The goal of the project is to improve HIV-related population outcomes by strengthening management systems at facilities, build the capacity of facility teams & management systems in coordination with the North West & Gauteng Provinces to support & integrate TB/HIV related services with overall health system strengthening as well as supporting facilities in identifying & setting up policies & programmes to improve the districts facility response to providing HIV/TB care, treatment, laboratory & prevention services & to support transition to a sustained national comprehensive HIV/TB care & treatment programme that supports two key priorities of the government including PHC re-engineering & national health insurance. The overall strategy involves a roving team allocated to each sub-districts PHCs & CHCs, who are managed by a sub-district manager & supported by a back-up team based in the sub-district. These teams will develop the capacity of DoH staff through targeted, on-site training & mentoring & will mentor facility staff to apply their learning from previous training interventions to improve quality of care & services. Roving teams will also provide additional training as required with follow on mentoring. To ensure that facility staff are mentored & trained effectively without disruption to services, two of the roving team will provide counselling & clinical service delivery whilst staff are trained & mentored by the rest of the WRHI team during that visit. This model will also provide additional opportunities for mentoring & training when integrated into the service delivery support. WRHIs technical specialist team & organisational management structures based at their head office will support teams based in the district.

WRHI HBHC activity will focus on technical assistance (TA) at the national, provincial, district, facility and community levels. TA includes training, mentoring, monitoring, evaluation, quality improvement (QI), problem identification with formulation of solutions and ensuring systems are implemented to provide routine quality clinical service. HIV infected adults in rural, semi-urban and urban districts of DKK, RSM and Region F are targeted. WRHI has aligned to the SAG and PEPFAR strategies focusing on quality of care in services, combating HIV/ AIDS and decreasing the burden of disease from TB in order to ensure A healthy Life for All South Africans. Vulnerable groups including those with TB, pregnant women, adolescents, men, sex workers, migrants, refugees, farm workers and MSM will be targeted.

WRHI district based teams will collaborate with the district on the key outcomes of the program: effective retention in quality care and efficient referral. This will be supported using the PHC re-engineering model to ensure: tracing and follow-up after HIV diagnosis and ART initiation; efficient referral of complex HIV cases; loss to pre-ART and ART programs is minimized. PHC level staging and rapid nurse initiation of ART for eligible patients will be promoted. TB patients will be referred immediately into TB treatment programs, while actively encouraging HIV screening. Within the care and referral system, non-adherent patients will be identified. WRHI will develop a model of support for patients failing ART and TB treatment, who require specialized support. IHI-supported processes focusing on the quality of care will be employed across all facilities by district teams. District Referral and Training Centers will be supported to become high quality referral network support, and training site for the development of clinical expertise.

This program will advise on integration and linkages of HIV care into maternal and child health, family planning, reproductive health services including cervical cancer screening, GBV centers, mental health services, PLHIV support groups and services, and nutrition as well as facilitate transition into chronic care and vice versa. Through the PHC re-engineering model, strong referral linkages will be made between communities, schools and health facilities.

WRHIs Monitoring and Evaluation teams support is cross cutting and provided for program monitoring, reporting, data quality, operations research, evaluations, data use, Health Management Information Systems, and other areas. Program outputs and outcomes will be reported quarterly for the indicators listed in the M&E plan. Data will be obtained from the DHIS and ETR.net. Patient level outcomes will be used as outcome indicators for the WRHI TA effort. These include: HIV positive adult (15 years and older) patients eligible for ART starting on ART; ART patients still on treatment at 12 months rate. Support will be provided to districts to set and achieve their targets. Together with the DMT, indicators will be reviewed and measured against targets. Where gaps are identified, strategies to improve outputs will be optimised and WRHI will provide technical assistance to address these. Reports, lessons learned, publications, presentations and other documents will be developed and disseminated to funder and stakeholders through the life of the grant.

WRHI will assist DoH in providing comprehensive integrated HIV/TB care which is cost effective and evidence-based. The operational plan aims to address gaps at the poorest performing facilities initially, but the overall goal is to improve the standard of care at all levels.

The model used to achieve this goal is a district based roving team that provides facility and district level support to the DoH. In addition, a specialist technical team offers supportive supervision to the district team as well as providing technical contributions to National and provincial guideline and policy committees. Technical team members are represented on SANAC who are the custodians of the NSP. The positioning of WRHI at all levels allows for the rapid dissemination of new policies and training on guidelines.

Attendance at district, provincial and National quarterly HIV/TB meetings allows for feedback, interpretation of data and identification of gaps in services together with the DoH and other partners, which allows a coordinated response.

Health service delivery models to improve HIV/TB integration and patient referral systems are being developed, implemented and assessed.

Capacitation of DoH staff and skill transfer is through supportive mentoring of facility clinical staff by the district teams. Technical team members provide on site supportive mentorship at special sites where complicated HIV/TB and drug resistant patients are treated. Teaching occurs at pre-service, undergraduate and post graduate level. The training at all levels and across all cadres of health care workers will establish a sustainable core of expertise within the DoH and allow for transition.

WRHIs district teams have dedicated data quality assurance members who support the collection and capturing of data at facility and district levels, this data is continuously monitored by the Technical teams and any trends or irregularities interrogated and acted on as they are identified.

Over the past year a large operational research and regional support project using GeneXpert as a point of care diagnostic was completed, the results will determine the use of Xpert in Region F. Interventions using Xpert are planned for the more rural areas of the North West province where laboratory cover is poor. WRHI is currently evaluating GeneXpert for paediatric diagnostics.

A specialist TB referral centre was developed and a supply of second line drugs obtained, lessons learned in the scale up of this service will be used to develop other OPD facilities to provide MDR services. DRAT assessments were conducted in WRHI supported districts and gaps identified are being addressed by the District teams. Various contact tracing methods were assessed in Region F and the paper slip method will be rolled out at all Region F facilities. The implementation of a revised TB register has allowed for more complete data collection and National DoH will be approached to adopt the register Nationally. Infection control assessments and training conducted in all facilities in WRHI-supported districts will be followed up with an assessment of the resulting interventions implemented.

The IPT guidelines are being reviewed and once finalized district teams will re-train all district facility staff on the new guidelines.

WRHI HSS support for PMTCT will focus on technical assistance at the national, provincial, district, facility and community level. Technical assistance includes training, mentoring, monitoring, evaluation, quality improvement (QI), problem identification and formulation of solutions and systematising interventions. In Region F, DKK and RSM 11 sub-districts are supported by mobile support teams assisted by specialist teams.

WRHI has and continues to support the NDoH in writing and implementing PMTCT guidelines and has supported districts to achieved MTCT rates of < 4. In the next 2 years we expect all facilities to be providing the new PMTCT regimen, transmission rates to be <3% at 6weeks and <5% at 18 months. However targets will be finalised jointly with the districts. WRHI and the DMT hold joint quarterly meetings where DHIS indicators are reviewed and measured against targets. Where gaps are identified, strategies to improve outputs will be optimised and technical support to address these provided with ongoing review of indicators to measure progress. Poorest performing facilities will be identified and prioritized, in time all district facilities will be reached. WRHI mobile outreach teams will rotate through facilities and provide onsite QI initiatives to improve PMTCT outcomes. One staff member will provide clinical services (simultaneously mentoring and auditing) to release key/clinical DoH staff from duties, while the other team members will provides onsite technical assistance.

Teams will: provide QI interventions to implement routine opt out testing for pregnant women including repeat testing for negatives at 32 weeks, in labour and post-delivery; improve systems to ensure all HIV infected pregnant/postnatal women receive CD4 cell count results timeously; train and mentor HCWs and trainers to provide the new regimens during pregnancy, delivery and post-partum with effective initiation and management of women on ART; train and mentor HCWs on benefits of exclusive breast feeding and safe feeding practices; and train and mentor HCWs to increase testing of HIV-exposed infants by PCR at 6-weeks and post breast feeding cessation and by ELISA at 18-months. Through QI interventions, WRHI will assist facilities to improve integration of routine HIV testing into EPI and well-baby clinics; train PHC re-engineering team leaders on referral of HIV exposed infants for testing and on how to support exclusive breast feeding. Health and tracking systems for mother-infant pairs will be developed to ensure continuity of care. WRHI will train and mentor team leaders and facility staff to increase the number of pregnant women booking before 20 weeks and to provide risk reduction counselling for HIV negative women including provision of condoms to reduce sero-conversion during pregnancy and to increase early access to ANC in order to reduce morbidity, mortality and support elimination of MTCT. WRHI will support: improving integrated care including of contraceptive services; implementing the new contraceptive policy; systems to engage the HIV affected couple intending to conceive to maximize health outcomes and limit transmission. WRHI will: provide technical assistance to procurement systems to ensure no stock outs; work with regional training centres to ensure trainers are trained on comprehensive PMTCT interventions to ensure sustainability of the program.

HR capacity development is strongly supported via comprehensive training & mentoring activities delivered by WRHI teams & addresses all levels of health care workers (HCWs) including new tiers of staffing. Collaborating with Regional Training Centers (RTCs), WRHI will ensure sustainability & institutionalization of training programs including capacity building for RTCs following the NDoH lead evaluation. Training & mentoring programs will be evaluated for on-going improvement, skills transfer & improved services.

Working through the National Leadership & Management forum, & with the RTCs, district, sub-district & facility-based leadership, governance & management will be addressed through needs assessments, appropriate learning programs & support for the development of district management plans utilizing routinely available data to set appropriate district, sub-district & facility targets & priorities.WRHIs District team includes an Human Resource (HR) practitioner provided by WRHIs sub partner, AHP. AHP will work with the DMT to conduct baseline assessments in districts to effectively analyse & prioritise critical requirements, plan for future HRH workforce needs & provide management information on HR issues including recruitment & placement priorities; skills available & required per district & facility; availability, compliance & alignment to job descriptions; management capacity to conduct performance reviews & retention programmes intended to retain critical positions. It is anticipated that the need for NIMART & PHC re-engineering support will continue, including training & support for DoH NIMART mentors, & facility managers to strengthen supportive supervision. In addition, the following training for facility based HCWs is still required: PICT & HCT; TB/HIV; PMTCT; adherence; mental health; & appropriate integration of services such as contraception. To strengthen facility level health & patient management systems, WRHI will train & mentor DoH staff in quality improvement (QI); National Core Standards; data management & other HSS learning needs. Emphasis is on practical application & progress towards achieving facility QI plans. Training is planned with the DoH & aligned with district health plans & priorities. Where possible, modular training will be conducted on-site, to reduce costs & ensure effective, targeted learning with strong links to improved practice. As initiations increase at primary level, referrals to hospital level will increase, shifting the role of clinicians, including expert nurses, from initiation to the management of complex cases. WRHI has developed an advanced HIV/TB training for these clinicians. WRHI will collaborate with & train district doctors to improve communication & referral processes with down-referral sites; identify weaknesses in the ART program to direct their targeted, responsive, mentoring support; & provide specialist care & training at up-referral sites. The quality of pre-service training in HIV/TB management is inconsistent, with little understanding of QI. WRHI will continue to provide HIV/TB training to University of the Witwatersrand medical students & provide TA in curriculum review & faculty to the Clinical Associate program. To improve the quality of HIV/TB & QI training for nursing students, their tutors will be offered a tailored program using the DoH high quality & specialist facilities as training sites.

WRHI HSS support for PMTCT will focus on technical assistance at the national, provincial, district, facility and community level. Technical assistance includes training, mentoring, monitoring, evaluation, quality improvement (QI), problem identification and formulation of solutions and systematising interventions. In Region F, DKK and RSM 11 sub-districts are supported by mobile support teams assisted by specialist teams.

WRHI has and continues to support the NDoH in writing and implementing PMTCT guidelines and has supported districts to achieved MTCT rates of < 4. In the next 2 years we expect all facilities to be providing the new PMTCT regimen, transmission rates to be <3% at 6weeks and <5% at 18 months. However targets will be finalised jointly with the districts. WRHI and the DMT hold joint quarterly meetings where DHIS indicators are reviewed and measured against targets. Where gaps are identified, strategies to improve outputs will be optimised and technical support to address these provided with ongoing review of indicators to measure progress. Poorest performing facilities will be identified and prioritized, in time all district facilities will be reached. WRHI mobile outreach teams will rotate through facilities and provide onsite QI initiatives to improve PMTCT outcomes. One staff member will provide clinical services (simultaneously mentoring and auditing) to release key/clinical DoH staff from duties, while the other team members will provides onsite technical assistance.

Teams will: provide QI interventions to implement routine opt out testing for pregnant women including repeat testing for negatives at 32 weeks, in labour and post-delivery; improve systems to ensure all HIV infected pregnant/postnatal women receive CD4 cell count results timeously; train and mentor HCWs and trainers to provide the new regimens during pregnancy, delivery and post-partum with effective initiation and management of women on ART; train and mentor HCWs on benefits of exclusive breast feeding and safe feeding practices; and train and mentor HCWs to increase testing of HIV-exposed infants by PCR at 6-weeks and post breast feeding cessation and by ELISA at 18-months. Through QI interventions, WRHI will assist facilities to improve integration of routine HIV testing into EPI and well-baby clinics; train PHC re-engineering team leaders on referral of HIV exposed infants for testing and on how to support exclusive breast feeding. Health and tracking systems for mother-infant pairs will be developed to ensure continuity of care. WRHI will train and mentor team leaders and facility staff to increase the number of pregnant women booking before 20 weeks and to provide risk reduction counselling for HIV negative women including provision of condoms to reduce sero-conversion during pregnancy and to increase early access to ANC in order to reduce morbidity, mortality and support elimination of MTCT. WRHI will support: improving integrated care including of contraceptive services; implementing the new contraceptive policy; systems to engage the HIV affected couple intending to conceive to maximize health outcomes and limit transmission. WRHI will: provide technical assistance to procurement systems to ensure no stock outs; work with regional training centres to ensure trainers are trained on comprehensive PMTCT interventions to ensure sustainability of the program.

WRHI HSS support for adult treatment will focus on technical assistance at the national, provincial, district, facility and community level of care. Technical assistance includes training, mentoring, monitoring, evaluation, quality improvement (QI), problem identification with formulation of solutions and ensuring systems are implemented to provide routine quality clinical service. HIV infected adults in DKK, RSM and Region F including those with TB, pregnant women, adolescents, men, sex workers, migrants, refugees, farm workers and men who have sex with men will be targeted in this program.

Support is offered to all cadres of health care workers. WRHI district team members work together, with one clinician providing clinical support to release DoH clinical staff, whilst colleagues provide onsite supportive training, mentorship and facilitation of NIMART accreditation, and supermentorship for DoH NIMART mentors together with QI support. Quality of care with a focus on retention in care and referral systems is strengthened through institutionalizing continuous QI methodologies, process mapping and the use of National Core Standards. Use of routine available data will identify the facility and sub-district-specific priority areas where targets are not being met. Poorest performing facilities will be prioritized but with time, all facilities will be reached. QI interventions will target these specific issues with measurable outcomes, and empower facility managers to implement improvements.

Retention in care and adequate referral will be supported using PHC re-engineering staff to ensure tracing and follow-up occurs. WRHI will ensure referral of complex HIV cases occurs efficiently, and that loss to pre-ART and ART programs is minimized. District Referral and Training Centers will be supported and will provide both a high quality referral network support and a training site for the development of clinician expertise in HIV, TB and Opportunistic infections. Novel mechanisms to improve retention in care will be developed and implemented, including the use of mHealth technologies.

Adolescent support groups have been established to encourage retention and adherence in this group of patients. WRHI is collaborating with DoH to establish ART adherence clubs. Experience gained will be used to offer further adherence support in supported districts.

WRHI will further address adherence and decrease loss to follow up through the PHC re-engineering processes, ensuring screening for mental illness and substance abuse, with linkages to care systems and support; and through specialized clinics for HIV, TB and OIs. Within the referral service, non-adherent patients will be identified. WRHI will develop a model of support for patients failing ART and TB treatment, who require specialized support, to prevent unnecessary morbidity. Training of facility managers as supervisors, through RTC, will be conducted.

Through close collaboration with DoH facility managers and training of DoH staff WRHI has been able to transfer all ART provision in the districts we support to the DoH, and currently provides the previously described support for these services. WRHI still provides pharmacists where the lack of DoH pharmacists are a barrier to services.

Continued training and skills transfer will enable the system to become self-sustaining in the future.

WRHI support for pediatric treatment will focus on technical assistance (TA) at the national, provincial, district, facility and community level. TA includes training, mentoring, monitoring, evaluation, quality improvement (QI), problem identification and formulation of solutions and systematizing interventions. In Region F, DKK and RSM 11 sub-districts will be supported by WRHI district teams. They will collaborate with DoH District Specialist Teams (DST) to achieve reductions in maternal and child mortality and improved HIV/TB outcomes. TA to guideline committees will continue.

QI methodologies will facilitate increased testing for HIV-exposed infants at 6-weeks, post breastfeeding and at 18-months with early referral into ART care for infected infants. Mechanisms for increasing PICT for children/adolescents at facilities will be developed, recognizing that a number of children are undiagnosed despite living with HIV infection. Review of DoH dashboard indicators for pediatric HIV testing and ART initiation will guide the teams towards targeted training and mentoring for HCWs by increasing capacity and skills in pediatric HIV/TB care. The team will identify HCWs who require IMCI training and pediatric NIMART certification and will assist with mentoring and facilitating training for these individuals. On-site mentoring and training, together with the WRHI district teams and DST will be conducted, appropriate to the HCW level and will range from clinic-based mentoring for the initiation of uncomplicated patients onto ART and appropriate monitoring with CD4 cell counts and HIV RNA, to the management of complicated pediatric and adolescent patients with virological failure, opportunistic infections, drug interactions and side effects. WRHI will assist the DoH district teams in establishing referral networks for HIV infected children and adolescents to district level hospitals to manage HIV-associated complications. Training and mentoring on management of children with ART failure, adherence and ART switching will be provided. For those requiring third line ART, TA to access and interpret resistance tests and on provision of third line ART regimens will be provided.

Retention in care for infants, children and adolescents is measured by clinic attendance and by HIV RNA suppression, and this will be monitored through file audits. Pediatric ART adherence is complex. In younger children, the need for caregivers to administer ART can add complexity. In older children, adherence issues are complicated by the challenges of adolescence. TA will be provided to: develop appropriate counseling skills for the various pediatric age groups; establish support groups; develop systems to appropriately up-refer to specialist psychological/psychiatric services. Linkages with community based organizations and PHC re-engineering teams to trace children/adolescents back into care will be established. Disclosure by caregivers to children needs to be stepwise and age-appropriate culminating in full disclosure by about 10 years of age. WRHI will supervise and mentor counseling staff in these disclosure processes. Disclosure support to friends and sexual partners for adolescents requires capacitation that the team will facilitate. TA for improved adolescent services including supporting the development and refinement of tools, facilitating the provision of family planning services, reproductive health services and transition to adult care will be provided.