SUMMARY:

The McCord Hospital/Zoe Life's overall activities relate to building capacity at four municipal clinics in the

Outer West area of Durban (KwaZulu-Natal province) to provide a strengthened and integrated prevention

of mother-to-child transmission (PMTCT) service which is linked with tuberculosis (TB) and HIV care and

treatment. Activities that will strengthen services include provider-initiated (with the option to opt-out)

counseling and testing of all pregnant women attending the antenatal clinics, testing of partners and

children of the index patient where possible, TB screening of HIV-infected pregnant women with referral for

treatment where needed, antiretroviral (ARV) prophylaxis for HIV-infected women and newborns, maternal

nutrition and infant feeding counseling and infant follow-up. Emphasis areas include local organization

capacity development, strengthening of referral networks between PMTCT and other vertical programs,

including pediatric services; human resource development through training, mentorship and supervision of

PMTCT staff, quality assurance and improvement through supportive supervision, technical assistance and

mentoring during site visits and strategic information strengthening through development of a simple

integrated monitoring and evaluation system. The primary target populations are pregnant women, HIV-

infected pregnant women, and their infants.

McCord Hospital currently receives funding for PMTCT and ARV treatment through the Elizabeth Glaser

Pediatric AIDS Foundation (EGPAF). This program described here focuses on strengthening the capacity of

public sector facilities, and it is distinct from the hospital-based program funded by EGPAF.

With FY2008 reprogramming funds, and as part of the optimization of services, the McCord PMTCT hospital

-based program will be conducting a basic program evaluation which will feed directly back into the activities

implemented by McCord Hospital and Zoë-Life. Up until now, the McCord PMTCT program focus has

centred on whether HIV transmission occurs 6 weeks postpartum. However, there has been no assessment

as to whether transmission is occurring later than 6 weeks postpartum and what the clinical and health

outcomes of the PMTCT intervention are for mother and child. There has also been no way of determining

whether infant feeding decisions made on discharge are, in fact, being correctly practiced. In addition, in an

effort to address the high rates of postnatal lost to follow up that the Program had been experiencing, a

follow up mother and baby wellness clinic, located within the PMTCT program, was recently established.

This clinic offers primary health care services and HIV-related care and treatment to both mother and child.

As such, an evaluation of this clinic will be conducted to determine whether it is proving successful in

addressing the problem of lost to follow up. A concurrent evaluation of the long term clinical and health

outcomes of the PMTCT program intervention will also be performed. These lessons will be used to

strengthen both the hospital-based program and the clinic strengthening program.

BACKGROUND:

The South African Government (SAG) recently published results of the PMTCT program per province (2006

Antenatal HIV and Syphilis Prevalence Survey). Results of this survey show that KwaZulu-Natal continues

to have the highest antenatal prevalence of HIV at 39.1%. This is 10% higher than the national prevalence

of 29.1%. Current statistics at the four municipal clinics in the Outer West area of Durban show suboptimal

uptake of PMTCT and poor follow-up of infants from the PMTCT program. There are currently no statistics

to indicate the success of infant feeding interventions, infant follow-up rates or involvement of partners.

This is an ongoing activity designed to strengthen PMTCT services within the framework of a

decentralization and integration of HIV care and treatment program. This project is supported by both

municipal and provincial government. All protocols followed will be in line with the Provincial Treatment

Guidelines, and outcomes of the program will be reported to the eThekwini (Durban) municipality as well as

to the KwaZulu-Natal Department of Health. The implementing organizations, McCord Hospital and Zoe-

Life, will strengthen capacity of staff employed by the municipal government (eThekwini Municipality) at the

four clinics to optimize current PMTCT services.

ACTIVITES AND EXPECTED RESULTS:

An emphasis on gender equity in this program area will focus on optimizing the number of pregnant women

who receive care, support and prophylaxis, as well as developing strategies to include partners of pregnant

women in decision-making and issues relating to PMTCT. Partners will be encouraged to test for HIV, and

infected partners or family members will be integrated into the HIV palliative care and antiretroviral

treatment (ART) services program areas. Access to couple counseling will be increased, with focus areas

around family planning, risk reduction, infant feeding choices and testing of family members included in the

counseling and support.

ACTIVITY 1: Human Resources Strengthening

PEPFAR-funded staff with PMTCT expertise will provide onsite mentorship and supervision of staff of the

PMTCT program at the four facilities to improve quality of PMTCT care; training and onsite mentorship of

counselors and clinical staff at the four facilities to increase skills in couple counseling and integration of

partners into PMTCT-related decision making; training of counselors and nurses in infant feeding choices

and maternal nutrition; and training of nurses to draw blood from infants to increase access to infant testing.

ACTIVITY 2: Monitoring and Evaluation

This activity will focus on the development of a monitoring and evaluation (M&E) system that can integrate

data from ART, TB, palliative care and PMTCT services. This M&E system will optimize the provincial

PMTCT data protocols and ensure smooth referrals into other vertical programs.

ACTIVITY 3: Technical Support in Response to M&E Results

PEPFAR-funded staff will provide regular onsite technical support and training of staff to understand the

outcomes of the M&E to improve quality of care and to highlight areas where necessary.

