The South African Medical Research Council (MRC) operates as a statutory Science Council and reports to the National Department of Health, and as such, its activities are aligned with the health priorities of government. In particular, MRC's 3 year strategic plan 2011-2013 strives to combat HIV and AIDS and decrease the burden of TB; and (iv) strengthen health system effectiveness. The MRC was a key player in drafting the first National Strategic Plan (NSP) and embraces the objectives and goals of both the current NSP and the Partnership Framework in Support of South Africa's National HIV & AIDS and TB Response 2012/13 - 2016/17 between the Government of the Republic of South Africa and the Government of the United States of America (December 2010) through a partnership with national, provincial and local government, as well as other stakeholders, e.g. NGOsMRCs portfolio of proposed activities for this year is diverse and falls under the following budget codes: MTCT, HVOP, HVTB, HVCT, HBHC, HTXS & HVSI. In many instances activities are undertaken on a national basis eg. the MTCT survey. Cost efficiency is achieved through improved budgeting mechanisms, technological innovations and optimal use of labour. The transition of activities to local organizations and monitoring and evaluation is done in consultation with the CDC field office. VEHICLES: Inventory (purchased/leased): - Purchased/leased under this mechanism from the start of the mechanism through COP FY2011 = 5; New requests in COP FY 2012 = 0 (until further notice);Total planned/purchased/leased vehicles for the life of this mechanism= 26.

The ThatsIt (Tuberculosis, HIV & AIDS Treatment Support and Integrated Therapy) project, a collaborative initiative between the Department of Health (DoH), the CDC, MRC and FPD, has as overall objective; the integration of TB and HIV services and care. It involves activities from counseling and testing, wellness care, ART services and all aligned TB/HIV activities to ensure that patients have better access to TB and HIV care. Hence the cross cutting of services and budgetary obligations. Several activities will be undertaken under the prophylactic treatment. Firstly, TB screening which is done at least bi-annually on all patients attending ART and pre-ART clinics by TB symptom screen as well as sputum analysis of identified TB suspects following a positive symptom screening questionnaire. Secondly, isoniazid preventive therapy (IPT) will be actively implemented using provincial IPT guidelines. Thirdly, co-trimoxazole prophylaxis (CPT) may prevent morbidity in patients infected with HIV. Currently 80% of all eligible patients in the ThatsIt program are on CPT. This activity will be continued with the additional funding. Fourthly, nutritional counseling to ensure that all PLWHA are enrolled in Wellness programs and eating healthy foods to boost their immune system, is important. At the same time activities will include nutritional assessments of patients, food counseling, the development of nutritional gardens, nutritional education of all persons and support of nutritional security programs that are offered by the Department of Health in the relevant thatsit supported districts. Lastly, infection control activities will be pursued by the training of community health workers in TB symptom screening, in basic infection control principles, in TB/HIV care and in PMTCT to protect unborn babies and ensure that mothers enroll in early ante-natal care. Patient tracers will continue to visit homes to ensure a diminished defaulter rate and to ensure that HIV positive persons are kept in care. Community outreach activities will continue to increase HCT uptake, to decrease stigma and to improve awareness of both HIV and TB in the community. Both HCT and outreach activities will continue with additional funding.The Thats It programme utilizes a data spreadsheet, developed during the initial and community roll-out phases of the project, as a best-practice M+E tool, with relevant patient information for both reporting and patient management purposes. After counseling and testing, all positive HIV patients as well as positive TB patients are entered into the tDS (thatsit Data Spreadsheet). This ensures that patients are retained in the continuum of care. Utilizing this tool ensures that the group of thatsit community health workers /patient tracers do regular follow up of all patients in care. Retention in pre-ART care will be further maintained by the formation of various support groups, including musical and other prevention with positives support groups and linkages with other NGOs and the existing health structures.

In the comprehensive integrated approach to TB and HIV services, the focus is on regular screening for all HIV positive patients, offering counseling and testing to all TB patients (where possible PICT), augmented clinical care to all patients, supplementing key personnel where indicated and providing community outreach initiatives to increase awareness of TB and HIV, utilizing community patient tracers to identify pregnant women for PMTCT referrals and to decrease the stigmatization of the dual epidemic. Patients in this activity are those that have been counseled and tested and have received their CD4 count and thus been enrolled in a wellness program. All HIV positive and TB patients receive nutritional support by nutritional assessments of all patients and various models on nutrition interventions were explored and are currently implemented. Regular nutritional assessments are done on all patients with a low BMI (<18.5 on initial assessment). Nutrition education and the running of nutrition gardens in the various sites have been a priority, especially in KZN in the Uthukela district but also in the Western Cape and in Bray in the far North West. These activities will continue in current sites. A specific objective of this activity is to enroll all HIV positive patients in Wellness programs to ensure that they are educated regarding good nutrition, the disease progress, adverse drug interactions and protection against opportunistic infections as well as infection control to protect those close to them. CPT prophylaxis was endorsed in all supported sites. Human resources support will continue in identified sites. To promote integrated care taking into account infection control principles, minimal refurbishment will take place at identified sites in newly supported sites.

MRC places to do two sub activities to strengthen monitoring and evaluation (M&E) : 1.1 Western Cape M & E capacity building and strengthening and 1.2 M&E capacity building and strengthening project (KZN) - TB and HIV/AIDS as probes. These activities aim to empower health management teams to use health and management information for strategic and operational decision making. Project activities for the Western Cape are well aligned with Epidemiology & Strategic Information (ESI) activities as ESI is already involved in M&E training. The PI met the KZN provincial leadership about the project and discussed the need to ensure that the activities of this project complement those of other existing M&E projects in the province. A priority list of potential activities was developed which needed to be prioritized and approved by the HOD Health. To date the project has focused on supporting an on-going project on decentralization of management of MDR-TB through training, supervision and on-site training in four sites. The training focused on recording, reporting, monitoring and evaluation. There is currently no collaboration on this project with UWC or other partners but the plan is to meet colleagues from UWC soon to share our plans, get a better understanding of their activities and explore how to complement one another to avoid duplication of efforts. The project does not seek to evaluate the entire re-engineered PHC but to use specific probes, in this case, TB and HIV/AIDS as ways of strengthening the health information system at district level.

MRC also plans to use respondent-driven sampling (RDS) to do HIV and/or risk behavior surveillance among high risk populations. South Africa has a large foreign migrant population, and it is estimated that 1-3 million Zimbabwean migrants alone are currently living in the county. Foreign migrants are able to self-settle in any area of their choosing in South Africa and are thus diversely distributed throughout the general population making them hard-to-reach by conventional HIV surveillance methods such as household surveys and/or sentinel surveillance systems that are designed to track infection in the general population. RDS is a sampling approach that gains access to hard-to-reach, vulnerable groups and is used to obtain unbiased HIV prevalence rates and risk behaviors among these sub-groups. In the budget year the activity aims to conduct a RDS study on approximately 300 high school dropouts in 2-3 sites in the Cape Town area.

Finally, MRC plans to Strengthen the STI (including HIV) Partner Notification Monitoring System in Khayelitsha Health Clinics.This project aims to strengthen the STI partner notification monitoring system in public clinics in Khayelitsha, Cape Town. In South Africa, the standard patient referral strategy for STIs other than HIV involves brief educational messages during the clinical consultation and the use of partner referral cards.

In this activity, as part of the THATs IT project, emphasis was given to the accreditation of down referral sites, the empowerment of pharmacist assistants by training, the appointment of pharmacist assistants to fill in much needed gaps in service delivery and the inclusion of and employment of pharmacists to supplement services in many sites. This contributed to the rapid down referral of stable ART patients to their feeder clinics. In the Eastern Cape support is given to nine identified TB hospitals and surrounding clinics. All the supported hospitals have now complied with accreditation requirements. In these sites support is extended to the feeder community clinics to ensure continuity of care and to improve accessibility of HIV care, including anti-retrovirals to TB patients. Activities will continue in this area to improve access to ART services for TB patients. Overall activities include, amongst others, clinical management, ART and adverse drug management, preventative and prophylactic treatment (including CPT), nursing care (TB screening, patient education, treatment adherence and HIV prevention) and a focus on infection control practices and awareness. Where necessary, infrastructure support will be considered to ensure compliance with infection control requirements.

MRC plans to continue the following activities:1. Rapid assessment of drug use and HIV risk behavior among vulnerable drug using populations.As part of the work with existing clients (MSM, CSWs) who are seen on repeat visits and new clients who are accessed through outreach activities, clients are offered HCT following required protocols for pre- and post-test counseling. All sub-partners employ accredited nurses to conduct the counseling and testing. Additionally one sub-partner, in addition to the accredited nurses, has an outreach worker to receive training to conduct HIV tests while another sub-partner has 3 lay counselors who have received the training and conducts HCT and also uses a medical doctor in addition to the nurses. For drug users who are accessed at drug treatment centers, counseling and testing is offered as part of the drug centers routine treatment program. The specifics of testing differ.For example one of the sub-partners regularly offers HCT at clubs and other venues frequented by MSM and they conduct the HCT in gazebos specifically purchased to give privacy. In other settings VCT is provided in a counseling room or rooms with more of a clinical setting. The MRC will continue to closely monitor the progress of these activities and evaluate their effectiveness.2. Develop a best practice approach to integrated TB-HIV managementThis activity is a component of the THATs IT project.In the HCT component of THATs IT , the focus is on providing counseling and testing for all TB patients. This intervention is currently provider initiated C&T activity. In addition, community outreach activities take place to target members from the community, businesses, and farm workers, to know their status. The project has 5 mobile clinics that target communities, the unemployed and male members of society. All identified positives are then enrolled into pre-Art care activities as provided by the project. In addition the project collaborates with the Dept of Health outreach initiatives to provide and support SAG HCT targets.

MRC plans to continue the following activities:1 .Addressing the link between addictive substance use and HIV in vulnerable populations in South Africa through the following sub activities: 1.1 Drugs and HIV - Continue to engage in HIV risk assessment and risk-reduction counseling with MSM, vulnerable women, Injection and Non-injection Drug Users in Cape Town, Durban, and Gauteng. 1.2 Bar project - Continue to explore methods by which the bar-based HIV prevention intervention can be incorporated into existing or new programs in drinking venues in both urban and rural areas. 1.3 Alcohol and HIV - Complete work to develop and implement interventions focusing on health workers and PLWHA aimed at reducing the effect of alcohol use on the progression of AIDS. 1.4 Drugs and Pregnancy - Continue with the analysis of substance using practices among pregnant women in Cape Town and associated health consequences, and inform health sector interventions. 1.5 Drugs and HIV patients - Continue investigating the relationship between substance use, health status and health behaviors of patients attending HIV clinics in Cape Town. 1.6 Alcohol and ART adherence - Continue to conduct an adaptation of an intervention to reduce non-adherence to ART due to problem alcohol use and determine acceptability of the culturally-adapted intervention.2. Substance abuse treatment services/systems research. Improving service quality - Activities focus on evaluating the previously developed service quality measures for SAs substance abuse treatment services in KwaZulu Natal and Western Cape.3. HIV prevention with men: development of a gender intervention for male circumcision settings and an intervention for HIV positive men - Continue the development of an intervention on gender and HIV prevention for use with men undergoing medical male circumcision and to develop an additional intervention for men who test HIV positive.4. Development and testing of a gender-based HIV AIDS risk reduction and coping skills intervention for HIV positive women - Continue to develop and pilot test an intervention with a focus on building gender-based HIV and AIDS risk reduction skills, coping skills and building social support networks for women living with HIV.

MRC plans to continue the following MTCT Activities:(1) Evaluation of the Effectiveness of the National Prevention of Mother-to-Child Transmission Program on Infant HIV up to Eighteen Months Postpartum in South Africa.The overall aim is to monitor the effectiveness of the South African National PMTCT program. This activity will be conducted in 580 facilities across all 9 provinces of South Africa. It will have two components, i.e. (i) to measure the effectiveness of the antenatal and intrapartum aspects of the PMTCT programme using 6-week HIV transmission as the main outcome of interest and (ii) to measure the effectiveness of the PMTCT programme between 6 weeks and 18 months i.e. postnatally in an era when postnatal prophylaxis is part of national guidelines. For part (i) we will aim to enroll 12 200 infants aged 4-8 weeks attending selected 580 facilities for their six week immunization. For part (ii) the infants who tested ELISA positive PCR negative (approximately 3500 infants) during their 4-8 weeks visit will be followed up at public health facilities where they received routine care, across all 9 provinces of South Africa.(2) Qualitative evaluation of the delivery of Early Infant Diagnosis (EID)This activity aims to explore the feasibility of integrating infant HIV testing with routine child health services including 6-week immunization services and to explore the experiences of mothers enrolled in the SA PMTCT program. This work will be done in two rural provinces that are under-researched e.g. Limpopo and North West province.(3) Impact of infant postnatal prophylaxis on infant NVP drug resistance: An analysis of specimens and data from infants enrolled in the SAPMTCT Evaluation (six weeks through 18 months)The overall aims of the study are: (i) to determine the impact of long-term exposure to NVP prophylaxis during breast-feeding on nevirapine drug resistance among HIV infected infants and (ii) to determine warning indicators of (risk factors) drug resistance among infants receiving NVP prophylaxis. This work will be undertaken at the NICD in Johannesburg with specimens obtained from up to 580 facilities across all 9 provinces of SA.

The Thats It project is a comprehensive best-practice approach to integrated TB/HIV care at ongoing sites and new sites across all provinces of South Africa in order to provide comprehensive, integrated TB/HIV care services and to improve accessibility of HIV care to TB patients. The Thats It program has developed a standard set of objectives to ensure compliance with their mission and vision, which is to provide an integrated service for TB and HIV positive patients. This approach necessitates a strong leadership team that is decentralized and that can manage the program from the rural and resource limited settings in which they operate. Technical advisors in TB supporting and training, data management and monitoring and project coordinators in the various sites, keep the project on course and in line with district strategies.Current the staff in ThatsIt is comprised of medical practitioners, nurses, dieticians, administrative staff, data capturers, pharmacists, pharmacist-assistants, clinic-based counsellors, community counsellors, tracers (these are community workers) and regional/area managers in the relevant provinces and districts where support is rendered. A continued effort will be made to transfer some of these crucial staff members to the NDoH for service delivery activities hence ensuring skills transfer and sustainability of the project. The improvement of operational systems and data collection remains one of the focus areas of the program.In the execution of the ThatsIt objectives for the next funding cycle, the project will continue its current activities but with an altered focus. TB and HIV technical support will be the main focus of activities, therefore the following activities will be prioritized: the training and mentoring of all NDOH staff in all the requirements of recording and reporting, NIMART, as well TB prophylaxis and care; other preventative care support modalities, e.g. PMTCT, the strengthening of monitoring and evaluation, recording and reporting as well as action research activities in an effort to strengthen current health systems, patient flow and embrace quality improvement in both the TB and HIV program.