SUMMARY:

Management Sciences for Health/Integrated Primary Health Care Project (IPHC) in collaboration with the

National Department of Health (NDOH) will support the expansion of Prevention of Mother-to-Child

Transmission (PMTCT) services at 80 public health facilities (hospitals and clinics) in eight districts in five

provinces (Eastern Cape, Mpumalanga, KwaZulu-Natal, Limpopo and North West) by building human

capacity of health workers to provide comprehensive PMTCT care. IPHC capacity building activities will

include training, mentoring, coaching and supporting healthcare providers to provide quality PMTCT

services to all antenatal care (ANC) clients in the facilities that are being supported. Providers' skills will be

enhanced to strengthen infant feeding counseling and contribute to a reduction in HIV transmission from

mother-to-infant in line with South African Government (SAG) guidelines. The target populations include

adults, pregnant women, HIV-infected pregnant women, HIV-exposed infants (zero to five), nurses, other

healthcare workers, community leaders and traditional healers. The major emphasis area is quality

assurance and supportive supervision, with minor emphasis on community mobilization/participation and

training.

BACKGROUND:

IPHC will work with the Department of Health (DOH) service providers at the facility level to increase the

uptake for HIV counseling and testing during antenatal care visit; increase the number of HIV-infected

mothers and infants on prophylactic treatment; and increase the support for infant feeding practices and

referral for antiretroviral treatment (ART) when required. IPHC will improve the quality of the service by

integrating PMTCT into routine Maternal, Children and Women's Health (MCWH) services. Through

integrating maternal and women's health and family planning programs, IPHC will pay special attention to

HIV-infected mothers who fall pregnant. These programs will ensure that HIV-infected women are aware of

the risks associated with mother-to-child-transmission and are able to make informed choices about

contraception. IPHC will strengthen the community support of HIV-infected mothers through post-test

support groups and ensuring linkages with community home-based care organizations. Strengthening

Pharmaceutical Systems (SPS) will partner with IPHC to provide support with PMTCT drug logistics.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training

IPHC will train several hundred healthcare providers (both professional and non-professional) in eight

districts in five provinces on comprehensive PMTCT service delivery using the South African NDOH

national PMTCT training guidelines and curriculum. Training is usually on-the-job training, but is

complemented by two-to-three day intensive sessions on topics such as PMTCT updates. The training will

be a participatory activity with the district management teams to ensure that the training is fully integrated

into the provincial PMTCT training plans and is sustainable. Health service providers will be trained to

counsel and test pregnant women and their partners, promote exclusive infant feeding for prevention of HIV

transmission from mother to child, conduct clinical staging of the HIV-infected pregnant mother, tuberculosis

(TB) screening and treatment of opportunistic infections (OI). They will also receive training on appropriate

client screening mechanisms and referrals for antiretroviral (ARV) triple therapy and provision of ARV

prophylaxis to HIV-infected mothers who do not qualify for triple therapy. IPHC will train service providers

from the eight districts in five provinces, increasing the number of health service providers with PMTCT

skills and improving the quality of PMTCT care. IPHC will coordinate with provincial governments in each

province to ensure the training is supportive of ongoing provincial PMTCT training efforts and may include

co-funding workshops with DOH to ensure sustainability. The newly acquired skills of trainees will be

strengthened through on-site mentoring and coaching by IPHC technical staff, who will visit each

facility/CBO/FBO at least twice a month to provide on-the-job support to healthcare staff, and in-service

training of facility staff on specific interventions for increasing PMTCT uptake. These may include provider-

initiated counseling and testing (opt-out) to all ANC clients.

ACTIVITY 2: System Strengthening

The focus of this activity will be to improve the quality of counseling services, logistics and commodity

management to ensure adequate supply of PMTCT-related commodities such as HIV test kits, nevirapine

and infant formula at the facility level. In addition, since the South African Government has recently

announced a policy shift from single dose nevirapine to dual therapy, this activity will also work with the

facilities to ensure adequate supply for the rollout of the new regimen. Emphasis will be placed on record-

keeping, reporting systems to improve data accuracy, quality of reports and data usage at facility level. In

addition IPHC will integrate PMTCT services into routine maternal and child health services to broaden the

use and availability of PMTCT services and will focus on improving mother-baby follow-up tools to track the

infants born to HIV-infected mothers. This is in line with the South African Government (SAG) policy of

testing babies born to HIV-infected mothers at specified intervals. DOH Program managers and supervisors

will be supported to strengthen referral systems between the three healthcare levels (e.g. Primary Health

Care, District, and Tertiary hospitals) and to ensure that ongoing support and mentoring is provided to

facility staff. IPHC will provide technical assistance support, mentoring and coaching to the facility health

service providers in the eight districts to standardize referrals and ensure that all referrals are followed up

and monitored to ensure that the client has received the required service.

ACTIVITY 3: Building Community Networks

IPHC will support community groups to encourage and advocate for couples counseling and testing (CT)

and to encourage more men to get tested. Traditional leader forums, community-based organizations, and

NGOs will identify community sources of supportive encouragement and follow-up for HIV-infected mothers

and their infants. Traditional leaders will be trained to increase and mobilize male/partner understanding of

HIV and AIDS and the need for CT and PMTCT and so strengthen the support network for the mother.

Community healthcare workers will be trained to promote and counsel for exclusive infant feeding practices

among HIV-infected women, tracking infants to ensure follow-up and nutrition support for mothers. IPHC will

assist districts to implement and strengthen counseling and support for HIV-infected pregnant women.

While activities from FY 2007 are still ongoing, FY 2008 COP activities will be expanded to include and

Activity Narrative: focus on increasing the number of pregnant mothers at IPHC supported facilities who are receiving clinical

staging and appropriate referral to treatment, care and support services during pregnancy. This will be

accomplished through in-service training and on-site mentoring. IPHC will work with other partners like

Regional Training Centers in Eastern Cape and ECHO Project in Limpopo which focus on training pediatric

doctors in /HIV and AIDS. PMTCT training will include coding mothers and babies, ensuring that mother

receive nevirapine during labor, CD4 cell count, and following-up of babies at six weeks and advice on

infant feeding. IPHC will work with the facilities to review the discharge plan and monitor for mother-baby

pairs and identify quality assurance interventions that need to be implemented. In addition, IPHC will

develop strategies to reduce the number of missed opportunities and ensure that the number of HIV-

infected pregnant women receiving prophylaxis is increased by reviewing the PMTCT data in the clinics and

coaching clinic staff on the importance of PMTCT and its related data management. Furthermore, IPHC will

improve the current system to ensure that mothers understand and comply with infant feeding options

through the community IMCI support groups and community home-based care groups. IPHC will also

strengthen the management of babies born to HIV-infected mothers and/or of mothers with unknown status

in order to refer the children for 6 weeks Polymerase Chain Reaction (PCR) testing, and increase family

planning uptake among mothers who are HIV-infected to prevent unintended pregnancies.

The IPHC Project will help PEPFAR reach the vision outlined in the USG South Africa five-year strategy by

increasing access to PMTCT services, improving the quality of PMTCT care services and increasing the

awareness and demand for PMTCT services, thereby contributing to the 2-7-10 goal of seven million HIV

infections averted. These prevention outcomes are in line with the USG goal of integrating maternal and

child services into the primary healthcare system in South Africa.

SUMMARY:

Management Sciences for Health/Integrated Primary Health Care Project (IPHC) in collaboration with the

National Department of Health (NDOH) will support the provision of basic care and support to HIV-infected

adults in 80 public health facilities (hospitals and clinics) in 8 districts in 5 provinces (Eastern Cape,

Mpumalanga, KwaZulu-Natal, Limpopo and North West). IPHC will provide technical assistance to both

provincial and district managers for HIV and AIDS programs to strengthen basic care and support services

to HIV-infected clients. The target populations are men and women of reproductive age, children and

adolescences, family planning clients, pregnant women, nurses and other health care workers. The major

emphasis area for this activity will be in-service training; child survival activities; quality assurance and

supportive supervision.

BACKGROUND:

This activity was initiated FY 2006 and continues in FY 2008. All activities will be supported directly by IPHC

in collaboration with district and provincial counterparts from the Department of Health. IPHC will also work

closely with service providers at facility level to ensure that a high quality, comprehensive service is

delivered. This activity will build on IPHC's past activities conducted at current sites and with an additional

focus on gender-related activities. Family-centered counseling will be a major part of the activities that will

be implemented. To ensure integration of programs, IPHC will strengthen the formation of district level HIV

and AIDS, STI and TB (HAST) committees and Local and District AIDS councils. This will ensure that

people living with HIV (PLHIV) are offered a comprehensive package of care that takes into consideration

opportunistic infections (OI) and the provision of cotrimoxazole at the facilities mentored and supported by

IPHC. IPHC is strengthening the referral system between the clinics and these groups, to ensure continuity

of care.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Human Capacity Development

IPHC will strengthen human capacity development by training health care providers (both professional and

non-professional) on basic care and support of HIV-infected clients and ensuring delivery of the preventive

care package. This will include screening for and treatment of opportunistic infections including

cotrimoxazole prophylaxis. Training will also include the clinical staging of clients using the WHO clinical

staging guidelines. Healthcare providers will also be trained on screening STI and TB clients for HIV.

Comprehensive nutritional counseling which will include babies will focus specifically on the nutritional

needs for HIV-infected and TB clients. IPHC will provide training to home-based caregivers using the

Department of Health (DOH) curriculum for community home-based carers (CHBC). The training of home-

based caregivers will include counseling components so that ongoing counseling can be provided to those

infected and affected by HIV and AIDS. In supporting the home base care providers, IPHC will ensure that

those infected and affected by HIV and AIDS receive comprehensive care. IPHC will extend support to local

HBC organizations by supporting their data management systems and subsequent reporting to local linked

healthcare facilities.

ACTIVITY 2: Support Groups at the Facilities

IPHC will continue to coach and support health service providers by focusing on psychosocial support and

clinical management of people infected and affected by HIV and AIDS. All CT sites supported by IPHC will

offer palliative care to HIV-infected clients. IPHC will also establish/strengthen the referral system that

begins at facility level and continues to home-based care (HBC) to ensure continuity of care for clients,

beyond the 80 supported facilities. IPHC will establish linkages and facilitate networks with community

organizations, local municipality and health facilities to increase access to palliative care. IPHC will assist

community-based organizations (CBO), non-governmental organizations (NGO) and faith-based

organizations (FBO) to access other sources of funding for home-based care programs. IPHC will work with

the municipalities to ensure that the CBOs, NGOs and FBOs within their local municipalities not only receive

support through Integrated Development Program of the municipality, but also are monitored by the local

community representatives. IPHC staff will visit the supported community-based organizations at least once

a month. These visits will be conducted with the clinic staff to strengthen the relationships between the staff

and the community groups, and also to build in sustainability of the program

ACTIVITY 3: Integration of Services

This activity will focus on the integration of HIV and AIDS services into routine Primary Health Care (PHC)

services to ensure a holistic approach to basic care and support to the HIV-infected client at the facility

level. Integration of services is important for the clinical management of HIV and AIDS clients. All IPHC-

supported PHC facilities will be strengthened to provide a basic health care package that includes routine

screening for opportunistic infection and the provision of cotrimoxazole prophylaxis, staging for those clients

who are ready to go on the ART program, and on-going counseling and support for those that are not yet

ready. IPHC will also focus on strengthening the referral system to and from facility level to home-based

care services. Service providers from the health facility and HBC services will be trained on the referral

system and how to refer clients appropriately. IPHC will support a care support program for clients who are

not yet ready to be on an ART program at the 80 IPHC supported facilities. The care support program will

provide education on nutrition, family planning and opportunistic infections. Addressing prevention with HIV-

infected individuals is an important part of a comprehensive care strategy. Through healthy living and

reduction of risk behaviors, these prevention with positives interventions can substantially improve quality of

life and reduce rates of HIV transmission.

At the facility level, IPHC will focus on ensuring that clients are counseled on prevention with positives and

that family members are provided with psychosocial support and HIV and AIDS education. IPHC will focus

on the following activities: prevention with positives, care support programs and support for the caregivers

activities. The preventive care package will be implemented at all IPHC supported facilities. IPHC will

support health providers to ensure stronger links between palliative care, CT, family planning, PMTCT and

ARV therapy at the facility level. IPHC will facilitate that gender related issues (behavior change, violence,

disclosure to mention a few) are addressed during HIV and AIDS support groups sessions.

Activity Narrative:

IPHC activities will increase the public health facilities' capacity to deliver quality basic health care and

support services and expand access to quality palliative care services, thereby addressing the priorities set

forth in the USG Five-Year PEPFAR Strategy for South Africa. IPHC will assist PEPFAR to achieve its goal

of caring for 10 million people.

SUMMARY:

Management Sciences for Health/Integrated Primary Health Care Project (IPHC) in collaboration with the

NDOH and respective PDOH will support the provision of basic care and support to those who have tested

positive in 80 public health facilities (hospitals and clinics) in 8 districts in 5 provinces (Eastern Cape,

Mpumalanga, KwaZulu-Natal, Limpopo and North West). IPHC project supports the mission of the South

African Government -National Department of Health (NDOH) in the prevention of the spread of HIV, STI and

TB infections as well as the mitigation of the impact of dual infection of HIV and AIDS and TB epidemic in

the country. The target population will be men and women (of reproductive age), family planning clients,

pregnant women (including HIV-infected women), PLHIV, HIV and AIDS-affected families, caregivers of

OVC and PLHIV, and nurses and other health care workers. The emphasis area for this activity is human

capacity development through training.

BACKGROUND:

This activity is a continuation of FY 2007. IPHC project will be guided by the NDOH Comprehensive Plan for

HIV and AIDS and the National TB Crisis Plan to improvement of quality in HIV and AIDS, STI and TB

(HAST) collaborative activities by ensuring compliance to TB/HIV policies and guidelines One of the major

challenges currently is the collection of quality data to monitor implementation of TB/HIV collaborative

activities. IPHC will support districts to develop and strengthen HAST committees by training the

committees to conduct regular reviews of the HAST program to monitor progress towards targets., To

improve flow of data and capturing of this to ensure accurate reporting of activities, IPHC will assist

provinces and districts by training health care workers on the TB Recording and Reporting Systems

including data management. Screening for TB in HIV-infected and offering VCT to TB clients will be

intensified to ensure that the number of TB clients who are tested is increased. IPHC will support the eight

districts in the 5 provinces in improving the TB management by training the supervisors to support the

TB/HIV and AIDS programs. This will provide in-depth reviews and identify gaps that can be addressed to

improve the quality of care. The IPHC project will partner with TASC-II TB Project in implementing these

activities.

Community awareness strategies form one of the pillars of the National TB Crisis management plan. To

improve compliance to TB treatment and improve treatment outcomes. IPHC will work with health care

workers and NGOs in the 5 provinces to intensify strategies to improve patient adherence to treatment. With

the lessons learnt from the ARV Programs, DOT Supporters, Lay Counselors and other community-based

organizations will be trained on adherence counseling.

Patient follow up is a challenge in many parts of the country especially in rural settings. Systems currently in

place are not well structured to ensure continuity of care. (not sure what to suggest here but need to talk of

strengthening follow up systems maybe develop patient recall system, work on back referral processes, but

for MDR patients, IPHC is working on a system where there will be a central register, patients have to go

back to the center monthly through province making the arrangements for this. There are also issues

around the implementation of an infection control policy and TASC TB has worked with the NTCP in

developing infection control guidelines)

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training

In FY 2008, IPHC will train 500 health care providers in 8 districts on TB diagnosis, HIV counseling and

testing of TB clients, treatment and adherence to treatment by PLHIV with active, screening for TB

symptoms in all PLHIV. IPHC will strengthen DOTS at the community level by monitoring treatment

compliance and contact tracing. IPHC will ensure that TB screening and treatment is initiated at primary

health care facilities. The continuity of care provided through the DOTS program will be strengthened by

ensuring the availability of treatment regimens at facility levels. IPHC will provide HIV, AIDS and TB clinical

management training to health care workers using the national treatment guidelines and the treatment care

and support policy of the NDOH.

ACTIVITY 2: Integrating Services

Integration of services through the HAST committees will be strengthened with DOT supporters' full

participation as members of HAST committees. IPHC will monitor the attendance registers from the

meetings to ensure there is consistent participation from DOT supporters. IPHC will ensure that TB and HIV

and AIDS programs are not stand alone services but are fully integrated with other Primary Health Care

(PHC) services. Working with managers and supervisors at primary, secondary and tertiary level, IPHC

project will strengthen the referral system to ensure continuity of care. Tangible networks will be established

between DOT supporters and community home-based care (CHBC) so as to facilitate enhanced community

healthcare and referral.

ACTIVITY 3: Human Capacity Development

Human capacity development of professional and non-professional staff will be a focal area to ensure

professionals and non-professionals are kept up to date on recognizing and detecting drug interactions and

improving record keeping of all TB clients. Since every TB client has to be tested for HIV, record keeping is

critical in monitoring the status of each client. Training and on-site mentoring will be provided to facilitate

rapid scaling-up of HIV counseling and testing (CT) of TB clients and also to encourage sustainability of

these activities. The quality of the TB management will be monitored on fortnight basis to ensure that the

clients continue with their TB treatment and are tested, and if positive, monitored so they can access ARVs.

IPHC will provide supportive follow up to ensure that the health providers are implementing the NDOH TB

Policy and referring TB clients for HIV counseling and testing. IPHC will also strengthen supervision of

facilities through training of supervisors on TB/HIV program management, and support district and facility-

level supervisors through regular "program indicators monitoring" meetings

FY 08 COP activities will be expanded to include:

Activity Narrative: -IPHC will conduct in-depth programs review and training on TB data management at the facility

-Closely monitor the TB program indicators and progress towards outcomes (register for case finding,

treatment interrupters, treatment failure rates)

-Monitor sputum collection intervals and turn around time

-Increase HIV screening for all TB clients

-Increase the number of TB clients who receive cotrimoxazole prophylaxis

This activity will be achieved by using the In-Depth TB review tool from the Clinic Supervisors Manual. The

reviews help to identify quality management gaps e.g. availability of equipment, like sputum jars, adherence

to Guidelines, protocols that need to be followed to ensure that the TB program is well managed. Improved

recording will result in identifying drop outs and TB defaulters. Linking with home-based carers and Directly

Observed Treatment Supporters (DOT Supporters), IPHC will decrease defaulter rates. This will be

achieved by training the health professionals and the DOT supporters on adherence counseling. One of the

strategies, currently used by IPHC, is to facilitate quarterly district reviews of TB data, where all the TB data

is reviewed by the district team. Team members learn from each other the strategies for improving the

program, with the support of the IPHC project.

IPHC activities contribute to the PEPFAR goal of providing care to 10 million HIV-affected people. In

addition, these IPHC activities will address the priority area of increased linkages between TB/HIV services

and health systems networks from the USG Five-Year Strategy for South Africa.

SUMMARY:

Management Sciences for Health, Integrated Primary Health Care Project (IPHC), in collaboration with the

National Department of Health (NDOH), will continue to support the expansion of the orphans and

vulnerable children (OVC) program in 5 provinces of South Africa (Eastern Cape, Mpumalanga, KwaZulu-

Natal, Limpopo and North West).

The OVC activities supported aim to strengthen communities to meet the needs of OVC and their families;

supporting community-based responses, helping children and adolescents to meet their own needs and

creating a supportive social environment. The activities under this program specifically aim to assist OVC

with access to education, economic support, provision of food and or nutrition, legal assistance, healthcare,

psychological support and protection from abuse. The target populations for the activity are OVC and their

caregivers and people living with HIV. The major emphasis areas are in local organization capacity and

wrap around activities with child survival interventions that link the IPHC partner organizations to their

nearest clinics.

In FY 2007, IPHC increased the number of partner NGOs from 7 to 23 and they now include the following:

-Eastern Cape Province: Inkwanca Home-based Care, Ikhwezi Lomso Child & Family Welfare Society,

House of Hope Hospice, Ncedisizwe Home-based Care, Bonukhanyo Youth Organization.

-KwaZulu-Natal Province: Khanyiselani Development Trust/National Peace Accord, Sibambisene

Organization, Inkosinathi HIV/AIDS Project, Masakhane Women's Organization,

-Limpopo Province: Makotse Women's Club, Direlang Project, Makhuduthamaga Community Home-based

Care Organization, Lafata Home-based Care, Mohlarekoma Home-based Care,

-Mpumalanga Province: Zimeleni Home-based Care, Thuthukani Home-based Care, Sizanani Home-based

Care, Luncedo Lwesizwe Home-based Care,

-North West Province: Thibela Bolwetse Project, Botho Jwa Rona Home-based Care, Pholo Modi Wa

Sechaba Home-based Care, Winterveldt HIV/ AIDS Project, Progressive AIDS Project.

BACKGROUND:

This activity is on-going and continuing from activities initiated in FY 2006 and FY 2007. IPHC will be

working with NGOs and Community-Based Organizations (CBOs) that are implementing activities aimed at

improving the lives of OVC. All NGO/CBO activities are integrated into the plans of the Departments of

Health and Social Development. With FY 2008 PEPFAR funding, the IPHC will also establish and

strengthen the referral system between the NGOs and CBOs and, local municipality and health facilities to

increase access to health services e.g. provision of childhood immunization, pediatric HIV testing, clinical

monitoring and management of ARV therapy when necessary. IPHC has a wrap around child survival

activity at the health facilities surrounding these OVC organizations and will work to actively encourage and

support referrals between the CBOs and the health facility. IPHC and its sub-partners will strengthen

collaboration between the South African Police Services and Child Protection Units to report cases of abuse

and rape especially in child-headed households. IPHC will engage traditional leaders to raise awareness

and address the abuse of girl children in their communities.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Community Mobilization and Participation

Using FY 2007 funds, IPHC managed to increase the number of NGOs providing care and support to OVC

from seven (7) to twenty-three (23) in the 5 provinces. As a result the number of OVC served surpassed the

set target of 10,000 for FY 2007. In FY 2008 the aim is to continue to increase the number of caregivers,

expand the services provided and increase the number of OVC that receive support. To achieve this IPHC

will build the capacity of NGOs and CBOs through training, expanding networks and partnerships, and

identifying opportunities for fund raising. This will enable organizations to effectively and efficiently

implement integrated programs that are responsive to the needs of OVC at local level.

IPHC will also increase the number of caregivers trained in psychosocial aspects of working with OVC,

including understanding their developmental needs and support requirements of children. IPHC will also

assist with the identification of accredited service providers to provide training to the NGOs on technical

aspects related to OVC care. Examples of such training include financial and project management, data

management and reporting, financial proposal development and fundraising. IPHC will work with the NGOs

that have crèches and drop-in centers and raise their knowledge in relation to children's needs and rights, in

line with the guidelines of the Department of Social Development on early childhood development. The

trainings shall be at local district level in the five provinces.

It is expected that a total of 15,000 OVC shall be reached by end of FY 2008.This will be done through

specific training that will be conducted on child rights, child participation and memory work' with children.

ACTIVITY 2: Capacity Building/Technical Support

With FY 2008 PEPFAR funding, IPHC will provide technical support to NGOs and CBOs to enable them to

provide a comprehensive package of care and support to OVC. The package includes support to OVC to

obtain birth certificates and identification documents; access social security grants; psychosocial support

that includes trauma, bereavement and basic counseling; emotional and spiritual support; counseling and

debriefing of caregivers to prevent burnout; referral to clinics and hospital for pediatric ARV treatment and

adherence; immunization; age appropriate messages on prevention of HIV infection; support for child-

headed households and protection interventions to prevent sexual abuse, rape, land grabs and provide

security of inheritance; access to life skills education; access to legal aid to prevent social neglect.

In FY 2008, IPHC will directly provide mentoring and technical support to NGOs in the areas of

administration, financial management and reporting, data collection, monitoring, evaluation and report

writing. A simple accounting and financial package, that is user friendly, will be provided to all NGOs trained

so that they can apply it in their financial reporting. The newly designed data collection and reporting forms,

registers and child in-take forms will be used in group trainings to build the skills of NGOs in data reporting.

All 23 NGOs shall be supported to develop a monitoring and evaluation system that has activity plans,

Activity Narrative: targets, simple indicators, outputs and outcomes and time-frames. This will be done through short-term one

week training sessions that will be followed up with on-site field visits by the technical advisor and provincial

coordinators.

ACTIVITY 3: Linkages and Networks

IPHC will facilitate partnerships between the 23 NGOs and other local organizations working with OVC in

order to encourage shared knowledge and learning. IPHC will also ensure that NGOs participate in the local

coordinating structures such as District AIDS Councils (DACs) to facilitate access to resources for OVC.

IPHC will also form Child Care Forums to ensure that OVC receive appropriate services and encourage

community protection of OVC. IPHC supported NGOs will also advocate for the inclusion of OVC care and

support service into the Local Government's Integrated Development Plans (IDPs). The 23 NGO sub-

partners will be linked to the child survival activities through the Integrated Management of Childhood

Infections (IMCI) portion of the IPHC implemented in conjunction with the Department of Health and other

partners. IPHC will ensure that OVC continue to be fully immunized through referrals by the 23 NGOs to

nearby clinics. The NGOs will also be encouraged to monitor the weight of children, especially in the light of

HIV/AIDS, to enable early detection of children failing to thrive. Access to ARVs will be improved through

facilitation of referrals of OVC to nearby health facilities that offer these services.

IPHC will assist PEPFAR to achieve its goal of caring for 10 million people, including OVC, by increasing

OVC access to government support, expanding linkages and referral systems with other health and social

services, and strengthening and expanding OVC policies and guidelines.

SUMMARY:

Management Sciences for Health/Integrated Primary Health Care Project (IPHC) in collaboration with the

National Department of Health (NDOH) will support the provision and referral of basic care and support to

those who have tested HIV positive in 80 public health facilities (hospitals and clinics) in eight districts and

five provinces (Eastern Cape, Mpumalanga, KwaZulu-Natal, Limpopo and North West). This activity will

support HIV voluntary counseling and testing (CT) services for men, women, and youth with specific focus

on out-of-school youth in facilities supported by IPHC. IPHC will prioritize the provision of these services to

men, as this needs improvement. The primary emphasis area is quality assurance and supportive

supervision, additional emphasis on training and the development of networks/linkages/referrals. This

activity also aims to test pregnant women and facilitate access to prevention of mother-to-child transmission

(PMTCT) and antiretroviral (ARV) services. The target population is secondary school students, adults,

family planning clients, pregnant women, nurses, and other healthcare workers.

In FY 2008, IPHC will align its activities with the recently launched HIV & AIDS and STI Strategic Plan for

South Africa, 2007-2011 (NSP). IPHC will work with 80 public health facilities to make CT widely accessible

and available and implement provider-initiated testing and counseling (PITC) in public health facilities as

recommended in the NSP.

BACKGROUND:

CT is the building block for all HIV and AIDS programs and it is an important activity in all IPHC-supported

facilities. This activity is a continuation of activities initiated in the FY 2007. IPHC directly supports all

activities and works closely with counterparts from the health departments at district and provincial levels to

increase the number of service outlets that make counseling and testing (CT) widely available. Activities will

include training of healthcare providers (professional and non-professional) on CT, couple counseling, and

methods of integrating PITC into primary healthcare services such as tuberculosis (TB), sexually

transmitted infections (STI), antenatal care (ANC) and family planning (FP). There will be a special

emphasis on expansion of CT services to both in- and out-of-school youth. IPHC has trained Clinic Youth

Mentors on HIV and AIDS so they can work closely with the health facility personnel to encourage other

youths who come to the health facilities to be tested for HIV. Youth mentors motivate other youths to take

up the test as part of the "Know Your Status Campaign". Once youth agree to test, they are referred to the

professional nurses in the health facilities who do the actual counseling and testing.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training

IPHC Project will train 300 healthcare providers (professional and lay) in CT skills in FY 2008. There is a

high staff turnover in the rural project sites. New professional nurses who come into the system each year

are not trained in CT. Most training institutions do not include CT in the pre-qualification curriculum of

professional nurses, which creates a need for CT at the beginning of each year. The project will use training

material developed by the NDOH. The training will enhance the quality of CT provided to clients through

mentoring supervision and by increasing the number of health facility staff that can provide CT. IPHC will

build the capacity of health providers to go beyond CT by supporting post-prevention services that include

the formation of pre- and post-test clubs to support those that have tested HIV negative and to encourage a

reduction in risky behavior among clients that test HIV positive. Clients that have tested HIV positive will be

encouraged to join a support group to focus on maintaining their health and referred to treatment and care

for CD4 count testing and staging.

ACTIVITY 2: Increasing CT among Youth

IPHC recently started a program aimed at training Clinic Youth Mentors in HIV and AIDS. The Mentors are

18-23 year olds who are placed at the health facilities. They work with other clinic staff to encourage other

youth who visit the facilities to accept CT and other services. They also visit schools, give talks to other

youth on the advantages of testing, and motivate young people to test for HIV, so they will know their status.

IPHC places one male and one female in each facility. The male Clinic Youth Mentors are critical in

motivating other male youth to use CT. Using USAID child survival and family planning funds, the Clinic

Youth Mentors have been trained to provide counseling and to encourage those who come to the facilities

for FP, STI and ANC to have an HIV test. IPHC will implement the Clinic Mentor Program in the health

facilities they are working in, and special attention will be given to the skills and attitudes of healthcare

providers to ensure that the facility staff support the youth. This will be done through training on

interpersonal relationships, and building an understanding of how cultural and social differences affect the

youth's access to health services. Training of youth from the communities and their work with in- and out-of-

school youth will increase community awareness. IPHC will facilitate community mobilization, networking

and establishment of linkages between community structures, health facilities and universities to ensure

greater community participation. Establishment of support groups to ensure greater participation of people

living with HIV (PLHIV) will increase access to CT through community awareness and reduction of stigma

and discrimination.

ACTIVITY 3: Improving the Quality of CT

This activity will focus on continuous improvement in the quality of the CT services provided at the 80

facilities that IPHC supports. Evidence from IPHC-supported facilities indicates that a large number of ANC

clients are not tested for HIV. Various factors affect the quality of CT; these include the training of the CT

providers, the physical settings in the facilities as well as burnout in the counselors. IPHC will provide

ongoing supportive supervision by building human capacity, address staff burnout and shortages to ensure

an improved quality of services at district level. Supervision and mentoring will focus primarily on clinic

supervisors and program managers, thus building their capacity to mentor and supervise other healthcare

providers. IPHC will also train the members of the HIV, AIDS, STI and TB (HAST) committee, clinic

committees and hospital boards to monitor and support the provision of these services. IPHC will support

district facilities to ensure that quality data management processes are put in place.

FY 2008 COP activities will be expanded to include:

Activity Narrative: - Advocate for psychiatric nurses and psychologist in the district health system to facilitate debriefing

session of the counselors.

- Administer the District STI Clinic Assessment (DISCA) tool in all supported facilities to improve STI

management and also increase CT service to STI clients.

- Directly observe and monitor CT sessions in order to make relevant inputs to improve quality of the

counseling provided.

- Promote CT in hospital maternity sections and family planning clinics.

- Increase the integration of CT package in ANC.

- Increase provider-initiated testing and counseling to all STI and TB clients treated more than 90% per

supported facility.

- Increase male CT uptake by involving the Men As Partners program in selected facilities.

IPHC will contribute to the PEPFAR goals of providing care to 10 million HIV-affected people, and ultimately

will assist in meeting PEPFAR's goal of providing treatment to HIV-affected people. In addition, these IPHC

activities will address the priority area of increased linkages between CT services and health systems

networks as laid out in the USG Five-Year Strategy for South Africa.

SUMMARY:

Management Sciences for Health/Integrated Primary Health Care Project (IPHC) in collaboration with the

National Department of Health (NDOH) will support the provision of ART services to those who have tested

positive in 15 hospitals and 35 feeder clinics in 8 districts in 5 provinces (Eastern Cape, Mpumalanga,

KwaZulu-Natal, Limpopo and North West). IPHC will assist the districts in implementing the National

Department of Health Operational Plan for Comprehensive HIV and AIDS Care, Management and

Treatment for South Africa (Comprehensive Plan) by assisting designated sites to meet the ARV

accreditation requirements. IPHC will mentor and support the management team at facility and district level

to implement the ARV program in accordance with the norms and standards of the Comprehensive Plan to

increase access to ARV therapy through increased number of service points for providing ARV services.

IPHC will build on its success of supporting accredited facilities and will continue to support others within the

same district through the accreditation process. Integration of the ARV program into the routine primary

health care (PHC) services will also be a key focal area to ensure that client adherence to ARV therapy is

improved.

The emphasis area is human capacity development. The target population will be men and women (of

reproductive age), family planning clients, pregnant women (including HIV-infected women), people living

with HIV (PLHIV), affected families and caregivers of orphaned and vulnerable children (OVC), and

healthcare providers (nurses) and other healthcare workers.

BACKGROUND:

This is an ongoing activity continuing from FY 2007. IPHC will continue to support the districts to address

the increasing demand for ARVs in South Africa. IPHC will support health facilities in providing a continuum

of care through the primary, secondary and tertiary level. This will be done by strengthening the ARV

program at hospital level, improving referral to feeder clinics of the hospitals and strengthening community

support for those patients on ARV, through direct referrals Community Based Organizations (CBOs) that

are working with the facilities. The ARV program will be integrated with other HIV and AIDS services as well

as PHC services to ensure sustainability. IPHC will continue to increase the number of accredited sites that

are able to provide clients with ARV treatment. Working in 5 different provinces, the project will share good

practices and lessons learnt from one site to the other. This will facilitate rapid start-up and fast-track

accreditation of new sites. Staff training will include training of pharmacists, pharmacy assistants and

professional nurses on drug management, staging and drug adherence strategies. Training will include

monitoring drug interactions, ongoing counseling and support for adherence and well-being, as well as

down-referral to community networks and home-based care service providers. IPHC will ensure adherence

to the NDOH policy and drug protocols through supportive supervision and onsite mentoring. IPHC will visit

each facility at least twice a month to provide onsite mentoring and support to facility staff. Using an

assessment tool developed by the project, IPHC will assess ARV programs in terms of leadership for

sustainability of the program, staff capacity, availability and management of ARV of drugs, laboratory

services for CD4 count testing and viral load assessment, and the comprehensiveness of the care provided;

including community involvement in the program. This will facilitate the improvement of staff skills in

providing quality clinical and counseling services.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Supporting the ARV Accreditation Process

IPHC will support the districts by preparing designated sites for the accreditation process; working with the

DOH site ARV task team to develop an ARV implementation plan for the site; training of healthcare

providers in assessment and screening of patients for ARV therapy; screening for and treatment of

opportunistic infections, adherence counseling, and nutrition counseling; training of community health

workers as treatment supporters, on nutrition counseling, and adherence counseling; training healthcare

providers to recognize adverse drug events and assist districts to develop an algorithm for continuum of

care from counseling and testing to treatment, care and support and preparing healthcare providers at clinic

level to assess clients for ARV; and implementing patient readiness program for ARV therapy. This process,

guided by the SAG accreditation strategy, will result in an increased number of eligible clients on ARV

therapy, and increased capacity of healthcare workers trained in the delivery of ARV services.

ACTIVITY 2: Linkages and Referrals

IPHC will facilitate linkages and referrals with other institutions such as TB hospitals, hospice and other

home-based care services to ensure clients are also screened for ARV treatment and are referred to the

appropriate service delivery point for ARV initiation and follow-up. Activities will include: conducting an

assessment of referral systems between public and private sector and community-based initiatives;

determining possible gaps in the referral system, developing referral systems with the various stakeholders;

training service providers in other sectors; training service providers in follow-up care; and ongoing

monitoring of the patient on ARV therapy. The result will be functional integration of ARV services with other

health services within the district.

ACTIVITY 3: Mentoring

IPHC is currently supporting the accredited sites by visiting the sites twice a month, using the assessment

tool to identify the strengths and weaknesses of each program. An intervention program to improve the

services is developed with the ARV team that includes hospital doctors, pharmacists, pharmacy assistants,

laboratory technicians, professional nurses and the leadership of the hospital. In addition IPHC will focus on

improving the quality of care provided. Using the Supervisors Manual, IPHC will review the quality of care

provided to all patients on ARVs as well as the quality of the PMTCT program and the ongoing counseling

provided to patients on ARVs. With the aim of increasing the number of HIV positive patients who are

accessing Family Planning service, IPHC will use an in-depth assessment tool to ensure that all ARV sites

meet the minimum requirements for providing FP to clients, including the availability of different

contraceptive methods and adherence to standards and protocols.

The IPHC activities contribute to the PEPFAR 2-7-10 goals.

Activity Narrative: SUMMARY: