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
SUMMARY:
The Reproductive Health and HIV Research Unit (RHRU), as part of an outreach project in deprived inner
city areas, and within the parameters of comprehensive and integrated HIV services, became a prevention
of mother-to-child transmission (PMTCT) partner in late 2007, after the FY 2008 COP was submitted. For
this reason, no targets were included in previous COP entries, even though some PMTCT work was being
undertaken as part of antiretroviral treatment (ART) services provided to pregnant women. This program
focuses on increasing gender awareness, child survival, safe motherhood and TB screening. Target
populations are adults, pregnant women, HIV-infected infants, people living with HIV and their families.
BACKGROUND:
RHRU, a unit of the University of the Witwatersrand in Johannesburg, currently provides technical support
to the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South
Africa, which includes the national antiretroviral (ARV) rollout. RHRU was intrinsically involved with the
development of the HIV & AIDS and STI Strategic Plan for South Africa, 2007-2011. The Executive Director
of RHRU heads the Program Implementation Committee at the South African National AIDS Council, and
two other senior members are represented on the Treatment Task Team. With PEPFAR funding since FY
2004, RHRU has provided regular on-site support, direct treatment, training and quality improvement to
Department of Health sites in three provinces. RHRU will continue these activities, and will continue an
inner-city program (Johannesburg), a district-wide program (Durban), and a discrete site-based provincial
program (North-West Province) focusing on providing support to complete up and down treatment referral
networks. In addition, RHRU will continue the provision of counseling and testing (CT), palliative care and
prevention services. RHRU will seek to develop models of service delivery that can be replicated and
expanded, and produce findings from lessons learned and targeted evaluations to disseminate and share
with others. It should be noted that the success of ART scale-up depends on the comprehensive approach
described in other program areas. In particular, the strengthening of referral from other primary health-care
programs such as tuberculosis (TB), family planning, and antenatal/postnatal and sexually transmitted
infections services is critical. HIV prevention is an integral part of this system and RHRU will focus its
prevention program on high-risk groups such as sex workers and their clients and people infected with HIV.
RHRU will aim to reduce mother-to-child transmission, and will build capacity of health-care workers and
community-based and non-governmental organizations with which it works. RHRU will also continue to
develop strategies to address underserved communities affected by HIV, such as couples (both concordant
and discordant), high-risk groups such as young people, and gender-based interventions with women at
risk, sex workers and their clients, and men.
ACTIVITIES AND EXPECTED RESULTS:
The accelerated access to ART programs, expansion of HIV counseling and testing at ANC services
(including partner testing), and increased training of health-care providers will facilitate RHRU reaching
PEPFAR targets.
ACTIVITY 1: Integration of Antenatal and Postnatal care with ART and Other Services
RHRU will focus on fast-tracking eligible HIV-infected pregnant women and newborns on to ART. Integral to
the PMTCT program is the integration of antenatal care (ANC) and post-natal care with ART services to
ensure continuum of care. Program specific counseling and support for maternal and infant nutrition,
support to new sites providing dual therapy or scale-up of delivery of the dual therapy PMTCT program, and
improving information sharing on adherence to dual therapy, infant feeding choice, access to cotrimoxazole
and disclosure to expectant mothers through additional counseling support at antenatal services will be
provided.
This will be achieved by (a) employing an additional two nurses and five counselors, (b) expanding
treatment to two new clinics, (c) increasing the uptake of PMTCT services, (d) ensuring quality assurance
and strengthening linkages and referrals to treatment, care and support services within 15 Johannesburg
inner-city clinics providing ANC services, a large maternal health clinic in North-West supported by a large
network of primary care clinics, and (e) direct training, staff and technical support within primary care clinics
in Durban. HIV-infected pregnant women attending ANC and their children will be enrolled in longitudinal
comprehensive HIV care including opportunistic infections and TB management. Appropriate nutritional
interventions will be facilitated among HIV-infected pregnant women and their infants, using National
Department of Health guidelines and resources, and through appropriate training and community
mobilization. Effective referral linkages will be established to support postnatal follow-up of HIV-infected
mothers and exposed infants. In line with RHRU's strategy to provide a family-centered approach to care
and treatment services, programs will be developed to promote partner testing for PMTCT clients and for
linking postnatal care with early infant diagnosis and testing.
RHRU is committed to strengthening integrated ANC and postnatal care with ART services to ensure
continuity of care, and facilitate rapid access to appropriate levels of ART and PMTCT treatment for eligible
women. Public sector health workers will be trained in the provision of ART and PMTCT services according
to South African and international standards.
-----------------------------------
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Gender
* Increasing gender equity in HIV/AIDS programs
Health-related Wraparound Programs
* Child Survival Activities
* Safe Motherhood
* TB
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $300,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $7,610
and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $1,240
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
RHRU will continue to offer the services outlined in FY 2008 and will continue to refine the systems that
ensure that its prevention activities are fully integrated with other care and treatment services provided.
RHRU will expand the focus of its community-based prevention services by linking this with other entry
points for those most at risk, particularly families of HIV-infected patients already receiving care. This will
include home visits to families of patients on treatment, patient networks identified through lost-to-follow-up
initiatives and active follow up of stepped down patients diagnosed with HIV. Through the provision of this
follow-up service, family members can be more effectively reached with a comprehensive range of services
including provider initiated testing and appropriately targeted prevention messaging.
RHRU continues to mobilize and develop a broad referral network of other local services, which can provide
support and identify and meet additional needs. These activities will take place in the deprived inner city
area of Hillbrow, which has a large migrant and refugee population. In this context RHRU will explore
opportunities to work with recent victims of xenophobic violence, if such a need is identified and such
opportunities exist. RHRU has been working to mobilize community-based organizations and non-
governmental organizations in the Hillbrow area to provide a more comprehensive and consistent response
to the epidemic. As part of this, RHRU has set up three forums focusing on three particularly challenging
groups: sex workers, youth, refugees and migrants. Each of these groups meets monthly, with participants
from relevant local organizations represented. This initiative will continue and encourages a more unified
and strategic response from the civil society sector to the HIV epidemic in identifying and addressing the
needs of these respective 'at risk' groups.
ACTIVITY 1:
RHRU's Women At Risk program works with Hillbrow female sex workers (FSWs) and will be expanded
through the development of a peer education program that will be piloted targeting FSWs with information
and referral for a range of appropriate issues including gender-based violence, risky sexual behavior, sexual
rights, correct and consistent use of condoms and issues around alcohol and HIV. In addition, RHRU will
continue with its Sex Worker Exit program that provides support to FSWs who wish to leave the industry
through the provision of income generation training, life skills and counseling support and skills building
workshops.
ACTIVITY 2:
RHRU will continue to work with young people (see also the counselling and testing section), and will pilot a
peer education program for 'out of school' and older youth in inner city Johannesburg to encourage HIV
prevention, delay of sexual debut, correct and consistent use of condoms for those who choose to enter into
sexual relationships, concurrent partner reduction, regular HIV testing, and other youth related issues such
as gender equity, alcohol and drug abuse.
ACTIVITY 3:
In KwaZulu Natal young adult women will be exposed to World Health Organization flipcharts on
reproductive choices and contraception for HIV-infected women developed by RHRU. Providers will be
trained to use these tools at selected sites, as requested and approved by the provincial Department of
Health.
ACTIVITY 4:
Across all sites, prevention for positives will be emphasized with intensive counseling provided to discordant
couples in conjunction with a strengthened condom distribution network male and female condoms will be
provided at all sites and RHRU will provide training to nurses and counselors around the demonstration and
use of female condoms.
-----------------------
SUMMARY: Reproductive Health and Research Unit (RHRU), as part of an outreach project in deprived
inner city areas, will implement four Other Prevention projects: Firstly, the provision of outreach prevention,
clinical and support services to commercial sex workers at an inner city primary health care clinic as well as
prevention information and condoms in the many brothels in Hillbrow, Johannesburg. Secondly, RHRU's
sub-partner, CARE, will offer home-based information, support and referral, and capacity building activities
to improve local faith-based organizations (FBOs), community-based organizations (CBOs) and non-
governmental organizations (NGOs). Prevention measures will be used as the entry point to household-
based work. Thirdly, RHRU will continue to provide a new program of prevention work for HIV-infected
individuals, using "motivational interviewing" techniques to reduce risky behavior. Lastly, RHRU will promote
the uptake of male circumcision through integration with existing services. Activities will include training,
workshops and other outreach covering condom usage and negotiation. Concurrent partner/partner
reduction strategies and HIV risk reduction will be integrated into all Other Prevention activities. The primary
emphasis area for these prevention activities is human development. The primary target populations for
these interventions are women, men, adolescents, people living with HIV, HIV-infected women including
pregnant women, commercial sex workers and their partners/clients, brothel owners, community-based and
non-governmental organizations (CBOs/NGOs). The sex worker component will be expanded in FY 2008 to
Activity Narrative: an additional neighborhood in Johannesburg. Prevention with Positives (PwP) will also be continued in all
CT and treatment programs.BACKGROUND: RHRU, a unit of the University of the Witwatersrand in
Johannesburg, currently provides technical support to the Operational Plan for Comprehensive HIV and
AIDS Care, Management and Treatment for South Africa, which includes the national ARV roll-out. Under
PEPFAR funding since FY 2004, RHRU has provided regular on-site support, direct treatment, training and
quality improvement to Department of Health sites in three provinces. RHRU will continue these activities,
and will continue both an inner city program (Johannesburg) and a district-wide program (Durban), focusing
on providing support to complete up and down treatment referral networks. In addition, RHRU will continue
the provision of counseling and testing (CT), palliative care and prevention services. RHRU will seek to
develop models of service delivery that can be replicated and expanded, and produces findings from
lessons learned and targeted evaluations to disseminate and share with others. It should be noted that the
success of antiretroviral treatment (ART) scale-up depends on the comprehensive approach detailed in
other program areas. In particular, the strengthening of referral from other primary healthcare programs
such as tuberculosis (TB), family planning, antenatal/postnatal and STI services is critical. Prevention is an
integral part of this system, and RHRU will focus its condoms and other prevention program on high-risk
groups such as commercial sex workers and their clients, people infected with HIV, and also on building
capacity of the CBOs and NGOs with which it works. RHRU will also continue to develop strategies to
address underserved communities affected by HIV, such as couples (both concordant and discordant), high
risk groups such as young people, and gender-based interventions with women at risk, including pregnant
women and commercial sex workers, and men.ACTIVITIES AND EXPECTED RESULTS: ACTIVITY 1: HIV
Prevention for Women At RiskRHRU will continue to target a large community of commercial sex workers
with prevention and care services, as well as treatment referral. The project is located in the deprived
Johannesburg inner city, which is densely populated, transitory and poor, with high HIV and unemployment
rates. All women will be referred for CT, and those with appropriate CD4 counts will be referred for ARV
treatment. New treatment sites will be identified in needy areas of the city, and the organization will work
with local public sector clinics in the area to sensitize staff to the special needs of this difficult-to-reach
group and to provide outreach clinics in local brothels, which are the hub of commercial sex workers in
Hillbrow and Berea Johannesburg. RHRU will also work with brothel owners, and clients and partners of
commercial sex workers to increase their awareness and affect a change in their norms and behaviors
regarding HIV and AIDS. A specific focus will be on changing gender norms through workshops and
trainings, which will include such topics as alternatives to risky behavior, women's rights, and reduction of
gender-based violence. The project will provide prevention outreach services including management of
sexually transmitted infection (STI), provision of condoms together with messages regarding correct and
consistent use of condoms, contraception and HIV prevention education including cross-generation and
transactional sex, as well as support for those who wish to leave sex work. The project will play a critical
role in raising awareness of HIV services and prevention through workshops and event days, and by
distributing IEC materials. Furthermore, this gender-related project will conduct HIV counseling and testing
on high risk and difficult-to-access groups, and will relate to the development of health networks and
linkages by providing referral to HIV and TB care and treatment services where necessary. To aid the
expansion and sustainability of this program, the local health authority will also contribute to this project. In
addition, a manual has been developed to provide a toolbox for other health authorities seeking to replicate
this program, and technical consultation will be provided. RHRU will share this with the Medical Research
Council and others involved with high risk populations.ACTIVITY 2: Prevention with Positives There is very
little focus on prevention in South Africa among people already infected with HIV. Prevention work to
encourage safe-sex behaviors and limit infection and re-infection for those already positive is currently
being developed by some South African organizations. Innovative prevention methods, the development of
which will draw on models that have proven successful in other settings, will be introduced in South Africa.
Clinicians will be trained in this specific focus area, and the program will be monitored and evaluated for
efficacy. Programs that are proven successful will be expanded into other areas and used as examples for
other organizations. In addition, RHRU is currently adapting a flipchart on contraception for HIV-infected
clients for use by South African health care providers. This will be piloted in FY 2007-2008 and will
contribute to improved prevention for positive clients and will be integrated into care and treatment
programs. ACTIVITY 3: Community-Based PreventionRHRU will extend care and support services further
into inner city areas, and incorporate prevention and behavior change into their activities. With a
combination of private sector and PEPFAR funding, RHRU runs an information and support center in a high
-risk area. A team of counselors and caregivers will be launched from this center into the surrounding
community. Team members will link with 30 households a week, with the primary purpose of educating
them on HIV prevention and understanding risk. Using prevention messages as the entry to the household
they will also assist them as needed with home-based care, reaching orphans and vulnerable children, men
and women, as well as contributing to the destigmatization of HIV and AIDS. ACTIVITY 4: Male
CircumcisionNo male circumcision training or service delivery will take place without the express consent of
the National Department of Health. In the absence of such approval and based on discussions with the
PEPFAR South Africa team, funds could fully or partially be reprogrammed. Should the approval for safe
clinical male circumcision activities be given, RHRU is proposing the following male activities: Male
circumcision has been identified as an important biological intervention that protects men from HIV infection.
It also creates opportunities to engage with men over a variety of reproductive health and risk-taking issues.
Men are grossly under-represented in terms of access to counseling and testing, as well as HIV clinical
services, including ART. Circumcision programs may allow expanded access to all forms of care, including
HIV testing. However, while the biological protection against HIV transmission has been demonstrated
beyond doubt, issues such as acceptability, operationalization, disinhibition and programmatic integration,
still remain. RHRU will explore the acceptability of integrating male circumcision into existing services to
broaden uptake. This will include piloting "opt out" circumcision for neonates, and developing methods of
raising awareness raising and counseling that address target groups including males and young people. All
activities will be conducted in accordance with the South African Government's new Strategic Plan. In FY
2007- FY 2008, RHRU will continue to undertake M&E activities to inform and develop quality HIV care.
RHRU will be in a position to conduct targeted evaluations (TE) and Public Health Evaluations (PHE) of
some of its prevention related projects in FY 2008-09. For each PHE, a detailed proposal will be developed
and submitted to PEPFAR for review and funding approval. RHRU will contribute to PEPFAR 2-7-10 goals
by providing prevention services to a most-at-risk population in a densely populated, poor, and highly
transient inner city community.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13788
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13788 9449.08 U.S. Agency for Reproductive 6611 5191.08 $339,500
International Health Research
Development Unit, South Africa
9449 9449.07 U.S. Agency for Reproductive 5191 5191.07 RHRU (Follow $110,000
International Health Research on)
* Addressing male norms and behaviors
* Reducing violence and coercion
* Family Planning
Estimated amount of funding that is planned for Human Capacity Development $80,000
Table 3.3.03:
Reproductive Health and HIV Research Unit (RHRU), as part of an outreach project in deprived inner city
areas, will promote the uptake of male circumcision through integration with existing services.
Africa, which includes the national ARV roll-out. Under PEPFAR funding since FY 2004, RHRU has
provided regular on-site support, direct treatment, training and quality improvement to Department of Health
sites in three provinces. RHRU will continue these activities, and will continue both an inner city program
(Johannesburg) and a district-wide program (Durban), focusing on providing support to complete up and
down treatment referral networks. In addition, RHRU will continue the provision of counseling and testing
(C&T), palliative care and prevention services. RHRU will seek to develop models of service delivery that
can be replicated and expanded, and produce findings from lessons learned and targeted evaluations to
disseminate and share with others. It should be noted that the success of antiretroviral treatment (ART)
scale-up depends on the comprehensive approach detailed in other program areas. In particular, the
strengthening of referral from other primary health care programs such as tuberculosis (TB), family
planning, antenatal/postnatal and STI services is critical. Prevention is an integral part of this system, and
RHRU will focus its condoms and other prevention program on high-risk groups such as commercial sex
workers and their clients, people infected with HIV, and also on building capacity of the CBOs and NGOs
with which it works. RHRU will also continue to develop strategies to address underserved communities
affected by HIV, such as couples (both concordant and discordant), high risk groups such as young people,
and gender-based interventions with women at risk, including pregnant women and commercial sex
workers, and men.
No male circumcision training or service delivery will take place without the express consent of the National
Department of Health. In the absence of such approval and based on discussions with the PEPFAR South
Africa team, funds could fully or partially be reprogrammed. Should the approval for safe clinical male
circumcision activities be given, RHRU is proposing the following male activities: Male circumcision has
been identified as an important biological intervention that protects men from HIV infection. It also creates
opportunities to engage with men over a variety of reproductive health and risk-taking issues. Men are
grossly under-represented in terms of access to counseling and testing, as well as HIV clinical services,
including ART. Circumcision programs may allow expanded access to all forms of care, including HIV
testing. However, while the biological protection against HIV transmission has been demonstrated beyond
doubt, issues such as acceptability, operationalization, disinhibition and programmatic integration, still
remain. RHRU will explore the acceptability of integrating male circumcision into existing services to
raising awareness and counseling that address target groups including males and young people. Key to a
successful male circumcision program is integration of comprehensive prevention messages based on an
ABC approach. All activities will be conducted in accordance with the South African government's National
Strategic Plan.
In FY 2009, RHRU will continue to undertake M&E activities to inform and develop quality HIV care. RHRU
will be in a position to conduct pre-approved basic program evaluations (BPEs) of selected prevention
related projects in FY 2009. For each BPE, a detailed proposal will be developed and submitted to PEPFAR
for review and funding approval. It is anticipated that these evaluations will provide the South African
government with important information for policy development and planning in this area.
Estimated amount of funding that is planned for Human Capacity Development $70,000
Table 3.3.07:
The Reproductive Health and HIV Research Unit's (RHRU) will continue to provide the comprehensive
package of care described above at all the sites it supports, including new initiation sites and their networks.
This includes cotrimoxazole prophylaxis and standard nutritional assessments as part of ongoing care. In
this program year, RHRU will focus activities on pre-antiretroviral therapy (ART) retention in care as a key
driver of improving transition into treatment programs when patients become eligible. This will include
exploring different wellness packages (using the Basic Care Package as a foundation) aimed at retaining
patients in care and addressing their needs holistically. This may also include developing broader wellness
packages tailored to the needs of different groups (families, men, and youth). These packages will also link
into local community-based organizations in order to offer a wider range of services including psychosocial
support, social care and opportunities to participate in income generating activities. RHRU will explore
opportunities to provide care and support to recent victims of xenophobic violence, if such a need is
identified and such opportunities exist.
In addition to this, RHRU will pilot a follow-up system using cellphone SMSes to increase pre-ART retention
in care across selected sites in KwaZulu-Natal, Gauteng and the North West province. Patients will receive
programmed reminders by SMS of key information, including date of last CD4 measurement, date of next
follow-up visit and location of facility where CD4 measurement can be done. Patients lost-to-initiation will be
tracked by dedicated tracers and followed-up by patient follow-up workers and home-based caregivers.
RHRU, at the request of the provincial Departments of Health (DOH), provides, and will continue to provide,
training for health care providers in line with the WHO Integrated Management of Adult Illnesses program.
RHRU will continue to provide public sector staff with training on all aspects of HIV Care and Support. In
addition, RHRU will work with the National DOH to disseminate the RHRU-developed HIV Standards, a self-
assessment tool designed to improve and integrate HIV services at Primary Health Care facilities, and to
prepare primary health sites for accreditation.
----------------------------
The Reproductive Health and HIV Research Unit's (RHRU) Basic Care and Support activities for FY 2008
will be part of an integrated program and will specifically include: (1) palliative care arising from clinical (both
ARV and non-ARV) services rendered by RHRU staff through the activities described under the ARV
Services program area; (2) the provision of psychosocial support to commercial sex workers, (3) the
provision of support, home-based care and referral; and (4) the implementation of health provider training in
all aspects of palliative care. The major emphasis area for these activities is quality assurance and
supportive supervision, with additional focus on human resources, development of referral systems, and
training. Populations targeted for these interventions include PLHIV (children, youth and adults), HIV-
affected families, commercial sex workers, refugees, and public sector doctors, nurses, pharmacists,
traditional healers and other health care workers
Africa, which includes the national ARV rollout. Under PEPFAR funding since FY 2004, RHRU has provided
regular on-site support, direct treatment, training and quality improvement to DOH sites in 3 provinces. The
RHRU will continue these activities, which include inner city, district wide and rural programs focusing on
providing support to complete up and down treatment referral networks. In addition, RHRU will continue the
provision of counseling and testing (CT), palliative care, and prevention services. RHRU continues to
success of ARV treatment scale-up depends on the comprehensive approach detailed in other program
areas. In particular, the strengthening of referral from other primary healthcare programs such as TB, family
planning, antenatal/postnatal and STI treatment is critical. Basic Health Care and Support is an integral part
of this system, and the RHRU will focus this part of its program on PLHIV, in impoverished areas such as
the Hillbrow neighborhood in Johannesburg, and at PHC clinics in Durban, and rural areas of the North
West province by delivering high quality palliative care, psychosocial support, and intensive training of
doctors, nurses, and other health care professionals. Furthermore, RHRU will continue to develop strategies
to address underserved communities affected by HIV, such as couples, high risk groups such as
adolescents, and gender-based interventions with women at risk, including pregnant women, commercial
sex workers, and men.
ACTIVITY 1: Provision of Palliative Care
Through comprehensive support and quality improvement programs to the Johannesburg inner city,
eThekwini District in Durban, and through Mobile Clinical Support Teams operating in North West, KwaZulu-
Natal (KZN) and Gauteng provinces, RHRU will continue to provide the preventive care package and
opportunistic infection prevention and treatment, identification and treatment of syndromic STIs, provision of
regular CD4 counts, and pain and symptom management in conjunction with ARV treatment to adults and
children in partnership with the DOH. In addition, STI treatment will be provided to HIV-infected patients at a
network of local health authority sites in the inner city of Johannesburg. This includes the Women At Risk
Project that reaches commercial sex workers through a clinical and support outreach service that moves
between the inner city brothels, and a special service run from the clinic every weekday morning (see the
Other Prevention section for more details). Integrated reproductive health/HIV services will be provided to
Activity Narrative: HIV-infected clients at a large family planning clinic in the Durban CBD and via the gender-related projects
described in the Other Prevention program area. Furthermore, health care and support will be provided to in
-patients at an HIV step-down and palliative care facility in KwaZulu-Natal. Lastly, as described in the Other
Prevention section, RHRU will provide home-based care in the deprived inner city suburb of Hillbrow
through its new program of community outreach.
ACTIVITY 2: Psychosocial Support
RHRU or its sub-partners will provide psychosocial support through counseling, wellness programs and
befriending. RHRU will assist with income generation, material support programs, and support group
facilitation. RHRU will be key in the strengthening of adherence initiatives through their work in HIV
treatment sites and within the community. RHRU will also assist the DOH in providing technical resources,
continuity and support to the up and down referral processes that must take place to enable ARV program
scale-up. Currently men are under-represented in seeking ARV treatment, and a family-based approach to
care ensures all family members are provided with treatment and prevention initiatives where appropriate.
Therefore, RHRU will also address gender issues by developing and providing specialized services such as
family clinic days 3 days per week, male clinic 5 days per week for CT and ART, and male only support
groups for families and men in order to improve access for these two key groups. In addition working with
antenatal and postnatal clinics, RHRU will provide psychosocial support and specialized adherence
counseling for HIV-infected pregnant women and new mothers, and will work with pediatric treatment sites
to provide specialized adolescent counseling and psychosocial support. Through the Women At Risk
project, commercial sex workers are provided with support and information on appropriate topics at
outreach sites by community health workers, and referred into other psychosocial services as required,
including support groups, workshops on CSW-relevant issues (such as gender violence and gender norms
and behaviors), prevention with positives interventions, and income generation projects to provide peer
support and encourage the exiting of sex work. Refugee populations, often a neglected, overlooked group,
will also be targeted with services provided by RHRU. A special program for the care of refugees will be
expanded to include more systematic identification of refugees seeking assistance through public facilities.
These individuals will be counseled and provided full referral and follow up services to the NGO and private
sectors to receive care, treatment and support if they are ineligible to receive services through the public
sector programs.
ACTIVITY 3: Human Capacity Development
The objective of the training is to increase skills in the delivery of quality palliative care services including
elements of the preventive care package. RHRU will provide on-site and didactic training to DOH and NGO
doctors, nurses and counselors, and will specifically target ARV and non-ARV sites that need to be able to
care for, manage and appropriately refer HIV-infected clients. RHRU will also provide mentoring to DOH
staff via bedside teaching, case reviews, the sharing of quality improvement approaches, and support
during consultations. RHRU's Primary Health Care Project will provide tools, training and on-site guidance
to DOH staff in primary healthcare sites relating to quality improvement of primary healthcare services,
including palliative care. This project will also provide support to ARV treatment and is described in the ARV
Services section. In FY 2007-2008, RHRU will continue to undertake M&E activities to inform and develop
quality HIV care. RHRU will be in a position to conduct Public Health Evaluations (PHE) of some of its
palliative care related projects in FY 2008-2009. For each PHE, a detailed proposal will be developed and
submitted to PEPFAR for review and funding approval.
These activities contribute significantly to both the vision outlined in the USG Five-Year Strategy for South
Africa and to the 2-7-10 objectives by ensuring that HIV-infected individuals and their families are able to
access comprehensive care, and by expanding access to these services in both the public and private
sector.
Continuing Activity: 13789
13789 9448.08 U.S. Agency for Reproductive 6611 5191.08 $500,000
9448 9448.07 U.S. Agency for Reproductive 5191 5191.07 RHRU (Follow $650,000
Construction/Renovation
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $3,000
Estimated amount of funding that is planned for Economic Strengthening $8,000
Table 3.3.08:
The Reproductive Health and HIV Research Unit (RHRU) will continue with all the activities described
above in the new program year. In addition, RHRU will strengthen its network and collaboration with public
sector facilities in the Johannesburg inner city through the development of a hospital based care and
treatment (C&T) and antiretroviral therapy (ART) initiation and referral model at Selby Hospital. This hospital
receives large numbers of "stepped down" patients from large local hospitals, many of whom have
undiagnosed or untreated HIV. RHRU will conduct in-hospital case finding through bedside voluntary
counseling and testing (VCT). All patients and visiting family members tested will receive support and
referral to other services, both clinical and non clinical as appropriate. Eligible patients will receive
adherence counseling and fast-track entry to treatment either on-site or through rapid referral to an initiation
site. Prior to discharge, patients will be referred to a named ART site with a map and a medical summary
indicating the urgency of accessing ART. Patients who are lost-to-follow up will be traced using home-based
organizations.
It should be noted that all RHRU assisted initiation sites now have designated down referral linkages which
are also receiving support from the program. Nurse initiation of ART at a primary health care (PHC) level
will be scaled up in appropriate PHCs, in line with findings from a pilot of this approach in partnership with
the Department of Health in Ekhuruleni. RHRU will ensure integration of new approaches and task shifting
responsibilities into trainings of health care providers and support staff.
RHRU has developed a set of HIV Standards to guide PHCs on the accreditation, provision and integration
of HIV care into their facilities and is working with the National Department of Health to roll these out to all
provinces over the next two years (see also Care and Support section). RHRU has been requested by the
Department of Health in all three provinces to expand its support to new sites. In 2009-2010, RHRU will
expand to a minimum of three new sites, along with their associated down referral networks in Gauteng,
North West province and KwaZulu-Natal (KZN).
RHRU will continue to place emphasis on the development and implementation of appropriate systems to
streamline and improve care and treatment in all sites it supports. This includes the continuing development
and implementation of the Cell Life pharmacy system, patient follow-up systems, case finding methods and
facility patient file audits.
Lastly, RHRU will work closely with general practitioner (GP) networks in eThekwini, KZN to ensure up
referral of indigent patients to public sector ART sites. RHRU will provide training of GP's and the
development and implementation of referral systems.
RHRU has made contact with local prisons, with the view of improving HIV conditions of care and referral
networks in the future. In addition, prisoners attending local ART clinics are being counseled regarding safe
sex practices; condom access in prisons has been assessed (and appear to be broadly available), while
knowledge of HIV prevention appears to be good amongst prisoners.
--------------------------
The Reproductive Health and HIV Research Unit's (RHRU) will provide ARV rollout support services with
Department of Health (DOH) partners in over 30 facilities in 4 provinces. The emphasis areas are
renovation, human capacity development, and wrap-around programs. Services target people living with
HIV (PLHIV) and their families, including children, pregnant women, caregivers, doctors, nurses, traditional
healers, and other healthcare workers.
RHRU currently provides technical support to the South African Government (SAG) that includes the
national ARV rollout. With PEPFAR funding since FY 2004, RHRU has provided regular onsite support,
direct treatment, training and quality improvement to provincial departments of health (DOH) sites in
Gauteng, North West, Limpopo and KwaZulu-Natal (KZN). RHRU will continue these activities as well as an
inner city program in Johannesburg. Up and down treatment referral systems are being improved in all
provinces. In addition, RHRU will continue the provision of counseling and testing (CT), palliative care, and
prevention services. RHRU will develop service delivery models that can be replicated and expanded, and
produces lessons learned to share with others.
An effective, sustainable ARV treatment (ART) program is founded on strong partnerships with local public
sector treatment sites. The needs of each facility vary, and successful incorporation of ARV services at
facilities requires a thorough facility-based situational analyses. RHRU's aim is to deliver decentralized HIV
care or up and down referral between hospitals and related primary care clinics. ARV clients will be
identified, screened, prepared and initiated on ARV treatment with access to future care at up or down
referral sites. This system reduces congestion at primary treatment sites and improves patient access to
care.
As of June 2007 RHRU-assisted sites were treating over 28,000 people with ART, and over 2,000 health
providers had been trained in ART. RHRU will continue assistance in existing sites and expand services to
several new sites. Pediatric support as well as ART for pregnant women will be expanded. In addition,
RHRU will continue an HIV Maternal Health Outreach Service, and provide planning, training and technical
assistance (TA) to two primary healthcare clinic (PHC) networks in Gauteng and KZN. This will enable
these clinics to receive down-referred patients, and initiate new patients in selected sites. Nurse-based
services will be promoted whenever feasible.
Activity Narrative: ACTIVITY 1: Treatment Support
Specialist HIV treatment teams will support urban and rural ARV sites for adults (including pregnant women)
and pediatrics. They will provide TA to new sites, and will develop and facilitate referral networks. Teams
include a doctor, nurse, management specialist and counselor and will rotate among a cluster of treatment
facilities providing onsite training and management support. In most cases, these teams will be anchored at
each site by a permanent quality improvement nurse and a patient tracker to reduce the number of patients
lost-to-follow-up and lost to initiation. The continuum of care will be emphasized including: prevention,
healthy lifestyle, responsible behavior, nutrition advice, opportunistic infection prevention/treatment,
palliative care, and ART. Materials previously developed to educate healthcare workers and HIV clients
about HIV care will be utilized. Outreach teams will provide ARV and referral clinics with TA on up and down
referral models. The teams will assist local clinic staff to improve practice, integrate and expand services
(including TB, see TB section), and maximize referral for CT, palliative care and ART. As part of this, clinic
renovations and provision of park homes, to maximize quality service delivery, may be necessary in
selected sites. RHRU will also explore the possibility of linking with the private health sector to access and
refer indigent populations into public sector care through low salaried family members on basic medical aid
plans. Furthermore, senior staff will provide TA to national and provincial government in the development of
policies and guidelines. ARV treatment and HIV care for perinatal women will provide outreach in maternal
services. Family-based and gender-specific services for underserved groups such as men and high-risk
women will also continue to be expanded.
ACTIVITY 2: Human Capacity Development
Insufficient skills in HIV care and program management have been a barrier to scale-up of site support.
RHRU will develop an internal site-based training program to enhance staff skills. RHRU also offers a
structured program for young doctors interested in pursuing a career in HIV. All RHRU staff involved in the
PEPFAR program will become skilled HIV clinicians and program implementers, benefiting the program in
the short-term, and improving the South African skill base in public health in the longer term.
RHRU will provide DOH staff in ARV sites with expert capacity and TA to develop models of effective
service delivery using existing infrastructure and resources. It will emphasize clinical training and promotion
of quality improvement techniques that can be applied by the DOH staff to develop local solutions to local
problems. The teams will provide onsite support to clinical management, referral, patient flow and data
management.
Through the PHC and decentralized care projects, RHRU will assist PHC sites to integrate HIV care into
routine service delivery and will support sites with ARV accreditation if appropriate. Nurses will lead these
services, with doctor support when necessary (task shifting). RHRU will conduct formal training courses
including foundation courses in adult and pediatric ART for healthcare providers and traditional healers, and
HIV management for nurses and doctors.
ACTIVITY 3: Pediatrics
RHRU and its partners will expand pediatric and services for young people to additional provinces based on
a review of needs and requests from provincial authorities. The pediatric clinical support teams will rotate
through DOH sites, capacitating and strengthening clinical skills, and supporting the development of referral
networks. They will aid collaborations between healthcare facilities and local FBOs, NGOs and CBOs to
provide holistic care for children on ART. RHRU will play a pivotal role in initiating pediatric ARV services at
facilities where no pediatric services exist. Innovative methods of improving pediatric and adolescent
adherence to ART will be investigated.
The National Adolescent Friendly Clinic Initiative (NAFCI) supports the public sector to provide quality
services geared to youth, and are developing a referral system for HIV-infected adolescents to receive
ongoing care and provision of ART. RHRU will support services at NAFCI sites in proximity to HIV treatment
facilities in Soweto.
ACTIVITY 4: Referral Networks
RHRU will provide training, mentoring, management support and consultants across 4 provinces, to assist
DOH ART sites with referral processes. This includes increasing referral capacity at secondary sites to
channel and monitor stable patients at peripheral sites closer to patient's homes. This mechanism will
reduce congestion at primary sites, enable clinics to see more patients, reduce patient transportation costs
and increase adherence. RHRU will aid capacity development and training of local organizations, as well as
develop linkages, referral systems, human resources, information, education and communication (IEC),
needs assessments, policy and guidelines and strategic information.
ACTIVITY 5: Nutrition
RHRU will support several ART sites including TB hospitals in Johannesburg and Durban by employing
dieticians to provide TA, coordinate supplies of nutritional supplements from the district health office to
facilities for pediatric and TB/HIV-infected clients, provide nutrition information and counseling support and
develop IEC materials. RHRU will provide TA to national and provincial DOH about appropriate nutrition
interventions at different stages of disease in people infected with HIV and TB.
ACTIVITY 6: Monitoring and Evaluation
In FY 2008, RHRU will continue to undertake M&E activities to inform and develop quality HIV care.
These activities directly contribute to PEPFAR's goal of 2 million people on treatment. RHRU will support
the South Africa 5 year strategy by expanding access to HIV services, improving ARV service delivery, and
Activity Narrative: increasing the demand for and acceptance of ART.
Continuing Activity: 13792
13792 9446.08 U.S. Agency for Reproductive 6611 5191.08 $22,022,260
9446 9446.07 U.S. Agency for Reproductive 5191 5191.07 RHRU (Follow $14,783,370
Estimated amount of funding that is planned for Human Capacity Development $4,000,000
Table 3.3.09:
FY 2008 COP activities will be expanded to include:
-Evaluating and referring children coming for regular immunizations and offering counseling and testing;
-Tracked infants from the time of discharge to ensure that they are tested at 6 weeks of age;
-Training of healthcare workers at frontline sites and working closely with them around case-finding to
ensure sustainability;
-Expansion of monitoring and evaluation tools to monitor clinical outcomes
-Conducting workshops to equip counselors in working with children and passing their skills onto other
practitioners
-Increasing participation of adolescents in clinic activities.
The success of pediatric ARV treatment scale-up depends on a comprehensive approach. In particular,
Reproductive Health and HIV Research Unit (RHRU) and its sub-partner Enhancing Children's HIV
Outcomes (ECHO). (RHRU-ECHO) continues to strive to strengthen referrals and linkages from other
programs such as PMTCT and primary health care programs like TB, Maternal, Child and Women's Health
(MCWH), Integrated Management of Childhood Illness (IMCI), and Expanded Program on Immunization
(EPI) in an effort to ensure that more children are identified for care. This program will maintain focus on
improving these linkages through direct support, and intensive training of doctors, nurses, and other health
care professionals. In recognition of the fact that pediatric ART cannot be provided in isolation of caregivers,
our program aims to provide a family-centered approach to care.
RHRU and its sub-partner ECHO will continue to provide care and support to 3 provinces which include
Gauteng (11 sites), KwaZulu-Natal (10 sites), Limpopo (9 sites) and the North West province (4 sites). The
program activities described in detail below will also be implemented across site networks which include
referral sites and other surrounding clinics.
Activities described in this section will be undertaken by RHRU and its partner ECHO. RHRU, a unit of the
University of the Witwatersrand in Johannesburg, currently provides technical support to the Operational
Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa, which includes
the national ARV roll-out. RHRU has provided regular on-site support, direct treatment, training and quality
improvement to Department of Health sites in three provinces. RHRU will continue these activities, and will
continue both an inner city program (Johannesburg), a district-wide program (Durban), and a more discrete
site-based provincial program (North-West Province) focusing on providing support to complete up and
down treatment referral networks. ECHO is attached to the University of the Witwatersrand in Johannesburg
and has worked as a sub-partner to the RHRU since FY 2005. RHRU and ECHO have provided direct
antiretroviral treatment for thousands of children, strengthening and improve state health systems. RHRU
and ECHO provide technical support to (and are involved in policy development and advocacy for) pediatric
care with the National and Provincial Departments of Health (DoH), with strong representation on the South
African National AIDS Council (SANAC). The organizations have expanded their program to include
Prevention of Mother to Child Transmission (PMTCT), pediatric HIV treatment, emphasis on psychosocial
and nutritional support and training and have been an integral part of the program since inception and the
joint program now operates from Gauteng with teams in the more rural North-West.
ACTIVITY 1: Case-finding
RHRU-ECHO, across all sites, will continue supporting this program by interacting with all the pediatric
entry points at hospitals and clinics. These include among others; the pediatric wards, out-patient
departments, EPI and IMCI clinics, nutrition departments and maternity wards. At each of these points,
RHRU-ECHO will be ensuring that active counseling and testing of caregivers of exposed children and
infants takes place. At pediatric and general out-patient departments, RHRU-ECHO staff will work with DoH
staff in order to increase awareness around typical signs and symptoms of HIV in children presenting there.
In pediatric inpatient wards, RHRU-ECHO will be involved with regular ward rounds where testing and
counseling of children will take place. There will also be regular updated training of ward staff around
identification of children.
At EPI clinics, RHRU-ECHO will be involved in evaluating children coming for regular immunizations and
offering counseling and testing which will include HIV exposed babies, symptomatic babies and also those
children born to parents with possible HIV infection. HIV counseling and testing will also be provided within
IMCI clinics, and access to cotrimoxazole prophylaxis for HIV-exposed babies evaluated.
RHRU-ECHO will also support the PMTCT programs at these sites to ensure that all HIV exposed infants
receive appointments and are actively traced to confirm their HIV status by 6 weeks of age through
polymerase chain reaction (PCR) testing, according to the national PMTCT guidelines.
All infants who test positive will be referred to, and actively followed to ensure that they attend ARV sites. At
each of these points, baseline information will be collected using a standardized tool which is already being
piloted at some sites in Gauteng.
The activities at these points will include giving routine HIV-related health talks to patients attending the
clinics, counseling caregivers and performing HIV testing (DNA PCR, rapid or ELISA ) with appropriate
access to cotrimoxazole and access to ART where indicated for HIV exposed and/or sick infants and for
older children. Caregivers will also be offered testing if their HIV status is unknown. If HIV-infected, they will
Activity Narrative: have CD4 testing and referral for treatment if necessary; they too will be actively traced into care.
RHRU-ECHO will be involved with training of healthcare workers at frontline sites and working closely with
them around case-finding to ensure sustainability. This will take the form of mentorship as well as regular
CMEs (Continuing Medical Education).
In the Johannesburg Inner city and in KZN, RHRU and ECHO will be participating in testing campaigns.
These will take place on an ongoing basis, where infants and children and their families will be tested and
referred into care if HIV-infected. The above will also apply to Limpopo where the RHRU team will support
the clinics surrounding Mankweng hospital. In the North-West, the RHRU-ECHO team will be going out to
selected clinics in Mafikeng, Ratlou and Disobotla where they will be working closely with the PMTCT team
in ensuring testing and counseling of HIV exposed infants and children. The team will be conducting
continuing medical education (CME) around identification of children who need to be tested and on referrals
to the ARV site for those who are eligible.
ACTIVITY 2: Links to other programs
RHRU-ECHO will utilize referral forms which are currently being piloted at some sites and which will be
used to track patients from the time they are tested to when they receive their results, to the point where
they arrive at the ARV site if eligible. Data is being entered, manipulated, and fed back to nurses at the
sites, and is used for program monitoring and evaluation purposes.
In terms of linking of referrals from PMTCT, mothers and babies will be tracked from the time of discharge
to ensure that they are tested at 6 weeks of age or re-tested after cessation of breastfeeding to the point
where they are referred to an ART site if necessary. This will be monitored on a weekly basis by the RHRU-
ECHO staff visiting the various service points.
ACTIVITY 3: Clinical monitoring and management of Opportunistic Infections (OIs) and other co-morbidities
RHRU-ECHO medical staff receives ongoing medical education and are able to monitor clinical events in
children with HIV, including opportunistic infections, immune reconstitution inflammatory syndrome and
treatment side effects. Clinicians at all sites will continue to have regular case meetings to discuss
management of complicated cases There is an active continuing medical education program for internal
clinical staff which also forms part of training curriculum for clinicians working at the sites where RHRU
offers support, and for other partners. RHRU actively trains primary health care nurses who not only are
able to diagnose, stage, initiate and maintain ART in children, but are also equipped to identify and
appropriately refer complicated cases. There is an active academic program and clinicians are encouraged
to report on interesting cases or events occurring within clinic populations in scientific journals.
ACTIVITY 4: Quality Control
As part of quality control, RHRU-ECHO, across all its sites, will continue to conduct file audits at least bi-
annually. These will be conducted using randomized sampling. Currently large program audits are
conducted at the larger sites, and data on outcomes of children on ART is available at these facilities.
ACTIVITY 5: Family support
It is not possible to provide pediatric care and support in isolation of caregivers. RHRU-ECHO aims to
provide comprehensive family support at all sites. At secondary and primary care levels, pediatric clinics are
integrated with adult clinics and parents can receive care for their own illnesses simultaneously. This is
often done in partnership with RHRU clinicians. At tertiary sites pediatric and adult clinics still run
separately. However, the imminent creation of a family HIV and TB unit at Chris Hani Baragwanath Hospital
will ensure a more comprehensive approach to family care. This will occur in a facility which will be
designed to maximize infection control. This flagship program may be replicated in other facilities where
RHRU works through collaborations with other partner organizations.
Of fundamental importance is the provision of psychological and social care in order to enable families to
provide the necessary support for HIV-infected children. This clinic-based program aims to support
caregivers in addressing important aspects of treatment such as disclosure of a child's HIV status and
adherence to treatment.
The program is based on the development of support groups which will cover relevant topics. Group work is
a necessity due to space and time constraints for individual counseling sessions. A "tool box" of approaches
for use in support group work will be provided for which indicators have been developed for purposes of
monitoring and evaluation.
ACTIVITY 6: Improve Service Quality
In an epidemic where so many children and adults are infected, focusing on increasing numbers in care
without assuring quality is a challenge to all healthcare providers. Through active tracing and monitoring,
RHRU is able, at their larger sites, to assess the quality of care in terms of numbers retained in the
program, viral load suppression rates, clinical and immunological responses as well as mortality rates.
Through expansion of these tools, RHRU will continue to monitor these outcomes, thereby informing the
quality of programs at all sites where RHRU operates.
The quality of psychosocial program and training activities will continue to be evaluated.
ACTIVITY 7: Support groups
Group Support of Children
Activity Narrative: In addition to psychological support provided through individual counseling and play therapy, children
benefit from participation in programs that encourage emotional literacy and the expression of feelings. This
is encouraged through group work at facility level where there are opportunities for play, dance and art. This
program includes workshops to equip counselors in working with children and passing their skills onto other
practitioners. It is proposed that a series of workshops structured to provide a safe holding environment
provide healthcare workers with the opportunity to explore the tools and application of art therapy specific to
working with South African children infected and affected by HIV and AIDS. These will be designed to assist
participants with the application and integration of arts-based interventions on a broader scale.
Group Support for Adolescents
The availability of antiretroviral treatment has meant that increasing numbers of perinatally infected children
are surviving into adolescence and beyond. This population has specific needs and challenges that are
related to this stage of development. The adolescent program aims to introduce "stand alone" youth friendly
services in clinics where numbers justify the introduction of such services. Activities include peer counselor
training, peer education programs, school holiday programs, community-based peer support groups and
caregiver-adolescent workshops aimed at building communication between adolescents and their
caregivers.
We aim to increase the meaningful participation of this population in clinic activities and more broadly to
encourage initiatives such as community-based peer support groups that foster community mobilization
through the development of networks. In achieving an aim is to partner with OVC organizations. In addition
adolescents are assisting in coping with everyday challenges through programs that focus on themes such
as gender and sexuality.
The above program was piloted during 2007-2008. This will be rolled out to three additional sites during the
FY 2008-2009, increasing to all sites in 2009-10. The implementation of this orientation will require the
training of multi-disciplinary teams to provide youth friendly services that include reproductive health.
Monitoring and evaluation is according to indicators set out in existing models for the development of gold
standard youth friendly services (YFS).
Caregiver support groups
Support groups for parents are ongoing at tertiary centers. Activities include an early developmental
stimulation program for caregivers of young children in collaboration with speech therapists and
physiotherapists working at the tertiary sites. Caregiver support will be expanded and rolled out at other
sites.
Estimated amount of funding that is planned for Human Capacity Development $30,000
Table 3.3.10:
RHRU and its sub-partner, Enhancing Children's HIV Outcomes (ECHO), will continue to provide care and
support to 4 provinces which include Gauteng (11 sites), KwaZulu-Natal (10 sites), Limpopo (9 sites) and
the North West (4 sites). The program activities described in detail below will also be implemented across
site networks which include the referral sites and other surrounding clinics. Services target people living
with HIV (PLHIV) and their families, including children, pregnant women, caregivers, doctors, nurses,
traditional healers, and other healthcare workers.
Activities described in this section will be undertaken by RHRU and its partner, ECHO. RHRU, a unit of the
site-based provincial program (North West province) focusing on providing support to complete up and
and has worked as a sub-partner to the Reproductive Health and HIV Research Unit (RHRU) since FY
2005. RHRU and ECHO have provided direct antiretroviral treatment for thousands of children,
strengthening and improve state health systems. RHRU and ECHO provide technical support to, and are
involved in policy development and advocacy for pediatric care with the National and provincial
Departments of Health (DOH), with strong representation on SANAC. The organizations have expanded
their programs to include Prevention of Mother-to-Child Transmission (PMTCT), pediatric HIV treatment,
emphasis on psychosocial and nutritional support and training and have been an integral part of the
program since inception and the joint program now operates from Gauteng with teams in a the more rural
North West. The success of pediatric ARV treatment scale-up depends on a comprehensive approach. In
particular, RHRU and its sub-partner ECHO (RHRU-ECHO) continues to strive to strengthen referrals and
linkages from other programs such as PMTCT and primary health care programs like TB, MCH, IMCI, EPI
in an effort to ensure that more children are identified for care. This program will maintain focus on
ACTIVITY 1: Increase access to treatment
There are currently almost 9,000 children who have been started on ARV treatment through support from
ECHO and RHRU. The SA DOH goal is to increase the proportion of children on ART to 15% of all people
on ART. This has already been exceeded in some areas where ECHO and RHRU are involved and as
partners continue to strive towards, and advocate for ensuring all children who are in need receive ART.
Despite improvements in the PMTCT program, which will likely reduce the numbers of HIV-infected infants,
it is believed that through active case management there will still be increasing numbers of HIV-infected
children being referred for ART. RHRU and ECHO teams consisting of doctors, nurse clinicians, counselors
will continue to support urban and rural sites in KZN, Gauteng, Limpopo and North West province, in
alignment where possible, with sites where RHRU provides adult services. RHRU and ECHO will also
continue to provide technical assistance and service provision at tertiary facilities. This work takes place
within DOH facilities and RHRU and ECHO staff work closely with the DOH staff at all the sites. In KZN and
Gauteng, sites will continue to be supported by pediatric nurses, pediatricians, psychologist, social workers
and dieticians in addition to generalist doctors and nurses. Data capturers will provide data support and
management services under the monitoring and Evaluation section. The utilization of Mobile Clinical
Support Teams (MCST) will continue throughout outreach sites, and as ART accredited sites demonstrate
capacity to provide treatment and care for children without the support of the ECHO and RHRU teams,
additional sites will be identified and the MCST will assist with mentoring staff at accredited sites to manage
HIV-infected children.
ACTIVITY 2: Loss-to-follow-up
Defaulter tracers will be based at all pediatric ART facilities to track all defaulters. Ongoing networking and
collaboration with other NGOs to assist with tracing of defaulters will occur. Also of concern are children
who are booked at sites but never show at the clinics. There is a high mortality in these children and
renewed efforts will be made to ensure that children who are booked for appointments are seen at the
treatment site, and urgently traced if they miss the appointment.
ACTIVITY 3. Quality assurance
The whole care pathway will be emphasized at all service points, which will include prevention, counseling
and testing, diagnosis and management of opportunistic infections including TB.
In terms of quality improvement, sites will conduct regular multidisciplinary activities which will look at
improving quality of care provided. Systems are being rolled out to ensure that outcomes of children of
treatment at all ART sites are being monitored.
ACTIVITY 4: Nutrition support
Nutritional support will continue to take the form of nutritional assessment and counseling of 'at risk infants
and children' as well as the provision of therapeutic or supplementary feeding support for clinically
malnourished patients in Durban and at Harriet Shezi Clinic in Gauteng. ECHO and RHRU dieticians will
Activity Narrative: continue to mentor DOH dieticians at outreach sites to ensure that malnourished children receive
appropriate interventions.
ACTIVITY 5: Tuberculosis (TB)
TB screening and diagnosis will continue to take place in accordance with the National TB Program
guidelines with the provision of INH preventive therapy to HIV-infected children exposed to sputum smear-
positive TB wherever necessary. In hospital settings, RHRU and ECHO will continue to work closely with
the pediatrics departments in the wards to monitor children in the wards already on ART and those needing
ART. If necessary, children will be started on ART whilst still in the wards. All children that have been
identified as being HIV-infected will continue to be referred immediately to the ARV site for further
management. This will include sick children identified through Integrated Management of Childhood Illness
(IMCI) programs as well as those presenting at EPI clinics.
ACTIVITY 6: Quality of care
As part of quality control, RHRU and ECHO will continue to conduct file audits at least bi-annually. These
will be conducted using randomized sampling. Currently large program audits are occurring at the bigger
sites and data on outcomes of children on ART is available at these facilities. In terms of quality monitoring,
viral load suppression rates will be looked at, as well as overall clinical outcomes a mortality rates.
ACTIVITY 7: Monitoring and Evaluation
RHRU and ECHO aims to strengthen monitoring activities as current services are often fragmented and
make monitoring and evaluation a challenge. With the implementation of case management and tracking,
RHRU and ECHO will assist sites in piloting and implementing data collection tools designed by DOH. The
aim is to strengthen the existing mechanisms within the DOH services for monitoring and evaluation. This
will most likely better inform treatment and support programs. RHRU and ECHO will thereby support South
Africa's Five-Year Strategy by expanding access to HIV services, improving pediatric care service delivery,
and increasing the number of children accessing care and treatment.
ACTIVITY 8: Human Capacity Development
RHRU staff will continue to train clinicians (doctors and primary health care nurses) providing antiretroviral
therapy on pediatric specific treatment issues through didactic courses and through on-site mentorship.
RHRU staff, because of their direct involvement and leadership in guidelines development (both for South
Africa and technical advice to WHO), are well placed to continue to train ARV clinicians as the guidelines
change and are updated. ECHO staff will continue to provide the pediatric component of the RHRU two-
week training course that runs quarterly. ECHO staff through the Mobile Clinical Support Teams will
continue to provide on-site mentorship at outreach ART sites. Clinicians working with other partners and the
pediatrics department will also rotate through tertiary ART sites and will continue to be mentored in this way.
Weekly continuing medical education programs aimed at increasing clinical capacity of nurses and doctors
will continue to be held; as will weekly case discussions where complicated cases are addressed in a
multidisciplinary forum. RHRU staff also will continue to lead development of the University of the
Witwatersrand Faculty of Health Sciences first year medical student curriculum which exposes students to
an understanding of antiretroviral therapy, among other topics. In KwaZulu-Natal, RHRU staff provides
direct on-site training and mentoring to Department of Health (DOH) staff in pediatric HIV treatment and
care at RHRU-supported health facilities.
Estimated amount of funding that is planned for Human Capacity Development $500,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $30,450
Estimated amount of funding that is planned for Food and Nutrition: Commodities $5,000
Table 3.3.11:
TB and families: In line with the Reproductive Health Research Unit's (RHRU) strategy to increase
counseling and testing (CT) services to family members of HIV-infected people, TB screening and contact
tracing will be offered as well. This will be coupled with updated TB screening protocols at selected sites
that move beyond identification of chronic coughs to fast-tracking sputum tests.
Facilitated Referral: RHRU will work with the Department of Health (DOH) to strengthen referral
mechanisms. Where patients are referred for diagnosis and treatment, opportunities will be sought to
promote, as best practice, escorted referral to ensure that patients reach the other side of the service
compendium.
Infection Control: TB infection control measures are essential to prevent the spread of M. tuberculosis to
vulnerable patients, health-care workers and communities. In light of the emergence and spread of drug-
resistant TB, the establishment of facilities that are safe from TB has become a priority. RHRU will promote
and implement improved TB infection control practices. These will include improved administrative (good
workplace practice including the triaging of coughing patients by on-site case finders), environmental (good
ventilation) and personal respiratory protection (DOH and WHO approved masks. At selected sites where
the provision of adequate natural ventilation is not possible, RHRU will support the provision of UV radiation
or filtration systems. Training will be provided to health-care workers (adherence to infection control plans,
triaging of patients and proper procedures for collection and handling of sputum samples) and patients
(cough etiquette, community awareness and the importance of testing family and partners).
Prevention of TB Disease: RHRU will continue work with primary health-care facilities and staff to identify
clients eligible for prevention of TB by INH prophylactic therapy, using the TB/HIV integration register and
the INH prophylaxis register. In addition, RHRU will work with DOH staff to adapt the INH prophylaxis
guidelines where appropriate.
Drug Resistant TB: RHRU will work with the National Health Laboratory Services (NHLS) laboratories and
DOH to identify multi- and extensively drug-resistant TB (MDR/XDR-TB) cases (through newer PCR-based
diagnostic testing) and facilitate appropriate management of these cases, including HIV testing,
commencement of antiretroviral treatment, contact tracing and referral for management of TB disease.
RHRU will work with stakeholders to implement guidelines for management of contacts of MDR/XDR-TB
patients.
------------------------------------
The Reproductive Health Research Unit's (RHRU) TB-HIV activities include the ongoing provision of TB
clinical services and the expansion of referral networks and service integration in a deprived inner city area
of Johannesburg, South Africa. In addition, in KwaZulu-Natal (KZN), the RHRU is supporting
implementation of ARV services at two TB hospitals (Don McKenzie & Charles James, where over 80% of
TB patients are coinfected with HIV. Lastly, RHRU will pilot a program to provide a health screening
program to health care workers in the inner city of Johannesburg, to ensure a healthy workforce and early
referral and management of chronic disease. Emphasis areas include human capacity development and
local organization capacity building. Target populations include PLHIV, adults and children.
regular on-site support, direct treatment, training and quality improvement to DOH sites in 3 provinces. They
will continue these activities, which include inner city, district wide and rural programs focusing on providing
support to complete up and down treatment referral networks. In addition, RHRU will continue the provision
of counseling and testing (CT), palliative care, and prevention services. RHRU continues to develop models
of service delivery that can be replicated and expanded, and produces findings from lessons learned and
targeted evaluations to disseminate and share with others. It should be noted that the success of ARV
treatment scale-up depends on the comprehensive approach detailed in other program areas. In particular,
the strengthening of referral from other primary healthcare programs such as TB, family planning,
antenatal/postnatal and STI treatment is critical. Basic Health Care and Support is an integral part of this
system, and the RHRU will focus this part of its program on PLHIV, in impoverished areas such as the
Hillbrow neighborhood in Johannesburg, and at PHC clinics in Durban, and rural areas of the North West
province by delivering high quality palliative care, psychosocial support, and intensive training of doctors,
nurses, and other health care professionals. Furthermore, RHRU will continue to develop strategies to
address underserved communities affected by HIV, such as couples, high risk groups such as adolescents,
and gender-based interventions with women at risk, including pregnant women, sex workers, and men.
Although approximately 58% of TB patients in South Africa are HIV infected, published data have shown
that a low number of patients are referred from surrounding TB sites to ARV services. A large percentage of
these patients will qualify for immediate ARV treatment, and represent an untapped population requiring
immediate access to ARVs. RHRU has been working with health authorities to provide TB clinical services
and training, with the support of Emergency Plan-funding. RHRU has integrated TB into general palliative
care training, and trained thousands of health providers in these areas in previous years. In addition, RHRU
programs assist in treating HIV-infected people for TB. In FY 2008, RHRU will build on this program by
continuing to train health care providers, and continuing to emphasize TB and HIV integration as part of on-
site technical support to ARV treatment sites and primary health care clinics and their referral facilities.
Activity Narrative: RHRU will continue to work with the national and provincial departments of health and specifically with the
HAST (HIV, AIDS STI, and TB) managers to prioritize interventions designed to address weaknesses
(identified by the departments of health) in the DOTS and TB/HIV programs. RHRU will focus on improving
policy adherence and patient follow-up. Individuals will be hired for each site as tracers to track patients and
ensure that referrals are completed. RHRU is setting aside funding to develop (with other relevant partners
or agreement counterparts) standardized tools to ensure that policies and guidelines recommended by
NDOH are followed, including guidelines for infection control. RHRU will continue to integrate TB/HIV
interventions with existing agreement programs as they work seamlessly and side by side with government
employees at government facilities.
ACTIVITY 1: TB Treatment Support & Integration
Tuberculosis treatment represents an ideal opportunity for entry in to an ARV program. Patients being
treated for TB have to deal with the public health system entry, daily adherence, drug toxicity, and regular
follow-up evaluation, all of which are key components of the ARV program. Ensuring that health care
workers understand that referral from TB sites should be seamless, and encouraging patients to test for HIV
through the DOH program, will ensure a constant stream of well-prepared co-infected patients entering the
system.
ACTIVITY 2: TB Referral & Staging
RHRU's teams will continue to work within the existing TB services in 3 provinces to expand CT, CD4
staging, initiation of opportunistic infection prophylaxis (cotrimoxazole) and preliminary ARV adherence
advice. RHRU will also facilitate direct referral of correctly staged patients into ARV treatment sites, and
ensure that other patients accessing ARVs in RHRU sites in the 2 provinces are referred for TB treatment
where necessary. Additionally, in the case of very immuno-compromised patients with TB who require
ARVs relatively quickly in terms of national guidelines, RHRU will train health care workers to recognize this
urgency and refer accordingly, while working with accepting ARV sites to similarly treat these cases with
urgency.
RHRU will continue to develop and scale up TB/HIV training programs for TB service providers operating at
all levels of facilities in the provinces in which RHRU works. The primary focus will be on increasing access
to ARV services from TB services through continual training and engagement with TB managers. RHRU
anticipates that this approach will maintain a steady stream of patients into their ARV programs (see ARV
Services section for more information).
ACTIVITY 4: Health Maintenance Program for Health Care Workers
RHRU will continue to provide screening for TB, HIV and chronic diseases among health care workers in
City of Johannesburg health facilities, to ensure the preservation of human capacity and to determine the
risk of TB infection among this important group. In FY 2008, RHRU will continue to undertake M&E activities
to inform and develop quality TB/HIV care. RHRU will be in a position to conduct Public Health Evaluations
(PHE) of some of its TB-HIV related projects in FY 2008-2009. For each PHE, a detailed proposal will be
developed and submitted to PEPFAR for review and funding approval. This activity will contribute to both
the vision outlined in South Africa's 5 Year Strategy and to the 2-7-10 goals by identifying and directing
more people to ART, and by increasing access to care.
Continuing Activity: 13790
13790 9444.08 U.S. Agency for Reproductive 6611 5191.08 $780,850
9444 9444.07 U.S. Agency for Reproductive 5191 5191.07 RHRU (Follow $805,000
Table 3.3.12:
All program areas described in the FY 2008 COP will continue in FY 2009, including counseling and testing
(CT) tailored to underserved groups such as adolescents, men, couples and women at risk. Through the
further implementation of the Reproductive Health Research Unit's (RHRU's) HIV standards materials at
RHRU-supported sites, routine testing offers will be emphasized at all primary health care (PHC) sites, and
bedside testing services will be increased at RHRU supported hospital sites. Where PHCs do not have
space to offer CT, RHRU will provide mobile testing units to render this service. At all sites, patients who
test positive will be given CD4 test results. Patients not collecting these tests will be followed up by clinic
staff to ensure maximum referral into care and treatment. Those referred for care and treatment will also be
followed up as necessary. In addition, RHRU will continue to hold CT "events" at selected sites in order to
increase the numbers of those tested and referred. RHRU plans to build on the recent piloting of "health
days" that provide a holistic, approach to testing, by offering it as part of a package of health tests and
demonstrations, in order to reduce stigma and increase HIV testing uptake. These events will be targeted at
different groups, and in particular young people and men, in underserved communities. Psychosocial
support will be provided within an enabling environment in collaboration with our sub-partner ECHO.
Increased attention will be directed at family-centered testing at the PHC level. Furthermore, RHRU will pilot
a case-finding/family testing program at Selby Hospital, Johannesburg. Active case finding will be coupled
with testing of families during hospital visiting times, and follow up for those who require further referral.
RHRU will explore opportunities to develop a youth center with other non-governmental organization (NGO)
partners within the Hillbrow Health Precinct, where, together with a package of health- and social-related
services, counseling and testing will be offered in a youth friendly manner.
RHRU will pilot a telecommunication system based on "short message services (SMS)" to increase repeat
CD4 measurements across selected sites in KwaZulu-Natal, Gauteng and the North West province. Mobile
CT vehicles will be used to provide services in areas where site-based CT services are hard to access.
These vehicles will be equipped with CD4 measuring machines for rapid provision of results with defined
linkages to treatment and care services.
RHRU will provide additional training in counseling and testing to existing teams of nurses and counselors
at supported sites. This training is given in the context of an expanding antiretroviral (ARV) treatment and
down referral program, and is tailored at capacitating staff to effectively deal with the challenges this
presents.
-----------------
The Reproductive Health and HIV Research Unit's (RHRU) PEPFAR-funded program, subsequently
referred to as the "Follow-on to the RHRU Program" (FRP), was re-competed through an Annual Program
Statement (APS) in 2007, and awarded to the RHRU. PEPFAR funds will support the FRP to continue to
provide counseling and testing (CT) services, and to expand services tailored to target groups such as
couples, pregnant women, young people, children, and families, as part of an integrated prevention, care
and treatment program. FRP will also provide training and mentoring in voluntary counseling and testing to
Department of Health (DOH) staff, to ensure the implementation of provider-initiated testing and counseling
(PITC) in TB, STI, antenatal/postnatal and contraceptive services at all levels. Major emphasis in this
program area is on quality assurance and supportive supervision, with additional emphasis on the
development of network/linkages/referral systems, human resources, and training. These activities target
HIV-affected families (children, youth, and adults), sex workers, men, pregnant women, discordant couples,
and public health workers.
Africa, which includes the national antiretroviral (ARV) roll-out strategy. Under PEPFAR funding since FY
2004, RHRU has provided regular on-site support, direct treatment, training, and quality improvement to
DOH sites in three provinces (Gauteng, KwaZulu-Natal and North West). The FRP will continue these
activities, which include inner city, district wide and rural programs focusing on providing support to a
complete up and down treatment referral network. In addition, FRP will continue the provision of counseling
and testing (CT), palliative care, and prevention services. FRP will seek to develop models of service
delivery that can be replicated and expanded, and produces findings from lessons learned and targeted
evaluations to disseminate and share with others. It should be noted that the success of ARV treatment
strengthening of referral from other primary healthcare programs such as TB, family planning,
antenatal/postnatal and STI services is critical.
In FY 2007, FRP will continue to focus on further strengthening DOH adult and pediatric treatment, and on
continuing the development of a family-based approach to HIV care and treatment in the public sector.
Furthermore, FRP will continue to develop strategies to address underserved communities affected by HIV,
such as couples, high-risk groups such as adolescents, and gender-based interventions with women at risk,
including pregnant women and sex workers, and men. FRP places strong emphasis on quality assurance
for all interventions supporting CT and will draw on the tools that have a proven track record in terms of
improving quality of care, such as pocket reminders for counselors, wall charts with trigger messages for
clients and counselors, and routine performance assessments.
ACTIVITY 1: Counseling and Testing
Activity Narrative: PEPFAR funds will support FRP to continue to directly provide CT services at multiple sites, and to expand
services tailored to target groups such as couples, family planning clients, children, families, men, pregnant
women, and sex workers as part of an integrated prevention, care and treatment program. Discordant
couples will be targeted for prevention education, and concordant couples can benefit from referral to a
wellness program. Both groups will benefit from fertility and family planning advice. FRP will work closely
with the national DOH and will ensure that CT is integrated into other health programs at all levels. In
addition, FRP will focus on integrating provider-initiated testing and counseling (PITC) into TB, STI,
antenatal/postnatal and family planning services as recommended in the HIV & AIDS and STI Strategic
Plan for South Africa, 2007 - 2011.
ACTIVITY 1.1: Gender-based Voluntary Counseling and Testing
Approximately 70% of individuals currently accessing antiretroviral treatment (ART) are women. FRP will
continue to develop services that aim to address this gender inequality, and to increase the number of men
who obtain HIV care. This will be done through the development of male-friendly CT methods, such as
family-centered counseling and testing, and interventions to encourage health-seeking behaviors. This
program will contribute towards increasing gender equity in HIV and AIDS programs.
ACTIVITY 1.2: Family-Centered Testing
Children and families have special needs that will be addressed in the program. Previous work in antenatal
clinics and in pediatric treatment will have given FRP the opportunity to promote family testing to DOH staff
and community social workers, and to develop approaches to this activity. A youth-friendly CT model will
continue to be developed and implemented in the inner city of Johannesburg and Durban. Mobile CT units
will be utilized to increase access to CT for families at weekends and to other hard-to-reach groups. Age-
appropriate counseling and testing techniques will be developed, and opportunities to scale-up counseling
and testing of this group will be identified and interventions implemented accordingly.
FRP will train counselors, doctors, nurses, and other healthcare workers to provide comprehensive and
appropriate CT services, in line with South African guidelines. This includes appropriate referral, and
updates on new practices and current debates in an evolving field. In addition, FRP staff will provide
mentoring to local NGOs, lay counselors, and DOH staff in the public sector facilities in which they work,
through weekly supportive supervision sessions with all counselors and regular meetings to discuss the
development and application of new practices.
In FY 2008, RHRU will continue to undertake monitoring and evaluation activities to inform and develop
quality HIV care. RHRU will be in a position to conduct targeted evaluations (TE) and Public Health
Evaluations (PHEs) of some of its counseling and testing projects in FY 2008 and FY 2009. For each PHE,
a detailed proposal will be developed and submitted to PEPFAR for review and funding approval.
These activities expand CT services to important high-risk populations, and serve as a critical entry point
into HIV care and treatment programs, thus contributing to the 2-7-10 goals by enabling access to treatment
and prevention for those who test.
Continuing Activity: 13791
13791 9445.08 U.S. Agency for Reproductive 6611 5191.08 $908,000
9445 9445.07 U.S. Agency for Reproductive 5191 5191.07 RHRU (Follow $1,125,000
Estimated amount of funding that is planned for Human Capacity Development $200,000
Table 3.3.14:
The Reproductive Health Research Unit (RHRU) will continue to support the development by the South
African government, of key technical documents, programmatic implementation plans, policies and position
papers in the areas of HIV and reproductive health.
Africa, which includes the national ARV roll-out. Through PEPFAR funding since FY 2004, RHRU has
sites in three provinces. RHRU will continue these activities, and will continue both an inner-city program
(Johannesburg), rural and urban programs (Gauteng and North West provinces) and a district-wide program
(Durban), focusing on providing support to complete up and down treatment referral networks. In addition,
RHRU will continue the provision of counseling and testing (C&T), palliative care and prevention services.
RHRU will seek to develop models of service delivery that can be replicated and expanded, and produces
findings from lessons learned and targeted evaluations to disseminate and share with others. It should be
noted that the success of antiretroviral treatment (ART) scale-up depends on the comprehensive approach
detailed in other program areas. In particular, the strengthening of referral from other primary health care
programs such as tuberculosis (TB), family planning, antenatal/postnatal and STI services is critical.
Prevention is an integral part of this system and RHRU will focus its prevention program on high-risk groups
such as commercial sex workers and their clients, people infected with HIV, on reducing MTCT and also on
building capacity of health care workers, CBOs and NGOs with which it works. RHRU will also continue to
and discordant), high risk groups such as young people, and gender-based interventions with women at
risk, and commercial sex workers, and men.
ACTIVITY 1: National
Key PEPFAR-funded RHRU staff participate in strategic policy making bodies such as the South African
National AIDS Council (SANAC) and the Southern African HIV Clinicians Society. These staff members
work on developing policy in support of the NSP. ECHO staff members have been integrally involved in
development of updated PMTCT guidelines which have been implemented since April 2008. RHRU and
ECHO staff members have, in conjunction with other partners, developed a training program around this
and will continue to support Provincial Guidelines in the provision of dual AZT and NVP to mothers and
babies.
ACTIVITY 2: Provincial
RHRU will provide the Department of Health at provincial, district and facility levels with technical assistance
for strategic information activities. This will include the training of NDOH and sectoral staff in implementing
national and provincial monitoring and evaluation systems and health management and information
systems. Focus areas include data collection, analysis, interpretation and dissemination. This will serve to
strengthen the monitoring of national outputs against targets, internal RHRU outputs with concomitant
reporting of results to government, donors and civil society.
Estimated amount of funding that is planned for Human Capacity Development $105,000
Table 3.3.17:
The Reproductive Health Research Unit (RHRU) will continue to provide technical assistance to the South
African government for policy development and program planning in HIV; reproductive health; and
tuberculosis (TB).
Africa, which includes the national antiretroviral (ARV) roll-out. Through PEPFAR funding since FY 2004,
RHRU has provided regular on-site support, direct treatment, training and quality improvement to National
Department of Health (NDOH) sites in three provinces. RHRU will continue these activities, and will
continue both an inner-city program (Johannesburg) and a district-wide program (Durban), focusing on
provision of counseling and testing (CT), palliative care and prevention services. RHRU will seek to develop
models of service delivery that can be replicated and expanded, and produces findings from lessons
learned and targeted evaluations to disseminate and share with others. It should be noted that the success
of antiretroviral treatment (ART) scale-up depends on the comprehensive approach detailed in other
program areas. In particular, the strengthening of referrals from other primary healthcare programs such as
TB, family planning, antenatal/postnatal and sexually transmitted infection (STI) services is critical. RHRU
views prevention as an integral part of this system and will focus its prevention program on high-risk groups
such as commercial sex workers and their clients, and people infected with HIV. Its prevention program will
also focus on reducing mother-to-child transmission (MTCT) and building the capacity of healthcare
workers, community-based organizations (CBOs) and NGOs with which it works. In addition, RHRU will
continue to develop strategies to address underserved communities affected by HIV, such as couples (both
concordant and discordant); high risk groups, such as young people; and will employ gender-based
interventions with women at risk, and commercial sex workers, and men.
RHRU will carry out the following two separate activities in this program area.
ACTIVITY 1: File Audits
RHRU has developed systems for the analysis and accurate reporting of indicator data to district and
provincial health departments. A key strategy here is the use of systematic retrospective patient file reviews
to provide evidence on the quality of care and treatment outcomes at ARV initiation sites. To-date files of all
patients accessing care at five hospitals/clinics (urban and rural) were reviewed and key information was
collected including demographic data, gender breakdown, CD4 and viral load at initiation and current patient
status. Data related to opportunistic infections, regimen changes and the causes thereof are documented
and analyzed. The findings have identified key areas in need of program improvement, and have been used
as baseline information to initiate defaulter tracing programs. They have also improved data systems and
quality of care at various sites.
Comprehensive findings are presented to appropriate NDOH staff and joint implementation plans for
improvement in quality of care are developed. This is a time and labor intensive activity with a further
challenge being the need to conduct reviews outside of site operation times. RHRU will conduct three file
audits at selected sites across our areas of operation.
ACTIVITY 2: Task-Shifting Models
RHRU will roll out a NDOH-approved task-shifting model and will evaluate how well it is being implemented.
These activities include nurse initiated ART at PHC sites and use of counselors for HIV and TB case
finding. The implementation of standard operating procedures (SOPs) and guidelines for decentralizing and
integrating HIV care and related training of health providers and health management is key to successful,
comprehensive task-shifting programs. RHRU will provide training and dissemination of good practice and
lessons learned in this regard.
Estimated amount of funding that is planned for Human Capacity Development $85,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $15,000
Table 3.3.18:
