SUMMARY:

UKZN proposes to use PEPFAR funding to strengthen existing prevention of mother-to-child transmission

(PMTCT) services, by continuing ongoing FY 2007 activities in the Eastern Cape province and providing

technical support to KwaZulu-Natal to facilitate better PMTCT implementation and integration with

treatment, care and support. Target populations for the project include pregnant women and infants born to

HIV-infected mothers, all cadres of health care workers engaged in maternal and child health services and

provincial PMTCT coordinators. Emphasis areas for the project include human capacity development, local

organization capacity building, and the provision of technical assistance. The UKZN PMTCT project has 2

components viz. (i) Expansion of the FY 2007 funded Demonstration Project which aims to create linkages

between health and social services in the EC; and (ii) Provision of technical assistance to 3 Health Districts

in KwaZulu-Natal with the highest antenatal HIV seroprevalence.

BACKGROUND:

MTCT rates prior to implementation of the national PMTCT program ranged between 20% - 34%. Since

2002, South Africa has made significant progress in the rapid expansion of PMTCT services. Several

national and provincial audits of the program have highlighted common gaps and challenges to

implementation, and as a result MTCT rates remain high, 20.8% at six weeks as compared to the

anticipated 12%-14%. Challenges to program implementation include: low uptake of CT, lack of ongoing

support for both HIV-infected and uninfected women, poor administration of ARV prophylaxis (less than

25%), policy confusion around nevirapine, poor postnatal follow-up (retention < 15%) and erratic and unsafe

infant feeding practices. In addition, with the implementation of ART programs, linkages between PMTCT

and ART programs have not been established successfully. In view of the above challenges and using FY

2006 and FY 2007 funding; the UKZN PMTCT project was conceptualized to begin to address these

deficiencies. Specific FY 2006 and FY 2007 activities included: establishing pilot sites in each province to

begin implementation of repeat HIV testing for pregnant women who were missed or who tested negative at

the first antenatal care visit. During FY 2006,, the project was completed in 12 primary health care clinics,

three in each of the provinces with the highest HIV antenatal prevalence, namely MP, FS, EC and GP and

using FY 2007 funds preparations for implementation in three primary health clinics in each of the remaining

provinces, namely North West (NW), Limpopo (LP), Western Cape (WC) and Northern Cape (NC) have

begun.

Using FY 2006 funding, a demonstration project aimed at improving follow-up and continuum of care of

women (HIV infected and uninfected) and children in the PMTCT program by fostering a partnership

between Health and Social Services in KwaZulu-Natal was implemented. This project serves as a

demonstration site for a holistic PMTCT program that focuses on enrollment of women into PMTCT

services, PMTCT service delivery and linking women and their infants to social welfare programs,

treatment, care and support. This project has commenced in collaboration with management of both

departments of Health and Social Development in KwaZulu-Natal and is due to be complete in July 2008.

Using FY 2007 funding, a demonstration site for holistic PMTCT service delivery is being set up in Eastern

Cape and expanded to two health facilities in KZN. Funding will ensure that each of the two provinces have

a best practices model which can be rolled out by the provincial departments of health and social

development. The project is supported by a trained team of clinicians, community health workers and social

workers who would perform a situational assessment of health service utilization and the provision of

comprehensive maternal and child health services among women and children, implement a

comprehensive package of clinical care for HIV infected and uninfected women and their children through

integrating HIV and PMTCT programs in routine maternal and child health services, establish a support

program for HIV-infected and uninfected women antenatally and postnatally until 18 months post-delivery

and facilitate and expedite access to social support services such as child support grants (CSG), child care

grants (CCG), and disability grants through interdepartmental collaborations viz. health, social welfare and

home affairs.

FY 2007 funding is also being used to provide ongoing technical assistance and support to four provinces,

namely Eastern Cape, Gauteng, Free State and Mpumalanga. Technical assistance will be provided at the

provincial level to ensure that provincial program managers develop skills to conduct program level

evaluations and can use these evaluations to strengthen existing PMTCT services. Technical assistance

will also be provided at the clinic level through the provision of a comprehensive training and capacity

building program, and an onsite, mentorship and support program.

FY 2008 Specific activities include:

ACTIVITY 1: Expansion of Demonstration Project

This activity will be expanded in the Eastern Cape to all peripheral clinics associated with Motherwell

Community Health Centre. UKZN will use PEPFAR funds to support the Department of Health in the EC in

its effort to improve the follow-up and continuum of care of women (HIV-infected and uninfected) and

children in the PMTCT program. To this end, UKZN will foster a partnership between Health and Social

Services in the EC. This project is a holistic PMTCT program that focuses on enrolling women into PMTCT

services, PMTCT service delivery, and linking women and their infants to social welfare programs,

treatment, care and support. An assessment of current systems of the provision of social services in these

communities will assist identification and networking of relevant stakeholders in the Departments of Health,

Home Affairs and Social Development. We will develop a strategy of facilitating rapid access to identity

documents and social grants for HIV infected women and children in consultation with the relevant role

players.

ACTIVITY 2: Support and Technical Assistance to KwaZulu-Natal

The premise behind this activity is to improve knowledge of health workers to ensure successful

implementation of a comprehensive HIV and AIDS plan at the primary health care facilities and to increase

awareness among patients regarding the availability of HIV and AIDS related health services at the facility

level. Technical assistance will ensure the facilitation of linkages between family planning, PMTCT, and

treatment. The focus of this activity includes the development of an integrated training strategy which

address operational and implementation issues for the delivery of a comprehensive package of care for

Activity Narrative: women and children affected by the HIV and AIDS pandemic. Technical assistance also target teams off

service providers from each of the facilities and their associated ART sites to establish and strengthen

referral mechanisms and a multidisciplinary team approach towards ensuring that women and children have

easy access to ARV treatment and continuum of care.

Training will take place at the facility level and will be implemented over three days per month. In addition to

on-site training and mentorship, audiovisual aids to promote education and communication at the health

facilities will also be implemented. These aids include video recordings, pamphlets and posters.

The UKZN PMTCT project aims to increase uptake of CT, PMTCT, improve maternal and infant follow-up,

better ART and medical adherence rates associated with reduction in maternal and child morbidity and

mortality, improve health awareness and service delivery. This project contributes to PEPFAR 2-7-10 goals

by preventing vertical transmission and linking women and infants to treatment programs.

SUMMARY:

The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine (NMSM) uses PEPFAR funds

to work closely with the KwaZulu-Natal (KZN) and Ethekwini Traditional Health Practitioner Councils, to

tease-out, refine and outline culturally appropriate and effective behavior change messages focused on

preventing the spread of HIV through abstinence and being faithful in relationships. The emphasis areas

local and human capacity building. The target population is the general population which includes children,

youth and adults.

BACKGROUND:

UKZN has an ongoing collaboration with associations of traditional health practitioners (THPs) in urban, peri

-urban and rural areas of Ethekwini District, KZN. THPs are influential and are a largely untapped resource

in HIV prevention and mitigation on the community level. THPs ascribe to and uphold traditional African

cultural values, including conservative attitudes toward sexual practices and abstinence that make them

natural partners in this effort. These values are a set of social and community norms that support delaying

sex until marriage and that denounce coerced sexual activity among married and unmarried individuals and

promote mutual monogamy. This THP cultural perspective has not been reinforced, nor has it been included

in public abstinence and being faithful (AB) campaigns in KZN. THP is often the first counselor sought for

married couples who wish to discuss issues related to marital relationships and couples counseling on HIV

and AIDS. Given the position the THPs hold in their social networks, working with the THPs holds great

promise for enhancing the uptake of a culturally appropriate version of the AB message. These activities

began in August 2005 with the arrival of FY 2005 PEPFAR funding. NMSM is implementing the project in

collaboration with the KZN and Ethekwini Traditional Health Practitioner Councils, with the eThekwini Health

Unit, and the eThekwini District Health Office of the KZN Department of Health.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Promotion of AB Messages

It is widely acknowledged among health professionals in KZN that the Abstinence, Be Faithful and correct

and consistent use of Condoms (ABC) messages are not having enough effect in this local cultural context.

This project trains and mobilizes THPs in KZN so that they will be effective promoters of HIV prevention

messages and strategies, including AB-focused behavior change messages. NMSM is adapting

Abstinence/Be Faithful messages to the cultural and healing contexts in KZN to inform and communicate

effective behavior change messages. NMSM is also developing prevention messages together with the

THPs and incorporating these messages into training workshops on an ongoing basis. NNSM is also

developing new prevention message formats for posters, pamphlets, instructional medical comic books, and

medical animations for training and for distribution to the THPs to use with their patients. These messages

are developed in Zulu and English, though they will be distributed primarily in Zulu. This project has also

been developing dramatic presentations that are used in the training workshops to deliver prevention

messages. These have been designed by the senior THPs on the project team and are embedded in Zulu

cultural practice. The prevention messages are developed jointly with the THP team members so that they

are culturally embedded and effective. Discussions with senior traditional healers on the PEPFAR-funded

team indicate they have a variety of interesting, potentially effective suggestions for ways to deliver modified

and improved prevention messages to the community that go beyond the confines of the traditional healer

practice sites. Using FY 2008 funding the following activities will take place:

(1) NMSM will call ongoing assessment workshops (usually one day) with the THPs to discuss the program

and assess the effectiveness of the prevention messages and materials for use in their practice.

(2) NMSM will continually assess the level of absorption and understanding (among the THPs) of the basic

scientific information underlying the rationale of the need for prevention activities, particularly in the value of

abstinence in preventing infection.

(3) The School will continually investigate and assess the value of partner reduction and faithfulness to one

partner, and the effectiveness of faithfulness if the other partner is not also being faithful (particularly

relevant in marriage situations).

(4) NMSM will facilitate meeting with indunas and amakhosi: these are headman and chiefs of the tribal

areas. Traditional healers meet with these leaders who command some authority in their communities, and

work together to speak to their constituents about prevention. Target communities include townships and

urban areas.

(5) The project will engaging parents. Modern mothers have often lost the knowledge of the traditional ways

of protecting their daughters and helping them to be abstinent. Traditional healers trained during this

program visit women's clubs and work with mothers to reintroduce these practices.

Formally integrating traditional healers into the public healthcare system is a stated objective of the National

Department of Health and the prevention objectives in the South African Strategic Plan for HIV and AIDS.

By expanding access to culturally and scientifically appropriate prevention messages, the Nelson Mandela

School of Medicine will directly contribute to the PEPFAR goal of preventing seven million new infections.

These activities also support the prevention objectives outlined in the USG Five-Year Strategy for South

Africa.

SUMMARY:

The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine (NMSM) is using PEPFAR

funds to support the development and implementation of innovative prevention messages specifically

adapted to the cultural practices of traditional healers (izangoma and izinyanga) in KwaZulu-Natal (KZN).

The major emphasis area for this program is information, education and communication, with minor

emphasis placed on community mobilization and participation, human resources, policy and guidelines,

quality assurance and supportive supervision, and strategic information. The target population includes

traditional health practitioners (THPs) in the private and public sector who are members of the KwaZulu-

Natal KZN and Ethekwini Traditional Health Practitioner Councils, and THPs in Ilembe and Umgungundlovu

Districts (to the North and West of eThekwini respectively) who are also members of the KZN THP Council.

BACKGROUND:

The University of KwaZulu-Natal (UKZN) has an ongoing collaboration with associations of traditional

healers in Ethekwini District, and the larger KwaZulu-Natal (KZN) province. Traditional Healers are

extremely influential in KwaZulu-Natal, and are a resource in HIV and AIDS prevention and mitigation at the

community level. They are also generally considered to hold conservative attitudes towards sexual practices

and abstinence that make them natural partners in HIV prevention efforts. This project provides THPs with

the necessary tools and training to act as effective HIV prevention agents. The message of Abstinence, Be

Faithful, and Condoms (ABC) has not been entirely successful in the Zulu cultural context. These issues are

continuously explored with the THPs in this program and UKZN is constantly developing more effective

ways of communicating prevention messages that resonate in the Zulu cultural context. Project training,

prevention message delivery and follow-up with the THPs emphasize a clear understanding of the facts of

viral transmission in sexual practices and the necessity of barrier methods to prevent viral transmission

during sex. THPs work with their patients and the community to change cultural practices (non-sexual) that

can contribute to viral transmission, such as blood-letting, scarification (use of razor blades to make

incisions for rubbing herbs directly into the bloodstream), and skin puncturing using porcupine quills that are

frequently used in an African type of acupuncture. Prevention messages delivered in training courses and

follow-up work with THPs emphasize the biomedical facts of viral transmission and the vital necessity of

safety precautions to prevent viral transmission in these cultural practices. In FY 2005, with the arrival of

PEPFAR funding, NMSM trained 224 traditional healers to deliver HIV prevention messages to their clients

and communities. NMSM will implement the project in collaboration with the KZN and Ethekwini Traditional

Healer Councils, with the eThekwini Health Unit, and the eThekwini District Health Office of the KZN

Department of Health.

ACTIVITIES AND EXPECTED RESULTS:

NMSM will build on English and Zulu language prevention messages developed with the traditional healers

by the KZN Provincial Department of Health. This project will also promote the understanding of infectious

disease in the traditional healer culture. Engagement with THPs through this project both in training

workshops and follow-up work have made it clear that the majority of THPs were previously uncertain about

what HIV is, that there is a "virus" that is transmitted, how this virus is transmitted both sexually and through

cultural healing practices, and how to prevent this transmission. Similarly most THPs were unclear about

what the virus does inside the body, how the activity of the virus leads eventually to AIDS, and what steps

could be taken to slow this progression. It was also unclear to most THPs what the relationship was

between HIV transmission and other sexually transmitted infection (STI) transmission, and why it was so

important to treat and clear up other STI pathologies. In KZN, HIV and AIDS are a heterosexual pandemic,

and largely a behavior-driven epidemic. The following activities will be achieved:

ACTIVITY 1: Increasing Uptake of Prevention Messages

NMSM will work to increase uptake of HIV prevention messages from the healers by both genders

(increasing gender equity in HIV and AIDS programs), specifically looking into novel ways to instill behavior

change ideas into their patients through counseling on the need for prevention. In addition, Traditional

Healers have specific practices that include use of scarification to introduce herbs directly into the

bloodstream, and use of porcupine quills to introduce herbs through the skin. Both of these practices are

discussed in prevention training sessions and modification of these practices to ensure there is no blood to

blood transmission of the virus by the razor blades, porcupine quills, or fingers of the THPs is ensured.

ACTIVITY 2: Community Mobilization

THPs will organize Imbizos (community gatherings) with their traditional leaders and or village chiefs in the

community. These gatherings will be used to discuss a number of topics including male norms and

behavior, including domestic violence in the context of the Zulu culture. Community

mobilization/participation will be used to enhance the capacity of traditional healers to deliver prevention

messages as they work with their patients and their families. A small number of medical school faculty,

support staff and traditional healers will receive salaries in order to facilitate this project. Specifically, they

will be responsible for monitoring and evaluation and training.

ACTIVITY 3: Monitoring and Evaluation

Monitoring and evaluation activities will measure the effectiveness of these interventions. Supervision and

monitoring will be achieved through regular site visits. Data from these activities will contribute to the

development of policies and guidelines for working with traditional healers.

ACTIVITY 4. Building Local Organization Capacity

Local organization capacity development will expand the capacity of the School of Medicine, the Ethekwini

and KZN Traditional Health Practitioner Councils. Through regular staff site visits, quality assurance and

supportive supervision, the development and implementation of prevention messages will be carried out.

Expected results of this initiative for FY 2008 include the development of new, innovative prevention

messages in English and Zulu, including messages to change cultural practices (non-sexual) that can

contribute to viral transmission; the development of better understanding of cultural perceptions, leading to

Activity Narrative: better prevention messages;-training of THPs and improving their prevention message delivery capacity as

they work with their patients and the patient families. In addition, increased correct and consistent condom

usage among sexually active community members who are not amenable to abstinence/be faithful

prevention messages; the assessment of the effectiveness of Other Prevention approaches within the Zulu

cultural context in Ethekwini will also be achieved.

By expanding culturally and scientifically appropriate prevention messages to communities that receive

much of their healthcare from traditional healers, the Nelson Mandela School of Medicine will directly

contribute to the realization of PEPFAR's goal of preventing 7 million new infections. These activities will

also support efforts to meet the prevention objectives outlined in the USG Five-Year Strategy for South

Africa.

SUMMARY:

The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine (NMSM) is using PEPFAR

funds to support the implementation and refinement of common clinical guidelines for HIV and AIDS

management by traditional healers, including: the standardization of HIV clinical staging for traditional

healers; collaborative introduction of Patient Record Keeping, Monthly Data Sheets, and Data Transfer to

the Medical School; and provision of basic medical supplies to trained healers. The main emphasis area is

training, with minor emphasis placed on human resources, logistics, policy and guidelines, quality

assurance and supportive supervision, and strategic information. The target population includes Traditional

Health Practitioners (THPs) in the private and public sector who are members of the KwaZulu-Natal (KZN)

and Ethekwini Traditional Health Practitioner Councils.

BACKGROUND:

UKZN has an ongoing collaboration with associations of traditional healers in rural areas of Ethekwini

District. Traditional healers are extremely influential and are a largely untapped resource in HIV and AIDS

prevention and mitigation on the community level. These activities began in August 2005 with the arrival of

FY 2005 PEPFAR funding. NMSM is implementing the project in collaboration with the KZN and Ethekwini

Traditional Healer Councils, with the eThekwini Health Unit, and the eThekwini District Health Office of the

KZN Department of Health.

ACTIVITIES AND EXPECTED RESULTS:

The principal focus of this project will be training and equipping traditional healers to better deal with the HIV

epidemic in KZN.

ACTIVITY 1: Training

Training will be provided through workshops run by the project training team (including senior traditional

healers). Trained THPs will be provided with a customized version of the home-based care medical kit

currently used by the KZN Department of Health (DOH), modified to include the elements of the Adult

Preventive Care Package including, nutritional referral, personal care, counseling, screening for pain and

symptoms, recognition of signs and symptoms of opportunistic infections, worsening condition such as

increased pain or wasting, and knowledge of when to refer to clinical providers. Treatment adherence,

prevention (including prevention with positives) and other holistic care activities as allowed (bathing, wound

care will also be covered. Training includes the refinement and implementation of common clinical

guidelines for HIV and AIDS patient management by traditional healers, including the standardization of HIV

clinical staging, the introduction of patient record keeping, monthly data sheets, and transfer of these data to

the Medical School.

ACTIVITY 2: Referrals:

NMSM is working closely with South African Government colleagues to establish viable bi-directional

referral pathways (including referral forms); formalizing and enhancing what is currently happening. This

process has involved consultation with municipal and district health authorities on the following:

1) the clinics that are near to the THPs and to which the THPs can send referrals;

2) the sharing with the government of the database of THPs registered with the project; this database

provides (in addition to other information) details on the location of each THP practice site, their contact

details, and the clinics to which these THPs are currently referring patients (informally);

3) a commitment by the government to include notification of referrals received by THPs in their Health

Information System; and

4) formalization of a referral form, already reviewed and approved by municipal and district Health, for THPs

to use in sending patients to clinics. Since current legislation does not permit public health officials to refer

patients to THPs formally, the referral form has a simple tear off sheet to give to the patients to take back to

THPs, simply acknowledging whether the patient was attended to at the health facility, and by whom.

ACTIVITY 3: Monitoring and Evaluation-patient record system

NMSM will also ensure that traditional healers have adequate stocks of appropriate medical supplies,

through collaboration with the provincial Department of Health. Regular site visits will be conducted to

monitor the implementation of these guidelines and data management protocols. THPs are visited regularly

by a team of 12 project data monitors to collect anonymous copies of patient record data for entry into the

project database. NMSM has determined that the optimum method is to use carbonized patient record

forms, patient follow up forms (both in book form) and referral forms (in tear-off pads) and provide patient

cards to the THPs. Each patient card is linked to a unique patient record identifier number, pre-printed on

the first-visit patient record forms. THPs must enter the patient record number on the patient follow-up forms

and patient card. The patient takes the card with them and brings it back to facilitate the THP's use of the

patient record system. The referral forms include a tear off sheet for use by the clinic, that the patient is

expected to bring back to the THP.

ACTIVITY 4: Medical Kit Supply

Initial medical kits are supplied to the THPs registered with the project using project funds and logistics.

These kits are a modification of the type of home-based care kits used by the Municipality and Province,

and contain additional items specific to the THP needs. The re-supply in eThekwini District is being provided

the District Health approved National Integrated Program (NIP) sites, and other NGO sites approved by

District Health. These sites are normally used by DOH to re-supply the DOH Home-based Care (HBC)

workers, and therefore are equipped with stock control staff and keep a registry of HBC workers using the

material. DOH has agreed to add the THPs on the project to this system, and is exploring with the project

the variable amounts of re-supply needed by different THPs (some are much busier than others), and the

specific needs of THPs that may vary from those of HBC workers.

ACTIVITY 5. Clinical Management Follow-Up

Activity Narrative: In the refresher training sessions and workshops with THPs already on the project, NMSM concentrates on

ensuring that fundamental facts about HIV, patient management, and referral criteria are clearly understood.

Discussions between traditional health and biomedical practitioners in these sessions focus on optimizing

patient management.

Expected Results:

1. Refine and implement Standardized Clinical Guidelines for HIV and AIDS management for traditional

healers.

2. Develop Standardized Therapeutic Protocol for HIV and AIDS patient management by traditional healers.

3. Improve collaboration and referral between biomedical and traditional healers.

4. Improve record keeping by traditional healers and availability of the anonymous data to public health

authorities.

5. Provide adequate basic care package to trained traditional healers.

6. Assess the usefulness of working with traditional healers to enhance their capacity to provide palliative

care to HIV-infected patients.

7. Human resources: Through this activity, traditional healers will be trained, equipped, with basic medical

supplies and enhanced clinical care knowledge. A small number of medical school staff, traditional healer

representatives, and support staff receive salaries from the project for administration, training, THP support

and monitoring and evaluation.

Logistics: Includes managing the medical kit supply and re-supply, with the trained traditional healers and

government colleagues. This overlaps with commodity procurement since NRMSM funds will purchase the

initial medical kits. Through regular site visits quality assurance and supportive supervision will be

conducted on the use of adapted clinical guidelines and HIV staging, medical kits and record keeping

systems.

Through training, monitoring and evaluation, medical supply and referral system implementation in

partnership with local government, policy and guidelines for working with traditional healers will be

developed.

By providing new tools and materials to traditional healers working with HIV and AIDS patients, this project

will expand basic care and support services in KZN, contributing to the PEPFAR goal of providing care and

services to ten million HIV-affected individuals. These activities will also support efforts to meet the care and

treatment objectives outlined in the USG Five-Year Strategy for South Africa.

SUMMARY:

The Nelson Mandela School of Medicine will introduce additional training modules to explore developmental

disability prevalence and interventions for orphans and vulnerable children (OVC) seeing Traditional Health

Practitioners (THPs), either directly as patients or as family members of patients. The primary emphasis

area will be training, with minor emphases in information, education and communication and needs

assessment. The target populations are OVC, their caregivers and traditional healers.

BACKGROUND:

It is estimated that 6 to 11 percent of South African children under 15 years of age are orphaned due to loss

of one or both parents due to HIV and AIDS. These children are particularly vulnerable to neglect within

households, marginalization within communities, and are less likely to receive adequate, education, growth

and nutrition, regular healthcare and social services. Many of these children may be infected with HIV

themselves. This emphasizes the need to address the bio-psychosocial problems facing this group of

children in addition to access to antiretroviral drugs. Traditional healers may facilitate preventive care in

these households and children.

ACTIVITIES AND EXPECTED RESULTS:

This traditional healer and the biomedical collaboration will facilitate the following specific activities:

ACTIVITY 1: VCT

Provide support for voluntary counseling and testing (VCT) of OVC, families and child caregivers, including

HIV prevention and treatment education.

ACTIVITY 2: Psychosocial Support

Provide psychosocial support to OVC, their caregivers and families by introducing coping strategies, mental

health assistance, counseling and referral for problems that can be dealt with on the biomedical side.

ACTIVITY 3: Training

Activities 1 and 2 will be included in one-day training modules for THPs (entire FY 2006 cohort) on a ten-

question screen for pediatric developmental disabilities as well as for HIV that lay counselors can also use.

This will be introduced and adapted to THP practice. OVC are especially at risk for developmental

disabilities, delayed school entry, etc. Field evaluation will follow to validate negative or positive screens of

OVC. Workers from the Department of Community Health at the Nelson Mandela School of Medicine

(NMSM) will apply an inter-rater reliability test for sample THP groups.

ACITIVITY 4: Stigma and Discrimination

A pilot workshop will be held with smaller group of THPs from FY 2006 cohort to explore assistance and

biomedical-traditional healing collaboration on managing stigma and discrimination problems for OVC.

Advise will be provided on treatment availability and confidentiality. In addition, the NMSM will explore joint

strategies with THPs on disclosure of child's status and daily drug regimens.

ACTIVITY 5: HBC

Integrating child health and wellbeing into home-based care (HBC) for the sick will be done in collaboration

with current HBC training modules. THPs visiting patients and patient families can do rapid checks on kids

when visiting homes or dealing with parents and determine if OVC are receiving government grants. This

will be added to the monitoring and evaluation practices.

ACTIVITY 6: Public Sector Services

NMSM will work to improve utilization of public sector services - such as social welfare and health, including

facilitating access to antiretrovirals. They will ensure that all THPs in the program are fully aware of social

security grants available and special facilities for kids, people in communities who receive special training to

engage children in early education activities, before pre-school. The same is true for care dependency

grants, foster care grants, disability grants. This training and collaboration will form part of training sessions

discussed in item 3 above. THPs could help direct children and their caregivers to social workers at

community level instead of patients only meeting a social worker at the tertiary level and having to be

referred back to the community level social worker (a common situation currently). NMSM will conduct

training and interact with THPs to include discussion of advocacy on behalf of children on issues of

guardianship, school attendance, and legal issues.

ACITIVITY 7: M&E

NMSM will carry out follow-up sessions with THPs on these issues during the course of the year to explore

implementation successes and failures and needs for modification of training.

The following parameters will be monitored to measure the impact of traditional healer involvement in

improving the health and wellbeing of OVC:

1. Numbers of OVC and households in the care of traditional healers;

2. Description of the psychosocial context and needs of OVC and their extended families;

3. Changes in utilization public sector services;

4. Changes in school attendance;

5. Access to social and welfare grants;

6. Access to preventative and curative healthcare services, including antiretrovirals, immunization, growth

and nutrition monitoring.

Activity Narrative: This project contributes to the PEPFAR goal of providing care to 10 million people, including OVC by caring

for OVC and their primary caregivers. It also contributes to the USG Five-Year Strategy by providing care

for OVC through local communities and improving their capacity to deliver quality care for OVC in their

communities.

SUMMARY:

The University of KwaZulu-Natal (UKZN) Nelson Mandela School of Medicine (NMSM) is using PEPFAR

funds to support the implementation and refinement of common clinical guidelines for HIV and AIDS

management by traditional healers. Specific activities include (1) the standardization of HIV clinical staging

for traditional healers; (2) collaborative introduction of patient record keeping, monthly data sheets and data

transfer to the Medical School; and (3) provision of basic medical supplies to trained healers. The main

emphasis area is first in training, with minor emphasis placed on human resources, logistics, policy and

guidelines, quality assurance and supportive supervision, and strategic information. The target population

includes Traditional Health Practitioners (THPs) in the private and public sector who are members of the

KwaZulu-Natal (KZN) and Ethekwini Traditional Health Practitioner Councils.

BACKGROUND:

UKZN has an ongoing collaboration with associations of traditional healers in rural areas of Ethekwini

District. Traditional healers are extremely influential and are a largely untapped resource in HIV prevention

and mitigation on the community level. These activities began in August 2005 with the arrival of FY 2005

PEPFAR funding. NMSM is implementing the project in collaboration with the KZN and Ethekwini

Traditional Healer Councils, with the eThekwini Health Unit, and the eThekwini District Health Office of the

KZN Department of Health.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Training

Training will be provided through workshops run by the project training team (including senior traditional

healers). The training includes sections on pre-pre-test counseling and post-post-test counseling, as the

THPs work with patients whom they themselves refer for CT, and with many who consult THPs after

receiving CT test results, seeking advice and counsel.

THPs on the project work both with HIV-infected patients who do not yet qualify for ART (CD4 count is too

high), or patients who are already on ART, or on the waiting list for ART. Clinicians on the project and senior

THPs who are part of the training team work with THPs in the project to ensure optimum management of

these patients, and timely referrals and follow-up.

ACTIVITY 2: Referrals

NMSM is works closely with South African government colleagues to establish viable bi-directional referral

pathways (including referral forms); and to formalize and enhance current events. This referral system

includes referral for CT services. NMSM is working with the government to ensure that these referrals are

captured in the Health Information System. Although public health staff are not currently permitted under the

law to refer patients to THPs, the NMSM has developed a referral form in collaboration with the THPs and

the government. This form permits the clinics to acknowledge receipt of the referred patient and to note

whether the patient was assisted at the public health facility, and by whom. Patients can, and frequently do

return to THPs.

ACTIVITY 3: Monitoring and Evaluation

A team of data monitors visit the THPs on an ongoing basis to collect patient record system data. This data

includes information on whether patients have been referred for CT, whether patients have come to THPs

with test results, whether the patients qualify for ART, whether they are on ART, and how the THP manages

all of these patients. This data is entered into the project database. The project is also working on a process

with local government to assure that referrals captured into the Health Information System will be

communicated to the project team and captured in the project database. This will assist in determining the

success of referrals for CT and ART.

Explanation of Training Activities

C&T 08 Explanation of Training Activities

1) Who is the target audience for the training?

The target audience for the training is the traditional health practitioners (THPs) enrolled in the project.

2) How will the training be used (e.g., trainees will become trainers, implement activities, supervise, etc.)?

Primarily the training is used by the trainees to enhance their work with their patients. The objective is to

provide THPs with the requisite skills to counsel their patients on the advisability of getting tested for HIV,

when appropriate, and to counsel those patients who have received HIV tests, whether positive or negative.

3) What topics are covered?

The training is part of the larger training program run by the project, which includes detailed understanding

of what HIV is, where it came from, how it is transmitted from person to person (through all possible routes),

and how to prevent its transmission. In this context, the necessity and advisability of HIV testing is

explained, and the details of the testing procedure and technology are explained to THPs, so that they can

clearly explain it to their patients. For Counseling purposes, the implications of positive and negative tests

are covered. The patient response pattern acronym DABDA (Denial, Anger, Bargaining, Depression,

Acceptance) is discussed and explored. The dangers of pre-existing depression, the necessity of partner

notification, the implications for family income and welfare are explored in the context of the type of patients

and the type of care and counseling given by THPs and expected of them by their patients.

A. The CT training session explains what the normal CT protocol is that patients can expect at CT clinic:

What is CT, Benefits of CT, Stages in Voluntary Testing and Counseling, Rapid HIV Test used in South

Africa, and Educating patients with HIV positive results

B. The ARV training session topics are Introduction, Goals of ART, Classes of ART, Side Effects, TB and

ART, Adherence, Resistance, and AIDS treatment for Children

4) What is the duration of the training?

The specific C&T section forms part of one day during the five day HIV& AIDS training course run by the

Activity Narrative: project. But the related information, including information on ARV management and side effects,

Opportunistic Infections and their management, and other relevant topics are covered during the week.

5) How frequent is the training offered?

The training is currently offered in alternate months.

6) Who is conducting the training?

The training team consists of the Project Coordinator and Co-PI who coordinates the training and

specifically teaches the section on Origins, What is a Virus, how is it transmitted, and how does it cause

disease.

The Clinical Coordinator and head of the Dept. of Family Medicine, teaches on clinical management of HIV

infected patients (Opportunistic Infections).

The Senior Nurse, who also has over 3 decades of experience in nursing and provides many practical

examples of the advantages of prevention and culturally successful ways to deliver the message. This

nurse, a native Zulu speaker, also provides translation for the Project Coordinator and the Clinical

Coordinator.

Three Traditional Healers, who have years of experience in HIV & AIDS education.

A Masters-level public health specialist who assists with translation and cultural understanding.

Additional senior leaders from the traditional healer project team members ("sub-district coordinators") who

assist in ensuring that their fellow healers understand the training content..

7) Is the training curriculum accredited by the South African Qualifications Authority (SAQA)? No

8) How do you assess training quality assurance? Pre- and post-workshop assessment questionnaires at

refresher trainings.