N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $2,004,379

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

The Swaziland HIV Estimates and Projections (2007) estimate that there are approximately 188,000 people living with HIV/AIDS

(PLWHA) in 2008, who all need some level of care and/or treatment services. The recent estimates also suggest that 62,769

people are in need of ART in 2008.

Despite strong government commitment to the delivery of HIV/AIDS treatment services and extremely impressive achievements to

date, the country still faces severe ART as well as other care and treatment service-delivery challenges. In its effort to roll out ART

services rapidly, the Ministry of Health and social Welfare (MOHSW) / Swaziland National AIDS Program (SNAP) has established

these services, with Global Fund resources, in an extremely vertical fashion, almost parallel to the existing primary health care

delivery system. Currently, there are 12 public hospitals or health centers that provide ART and a number of additional outreach

sites that are serviced by them. In addition, there are private health care providers that deliver ART, albeit on a limited scale.

•SNAP estimates that, thus far, close to 30,000 people have been started on ART. However, more than one third of those have

been lost to follow-up within the first 12 months of treatment, owing to highly centralized services, ineffective adherence support

and poor patient monitoring.

•SNAP also reports that 48,037 people have been enrolled in the pre-ART program. This program, however, is in its very early

stages of development. While people are duly eligible and registered for it, the actual services are mostly sparse, un-coordinated,

or not available at all.

•Finally, SNAP reports 59,496 HIV/AIDS related home-based care person-visits in 2008. However, while some excellent models of

community-based and home-based care programs have been implemented, they are mostly driven by small grassroots NGOs or

FBOs and very localized and limited in scale. A nation-wide and well-coordinated home-based care program does not exist.

Nevertheless, SNAP and its stakeholders are working tirelessly to tackle the multiple problems and issues discussed above, with

a clear goal of implementing a more decentralized, integrated and comprehensive HIV/AIDS-related care and treatment package,

while dramatically increasing the quality of service delivery, in the existing ART-centers and in the rest of the health service

delivery system.

Over the past few years, several PEPFAR partners have been key members of the National Care & Treatment Technical Working

Group (TWG) and the National Palliative Care TWG and participated in the development of policy, technical guidelines, training

curricula, etc. for HIV/AIDS-related care and treatment services. PEPFAR has provided considerable support towards the roll-out

of the ART program, primarily in the context of PMTCT+, and the implementation of other HIV/AIDS-related care and treatment

services. PEPFAR partners have been involved in training and mentoring of key PMTCT and ART program personnel and in

actual on-site implementation support to address issues of service quality and treatment adherence. In addition, PEPFAR partners

have played a crucial role in planning with SNAP to re-position ‘pre-ART' and to develop a ‘Comprehensive HIV/AIDS Care

Package' that is currently being implemented. PEPFAR has also supported the community-based and home-based extension of

service-delivery, through its support to several community-based NGOs and FBOs. Finally, PEPFAR has recently assisted SNAP

with an assessment of the current linkages and referrals within HIV/AIDS services. This assessment was part of a multi-step

process defined by the National Linkages and Referrals TWG to develop an evidence-based and much-improved referral system

to address the country's fragmented continuum of care. Besides direct support to care and treatment service delivery, PEPFAR

has also provided considerable technical support to improve the availability and quality of HIV/AIDS-related diagnostics and to

address issues around ARV and other OI management drugs availability and consistent drug supplies.

Swaziland has been designated as a FY08 Compact Country, and care and treatment is one of the five key areas for much

increased PEPFAR involvement. The PEPFAR care and treatment support will be in line with the new National Strategic

Framework (NSF) for 2009-2013 that is currently under development.

In FY09, PEPFAR and its partners (it is expected that additional implementing partners will be contracted) will step up their

support for SNAP plans for scale-up and quality improvement of HIV/AIDS related care and treatment services. Support will be

centered on the implementation of a more decentralized, more integrated, and comprehensive HIV/AIDS care and treatment

package.

1) PEPFAR Partners will continue to work closely with the MOHSW and other stakeholders, including WHO, Clinton Foundation,

and Baylor College, through the TWG and/or other stakeholder consultations, on the development of policies and technical

guidelines in support of a comprehensive pre ART, ART, nutrition, and end-of-life care package. Critical policy issues to be

addressed include, but are not limited to, decentralization of services, linkages and referrals, and task shifting.

2) The ‘Comprehensive Care Package' that is currently being developed by the MOHSW, with technical assistance from ICAP,

includes:

•Provider-Initiated HIV Testing and Counseling (see HVCT)

•Baseline assessment

•Lab & clinical monitoring (see HLAB)

•Regular TB screening (see HVTB)

•Provision of prophylaxis with CMX, INH, Fluconazole

•Managing common symptoms

•Diagnosis and treatment of OIs

•ART

•Screening for cervical cancer, breast cancer, Kaposi Sarcoma …

•Sexual and reproductive health (see MTCT)

•Mental health

•Adherence to care & treatment

•Psychosocial support

•Positive prevention (see HVAB)

•Nutrition support

•Hygiene, water and sanitation support

•End-of-life care and support

3) PEPFAR partners will continue their implementation support to the existing ART-centers at hospitals and health centers. The

emphasis of their support will be on strengthening quality of services and improving outcomes. Support to facilities will include the

improvement of various systems including: patient flow, service scheduling, appointment systems, document of patient

information, referrals etc. In addition, the Expert Client program, utilizing ‘experienced' PLWHA to provide counseling and

psychosocial support to new clients, will be expanded. Finally, new interventions will be designed and implemented to address

client retention and treatment adherence, such as monitoring of missed appointments and different approaches to defaulter

tracing.