ACTIVITY 4: Follow-up of Infants

Activity Narrative: This activity will focus on the development of sustainable strategies to improve follow-up of infants using

M&E tools and optimization of routine infant clinic visits (e.g., for immunizations, weighing, etc.).

NEW ACTIVITIES:

FY 2008 funding will go toward the following activities:

(1) Counseling services will be expanded to include pre-conception counseling, discordant couple

counseling, extended family counseling and establishment of relevant and appropriate psychosocial support

interventions including focused outcomes based support groups.

(2) Testing services will be expanded to include a second HIV test for all women at 36 weeks gestation who

tested negative at first booking. This will ensure that all women who may have seroconverted during the

pregnancy are able to participate in the PMTCT program.

(3) Care and Treatment services will be strengthened by improving early identification of women who

require treatment, and by offering these women referral and fast tracking into established ARV treatment

program.

(4) Follow up of infants will be strengthened by establishment of child-friendly spaces within the clinics and

through sensitization of staff to improve case finding of all children attending the clinic and strengthening

linkages with community-based health workers and birth attendants where possible.

(5) Linkages with the most common hospital-based delivery sites will be strengthened with the aim of

improving perinatal management of the HIV-infected women through staff training, technical support and

strengthening of case finding systems within the maternity unit.

(6) Linkages with schools and educational services will be formed and a program developed to sensitize

young people to the realities of PMTCT and family planning. This activity will link with the provision of

counseling and testing services at these centers, and will link schools with the clinics and NGOs that

provide optimum PMTCT services.

Sustainability is addressed through the capacity building focus of this program area. PEPFAR-funded staff

will not be permanently assigned to these clinics but will lend support and build capacity until South African

Government-funded staff are able to sustain the program without assistance. The M&E system developed

will be offered to the municipal and provincial government if it is useful within this context.

This program area expects to add quality and to increase uptake of PMTCT services in four municipal

clinics. Uptake of PMTCT services is expected to increase by 30-50%. Zoe-Life and McCord Hospital

expect to provide additional counseling services such as couple counseling, partner counseling and testing,

and maternal nutrition testing. A follow-up system for infants will be developed which will capitalize on the

routine immunization schedules, and an increase in infant and sibling testing is expected. HIV-infected

infants or children will be supported according to the provincial pediatric treatment guidelines. Referral

systems will be strengthened to ensure continuity of care. Infected infants will be referred for initiation of

treatment and referred back to the ARV services program area for ongoing care once stabilized. This

program area will thus increase access to treatment for infants and children.

The McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa

Five-Year Strategic Plan by integrating PMTCT and HIV services, strengthening the public sector and

expanding access to care and treatment.

SUMMARY:

The McCord Hospital/Zoë-Life (MZL) activities in this area will build capacity in four municipal clinics, three

NGOs, and businesses in Durban, KwaZulu-Natal, to provide a comprehensive range of care and support

services for HIV-infected clients and their families. These services will be available to adults and children

from the time of CT, and will support sustained care services for clients not on ART as well as those

receiving treatment. Services will extend to end-of-life care with referral linkages to community-based care

services where available. Emphasis areas include community mobilization (church or community groups) to

augment spiritual and psychosocial services; development of linkages and referrals, particularly with regard

to end of life, spiritual support and community-based care; human resource development with regard to

training, mentorship and supervision of staff to provide sustainable services; organizational capacity

development by training key personnel to manage sustainable palliative care systems at each site; and

quality assurance and improvement through the development of an integrated monitoring and evaluation

(M&E) system. The primary target groups are the general population; refugees and asylum seekers; and the

private sector.

McCord Hospital receives funding for PMTCT and ARV treatment through the Elizabeth Glaser Pediatric

AIDS Foundation (EGPAF). This program focuses on strengthening the capacity of public sector facilities,

and is distinct from EGPAF's hospital-based program.

BACKGROUND:

This project seeks to address health seeking behavior by helping communities access comprehensive HIV

care proactively in a primary health setting, encouraging HIV-infected individuals and their family members

to access care as early as possible, and in so doing emphasize sustained wellness, quality of life and

productivity for as long as possible. Palliative care services offered by a multidisciplinary team will play an

integral part in this health behavior change model of care and improve palliative care services within the

context of both an HIV care program and ARV services. Clinical services will be nurse-led, with only

complex clinical issues referred to a clinician or secondary level facility. The emphasis on care services will

promote screening for pain and symptoms, prophylaxis and prompt treatment of opportunistic infections

(OIs), integration prevention services including prevention with positives, with well established systems for

tuberculosis (TB) screening and treatment. Psychosocial services are essential to promote early

engagement with health services, family-centered care, and the chronic health model. Increasing access to

care and treatment for men is a critical gender issue for the success of this program. This will be addressed

through access to couple counseling, family-centered services and mobile services offered in the workplace

to employed men (and women). This project is supported by both municipal and provincial government. All

protocols followed will be in line with the provincial treatment guidelines, and outcomes of the program will

be reported monthly and quarterly to the eThekwini municipality (Durban) as well as to the KwaZulu-Natal

Department of Health (KZNDOH).

ACTIVITES AND EXPECTED RESULTS:

The areas of legislative interest addressed in this program area are increasing gender equity as described

in the summary above, and increasing women's access to income and productive resources through

linkages with the three NGO income-generating programs.

ACTIVITY 1: Human Capacity Development

This activity will focus on training multidisciplinary teams in each site to provide comprehensive palliative

care services. Clinical staff will be trained to provide prophylaxis, screening and treatment for opportunistic

infections; training of counselors, community workers and spiritual supporters to provide augmented

counseling and support services to adults and children.

Clinical and psychosocial staff will support and mentor staff to develop skills and confidence to provide the

following services: couple counseling, psychosocial support for children, family-centered counseling,

wellness literacy for adults, children and caregivers, clinical care (including screening and prophylaxis of

OIs) and treatment of primary health level OIs.

ACTIVITY 2: Psychosocial services

MZL will establish community linkages to strengthen community referrals and to utilize existing community-

based psychosocial services (such as home-based care, church-based counseling and support groups).

MZL will develop and implement sustainable psychosocial support services, including a support group for

children at two clinics and one NGO site.

ACTIVITY 3: Monitoring and Evaluation

MZL will develop a monitoring and evaluation (M&E) system for palliative care services for use in quality

improvement and capacity building at local and provincial level.

ACTIVITY 4: Care services for refugee and asylum seekers

MZL will provide appropriate palliative care services for refugees and asylum seekers in the Durban central

area in collaboration with the United Nations High Commission for Refugees (UNHCR) and KHWEZI AIDS

Project. These services will be provided in French and Swahili. Palliative Care services for HIV-infected

clients and their families, adults and children from the time of testing, and will support sustained care for

clients not on ART as well as those receiving treatment, and includes: psychosocial support services

(patient HIV literacy, psychosocial assessments, augmented counseling, interventions and appropriate

referral); initial care screening: WHO staging, CD4 screening, TB screening, pregnancy tests; basic primary

health care: screening for pain and symptoms, prophylaxis and prompt treatment of opportunistic infections

(OIs), treatment with clinic level drugs from a limited formulary and referral for more complex medical

problems; care support: CD4 counts at regular, designated, appropriate intervals, support groups, spiritual

support, health education updates.

Services will extend to end-of-life care with referral linkages to community-based care services where

available.

ACTIVITY 5: Mobile services

A range of onsite palliative services will be provided for employees in industry who do not have access to

medical aid. PEPFAR will fund staff to provide mobile onsite services such as counseling, wellness literacy,

Activity Narrative: CD4 count monitoring, screening, prophylaxis and treatment for OIs where possible and integrated

prevention services including prevention with positives. Drugs and laboratory tests will be supplied by the

KZNDOH.

Sustainability at the municipal clinic sites will be addressed by assisting sites to become accredited with the

KZNDOH, and thus making all direct costs of maintaining a quality palliative care service the responsibility

of the KZNDOH. This project will build capacity in these sites to effectively manage the program without

ongoing technical assistance. The NGO sites will be assisted to build infrastructure and referral networks to

ensure sustainability of services. The long-term plan for the NGO sites is to build strong relationships with

nearby clinics with the intent of building clinical capacity to take over the clinical aspects of palliative care

services. This project will later build capacity with these institutions to become accredited sites. Staff will

assist the NGOs to source alternative funding. The services for workers in an industrial setting will be co-

funded by industry.

NEW ACTIVITIES for FY 2008:

1.Staff at the clinics and NGOs as well as community-based organizations will be trained to provide

nutritional assessments and counseling, and to link eligible clients with nutritional support. This entails

accessing nutritional supplementation available from the KZNDOH, as well as infant feeding

supplementation included in the PMTCT program.

2. Additional training will be provided at community level to assist with TB and other OI screening and

referral.

3. Linkages with social services, home-based care and community-based services will be strengthened to

ensure sustainable food security and follow up

PLHIV will receive at least one clinical and one other category of palliative care service. Palliative care to

family members of PLHIV or OVC will be provided in at least two or the five categories of palliative care

services.

With FY2008 reprogramming funds, MZL will undertake a basic program evaluation focused on expanded

HIV testing and linkage to care. While McCord has focused on retention in care of HIV-infected patients who

have already initiated ART, data suggests that substantial numbers of HIV-infected persons never reach

care following the HIV diagnosis. The currently proposed program evaluation will focus on determining the

success of linkage to care of patients along the pathway from being offered an HIV test to beginning and

maintaining care at McCord and St. Mary's Hospital (a collaborating partner). The evaluation will identify

socio-demographic and clinical factors that correlate with patients who are most likely not to be in care 12

months after a new HIV diagnosis. In addition, the two sites will also develop, pilot, and evaluate a

multifaceted, supportive intervention to improve linkage to HIV care for HIV-infected individuals at McCord

and St. Mary's. The pilot intervention will provide insight into the feasibility, efficacy, and cost of preventing

pre-treatment loss to care in these settings. Insights from this evaluation will enhance both the McCord

Hospital-based HIV testing program as well as strengthen linkage to HIV care at its primary clinic sites.

The McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa

Five-Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.

SUMMARY:

McCord/Zoe Life activities will build capacity in four municipal clinics, three non-government organizations

(NGOs) and a corporate outreach program in Durban to provide proactive and integrated TB/HIV services

within the framework of a primary health decentralized HIV care and treatment program. Emphasis areas

include: development of referral systems between vertical HIV-related programs and other health services;

local organization capacity development; and development of a workplace program.

BACKGROUND:

The prevalence of tuberculosis (TB) in KwaZulu-Natal (KZN) is high, with 60% of TB clients co-infected with

HIV. Local TB programs are vertical programs that do not integrate HIV and TB care. An outbreak of

multidrug-resistant tuberculosis (MDR-TB) along with poor treatment completion rates highlights the

challenges of TB management in KZN. The tools used for diagnosis of TB where an estimated 75% of

active TB is extrapulmonary and/or sputum negative pulmonary TB are limited to sputum microscopy for

AFB. Chest x-rays (CXR) do help with diagnosis, but is not confirmatory, and the CXR picture of pulmonary

TB in HIV is not the classic picture. Diagnosis is often complicated by other infections such as pneumocystis

carinii pneumonia (PCP). The yield on sputum culture for TB is higher, especially with sputum negative on

microscopy, and the yield of AFB on blood cultures in extrapulmonary and sputum negative TB is also fairly

high. The best tool at this stage, however, is the clinician with a high index of suspicion for TB. Effective

management of TB is one of the most important upcoming fields of care in South Africa. This new project

will be implemented by the McCord/Zoe Life team and seeks to integrate HIV and TB care using National

Department of Health (NDOH) guidelines and best practice models to provide a seamless continuum of

care to clients co-infected with TB and HIV. Gender will be addressed by increasing access to TB screening

in the workplace, increasing TB screening for women in PMTCT projects and in women's income generating

projects run through the NGOs. The project will also provide TB/HIV care to refugees.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training

Counselors and clinical staff will be trained in provider-initiated CT, and this service will be offered to all TB-

infected clients accessing care at the municipal clinics, and to TB patients accessing services at NGO sites.

Counselors will be trained to enroll all HIV-infected clients into wellness/ARV services and to refer for CD4

screening. Counselors will be trained to screen for TB during any contact with an HIV-infected client and to

refer appropriately. Nurses working in prevention of mother-to-child transmission (PMTCT) or sexually

transmitted infections (STI) NGOs will be cross-trained to screen all HIV-infected clients at each contact and

to refer appropriately for quick diagnosis, treatment and CD4 monitoring. They will be trained to provide

focused wellness and adherence counseling to patients co-infected with TB and HIV. Staff working within

clinic-based TB programs will be trained in integrated TB/HIV management and reporting, including

provision of cotrimoxazole. Staff at NGOs will be trained to screen for TB in community settings and provide

community-based wellness training, dual testing for TB/HIV, and household adherence support for TB/HIV.

ACTIVITY 2: Increase screening of TB in all HIV-related settings including community

This activity will provide technical support for counselors, community workers and nurses to routinely screen

for TB in PMTCT, CT, palliative care and ARV services using a simple symptom-based screening tool.

ACTIVITY 3: Mentorship and supervision of staff

Mentorship and supervision of staff will provide integrated active case management of TB/HIV with

multidisciplinary service provision in palliative care and ARV services where required. Staff will be assisted

to integrate all patients with TB/HIV into comprehensive HIV management services with contact tracing,

screening and partner/family testing encouraged as standard of care. Sites will be assisted to provide

cotrimoxazole to all TB/HIV clients.

ACTIVITY 4: Linkages and referrals

McCord/Zoe Life will assist in strengthening linkages and referrals to ensure full range of HIV care and

treatment services (including extrapulmonary TB) are available without loss of continuity of care or patients

lost to follow-up.

ACTIVITY 5: Development of workplace program and mobile clinic

Staff and employees participating in the HIV workplace program will be trained to understand the link

between HIV and TB. Employees accessing the workplace CT services will be screened for TB by history

and symptom screening. Occupational nurses will be trained to screen for TB per protocol in the

management of HIV. Additional funding will be sought to equip a mobile clinic with a mobile x-ray machine

and microscopy. This unit will be used to provide TB and HIV screening and diagnosis to all workers

accessing the workplace wellness program. Funding will be sought through industry and international

funding to purchase this equipment which is vital to managing TB in the workplace. Until this is a reality,

linkages between workplace programs and referral centers for treatment will be established. Where

possible, TB treatment will be initiated onsite and TB rates reported to the district TB program.

ACTIVITY 6: Development and strengthening of M&E system

An M&E system should have the capacity to track HIV-infected clients receiving TB treatment, to ensure

tracking of visits, active case management and retrieval of TB patients. The system will require

strengthening of linkages between the municipal clinics, the Durban TB clinic and the DOTS workers. A

patient-held record for communication between health facilities will be used in conjunction with the

pharmacies and providers at the health facilities to ensure continuity of care in all services.

ACTIVITY 7: Sharing best-practices

Activity Narrative: McCord/Zoe Life will engage with provincial and district TB coordinating bodies to share best-practices to

improve services. This includes revisiting diagnostic algorithms, accessing funding to pilot better diagnostic

testing algorithms and expanding treatment centers.

ACTIVITY 8:

Staff will be trained and technical support provided to implement sustainable and affordable infection control

policies and measures within each environment.

Sustainability is addressed through development of integrated services within existing public health

facilities, establishment of linkages and referral pathways making access to diagnosis of TB easier, and

through cost sharing in workplace programs.

Through integrated TB/HIV services, McCord Hospital/Zoe Life expects to increase provider-initiated HIV

testing through the municipal TB services to all TB patients, expecting 40-60% of TB patients to be HIV

infected. Any HIV-infected client on TB treatment will be offered the full spectrum of palliative care services

and be referred to for ARV services according to provincial treatment guidelines. All HIV-infected clients will

be screened for TB. It is expected that 20% of all HIV-infected clients will require TB treatment. In the NGO

setting the goal is to increase community-based referral for TB screening, adherence support and

strengthening of referral systems. In the workplace, the goal is to increase workplace screening, diagnosis

and treatment of TB in the HIV workplace program through mobile onsite services.

The McCord Hospital activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year

Strategic Plan by strengthening the public sector and expanding access to care and treatment.

SUMMARY:

McCord Hospital and Zoe Life (McCord/Zoe Life) aim to increase capacity to expand integrated counseling

and testing (CT) services within the framework of a comprehensive HIV care and treatment program in

seven sites: four municipal clinics and three non-governmental organizations (NGOs). Capacity will be

developed by (a) training voluntary lay counselors at the NGOs to provide best-practice services; (b)

mentorship of NGO and municipal counselors and clinical staff to provide integrated, provider-initiated CT

services; and (c) strengthening continuity of care post-CT through referral of HIV-infected clients by

counselors to the HIV care and treatment services. The emphasis areas are the development of referral

systems between vertical programs, human resource support, development of a training curriculum aimed

at CT of children, strengthening the local organizational capacity to increase CT services, quality

improvement, supportive supervision, and in-service training of staff. Specific target populations are the

general population, refugees and internally displaced persons (through the KHWEZI AIDS Project in central

Durban), and workers within the business community. Counseling and testing will be provided in French and

Swahili in the KHWEZI AIDS project to reach refugees and asylum seekers from Central and West Africa

who currently reside in the Durban area.

McCord Hospital receives funding for prevention of mother-to-child transmission (PMTCT) and antiretroviral

treatment (ART) treatment through the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). This program

described here focuses on strengthening the capacity of public sector facilities, and it is distinct from the

hospital-based program funded by EGPAF.

BACKGROUND:

Counseling and testing is the entry point to prevention, care, treatment and support of HIV-infected persons.

If access to care and treatment is to be accelerated, then access to CT should be aggressively pursued. In

KwaZulu-Natal, lay counselors in municipal and local health authorities have traditionally provided a stand-

alone vertical service to persons requesting HIV testing. Uptake of CT services has largely been a result of

the PMTCT program, with referral from other programs (sexually transmitted infections (STI) and

tuberculosis (TB)) and self-referral contributing a small percentage to the uptake of CT. In the NGO setting,

patients are largely referred for CT from community health workers who suspect advanced HIV disease.

Thus, apart from PMTCT where CT is provider-initiated, clients who are already symptomatic with AIDS and

who require a definitive diagnosis and ARV treatment request the bulk of CT services.

The emphasis of this new project would be to shift the trend of voluntary counseling and testing (CT) to a

universal, provider-initiated opt-out service designed to increase uptake of services and to promote early

diagnosis of HIV while patients are still well enough to access wellness and health promotion services. This

project would also emphasize increasing opportunities to counsel and test children. In addition to increasing

uptake of CT, this project seeks to ensure that clients who learn of their HIV status will be seamlessly

integrated into care, support and treatment services. Lastly, this project seeks to take CT into the business

community to workers who would not otherwise have an opportunity to be counseled and tested. The

KwaZulu-Natal Department of Health (KZNDOH) supports these activities. Activities within the municipal

clinics will be undertaken with the support of the eThekwini (Durban) Municipality. Gender issues will be

addressed by taking CT services into the business community, where many employed men have no access

to services. In addition, counselors will proactively encourage partners of women tested in PMTCT services

to access testing. Where possible, the technical support team will investigate the possibilities of extended

hours of CT services to include weekends or evenings.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training

McCord/Zoe Life will work with three NGOs currently providing psychosocial support to HIV-infected clients

in their communities using voluntary lay counselors. These voluntary lay counselors have been trained by a

variety of organizations. In order to standardize the quality of counseling which will be offered through this

project, McCord will train all participating lay counselors. Training will be conducted over 10 days according

to the South African national counseling guidelines (minimum standard). Lay counselors employed by the

four municipal clinics will have benefited from the 10-day training course as a pre-employment requirement

and will not require further training in CT. Staff from all seven sites will be trained in CT of children to

increase confidence and skill in this area. Counselors will be trained to conduct pre- and post-test

counseling with caregivers and children where appropriate. Clinical staff will be trained in testing of children,

which includes skills to draw blood from small children or babies. This is currently a barrier to widespread

testing of small children outside of a hospital setting. Counselors who have not already had exposure to

training in couple counseling will be trained and urged to encourage partner or family attendance at clinic or

NGO activities with the view of encouraging testing and other palliative care services.

In addition, staff will be trained and supported to provide family centered counseling aimed at increasing

retention and improving case finding within families. Also, training will be provided to increase skills to

counsel and test children and adolescents in both the clinical and community/educational settings.

ACTIVITY 2: Workshop in Provider-Initiated Counseling and Testing Within a Multidisciplinary Team

All staff who participate in this project will attend a preparatory workshop on the concept, advantages and

implementation challenges of provider-initiated or opt-out CT services. During this workshop, the seven

sites will be assisted in formulating an approach to implementing provider-initiated CT or opt-out counseling

as an augmentation to their current services, which would include PMTCT, STI, TB, children's clinic,

immunization services. Staff will be assisted to include lay counselors into a multidisciplinary team that will

span across vertical programs. Staff will be assisted to develop referral systems that are effective and

ensure continuity of care between CT, HIV care and treatment and the other programs. Special attention will

be paid to increasing confidence in counseling and testing of children.

ACTIVITY 3: Technical Support to Implement Provider-Initiated or Opt-Out CT

All sites will be supported technically to implement provider-initiated or opt-out CT through weekly

Activity Narrative: mentorship of counselors and clinical staff, facilitation of multidisciplinary and inter-program referrals, and

problem solving. McCord/Zoe Life will assist sites to strengthen monitoring and evaluation systems linked to

CT. Information relating to the implementation of CT services will be reviewed and fed back to staff at the

sites for ongoing quality control and problem solving. Counselor mentors will monitor quality of counseling,

assist with complex cases and strengthen referrals. Clinical support will be given to staff that require

assistance with testing of children.

ACTIVITY 4: Human Resource Augmentation

In sites where uptake of CT exceeds the staff capacity, PEPFAR-funded counselors will be employed to

increase capacity whilst the organization motivates for increasing human resources from the KZNDOH or

from other funding sources.

ACTIVITY 5: Mobile CT

Mobile counseling and testing services will be offered to at risk populations or difficult to reach populations

such as unemployed, migrant or displaced peoples. These services will be provided as an outreach service

linked to the current sites. Sites' staff will be used to link population at risk or in difficulty with appropriate

services.

ACTIVITY 6: Increase CT for OVC

Linkages with educational facilities and facilities housing orphans and vulnerable children will be

established and counseling and testing services will be offered to these facilities, either on site, or in

conjunction with the Zoe-Life/McCord sites, in addition to linkages with care and treatment services.

The McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa

Five-Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.

SUMMARY:

McCord Hospital and its implementing partner, Zoe Life (McCord/Zoe Life) will support and provide

technical assistance in the delivery of antiretroviral drugs (ARVs) to patients at seven sites - four municipal

clinics and three non-governmental organizations (NGOs). The activity will also extend to participating

industry sites for workers without medical insurance in Durban, KwaZulu-Natal.

The emphasis areas are human capacity development, local organization capacity building, and workplace

programs. The primary target populations are the general population, refugees and asylum seekers, and

business community. Refugees and asylum seekers are an important target group, as they cannot access

free antiretroviral treatment in the public sector.

McCord Hospital receives funding for prevention of mother-to-child transmission (PMTCT) and antiretroviral

treatment (ART) through the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). The program described

here focuses on strengthening the capacity of public sector and NGO facilities, and it is distinct from the

hospital-based program funded by EGPAF. Note: EGPAF will also be supporting a similar program in three

Department of Health (DOH) clinics in the northern sub-district of Durban.

BACKGROUND:

This new project will be implemented by the McCord/Zoe Life team in partnership with the eThekwini

Municipality (Durban), three NGOs and private sector sites, to decentralize antiretroviral treatment (ART)

provision to primary healthcare settings. Stable patients initiated on ART at local hospitals will be referred to

the above sites for ongoing follow-up and for monthly ART dispensing. New stable patients will be initiated

on ART at the decentralized sites and continue follow-up and ART dispensing at these sites.

McCord Hospital currently dispenses ART to approximately 2,000 patients, and has now become an

accredited site with the KwaZulu-Natal Department of Health (KZNDOH), which will ensure long-term

sustainability of ARV drug supplies. The KZNDOH is committed to increasing the number of patients

provided with ART in the province. The project described here to support public sector and NGO sites is

supported by the metropolitan and provincial health departments. KZNDOH ARV guidelines will be used in

the provision of ARVs wherever appropriate. Gender issues will be addressed through increasing access to

ART in workers (assuming most are men) in a workplace program, and by ensuring that a family-centered

treatment approach is offered to partners and family members of index patients via access to couple

counseling, community-based referrals, provider-initiated palliative care for partners and active case

management of families. The project will also increase access to ART for refugees.

There will be links between ARV use data and laboratory and clinical data for overall program improvement.

ACTIVITES AND EXPECTED RESULTS:

ACTIVITY 1: Site Accreditation

McCord/Zoe Life will support a process of site accreditation at four metropolitan clinics through negotiation

with the metropolitan and provincial health departments to ensure sustainability and ongoing provision of

ART drugs to these sites. Once the sites are accredited, they would be able to access ARV's through the

KZNDOH.

ACTIVITY 2: Accreditation Guidelines

McCord/Zoe Life will assist the KZNDOH to develop accreditation guidelines for NGOs and workplace

programs to ensure ongoing provision of ART to these sites.

ACTIVITY 3: ART to Decentralized Sites

This activity will support and strengthen systems on site to provide ART efficiently at decentralized sites.

This will be done through meetings with various stakeholders, particularly the provincial and district

pharmaceutical services, to look at the logistics and processes required to supply ARVs sustainably to

community-based sites.

The McCord hospital pharmacy currently manages the ART supply chain for more than 2,000 patients. This

project will hire staff to expand this service to decentralized sites and to strengthen current systems. ARVs

will be selected from national regimens according to trends from previous forecasting. Drugs will be

procured, stored and regulated by the McCord Hospital Dispensary which is registered as a hospital

pharmacy, where necessary. Systems will be developed to procure ARVs for the municipal clinics from their

nearest ARV initiating hospital (RK Khan). As McCord Hospital is accredited with the KZNDOH, ARVs will

be ordered from and supplied by the central Department of Health Pharmacy. Two month's buffer stock is

stored.

All drugs received by the pharmacist will be stored in the McCord Hospital dispensary under the care of the

pharmacists who adhere to good pharmacy practice conditions. Drugs will be ordered twice a month.

Systems are in place to select, procure, store, track and distribute the drugs privately from alternative

sources if there are stock-outs. Monitoring of purchases and distribution is done both manually and

electronically. If stock-outs (less than five days) occur, stock will be purchased from an alternative source.

Discussions will be held with the DOH pharmaceutical services as well as the local DOH District office to

evaluate the logistics required for ARVs to be supplied to clinics from DOH facilities - from either the closest

district hospital or a community health center, following the same process by which other chronic drugs are

supplied.

A PEPFAR-funded pharmacist will liaise with the pharmacists at municipal, NGO and industry sites to

forecast ARV needs on a weekly basis. ARVs will be prepackaged for the decentralized sites and delivered

weekly to each site. Pediatric formulations will also be delivered to sites weekly. The McCord/Zoe Life team

will provide technical support to ensure that onsite storage and dispensing systems are in place before

Activity Narrative: ARVs are dispensed. Scripts will be written by dispensing nurses at the decentralized sites and kept in a

register in the pharmacy. In clinics without a pharmacy, drugs will be stored in a secure cupboard. A register

of scripts and drugs dispensed will be maintained at each clinic by a senior dispensing nurse. Records will

be captured in the logistics database on a weekly basis. Excess or expired medicines are disposed of

through a waste management company.

Sustainability is addressed at provincial level through accreditation of municipal sites and development of

accreditation policies for NGO and corporate sites.

Human capacity development is strengthened through technical support and mentorship of pharmacists and

senior nursing staff at the sites to improve logistics management regarding ARV supply. Staff will be trained

in monitoring and evaluation to strengthen the efficiency of the systems, and to optimize tracking of missed

drug pick up, liaising with the multidisciplinary team who will follow up these clients.

The McCord Hospital/Zoe Life activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa

Five-Year Strategic Plan by strengthening the public sector and expanding access to care and treatment.

With FY08 reprogramming funding, EGPAF will provide support to the national Department of Health and 3

provinces (KwaZulu-Natal, North West and Free State) in training and mentoring of health workers to

implement the new (2008) PMTCT dual therapy guidelines. Tools to measure compliance to these new

guidelines are being developed and will be rolled out to facilities in the three targeted provinces, and

beyond.

SUMMARY:

McCord Hospital and its implementing partner, Zoe Life (McCord/Zoe Life) will support and provide

technical assistance in the delivery of antiretroviral (ARV) services. The McCord Hospital/Zoe Life activities

of this program area relate to strengthening capacity at four municipal clinics and three non-governmental

organizations (NGOs) to provide comprehensive antiretroviral treatment (ART) services in a primary

healthcare setting as part of a decentralization plan. A mobile service will provide ART to infected workers

as part of a workplace program. Emphasis areas are development of referrals across vertical programs (CT,

PMTCT, TB/HIV), community programs and to secondary and tertiary facilities; local organization capacity

building (major emphasis); quality assurance, improvement and supportive supervision; strategic

information; training; and workplace programs. The primary target populations are the general population,

people affected by HIV and AIDS, refugees and the private sector (workers without health insurance).

McCord Hospital receives funding for PMTCT and ARV treatment through the Elizabeth Glaser Pediatric

AIDS Foundation (EGPAF). This program described here focuses on strengthening the capacity of public

sector facilities, and it is distinct from the hospital-based program funded by EGPAF.

BACKGROUND:

There are a number of constraints to the rapid rollout of ART in the public sector. This is largely due to the

lack of human and infrastructural resources, and that ART is generally offered at secondary or tertiary care

level. McCord Hospital has over 2,000 patients on ART, and it is not sustainable to continue the follow-up

of stable patients at this or any other hospital. This new activity will be implemented by the McCord/Zoe Life

team in partnership with the eThekwini Municipality (Durban), three NGOs and participating corporate

bodies. The project will build capacity at primary health care (PHC) level to continue follow-up of down

referred stable patients on ART (initiated at hospital level) and to increase skill at PHC level to provide ART

services (including initiation of ART in patients who are stable). This project is supported by metropolitan

and provincial health departments. Provincial ART guidelines are followed. Gender issues will be addressed

through increasing access to ART in workers (assuming most are men) in a workplace program, and by

ensuring that a family-centered treatment approach is offered to partners and family members via access to

couple counseling, community-based referrals, provider-initiated palliative care for partners and active case

management of families.

ACTIVITES AND EXPECTED RESULTS:

ACTIVITY 1: Site Accreditation

This activity will support site accreditation at four metropolitan clinics through negotiation with metropolitan

and provincial health departments to ensure sustainability and ongoing provision of staff and commodities

for ART services.

ACTIVITY 2: Human Capacity Development

Nurse-led multidisciplinary teams at each site will be trained to provide comprehensive ARV services at

clinics. Training will include adult and pediatric clinical services, psychosocial support/adherence

counseling, pharmacy management and monitoring and evaluation (M&E). Teams will initially be trained to

follow up down referred patients on ART, and will later be supervised to initiate stable clients on ART.

Counselors will be trained to provide routine focused HIV prevention counseling to clients on ART. This will

also be included in routine treatment readiness training for patients. Staff will be trained to provide services

with a French/Swahili interpreter to increase access to refugees/asylum seekers.

ACTIVITY 3: Pharmacy Systems

Pharmacy systems will be strengthened to support drug chain management. Commodity procurement will

be largely the responsibility of the provincial government, and McCord Hospital has been accredited as a

KwaZulu-Natal Department of Health (KZNDOH) site, with the result that decentralized ARV service sites

will also fall under the KZNDOH. Provision of ARV drugs, test kits and labs will be supplied by the DOH as a

cost-share.

ACTIVITY 4: Technical Support

These activities will build capacity through technical support, mentorship and supervision to implement a

comprehensive care and treatment program. This project will provide experienced staff to each site on a

weekly basis to ensure that ARV services are seamlessly linked with wellness services, TB/HIV and PMTCT

to strengthen continuity of care and patient retention. This will be supported by development of referral tools

and regular M&E feedback with problem solving support.

ACTIVITY 5: Pediatric ART

McCord/Zoe Life will provide technical support to increase provision of ART to children. Staff from the

municipal and NGO sites will attend a preparatory workshop in which an approach to increasing pediatric

services will be formulated. Technical support will be offered to integrate ARV services into current vertical

services such as PMTCT, TB, children's clinic, immunization services and community-based psychosocial

services. Staff will be encouraged to implement routine testing of children, and assistance will be given to

develop effective systems which ensure referral of infected children to voluntary counseling and testing, HIV

care, and other programs.

ACTIVITY 6: Referrals

McCord/Zoe Life will assist in strengthening referrals and linkages by establishing a system of up referral for

specialized or hospital-based care, and down referral from any accredited ARV site to the municipal clinics

and NGO sites for patients living in the area; and establish referrals for workers receiving ART (workplace

program).

ACTIVITY 7: Adherence

Activity Narrative:

A strong community-based family-centered adherence component with existing and new role-players for

continuity of care between facility and community will be developed. Where possible, treatment readiness

and adherence support programs will be decentralized further into community facilities.

ACTIVITY 8: M&E

The project will develop and implement a model of M&E that can be integrated into, as well as strengthen

the current data collection systems for partners across both community and vertical programs and up to the

secondary and tertiary level. This will improve quality, ensure a multidisciplinary continuum of care and

manage referral pathways.

ACTIVITY 9: Staff Programs

Partnerships will be developed to provide ARV services to employees who do not have access to medical

insurance.

Sustainability at the municipal clinic sites is addressed by assisting sites to become accredited with the

KZNDOH. This project will build human capacity to effectively manage the program without ongoing

technical assistance. NGO sites will be assisted to build infrastructure and referral networks to ensure

sustainability of services. The long-term plan for the NGO sites is to build strong relationships with nearby

clinics where clinical capacity can be increased to take over clinical aspects of decentralized ART. These

institutions will be included in FY 2008 funding to become accredited sites. NGOs will be assisted to source

other funding. The workplace services will be co-funded by industry. Where possible, corporate

occupational health clinics will be assisted to become accredited KZNDOH sites.

New activities in FY 2008 are:

1. Linkages with educational facilities and facilities housing orphans or vulnerable children will be

established and counseling and testing services will be offered to these facilities in addition to linkages with

care and treatment services. Children found to be HIV infected at these sites will either be referred to

nearby treatment centers (either PEPFAR funded sites or referral sites, dependant on the severity of

illness).

2. Staff at educational or facilities housing orphans or vulnerable children will be trained in basic ARV care

principles so that they will eventually be able to provide ongoing adherence support and monitor side-effects

with appropriate referrals.

3. Staff at sites will be trained in family counseling techniques. This counseling approach encourages

participation of all family members including men (partners and fathers) and will assist counselors to involve

men in both decision making and caring processes. Where possible, counseling will be offered at times that

are suitable for employed men

4. Patient retention will be strengthened through strong patient tracking systems, community-based

adherence support, psychosocial support services which offer a comprehensive range of services, child

friendly sites which encourage ongoing participation with the services, and linkages with community based

organizations which offer other services which may appeal to patients, such as art/drama, nutrition support,

income generation.

The McCord Hospital activities contribute to the 2-7-10 PEPFAR goals and the USG South Africa Five-Year

Strategic Plan by strengthening the public sector and expanding access to care and treatment.