HIV and AIDS is a strategic risk to the SA military human resources and therefore to mission readiness and operational capability. The US DOD in collaboration with the SA National Defense Force (SANDF), the DOD HIV Prevention Program (DHAPP) and PEPFAR supports the SANDFs Masibambisane HIV/AIDS Program to optimize the implementation of HIV Prevention, Treatment, Care and Support programs targeting approximately 74,000 military personnel and about 350,000 dependants.

Areas of particular focus include:

-Improving quality of health services

-Revitalization of infrastructure, a number of pharmacies and clinics have been upgraded and mobile health services added through provision of mobile clinics in rural and deployment areas

-Increasing access to Prevention, HIV Testing and Counseling (HTC) and improving access to HIV Treatment and Care services

To date:

-Approximately 136 service outlets provide HIV related health services

-Approximately 35 000 military health workers trained in various aspects of HIV care over the years

-About 1300 members enrolled on ART at military healths roll out sites while about 6000 more previously enrolled on the Phidisa research project are on ART supported by US NIH and PEPFAR

-Ongoing construction and renovation of clinics, pharmacies and hospices

Going forward:

-Conduct a sero-prevalence survey to strategically inform future programming

-Strengthen HIV prevention activities through collaboration and partnering with Population Services International/Society for Family Health.

-Provide Voluntary MMC as part of overall prevention program accessible to all male military members - focus on new recruits

-Strengthen HIV prevention activities at both internal and external deployment areas including border patrol areas

-Transition

The goal of this program is to provide quality HIV treatment and care to military personnel, their partners and families. The basic care package includes clinical staging and baseline CD4 counts for all HIV positive patients, CD4 cell monitoring and cotrimoxazole prophylaxis as per national guidelines, diagnosis and treatment of opportunistic infections and psychosocial support. In order to improve the quality of care provided at clinics, hospitals and at hospices, military health care providers will be trained in palliative care, all nurses and doctors will undergo the annul ARV management refresher which includes diagnosis and management of STIs/OIs and psychological effects of HIV infection. In order to increase access to these services the SAMHS aims to 1) utilize the mobile clinics which will be linked to the clinics to reach troops in the border and internal deployment areas to conduct HTC, HIV staging and CD4 monitoring and follow up; nutrition counselling, reproductive health counselling to prevent unintended pregnancies, prevention with positives and spiritual care 2) Strengthen and expand the support group structure that is working well in one province to other provinces in order to improve on loss to follow up and ensure adherence to treatment 3) train counsellors who are primarily social workers in treatment adherence, safe HIV status disclosure procedures, improve post-test counselling procedures, increase acceptance of diagnosis and improve on the retention in pre-ART care 4) To assist in the expected increase of follow-up and counselling, the Director Psychology plans to select approximately 60 Military Skills Development members (young recruits) in 2012, and provide them with pre-service training on Counselling, Support and Home Based Care. Each of them will be provided with a toolkit to enable them to communicate effectively and assist them in their function. These members will also be utilised to provide community based care to members and their dependants that utilize Mobile Clinic Services provided to rural areas and communities far from established military health care facilities.

The provision of safe voluntary male medical circumcision (VMMC) as part of the comprehensive Masibambisane prevention program is the primary objective the SANDF VMMC program. The service will be available to military men and male dependants aged 18 49 years. In December 2011, a decision was taken by the SAMHS Command Council to introduce VMMC in the military. Since then, approximately 100 circumcisions were performed in Mpumalanga through collaboration with a local provincial hospital. Three sites have been identified, KwaZulu Natal, Mpumalanga and the Western Cape. It is anticipated that approximately 7000 circumcisions will be performed in year 1. There is no MMC prevalence data in the military, estimates were set based on available trained workforce to provide high volume safe MMC services and the operations of the military. Although the number of anticipated MMCs for year one is a modest figure, it is anticipated that figure will increase as the service becomes available in other sites. Considerations to ensure that the battalions are not destabilized by the necessary down time for healing have to be taken into account.

The partner NGO (SFH) will work with the SAMHS on the following focus areas of VMMC implementation:

- Refurbishment of facilities, procurement of equipment and supplies

- Production and distribution of militarized IEC material as part of demand creation through the existing Masibambisane program

- Use the Commanders hour and targeted campaigns to further increase demand

- Training of the SAMHS doctors, nurses and counselors on the MOVE model following NDoH guidelines and provision of VMMC package which includes:

o VMMC education and counseling on risk reduction and safer sex,

o PITC and appropriate referral

o Promotion and provision of male and female condoms

o Comprehensive medical examination including STI management

o VMMC surgical procedure and follow up care

- Documenting key VMMC information such as numbers circumcised, testing, adverse events surveillance and counseling. In addition SFH will work with the SAMHS to monitor and evaluate acceptance, safety and impact of VMMC.

- Provide support for both internal and external quality assurance

The overall goal of the activity is to reduce new infections in the military. The main mechanism of delivery is through behavior change communication. The focus is on abstinence and fidelity targeting military personnel and their families, paying particular attention to factors that place them at risk of infection such as separation from families and regular sexual partners, mobility and age. Key prevention strategies include: 1) appealing to the ethical and moral and spiritual conduct of soldiers 2) capacity building by integrating Combating HIV and AIDS through Spiritual and Ethical Conduct (CHATSEC) prevention messaging into peer education programs and interpersonal communication sessions 3) promotion of counseling and testing services. The CHATSEC program has been conducted by the Chaplains and is an important part of the Masibambisane HIV prevention program. Although the impact of CHATSEC is yet to be evaluated, the program continues to reach thousands of troops particularly young recruits with prevention messages. The chaplains will work closely with NGO partner- Society for Family Health (SFH) to update training and communication materials to reflect best practices and to ensure that the material is in line with current prevention strategies such as couples counseling and testing, integration of family planning into HIV and AIDS programming, gender based violence and prevention of alcohol abuse. The activity is related to and is integrated into all health service areas such as HPOV, HVCT and CIRC activities.

The Social Work driven life skills program is an empowerment program aimed at the Military skills Development Program members. These are thousands of young recruits who remain in the military for at least 2years and undergo intensive training in the first six months. The program complements all other HIV prevention interventions as it provides youth with life skills such as decision making and self competency.

The overall goal of this activity is to increase the number of military members and their families who know their HIV status and are linked to care and support services. This will be achieved through scaling up Testing and Counseling and providing integrated treatment care and prevention services to high risk groups. There are approximately 93 health service points at all military bases and 3 military hospitals which currently provide testing and counseling services. In addition HIV Testing and Counseling is offered routinely in the South African military as part of the Comprehensive Health Assessment (CHA) process. The political environment in the military is now conducive to HIV testing as the working opportunities for those who are infected with HIV are no longer affected by their HIV status. The military therefore plans to take advantage of this environment by intensifying efforts and increase demand for HTC through:

- Training of health workers in Provider-initiated Testing and Counseling, Couples testing and counseling and prevention counseling.

- Facility based HCT services will collaborate with mobile clinics to increase access to border areas and internal deploying areas to ensure geographic reach. The 3 mobile vans are located in KwaZulu-Natal, Mpumalanga and Limpopo

- Reviewing of the current HTC Module to include links to care and treatment and VMMC services.

- Strengthen counseling skills of both social workers and nurses to include counseling for gender based violence and substance abuse.

- The partner NGO (SFH) will develop IEC material for HCT linking with other prevention interventions. There will be a concerted effort to ensure that the material reaches the SA Navy, SA Air Force and the SA Army through the peer educator program and other military distribution mechanisms.

- Improve monitoring and evaluation and quality assurance through NGO technical assistance support

The SA DoD will procure HIV test kits as per national guidelines. 3 CD4 machines were procured with PEPFAR support to increase point of care services and timely referral to pre-ART and treatment and care services.

The armed forces are considered one of the most susceptible populations to HIV infection and transmission. When the military is weakened by the impact of HIV and AIDS, the states ability to stabilize, defend or protect the citizens weakens. HIV is thus recognized by the South African military as a strategic & The overall goal of this activity is to reduce new HIV infections in the military through behavior change communication (BCC), edutainment events at bases coordinated by trained peer educators including drama and a focus on correct and consistent use of the soldiers condom. The NGO partner, Society for Family (SFH) will work with the Directorate HIV and AIDS and other implementing directorates to aggressively mobilize high risk military communities with increased efforts to reach soldiers on internal and external deployment with prevention interventions. Key to this will be the development and implementation of a targeted pre and post deployment packages. The package includes testing and counseling, packaged soldiers condoms that can be carried in specially designed military pouches, strategies for dealing with difficult deployment issues such as boredom and alcohol abuse. These interventions will be delivered by a multidisciplinary team of nurses, social workers, psychologists and a peer educator per platoon. SFH will also provide technical assistance in reviewing all military training materials, review and update IEC material and provide technical assistance in the management and distribution of both male and female condoms. Other key activities which will be undertaken during FY12 include:

- Conducting a KAP survey whose results will inform the development of peer education material, other HIV prevention training material and IEC

- Strengthening interventions for youth and new recruits. Approximately 8000 recruits enlist in the SADF annually

- Conducting a situation analysis of current gender based violence prevention and management programs with subsequent of training of all involved cadres such as the military police, social workers, doctors and nurses. Prevention of GBV and reviewing the Gender Equity Program will be the focus for FY12

There are currently 3 military hospitals which provide antenatal and prevention of mother to child services in the SANDF. Access to these services is limited particularly in hard to reach rural and border areas. Women who require PMTCT and ANC services in these areas are currently referred to nearby National Department of Health facilities or the private sector with the military bearing the cost. Although nurses in the 93 plus base clinics and health centers are trained to provide ANC services, it has not been the practice for them to take up this responsibility due to small numbers of pregnant women in the military. The number of women recruits has over the past few years increased necessitating the increase of facilities providing the service. There is now a military instruction to have all sickbays and clinics to provide ANC services with clear referral criteria for tertiary care in line with the PHC approach. Funding in this FY will be used to increase training and reorienting nurses and other health care providers to ANC and PMTCT service provision and ensure access to a network of services for PMTCT and their families, link MTCT services to other HIV and MCH services. The SAMHS aims to use as much as possible the existing capacity and technical expertise currently available at Phidisa to strengthen PMTCT services including quality assurance and M&E skills at local level.

- Pregnant women will be offered testing and counseling aim for 80% of such women, provision of male partner and family centered testing; family planning; safer pregnancy counseling and nutritional counseling and services for gender based violence.

- Provision of ARV prophylaxis and ART for eligible women per national guidelines

- Strategies to follow up on HIV exposed infants; early infant diagnosis and cotrimoxazole prophylaxis

- The training of both hospital and local level service providers on the new service delivery guidelines and promotion of exclusive breastfeeding.

In terms of ART, the SANDF aligns its policies to that of the National Department of Health. With the support of the PEPFAR program and the US National Institutes of Health (NIH), over 4 500 military members and their families are currently on ART through Phidisa and the SAMHS rollout sites. Currently there are ten treatment sites throughout the military including three military hospitals. In order to increase access and to implement national government vision of bringing care closer to where people live, all sick bays and local clinics are in the process of preparing for provision of ART services as part of a PHC package. Some of the preparation includes the training of nurses in NIMART and training of doctors for mentoring and support; provision of necessary equipment, laboratory and referral systems. In addition, three mobile clinics are posted in three provinces to provide prevention, treatment and care services to troops around the borders and those on internal deployment. Treatment has been made available to troops on external deployment as well in areas such as Burundi and the Sudan. The progressive increase in numbers of clinics and sick bays offering ART services is of paramount importance as Phidisa winds down the standard of care aspect of their operations to now focus on research. The SAMHS is working aggressively to ensure a timely and smooth transition both from Phidisa, to transitioning funding support and strengthening own procurement and supply chain systems. During this process of transition, there will be increased efforts to ensure facility level capacity for data collection, reporting and use with a focus on ARV drugs management, HIV and AIDS case management and improved quality implementation and evaluation.

It is envisaged that the change in policy as it relates to treatment initiation, and the conducive environment within the military that encourages members and families to test for HIV without fear of work related repercussions, will result in an increase of about 10-20% in patients requiring treatment in the next financial year.

The key objective of this program area is to strengthen the provision of ARVs at facility level. Currently only designated roll-out sites, Phidisa clinics and the three military hospitals are providing ART services. However, in line with the PHC approach and the required increases in access to treatment, every sick bay or health centre will progressively provide ART services. To this end, all health service points are currently conducting site appreciatiations in order to inform planning and implementation.

Focus therefore for FY12 going forward will be:

- Ensuring that the SAMHS roll-out sites are equipped to deal with the scale up in terms of equipment and human resources

- Conducting at least two NIMART training courses for approximately 60 nurse, conducting two clinical mentoring workshops aimed at provision of continuous and consistent support to the NIMART trained nurses

- Conduct two Master training course on NIMART in collaboration with the NDoH NIMART facilitators to ensure continuity and sustainability of the program

- Provide ART support services for military members who are deploying to the Sudan and Burundi on peacekeeping missions whilst on ART.

- The SAMHS has been working collaboratively with the University of Pretoria to provide ARV training and refresher courses for the multidisciplinary team which comprises of nurses, doctors, social workers, dietitians and psychologists. Approximately 120 members were trained in the last year. The SAMHS aims to continue to provide this training in next FY 12 in order to support the provision of ART services to military members and their families.