4) PEPFAR will focus most of its efforts on assisting SNAP with its decentralization process. Several PEPFAR partners will be

involved in supporting the roll-out of the "Comprehensive Care Package" to the primary health care level. PEPFAR will adopt a

"grassroots" approach of supporting approximately 25 primary health care clinics within the country, enabling them to provide the

Comprehensive HIV/AIDS Care Package. Support to these primary health care clinics will include infrastructural upgrades,

equipment, additional staffing (where applicable), adequate lab access, adequate drugs and medical supplies, training, mentoring,

supportive supervision, etc. Assuming that most clients access health care at clinic level first, the decentralization of HIV/AIDS

related services to that level should ensure greater accessibility and up-take of services. This may result in earlier and increased

access to HTC, earlier access to basic care services and, eventually, more timely access to ART. In addition, bringing the service

closer to clients would have to result in improved client retention, treatment adherence and, ultimately, better treatment outcomes.

5) In addition to the decentralization of HIV/AIDS related care and treatment services to clinics, PEPFAR will also build upon the

already existing community-based health care structures to further support the continuum of care concept and to increase the

involvement of client families. The MOHSW's Rural Health Motivators and the Home-based Carers from various community-based

NGO's and FBO's will be used to create stronger facility-community linkages. These should increase the number of individuals

and families accessing HIV/AIDS care and treatment services and should decrease the number of patients who discontinue

treatment or become lost to follow-up. These community-workers will also be deployed as care supporters to provide direct home-

based services to people living with HIV/AIDS. Besides care, responsibilities could include prevention for positives, psychosocial

support, identification and referral for nutritional needs, identification of basic infections and referral to the community clinics.

6) PEPFAR partners will continue to support the MOHSW by further developing training curricula and providing in-service training

to key personnel on all aspects of HIV/AIDS-related care and treatment. PEPFAR partners will collaborate to explore efficiencies

and ways to coordinate different aspects of training in order to minimize the burden on health personnel and their availability for

service delivery. In addition, PEPFAR will work with tertiary training institutions for health care workers to incorporate HIV/AIDS-

related care and treatment in their training curricula. Working with nursing schools will be the starting point, but this may

eventually expand to other health cadre training institutions (see HRH/HCD).

7) PEPFAR partners will continue to assist MOHSW with program guidance for adequate referral mechanisms for post-test

support, prevention, and care and treatment services for HIV-infected clients. (see HVSI, HVCT, OHSS). This work, under the

Referrals Working Group, will build on the outcome of the ‘referral assessment' that was recently completed and on previous

efforts at establishing ‘referral directories', in order to improve the continuum of care. A particular area of emphasis will be the

establishment of diagnostic sample transportation systems to reduce the actual referral of patients for diagnosis.

8) Through MSH, PEPFAR has developed an ART patient management information system, RxSolution, currently used at the

existing ART sites. Besides providing routine site-level data and periodic reports, it allows for better patient management,

including the identification of defaulting patients. MSH will ensure that infrastructure, training and mentoring for RxSolution will

follow the decentralization of services. Other partners will concentrate on skills development of health facility staff to be able to

use the information collected and to make informed care and treatment service improvements, addressing issues of standards of

care. PEPFAR partners will assist in the completeness and quality of data recorded on registers, patient records and logs which

would also include writing of proper patient notes and observations.

9) Through DOD, PEPFAR will undertake dedicated initiatives to support HIV/AIDS care and treatment services, and to implement

the Comprehensive Care Package, for the military and other uniformed services. Another initiative will be aimed at providing

HIV/AIDS services throughout the prisons system.

Products/outputs:

•National Guidelines for ART and PEP

•National Guidelines for Community-based Care and Support

•Comprehensive HIV/AIDS Care Package

•Modular training curricula for HIV/AIDS-related care and treatment

•Referral Directories

•Quality assurance plans with supervisor guidelines

•Quality assessment tools

The Compact provides PEPFAR with a significant opportunity to decentralize and extend care and treatment services throughout

Swaziland. Refurbishment of facilities, task shifting, recruitment and training of significant numbers of staff in both the public and

private sector are heavily dependent on Compact funding. With pre-Compact funding levels, PEPFAR will continue to support

quality care and treatment services at the existing national ART sites, including major hospitals and health facilities in urban

areas. Execution of the national plan to broaden access to high quality care and treatment services is in large part dependent

upon the availability of compact-level PEPFAR technical and material support.

Table 3.3.08: