert trainers which are directly
aligned to the success of St. Mary's ART program. All three sites within St. Mary's Hospital strongly
emphasize human capacity development. Within the entire Hospital setting (including the three ART sites)
patients who have tested HIV-positive but whose CD4 counts and staging preclude them from treatment
form part of a wellness program. Opportunistic infections are treated at every point of care, and service and
nutrition interventions are made, as per SAG protocols and guidelines. Social support services, which may
take the form of social grants in accordance with the SAG guidelines, are also initiated as appropriate,
providing patients with access to financial resources.
The community clinics surrounding St. Mary's are linked into St. Mary's via the referral patterns already
established. The implementing organization will be St. Mary's Hospital and local partners will be recruited to
assist with the WHO ART training modules. Gender issues will be addressed throughout the project as well
as stigma and discrimination, twinning, the use of US-based volunteers from a training perspective, as
stated in the palliative care section. Gender equity will become an increased focus as women are provided
with resources (grants, nutrition) and capacitated to become self-sufficient. Through a partnership with the
Treatment Action Campaign (TAC) male norms and behaviors will be addressed directly through patient
education, encouraging prevention, 'know your status', and promoting family values. A comprehensive
nutrition program will be implemented to boost immunity with the patient cohort which will be the
responsibility of the dietician employed at St. Mary's Hospital, and is supported via a partnership with the
KwaZulu-Natal Department of Health (DOH). As an accredited ARV rollout site this is a vital component to
the success of the treatment program. A patient follow-up program, funded as part of the CRS activity
treatment program, makes use of therapeutic counselors (TCs) in the community to support patients from
St. Mary's Hospital. As the patient numbers have increased, St. Mary's acknowledges that additional
human resources are required for patient follow-up and support activities. The current treatment activity
program addresses the need to make use of TCs based in the community referral clinics, to help capacitate
the clinics to offer support to all patients in the community. This will be part of the clinic strengthening
activity plan. It is envisioned that the TCs will mentor community health care workers to ensure the long-
term sustainability of ARV treatment in communities.
Activity 2: Pediatric Treatment.
As stated previously, St. Mary's is a DOH accredited ARV rollout site and the partnership will be enhanced
and expanded through the additional PEPFAR funding. Within the antenatal clinic, patients who have
received PMTCT are followed up post-delivery and if clinically appropriate, placed on antiretroviral
treatment. This is a seamless program which also places the children of HIV-infected mothers on ART if
clinically appropriate. The program also provides education and nutrition support in partnership with the
KwaZulu-Natal DOH. Pediatric HIV care is strengthened through early testing and diagnosis. The hospital
has secured the services of a volunteer pediatrician from Harvard Medical School twice a week. The
pediatrician will treat HIV-infected children in-hospital and manage children as outpatients from the PHC
facility. The pediatrician will also mentor clinical staff in the facility. The main challenge is polymerase chain
reaction (PCR) testing and follow-up in this area, given that 19 clinics are being supported in the process.
St. Mary's currently has a relationship with Toga Laboratories (a PEPFAR partner) and it is envisioned that
counselors visiting clinics will refer patients requiring PCRs to the hospital's PMTCT program so that tests
can be conducted through Toga Laboratories.
Activity Narrative: Activity 3: Rehabilitation Services.
The rehabilitation department consists of a physiotherapy department (inclusive of a speech therapist) and
an occupational therapy department with a small community outreach service. Care and treatment will be
provided to those in and outpatients experiencing ARV side-effects, primarily related to neurological
conditions; and care and treatment to HIV-infected inpatients that are severely disabled, who have had
strokes or heart attacks. Rehabilitation support is also required to babies experiencing developmental
delays born to HIV-infected mothers. The areas of care will be at an inpatient hospital level and primary
health care (PHC) level as an outpatient service. Many babies born in hospital are referred to the PHC
facility for follow-up, and a clinic treatment day is held for babies experiencing developmental delays.
Weekly outreach treatment, education and support clinics are offered to one of the larger referral clinics in
the district as well as to children in an orphans and vulnerable children partner program.
By strengthening the down referral system, providing technical assistance to the public sector, and
providing supportive treatment for patients on ARVs and affected by HIV and AIDS; St. Mary's hospital is
contributing to the PEPFAR 2-7-10 goals.
Continuing Activity: 13833
13833 8264.08 HHS/Centers for St. Mary's Hospital 6626 4760.08 $1,552,000
8264 8264.07 HHS/Centers for St. Mary's Hospital 4760 4760.07 New APS 2006 $700,000
Estimated amount of funding that is planned for Human Capacity Development $57,359
Table 3.3.09:
FY 2008 COP activities will be expanded to include:
-Assurance of dedicated palliative care team and trained personnel to ensure delivery of quality services for
pediatric patients;
- Commodity procurement for HIV-exposed and infected children.
resources, training and consumables, focused on children 0-15 years. A dedicated palliative care team will
identify and provide clinical, spiritual, psychosocial, social and preventive support to the HIV-infected client
and family. A hospital-wide education program will be initiated to enhance knowledge of palliative care
practice. In addition a number of consumable items will be purchased to assist in managing pain and
symptoms related to HIV and AIDS and ensuring comfort of persons living with HIV (PLHIV). The emphasis
areas of the project are related in particular to human resource support for the palliative care team, training,
commodity procurement and the development of networks/linkages/referral systems. The primary target
population is pregnant mothers and children.
This is a split program with adult care funded since FY 2007. The project is an expansion of the current
palliative care program that is based at St. Mary's Hospital. The hospital, established in 1927, serves a peri-
urban/rural community of 750,000 people, a third of which are HIV-infected. The community has a high
unemployment rate of around 60% and an estimated 25,000 people in the community require anti-retroviral
therapy (ART). On an annual basis approximately 700 children of St. Mary's inpatients require palliative
care support.
identified in the inpatient, maternity section, pediatric outpatient and ART clinic, and hospice care settings.
The HIV-related services offered by the hospital and its hospice service is based on the belief that the
palliative care activity is central and automatically provides a network of services, from counseling and
testing, stigma reduction, integrated preventions services, including prevention with positives, ART and
adherence, counseling and support to the individual and family, end of life care, referral to other
organizations and continuous education and support thereafter to all concerned. The palliative care team
will work with other facility-based health providers to ensure that HIV-infected children in all facility settings
are either provided or referred (with follow-up) for evidence-based preventive care interventions which
include the following: OI screening and prophylaxis (including cotrimoxazole, TB screening/management),
counseling and testing for clients and family members, safe water and personal hygiene strategies to
reduce diarrheal disease, appropriate child survival interventions for HIV-infected children and nutrition
counseling, clinical measurement, nutrition monitoring and targeted support based on WHO criteria for
severely malnourished PLHIV. The package of services also includes basic pain and symptom
management and facility-based support for adherence to OI medications (including cotrimoxazole
prophylaxis and TB treatment) and antiretroviral therapy (ART).
Community and home-based psychological support, stigma reduction strategies and adherence support for
OI medications and ART will be provided by therapeutic counselors (TCs) who are trained PLHIV, employed
by the hospital that visit the patients and their families in the community. In addition to care for PLHIV,
therapeutic counselors and hospital staff will also expand their provision of psychological, spiritual and
social support of affected family members. A complex referral network to a number of organizations, inter
alia the KwaZulu-Natal Department of Health (KZNDOH), the Ethekwini Metropolitan (Durban), other non-
government organizations (NGOs), the Highway Hospice, and the Dream Centre exists and is used on a
St. Mary's has adopted a family approach to the treatment of HIV-infected children as all children are
treated in the ARV family clinic. Siblings who may or may not be HIV-infected are also supported within the
home setting through the TCs support visits as discussed above.
accreditation requirements essential to providing holistic quality health care to patients.
In FY 2009, St. Mary's will scale up its palliative care training for all health professionals, volunteers and
PLHIV therapeutic counselors involved in palliative care service delivery. Clinical protocols designed and
approved by the HPCA are used for support and clinical services for opportunistic infections and pain
assessment and management. St. Mary's has a number of partnerships with US universities and interest
and support from US-based volunteers. On average, four to six U.S. volunteers will be accommodated by
St. Mary's on a monthly basis (supported with non-PEPFAR funds). A relationship is currently being
Activity Narrative: explored to link in with an active OVC program in the area that cares for children at drop-in centers in and
around the community. St. Mary's will offer testing; counseling and treatment services; and the OVC
program will provide the ongoing adherence support for the children. All palliative care support services will
be offered by St. Mary's Hospital to children in care at the relevant drop-in centers.
In addition the school nurse who is a KZNDOH employee will be trained to provide early identification
services of children requiring palliative care support and then referral to the St. Mary's Hospital's care and
support services.
The follow-up and linkages between all programs such as PMTCT, ART, schools, OVC programs and any
other hospital-based or community-based programs will be strengthened so quality care and support
services are provided to the children referred to St. Mary's Hospital.
pain control, syringe drivers, anti-nausea medications, cotrimoxazole and other drugs for symptom control
and the clinical management of OIs, especially in the arena of TB). Provision for such palliative medications
and supplies are included in this activity and are vital to the overall success of the program.
There will be a focus on the provision of cotrimoxazole (CTX) to HIV-exposed and infected children as an
urgent priority, according to national guidelines for PMTCT. This will be at the ward level in-hospital, at the
outpatient site within the Hospital, at the primary health care facility, family care ARV treatment clinic and
promoted at all down referral treatment site clinics in the community. Children born of a HIV-infected mother
advise Cotrimoxazole from the age of 6 weeks, which will be addressed at in-hospital and out-patient sites
at St. Mary's Hospital.
Nutritional assessment will be provided to all children in-hospital at ward level and at the ARV family clinic.
Provision will be made for those children that require multi-nutritional supplements, as well as therapeutic or
supplementary feeding support for clinically malnourished patients. In the PMCTC activity program there is
some provision for infant feeding support that is linked to the PMTCT programs.
Estimated amount of funding that is planned for Food and Nutrition: Commodities $4,161
Table 3.3.10:
the development thereof both in the community as well as in the hospital. The expansion plans for FY 2009
is to provide holistic treatment and care to patients that are experiencing side effects of ART as well as
babies born to mothers that are HIV-infected.
Since 2003, St. Mary's hospital has successfully implemented an ART program based on holistic and
added additional funding to St. Mary's Hospital to focus on pregnant women and their children.
the hospital setting to the community clinics. Just over 300 pediatric patients are currently in HIV care and
treatment.
As an accredited South African Government (SAG) antiretroviral (ARV) roll-out site and as an extension of
the service level agreement the Hospital has with the Department of Health, St. Mary's will contribute to the
success of the SAG ARV roll-out plan through this project. The funding allows St. Mary's to continue to
initiate patients on ART, and once stable, down refer them to the community clinics in the area. St. Mary's
will assist with the training of health workers at clinic level to facilitate this. St. Mary's has identified local
partners to facilitate this process.
assist with the ART training modules. A comprehensive nutrition program will be implemented to boost
immunity with the patient cohort which will be the responsibility of the dietician employed at St. Mary's
Hospital. As an accredited ARV roll-out site this is a vital component to the success of the treatment
program. A patient follow-up program, funded as part of the CRS activity treatment program, makes use of
therapeutic counselors (TCs) in the community to support patients from St. Mary's Hospital. As the patient
numbers have increased, St. Mary's acknowledges that additional human resources are required for patient
follow-up and support activities. The current treatment activity program addresses the need to make use of
TCs based in the community referral clinics, to help capacitate the clinics to offer support to all patients in
the community. This will be part of the clinic strengthening activity plan. It is envisioned that the TCs will
mentor community health care workers to ensure the long-term sustainability of ARV treatment in
communities.
Activity 2: Pediatric Treatment
As stated previously, St. Mary's is a DOH-accredited ARV roll-out site and the partnership will be enhanced
and expanded through the additional PEPFAR funding.
Early infant diagnosis of HIV will occur at inpatient and outpatient settings within the hospital. The areas
addressed are; children's ward pediatric outpatients, the primary health care facility (PHC) and the
prevention of mother-to-child (PMTCT) program. Sick children admitted to hospital will initially be 'flagged' at
pediatric outpatients and counseling and testing (CT) services will be offered to mother and child in this
department. If the child is admitted to children's ward and if no CT services were offered through the
pediatric outpatients department then CT services will be offered in children's ward. All other children
admitted to children's ward who were not admitted first through pediatric outpatients will be offered CT
services at ward level. The PHC facility and PMTCT will offer CT services and thereby identify children that
require care, support and possible ARV treatment. Polymerase chain reaction (PCR) testing with dried
blood spots will be offered for children age 6 weeks - 6 months; at 9 - 12 months and antibody test will be
offered and at 15 - 18 months and older routine antibody testing. These tests will be sent to the National
Health Laboratory Services (NHLS), and will be offered at all levels of service as discussed above. As with
the criteria for CT, routine pediatric testing will be implemented at all hospital service settings.
The hospital is accredited as a baby-friendly hospital so repeat testing will be the norm for those children
who test HIV-negative but have ongoing exposure through breastfeeding. Within the antenatal clinic,
patients who have received PMTCT are followed up post-delivery and if clinically appropriate, placed on
antiretroviral treatment. This is a seamless program which also places the children of HIV-infected mothers
on ART if clinically appropriate. The program also provides education and nutrition support in partnership
with the KwaZulu-Natal DOH. A full-time dietician is on site to assess HIV-infected pediatric patients
requiring nutritional supplements as well as to advise the mother and extended family on the nutritional
needs of the child upon discharge.
There may be possible shortages of cotrimoxazole; however, pediatric HIV-exposed infants will be
Activity Narrative: prioritorized as patients receiving the treatment as of 6 weeks of age. Should this national shortage persist,
children will still be prioritized. HIV-infected patients will be identified and referred at the various service
settings within the hospital to the ARV pediatric treatment clinic within St. Mary's Hospital. If the patient is
admitted at ward level, the treatment will commence at ward level. Referral to the ARV treatment clinic will
occur once the child is discharged from the hospital in-patient facility. TC home-based care and support will
ensure address adherence to the drugs, the need to manage any side effects to drugs as well as general
support in the home setting.
As discussed in the TB activity plan, HIV and TB are fully integrated services within the hospital. Diagnosis
and treatment of children will occur at all settings where pediatric care is offered. Screening for TB and HIV
will be routine within the hospital, as well as in the community through the TCs that are visiting the homes of
referred patients from the hospital. There will be a focus on the provisions of Isoniazid (INH) preventive
therapy to all HIV-infected children exposed to sputum smear positive TB.
During FY 2007/2008, the hospital had secured the services of a volunteer pediatrician from Harvard
Medical School twice a week. The pediatrician treated HIV-infected children in-hospital and managed
children as outpatients from the PHC facility. The pediatrician also mentored clinical staff in the facility,
which has allowed clinical staff to be more focused on pediatric care and treatment.
TCs dedicated to pediatric care; and health care workers in the community clinics that provide home-based
care support will be trained in Integrated Management of Childhood Illnesses (IMCI) strategies. It is
envisioned that this training will equip the TCs and home-based care workers with sufficient information to
provide adequate support and basic care to pediatric patients in the community. This training will also be
transferred to the community at large when home visits occur. If there is a need, the referral of the patient
to a more appropriate facility will be advised.
The activities will also address health promotion in the schools which is part of the Ethekwini District Health
Plan. Schools will be visited by the school nurse and therapeutic counselors who will address counseling
and testing as well the need for referral to clinics and the hospital in the case of the possible need for
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.
providing supportive treatment for patients on ARVs and affected by HIV and AIDS, St. Mary's hospital is
Table 3.3.11:
St. Mary's Hospital in Durban, KwaZulu-Natal will continue with TB screening services to the community to
encourage patients' referral to the hospital for treatment as well as screening for HIV. The activities will
encompass human resources, training and laboratory supplies. The emphasis area of this activity is to
provide, identify and intensify TB case findings at all levels in the hospital, and at local and community clinic
level. The activities will also address the need for various screening tests for TB.
This is a new program activity funded in FY 2009, although St. Mary's has received previous PEPFAR
funding as a sub-partner to another PEPFAR partner, Catholic Relief Services. This activity will enhance the
antiretroviral treatment (ART) programmatic area as well as be incorporated into prevention of mother-to-
child transmission (PMTCT), and palliative care programs that were funded by PEPFAR in FY 2007. The
South African government supports the program as St. Mary's Hospital has a service level agreement with
the provincial Department of Health and the Hospital is in partnership with the District Office of the
Department of Health to provide HIV and AIDS training to all clinical staff over the next two years.
ACTIVITY 1: TB and HIV Training
There is a need to provide additional training to therapeutic counselors, counselors and community health-
care workers that address the need to address referrals to the hospital effectively, as well as follow-up on
patients down referred to the community clinics. The therapeutic counselors will be used to improve TB
case findings in the community. This training will also address the need for counselors and nursing staff in
all programmatic areas to screen all HIV patients for TB. This training will also extend into the community for
effective management of TB patients in the home.
Comprehensive TB training will also be provided to hospital staff as a focus, especially for pediatric cases,
which will be in-hospital at ward level, in the pediatric outpatients department, and at the primary health-
care facility.
The hospital has an onsite nursing college, which will ensure TB is a focus at the level of nurse education.
The student nurses complete their practical training at the hospital so this training will automatically filter into
the hospital. The training of all health-care workers, including therapeutic counselors, will also include the
importance of the delivery of isoniazid preventive therapy. Training specialists from Georgetown University
are currently enhancing the nurse's training program at the college.
ACTIVITY 2: Screening Patients for TB
There is an integrated approach to the treatment of TB and HIV at all ward levels in the facility. This will
ensure that all TB patients will be routinely tested for HIV, and all newly diagnosed HIV-infected clients at
the facility will be screened for TB. Clinical TB screening will include sputum collection and if required
further culture analysis, any other laboratory screening tests and chest X-rays. Effective referrals and follow-
up is required; these should be linked in with the Department of Health as well as the therapeutic
counselors in the community as discussed in activity one.
As discussed earlier, the ART program and the TB services program are fully integrated within all the
services at the hospital. This allows a more efficient service for patients co-infected with TB and HIV. The
therapeutic counselors who visit ART patients at their homes will be trained to assist with early detection of
TB, the referral for timely initiation, and will assist with monitoring the adherence to the TB treatment. The
continuum of care for individuals who are co-infected with TB and HIV will be provided at all levels of care,
within the hospital, at the outpatient clinics, and within the community at a home-based care level.
Linkages and referrals will be strengthened between the clinics and the hospital. The Department of Health
has provided the hospital with two on-site health-care workers to coordinate the services among the
hospital, clinics and the community. Together with the Department of Health's tracer teams and the
therapeutic counselors, there will be a focus on addressing linkages for patients requiring TB support
services, as well as adherence to treatment.
These activities will also link in with the counseling and testing programmatic area as well as the treatment
programmatic area using mobile clinics. Access to TB screening and HIV testing will be conducted in the
community. All statistical data on TB are managed and submitted to the Department of Health through the
monthly district office statistical submissions.
ACTIVITY 3: Procurement of Drugs
Due to the possible shortages of cotrimoxazole, St. Mary's Hospital will prioritize HIV-infected TB patients
as one patient cohort that requires the drug as a matter of necessity. If this national shortage persists, TB
patients will continue to be prioritized.
IPT will be provided to all HIV-infected persons in whom TB disease has been ruled out according to
national guidelines. This will be a focus at all levels of care, starting at the home setting identified by
therapeutic counselors right through to the community clinics and hospital where the patients have been
referred. Registers and data management will remain a key element in ensuring this linkage.
ACTIVITY 4: TB Infection Control
St. Mary's Hospital will continue to implement TB infection control policies at supported service delivery
Activity Narrative: points at hospital level and will assist down-referral clinics to develop their own TB infection control policies
and plans (administrative, environmental, and personal protection).
These activities augment the current PEPFAR funded ART program funded through Catholic Relief
Services.
Estimated amount of funding that is planned for Human Capacity Development $8,571
Table 3.3.12:
Modification Plans to Activity One in FY 2009:
In FY 2009 it will be emphasized to all healthcare workers that at any interaction with patients at all levels of
care, counseling and testing (CT) will be initiated by the healthcare worker and offered to the patient in the
consultation room. The hospital will work towards ensuring that healthcare workers strive to make HIV
testing an essential component of the diagnostic process, rather than a separate event which occurs in a
different location. The tuberculosis (TB) service delivery site will be a focus for FY 2009. HIV-negative
patients will be briefly counseled on preventative measures and additional in-depth counseling will be
provided by lay counselors as well as referral to the care and treatment within the Hospital to HIV-infected
patients. In depth preventative counseling remains a concern and the referral of HIV-negative patients to
counselors and therapeutic counselors (TCs) post testing will be addressed.
Couple CT will be a focus at the prevention of mother-to-child (PMTCT), antenatal care (ANC) settings and
within the home if possible. Training in couple counseling and testing will be provided to health care
workers, therapeutic counselors (TCs) and counselors.
Disclosure of HIV status to sexual partners will be stressed and encouraged, if the couple is not tested
together and various approaches will be explored that will address partner notification.
Modification Plans to Activity 2 in FY 2009:
There will be an increased focus on CT using mobile clinics to support designated down-referral clinics by
not only being used as a point for care and treatment but also offering PICT at these clinics and in the
communities. There will be a link with the local schools and community outreach programs to intensify HIV
testing. An increased focus will be on the referral of HIV-infected patients to the clinics, and hospital for
follow-up services. Once CD4 counts are provided to the patient the need for additional support via support
groups or treatment facilities will be advised. Follow-up on patients receiving CT will be a key element to
ensuring that patients receive antiretroviral (ARV) treatment when required. Patient tracking systems will be
implemented at the clinic level, within St. Mary's Hospital and within the mobile clinics. Referral to support
groups with a similar tracking system will be key to ensuring that patients who require future treatment are
not lost to follow-up.
Rapid tests will be used as a diagnostic tool and will be used in parallel to minimize the time in CT settings.
The quality assurance (QA) or rapid testing services are as follows:
i) Regular on-site audits conducted by the senior counselors, which includes record-keeping, and
observation of staff performance.
ii) Blinded re-checking will also be implemented where a selected sample of specimens will be retested in a
laboratory using patient samples. St Mary's has a high volume through put, so this is a good measure for
quality
iii) Once the National Health Laboratory Services have a QA standard operating procedure (SOP)
approved, St. Mary's Hospital will adhere to the policy.
Ongoing training is being provided to new TCs, counselors and health care workers, but any new training
will focus on supervision and the management of CT services, as well as couple, child and family
counseling as the CT services are being extended rapidly into the community via the mobile clinics as well
as through the community clinics.
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St. Mary's Hospital in Durban, KwaZulu-Natal will implement extensive counseling and testing services in
the hospital as well as in the community to encourage patients' referral to the hospital for antiretroviral
treatment (ART). The activities will encompass human resources, consumables and asset procurement.
The emphasis area of this activity is to provide counseling and testing to the family unit and communities
and in particular, there will be a focus on couple counseling at the prevention of mother-to-child
transmission (PMTCT) program. This is in line with the goals of the HIV & AIDS and STI Strategic Plan for
South Africa, 2007-2011 to reduce the impact of HIV and AIDS on individuals, families, communities and
society and with the ultimate aim to reduce the number of new infections. The target group for this activity is
the general population and pregnant mothers; partners of pregnant mothers, children from prior pregnancies
and extended families of HIV infected individuals. There is also a focus on men in the workplace as
counseling and testing and referral to St. Mary's Hospital for treatment has been offered to industries
surrounding St. Mary's Hospital.
PMTCT, palliative, treatment and care programs that were funded by PEPFAR in FY 2007. The program is
supported by the South African government as St. Mary's Hospital has a service level agreement with the
provincial Department of Health and the Hospital is in partnership with the District Office of the Department
of Health to provide HIV and AIDS training to all clinical staff over the next two years.
Activity Narrative: ACTIVITIES AND EXPECTED RESULTS:
ACTIVITY 1: Dedicated Counselors in the Hospital Setting Providing HIV Testing and Counseling
The overall objective of this activity is to routinely counsel and test as many patients as possible in the
hospital setting. Patients and extended family members will be encouraged to be tested and continuously
be re-tested in order to refer to the care and treatment programs if appropriate. The goal will be to counsel
and test all patients attending the facility whether or not the patient has symptoms of HIV and regardless of
the patient's reason for attending the facility. In addition, the focus will also be on encouraging those that are
negative to remain negative. This will be addressed through extensive counseling and the need for a
change in behavior if necessary. All areas of the hospital will be targeted both inpatient and outpatient
areas. In particular, the PMTCT program will encourage the counseling and testing of couples and members
of the family unit. A provider-initiated testing and counseling (PITC) approach has been adopted as the
preferred method of counseling and testing throughout the facility.
There is an integrated approach to the treatment of TB and HIV at the facility. This will ensure that all TB
patients will be routinely tested for HIV, and all newly diagnosed HIV-infected clients at the facility will be
screened for TB (via the Catholic Relief Service funding).
A group of thirteen counselors will be in the wards, outpatient section and the primary healthcare clinic,
which is an integrated clinic setting that addresses TB, hypertension, diabetes, antenatal services, primary
health services and PMTCT. Approximately 2 000 patients make use of this facility on a monthly basis. In
order to maximize the goals of this activity it is important to have counselors spread throughout the facility.
The counselors will be trained and continuously updated through the treatment program activity area to
ensure that patients will make informed decisions. Government counseling and testing protocols will be
adhered to. The expected results of this activity is to (a) create a culture in which all people regularly seek
counseling and testing and re-counseling and testing on an ongoing basis for HIV; (b) provide HIV and
AIDS care and treatment to those who require this treatment, and particularly addressing the referral and
access to treatment programs; and (c) provide accurate clinical information to health care workers when
treating patients.
ACTIVITY 2: Community Mobilization/Outreach
A vehicle will be purchased and a team of two counselors and a nurse will be tasked to work with the 19
referral clinics to St. Mary's Hospital and the primary healthcare clinic to provide mobile HIV counseling and
testing. The primary goal of the activity is to encourage regular counseling and testing in the clinics; and
counseling and testing for family members in a home setting. This activity will be an extension of the
PMTCT program. The community mobilization of testing and counseling will extend to a large industrial
community that surrounds St. Mary's Hospital. A team of counselors will primarily target men in the
workplace and offer testing and counseling to all, and treatment to those who require treatment.
Currently a local radio media campaign exists (not a St. Mary's Hospital funded activity) that encourages
industry to establish a culture of ongoing testing and counseling in the workplace; and support and referral
to treatment sites for those that require treatment. St. Mary's activities will support this initiative. The
outreach counseling team will also address loss to follow-up and counseling and testing of partners of
pregnant mothers and extended family members of the pregnant mother. The expected results of this
activity is to (a) address couple counseling and testing but in a home-based program which has shown to
reduce HIV transmission in sero-discordant couples; (b) address referral links for care and treatment to St.
Mary's Hospital from referral clinics and home-based settings; and (c) address the culture of counseling and
testing in the community.
Continuing Activity: 13834
13834 13834.08 HHS/Centers for St. Mary's Hospital 6626 4760.08 $194,000
Estimated amount of funding that is planned for Human Capacity Development $11,471
Table 3.3.14:
