PEPFAR's annual planning process is done either at the country (COP) or regional level (ROP).
PEPFAR's programs are implemented through implementing partners who apply for funding based on PEPFAR's published Requests for Applications.
Since 2010, PEPFAR COPs have grouped implementing partners according to an organizational type. We have retroactively applied these classifications to earlier years in the database as well.
Also called "Strategic Areas", these are general areas of HIV programming. Each program area has several corresponding budget codes.
Specific areas of HIV programming. Budget Codes are the lowest level of spending data available.
Expenditure Program Areas track general areas of PEPFAR expenditure.
Expenditure Sub-Program Areas track more specific PEPFAR expenditures.
Object classes provide highly specific ways that implementing partners are spending PEPFAR funds on programming.
Cross-cutting attributions are areas of PEPFAR programming that contribute across several program areas. They contain limited indicative information related to aspects such as human resources, health infrastructure, or key populations programming. However, they represent only a small proportion of the total funds that PEPFAR allocates through the COP process. Additionally, they have changed significantly over the years. As such, analysis and interpretation of these data should be approached carefully. Learn more
Beneficiary Expenditure data identify how PEPFAR programming is targeted at reaching different populations.
Sub-Beneficiary Expenditure data highlight more specific populations targeted for HIV prevention and treatment interventions.
PEPFAR sets targets using the Monitoring, Evaluation, and Reporting (MER) System - documentation for which can be found on PEPFAR's website at https://www.pepfar.gov/reports/guidance/. As with most data on this website, the targets here have been extracted from the COP documents. Targets are for the fiscal year following each COP year, such that selecting 2016 will access targets for FY2017. This feature is currently experimental and should be used for exploratory purposes only at present.
Years of mechanism: 2008 2009
SUMMARY:
Prevention of mother-to-child transmission (PMTCT) activities support the comprehensive antiretroviral
treatment (ART) program carried out by Catholic Relief Services (CRS) in 24 field sites in 7 provinces in
South Africa. The area of emphasis is the improvement of care and support to HIV-infected pregnant
women in the program, ensuring the wellness of both mother and infant. The field sites target those in need
of these services, who live in the catchment area of the site, and who cannot access the services in the
public sector. The major emphasis area is to provide linkages with other sectors and initiatives, ensuring
that pregnant women receive the much-needed care in line with national guidelines. These will include dual
therapy for pregnant women with a CD4 above 200, fast tracking and provision of highly active antiretroviral
therapy (HAART) for eligible pregnant women, testing of infants and other HIV-exposed children. All high-
risk HIV-exposed children and their mothers in HIV care and support should be provided with related
services for wellness, opportunistic infection (OI) and TB treatment and prevention and nutritional
supplementation. Minor emphasis areas are partner involvement, nutritional counseling, community
mobilization/participation, development of networks/linkages/referral systems, and human resources. The
main target populations are HIV-infected pregnant women, HIV-exposed children and their families as well
as caregivers.
BACKGROUND:
AIDSRelief (the Consortium led by CRS) received Track 1 funding in FY 2004 to scale up ART rapidly in
nine countries, including South Africa. Since FY 2005, South Africa COP funding was received to
supplement central funding, with continued funding applied for under COP 2009. The activity is
implemented through two major in-country partners: the Southern African Catholic Bishops' Conference
(SACBC) and the Institute for Youth Development South Africa (IYD-SA).
Currently, two thirds of patients in the program are women, most of them of childbearing age. Many of the
rural areas AIDSRelief serves are resource poor and antenatal care and PMTCT services are scarce due to
the remote and rural nature of these locations. AIDSRelief is trying to address this by identifying pregnant
women and HIV-exposed children while providing home-based care, as well as putting increased focus on
family-centered voluntary counseling and testing. In addition, AIDSRelief will involve all cadres of health-
care workers at selected sites to identify pregnant women and HIV-exposed children's needs. Where the
AIDSRelief sites cannot provide the services, a functional referral system will be put into place.
ACTIVITIES AND EXPECTED RESULTS:
With funding provided in FY 2009, AIDSRelief will continue implementing activities in support of the South
African National PMTCT program. Utilizing technical assistance from AIDSRelief's staff and South African
experts, support and guidance will be provided to sites in the form of appropriate medical training courses,
patient tracking and reporting, monitoring and evaluation mechanisms and other necessary support.
Although the majority of the AIDSRelief sites cannot provide a comprehensive antenatal, intrapartum and
baby wellness care packages, the sites will focus on strengthening and establishing clear mechanisms of
tracking and follow-up of mother and HIV-exposed children, and by providing support services where
needed. The AIDSRelief sites will provide the following services where needed: routine offer of counseling
and testing to women, their partners and their HIV-exposed children, support to enable mothers to safely
disclose their HIV status, provision of dual therapy or highly active antiretroviral therapy (HAART) to
pregnant mothers in line with the South African National PMTCT program in cases where the patient does
not have access to ARV prophylaxis, provision of essential care for pregnant women in care with an
emphasis on OI prevention and treatment, maternal and pediatric cotrimoxazole and provision of nutritional
supplements according to South African guidelines (and PEPFAR guidance), provision of essential care for
all HIV-exposed children and infant feeding and nutritional support by supporting and informing mothers to
make and adhere to safe feeding choices. Another emphasis will be on involving partners with PMTCT
activities and establishing support groups for pregnant women and mothers.
Home-based caregivers are recruited through parish networks, and are deployed in the areas they live in,
with the intention that they should serve patients who live within the walking distance of their homes. All
provincial health departments pay stipends to their caregivers. Home-based caregivers within the CRS
network tend to pay their caregivers the same stipend that the Department of Health (DOH) pays theirs, as
the training that they undergo is the same, as well as the workload. Stipends paid to caregivers vary from
one site to another according to the differences in stipends paid by different provinces. Caregivers are also
reimbursed for transport expenses.
Some of the AIDSRelief sites also receive PEPFAR and other funding through different sources for the
provision of orphans and vulnerable children (OVC) care. The provision of these services gives OVC access
to both care and treatment services provided under the program.
The program will involve partners (through increased partner testing, male support, prevention and
interventions in regards to gender-based violence) with PMTCT activities, including support groups for HIV-
infected pregnant women and mothers. Other activities, where applicable, will include programs targeting
partners of pregnant women and providing information to men on PMTCT, counseling and testing,
prevention and other health issues, and encouraging couple counseling and testing in an attempt to
increase men's involvement in HIV and AIDS treatment and care programs and to reduce stigma and
violence against women. The approaches will include couple counseling and testing at CT and PMTCT sites
with the view of promoting testing of men as well as building their support for their female partners, where
possible. Efforts will be made to include health worker trainings to recognize signs of gender-based
violence, to provide appropriate counseling and referral services to social, legal, and community-based
support groups, as well as training and employment of women as health-care providers to increase the
confidentiality and comfort of women and girls seeking treatment for HIV.
Activity Narrative: On the staffing front, AIDSRelief is making a conscious effort towards staff retention, through skills
development and strengthening, retreats and debriefing sessions for the staff at the site level where burnout
and compassion fatigue support groups are facilitated. In addition, staff remuneration is monitored and, to
the extent possible within the faith-based environment, reasonable packages are offered. All activities will
be implemented in close collaboration with the South African government's (SAG) HIV and AIDS directorate
and the respective provincial authorities to ensure coordination and information sharing, thus directly
contributing to the success of the SAG's PMTCT program and the goals of PEPFAR. These activities are
also aimed at successful integration of AIDSRelief activities into those implemented by the SAG, thus
ensuring long-term sustainability. This activity will directly contribute towards the goals of reaching 80% of
HIV-infected pregnant women with prophylaxis and reducing new infant infections by 50%. This support will
be in line with OGAC and SAG guidance and standards on PMTCT.
New/Continuing Activity: New Activity
Continuing Activity:
Emphasis Areas
Human Capacity Development
Estimated amount of funding that is planned for Human Capacity Development $690,000
Public Health Evaluation
Food and Nutrition: Policy, Tools, and Service Delivery
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $115,000
and Service Delivery
Food and Nutrition: Commodities
Estimated amount of funding that is planned for Food and Nutrition: Commodities $175,000
Economic Strengthening
Education
Water
Table 3.3.01:
ACTIVITY HAS BEEN MODIFIED IN THE FOLLOWING WAYS:
Provision of cotrimoxazole prophylaxis has been implemented at a large majority of the AIDSRelief (the
Consortium led by Catholic Relief Services (CRS)) treatment sites; however, difficulties are being faced with
the reporting aspect. The AIDSRelief monitoring and evaluation (M&E) team is providing assistance to the
sites to improve reporting on this particular aspect of the program. During FY 2008, two AIDSRelief sites
have handed over their patients to the South African Government (SAG) due to strong presence of SAG-
sponsored treatment programs - at Sinosizo (Durban suburb) in KwaZulu-Natal province, as well as in
Bethal in Mpumalanga province. Access has greatly improved from the SAG sites and the sites were able to
transfer patients out in order to avoid duplication of services. At the same time, new sites have been opened
in Kokstad (KwaZulu-Natal province) and Parys in Free State, leaving the total number of treatment sites
unchanged.
In FY 2009, there will be renewed emphasis on patients in the wellness phase (patients in care who do not
qualify for antiretroviral therapy (ART) yet), tracking patients in care, using community health care workers
to identify household dependants, renewed emphasis on family-centered care and involvement of men, and
increased screening conducted in community by home-based carers entering homes.
Proposed human capacity development activities include ongoing training: to equip staff to support the
patient from the time of HIV diagnosis, throughout the continuum of HIV infection with renewed emphasis of
follow-up of the wellness phase, and providing HIV related care (such as TB, prophylaxis, nutritional support
etc.). Training of data capturers, nurses and managers on M&E indicators and electronic database is
planned to assist with M&E activities with the view of increasing effective care and retention.
All adults in care and support (regardless of whether on ART) with BMI below 18.5 qualify for food support
according to USG guidelines. As such, activities will include identifying the needy patients and provision of
nutritional supplements to qualifying patients according to USG guidelines. Food support may be provided
in either the facility or community-based settings for nutritional rehabilitation of severely and moderately
malnourished PLHIV.
The National Strategic Plan (NSP) target is to provide an appropriate package of treatment, care and
support services to 80% of people living with HIV and their families by 2011 in order to reduce morbidity and
mortality as well as other impacts of HIV and AIDS. In order to meet this target, the AIDSRelief sites will pay
attention to the following key issues: focusing on specific issues and groups: the prevention of mother-to-
child transmission, the care of children and HIV-infected pregnant women, and wellness management of
people before they become eligible for ART.
Activities and approaches to address gender issues will include involvement of men in the program as
decision-makers, family-centered care, couple counseling and testing link with OVC programs - Identifying
female/child headed households in need of care and support. The program will involve partners (through
increased partner testing, male support, prevention and interventions in regards to gender-based violence),
including support groups for HIV-infected patients. Other activities, where applicable, will include programs
targeting partners of pregnant women and providing information to men on prevention of mother-to-child
transmission (PMTCT), counseling and testing (CT), prevention and other health issues and encouraging
couples counseling and testing in an attempt to increase men's involvement in HIV and AIDS treatment and
care programs and to reduce stigma and violence against women. The approaches will include couple
counseling and testing at CT and PMTCT sites with the view of promoting testing of men as well as building
their support for their female partners, where possible. Efforts will be made to include health worker
trainings to recognize signs of gender-based violence, to provide appropriate counseling and referral
services to social, legal, and community-based support groups, as well as training and employment of
women as health care providers to increase the confidentiality and comfort of women and girls seeking
treatment for HIV.
------------------------
Activities support the provision of palliative care under the comprehensive antiretroviral treatment (ART)
program carried out by Catholic Relief Services (CRS) in 25 field sites in 8 provinces in South Africa. The
area of emphasis is the improvement of quality of life to people living with AIDS who are not yet on
antiretroviral treatment (ART), ensuring their wellness to delay the necessity of commencing the ART for as
long as possible, ensuring optimal health for persons on ART, and ameliorating pain and discomfort for
those in the terminal stages of the disease. The field sites target those in need of these services, who live in
the catchment area of the site, and who lack the financial means to access services elsewhere. The major
emphasis area is linkages with other sectors and initiatives. Minor emphasis areas are community
mobilization/participation, development of referral systems, and human resources. The main target
populations are HIV-infected individuals and their families as well as caregivers.
AIDSRelief (the Consortium led by CRS) received Track 1 funding in FY 2004 to rapidly scale up ART in
nine countries, including South Africa. In FY 2005, FY 2006 and FY 2007, South Africa COP funding was
received to supplement central funding, with continued funding applied for under COP 2008. The activity is
implemented through two major in-country partners, Southern African Catholic Bishops' Conference
All sites operate under the terms of a Memorandum of Understanding (MOU) with the provincial Department
of Health (DOH) in which they operate, observing the national and provincial treatment protocols. There is a
concerted effort at each site to ensure coordination with the South African Government (SAG) and
sustainability by either having the SAG provide antiretroviral drugs, or by referring stable patients in to the
SAG treatment plan. Progress made in this regard is discussed below under activities and expected results.
Activity Narrative: Contrary to initial expectations, the most difficult issue has been ensuring that men access HIV care and
treatment services. Currently, only a third of patients on ART in the program are men. Many of the
challenges faced in the implementation are rooted in social and cultural backgrounds of the South African
male population, which AIDSRelief is trying to address by involving men while doing home-based care, as
well as putting increased focus on family-centered CT. In addition, AIDSRelief will involve dieticians at
selected sites to identify nutritional deficiencies and problems with patients, in order to assist with referral
and proper food supplementation where needed.
With funding provided in FY 2008, AIDSRelief will continue implementing activities in support of the South
African national ARV rollout. Of the 25 existing field sites activated in March 2004, two have transferred all
their ART patients into SAG sites, and have ceased providing treatment. Two new field sites have been
activated in FY 2007 to enroll additional ART patients in support of the SAG rollout plan.
Utilizing technical assistance from AIDSRelief staff members and South African experts, ongoing support
and guidance will be provided to sites in the form of appropriate refresher medical training courses, patient
tracking and reporting, monitoring and evaluation mechanisms and other necessary support.
Basic palliative care services including elements of the preventive care package will be provided by the 25
field sites to patients through clinic-based and home-/community-based activities aimed at optimizing quality
of life for HIV-infected clients and their families throughout the continuum of illness, by means of pain and
symptom diagnosis and relief; psychological and spiritual support; clinical monitoring, related laboratory
services, management of opportunistic infections and other HIV and AIDS-related complications (including
pharmaceuticals); integrated prevention services including prevention with positives; and culturally-suitable
and religiously-appropriate end-of-life care. Patients within the CRS home-based care network will be given
cotrimoxazole prophylaxis where necessary. Effort will be made to ensure equitable access to care services
for both males and females.
The home-based carers are recruited through parish networks, and are deployed in the areas they live in,
provincial DOHs pay stipends to their caregivers. Home-based carers within the CRS network tend to pay
their caregivers the same stipend that the DOH pays theirs, as the training that they undergo is the same,
as is the workload. Stipends paid to caregivers vary from one site to another according to the differences in
stipends paid by different provinces. Caregivers are also reimbursed for transport expenses.
AIDS is stigmatized in many South African communities because of the association with death. This is
because of the belief that AIDS inevitably leads to death. As the number of patients on treatment grows,
and as communities see that those on treatment are living normal, healthy lives, stigma is decreasing visibly
and more and more patients are presenting themselves to be tested, either in CT, or if they know that they
are positive, to have their CD4 counts tested and see whether they qualify for treatment. This process has
been accelerated by the way in which patients on treatment at each site are used as community peer
educators and counselors.
All activities will continue to be implemented in close collaboration with the SAG HIV and AIDS directorate
contributing to the success of the SAG's own rollout and the goals of PEPFAR. These activities are also
aimed at successful integration of AIDSRelief activities into those implemented by the SAG, thus ensuring
long-term sustainability.
Holistic palliative care services are provided to all people who come to the field sites irrespective of their
age, gender, nationality, religious or political beliefs. Historically, adults with HIV of both genders (children to
a lesser extent) have been admitted for palliative care services in partner field sites providing such services.
Palliative care services are provided by SACBC and IYD-SA at their respective sites, through the provision
of services aimed at optimizing quality of life for HIV-infected patients and their family members,
psychological support, management of opportunistic infections (where necessary), other HIV and AIDS
related illnesses, and end-of-life care provided either at the clinic level (where available) or through home-
based care mechanism. Field sites managed by SACBC provide a vast range of services, ranging from
basic (home-based care) palliative support, to in-house, facility-based beds and full palliative care services,
depending on the specifics of each site. IYD-SA also provide a different range of palliative care services,
ranging from referral to other SAG clinics in the area, to home-based carers who provide compassionate
and valuable services to palliative care patients. Even though prevention is not a specific program activity of
the overall program, it is promoted through provision of information to patients regarding HIV and prevention
of spreading the virus (prevention with positives). Secondly, skills training is provided to vulnerable
populations, empowering them to make safer choices about their lives. Additionally, AB messages are
shared with the target population, as well as accurate information regarding condoms is provided.
provision of OVC care. The overlapping of these services provides OVC with access to both care and
treatment services provided under the program.
On the staffing front, AIDSRelief is making a conscious effort towards staff retention, through skills
the extent possible within the faith-based environment, reasonable packages are offered. The task shifting
strategy involves shifting certain tasks that medical nurses can do (such as screening the initial patients,
follow-up and monitor stable patients) from medical doctors so that the overall workload is more
manageable. Treatment counselors and community care workers are encouraged to provide pre- and post-
test counseling, adherence training and support and help with basic administrative follow-on work. Other
activities include considerations of community care workers conducting the oral rapid HIV tests, and nurses
Activity Narrative: only doing the confirmation tests if necessary.
FY 2008 COP activities will be expanded to include nutritional supplementation for patients receiving care or
treatment under the program, primarily to support the effective use of antiretroviral drugs for the patients
already on ART, or to assist patients awaiting to be placed on ART by providing them with necessary
nutritional supplements, and increasing their chances of accepting ARV drugs once placed on ART. This
support will be in line with OGAC guidance on therapeutic feeding. In addition, cotrimoxazole prophylaxis
will be given to qualifying HIV-infected persons receiving palliative care within the operational guidelines of
the host country and the donor, with special attention given to exposed or infected children.
This activity will directly contribute towards the 10 million people in care component of the 2-7-10 PEPFAR
goals by increasing the quality and access to care.
New/Continuing Activity: Continuing Activity
Continuing Activity: 13710
Continued Associated Activity Information
Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds
System ID System ID
13710 3832.08 HHS/Health Catholic Relief 6580 2790.08 $4,750,000
Resources Services
Services
Administration
7490 3832.07 HHS/Health Catholic Relief 4438 2790.07 $1,400,000
3832 3832.06 HHS/Health Catholic Relief 2790 2790.06 $1,219,000
Estimated amount of funding that is planned for Human Capacity Development $1,460,000
Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $230,000
Estimated amount of funding that is planned for Food and Nutrition: Commodities $690,000
Table 3.3.08:
Training will be provided to health care providers from various stakeholders (department of health (DOH),
Municipalities, community-based organizations (CBOs)), nurses, doctors, pharmacists /pharmacist
assistants, dieticians where available and data capturers. The outcomes of training are improved service
delivery, role clarification and responsibility, strengthened partnership with stakeholders, increased
enrolment of males, quality assurance, integration of services, as well as better coordination and monitoring
of the HIV and AIDS programs, improved compliance of treatment and reduced HIV and AIDS prevalence.
Quality assurance will be provided through continuous oversight and follow-up by the AIDSRelief agency
members, field trip visits, annual antiretroviral therapy (ART) conference, and on-site support to clinical staff
implementing the program.
Family-centered testing and care approach will be used where possible. Couple counseling and testing (CT)
at CT and prevention of mother-to-child transmission (PMTCT) sites will be used to promote testing of men
and to build their support for their female partners. It is also hoped that, through a community-based testing,
increased outreach will be made to women and children in villages. Where possible, training and
employment of women as health care workers to increase the confidentiality and comfort of women and
girls seeking treatment will be emphasized.
Given that AIDSRelief sites operate in rural and remote areas, where technical capacity and infrastructure is
lacking, heavy emphasis is put on provision of laboratory services through a quality service provider. To
overcome this challenge, a Johannesburg-based Toga Laboratories, another PEPFAR-funded partner, has
been selected as the laboratory service provider for laboratory tests to be conducted under the program.
The company has been established by Prof. Des Martin and Dr. John Sims, long-time South African
virology experts. Toga Laboratories has an ongoing quality assurance (QA) program to monitor and
evaluate, objectively and systematically, the reliability of the laboratory data. There is an in-house laboratory
quality unit which coordinates external quality assurance. For every test performed in the laboratory, there is
a quality control plan stated in standard operating procedures (SOP). Internal quality controls (IQC) are
performed daily on all instruments as well as for manual tests and recorded. External quality assessments
include the UK National External Quality Assessment Scheme (UKNEQAS) as well as National Health
Laboratory Services (NHLS) assessment programs, among others.
--------------------------------
SUMMARY:Activities are implemented to support provision of quality ARV services under the
comprehensive antiretroviral treatment (ART) program carried out by Catholic Relief Services (CRS) in 25
sites in 8 provinces in South Africa. Major emphasis will be on human capacity development and local
organization capacity building. The target population includes people affected by HIV and AIDS as well as
higher risk populations such as migrant workers and refugees.BACKGROUND: AIDSRelief (the Consortium
led by Catholic Relief Services) has received Track 1 funding since FY 2004 to rapidly scale up antiretroviral
therapy (ART) in 9 countries, including South Africa. Since FY 2005, South Africa in-country funding was
received to supplement central funding. The activity is implemented through two major in-country partners,
Southern African Catholic Bishops' Conference (SACBC) and Institute for Youth Development South Africa
(IYD-SA). ACTIVITIES AND EXPECTED RESULTS:With funding provided in FY 2008 AIDSRelief will
continue implementing the activities in support of the South African Government (SAG) national ARV rollout.
In the interest of maximizing available funds the focus will be on strengthening the existing sites providing
services rather than on assessing and activating new sites. Utilizing technical assistance from AIDSRelief
staff members and South African experts, ongoing support and guidance will be provided to sites in form of
appropriate refresher medical training courses, patient tracking and reporting, monitoring and evaluation
mechanisms and other necessary support. ARV services will be provided through the 25 sites to ARV
patients through clinic-based and home-based activities to optimize quality of life for HIV-infected clients
and their families. All the relevant healthcare providers and administrative support staff at the sites will be
trained to implement the ART program, using government-approved training curricula. Staff who have
already received initial training will undergo refresher courses (either in-house or external), coupled with
exchange of training courses and materials between sites with active support from the local training
provider, Kimera training center. Treatment adherence training is provided to all patients who are enrolled
on the ART program.In most sites home-based care networks will follow up and support patients. This
follow-up is conducted through direct visits to patients through the extensive home-based care outreach at
the SACBC sites, while IYD-SA sites follow up through means of telephonic contact in most cases. In case
the patient cannot be reached, a "treatment buddy" is contacted to inquire the whereabouts of the patients
who did not come back for the monthly drug package. Inevitably, some patients become lost-to-follow-up in
spite of all the efforts to locate them, due to migrating populations and illegal immigrants served by the
program. This number currently stands at less than 4% of the patients ever enrolled on the program.Each
site ensures that HIV-infected patients are screened for tuberculosis (TB) prior to placing them on
antiretroviral treatment, and are referred to TB treatment if they tested positive. Screening and testing for TB
is conducted in a number of different ways, and these testing methods are specific to each site. While
screening is conducted by a medical professional at each of the sites, in most cases patients are referred to
the nearby SAG medical facility for TB testing and are only enrolled in antiretroviral treatment once they
have completed two months of TB treatment, or have been found not to have active TB.PEPFAR funding
will also be used to support laboratory services, which are outsourced to a private provider, Toga
Laboratories (a new PEPFAR partner since FY 2007). A courier service collects blood that is drawn at each
site, and delivers these samples to the laboratories. Results are e-mailed or faxed back to the site within 48
hours of the laboratory receiving the blood samples. The program is designed to improve each site's
capacity to implement the national ART program in the long-term, and to strengthen clinical, administrative,
financial and strategic information systems. Sites will be assisted in developing appropriate policies and
protocols and in setting up sound financial and strategic information systems. Each site will also develop a
unique community mobilization plan for the ART program and implement it in collaboration with relevant
community organizations and leaders. Many of the sites are already involved in HIV and AIDS community
mobilization activities and these will be linked to ART services. These lessons learned will be of value to
other partners working in the non-governmental organization (NGO) sector.All activities will continue to be
implemented in close collaboration with the Department of Health HIV and AIDS Unit and the respective
Activity Narrative: provincial authorities to ensure coordination and information sharing, and this will directly contribute to the
success of the SAG's own rollout and the goals of PEPFAR. These activities are also aimed at successful
integration of AIDSRelief activities with those implemented by the South African Government, thus ensuring
long-term sustainability.All sites operate under the terms of a Memorandum of Understanding (MOU) with
the provincial Department of Health in which they operate, observing the national and provincial treatment
protocols. There is a concerted effort at each site to ensure sustainability by having the SAG provide
antiretroviral drugs, or by down referring stable patients into the SAG's primary healthcare clinics after
providing training for the SAG clinic staff. St. Mary's Hospital, which accounts for more than a third of patient
numbers, has already been accredited as a SAG rollout site. Sinosizo receives drugs from the National
Department of Health due to its status as a down referral clinic for Stanger Hospital, and at a further two
sites, Centocow and Bethal, all patients already receive drugs via the SAG rollout. Monthly statistics are
shared with the South African National Department of Health, as well as with relevant provincial health
departments in provinces where AIDSRelief implements the program.There is a concerted effort to include
men and children in the program, and all sites have specific plans to increase enrolment, including couple
counseling and using a family-based approach. Although there is no specific PMTCT program, eligible
pregnant women are provided with triple therapy to ensure maximum viral suppression to prevent the
transmission to the baby. Newborn babies are provided with monotherapy after birth. AIDSRelief sites are
encouraged to provide babies with cotrimoxazole after 4-6 weeks of life, and PCR testing is conducted
when relevant. Mothers are encouraged to use safe feeding practices as appropriate to individual
circumstances. Most sites have clinic-based gardens to assist with nutrition programs, and several sites
provide nutrition supplements, as per South African treatment guidelines. All sites provide ART access to
non-South Africans, including refugees. Some of the AIDSRelief sites also receive PEPFAR and other
funding through different sources for the provision of OVC care. The overlapping of these services provides
OVC with access to both care and treatment services provided under the program.In terms of the
continuous qualitative review of the program, the annual clinical evaluation is done on available patient data
by two South African ART experts, who not only evaluate the data within the program but also compare it to
other large resource-limited programs, such as the program in Khayelitsha. Even though prevention is not a
specific program activity of the overall program, it is promoted through provision of information to patients
regarding HIV and prevention of spreading the virus (prevention for positives). Secondly, skills training is
provided to vulnerable populations, empowering them to make safer choices about their lives. Additionally,
AB messages are shared with the target population, as well as accurate information regarding condoms is
provided.
With supplemental funding in FY08, the following activities will be added:
a) Open and staff a new wellness center in Winterveldt for HIV care and treatment services (satellite center)
b) Provide additional space (parkhome) in Orange Farm for HIV care and treatment services
c) Open a satellite HIV care and treatment program in Pary
d) Implement a new patient data system to accurately collect routine HIV care and treatment data -
including equipment where necessary.
Continuing Activity: 13714
13714 3288.08 HHS/Health Catholic Relief 6580 2790.08 $4,179,000
7487 3288.07 HHS/Health Catholic Relief 4438 2790.07 $3,650,000
3288 3288.06 HHS/Health Catholic Relief 2790 2790.06 $2,209,000
Estimated amount of funding that is planned for Human Capacity Development $775,000
Table 3.3.09:
FY 2008 COP activities will be expanded to include:
-Ensure the provision of a basic care package to HIV-exposed children;
-Identify all HIV-exposed children of adults in HIV care and support; and
-Strengthen health systems serving patients in HIV care and support.
Activities under the Pediatric Care and Support program activity support the provision of comprehensive
antiretroviral treatment (ART) program carried out by Catholic Relief Services (CRS) in 24 field sites in
seven provinces in South Africa. The area of emphasis is the improvement of care and support to HIV-
exposed children in the program, ensuring their wellness. The field sites target those in need of these
services, who live in the catchment area of the site, and who cannot access the services in the public
sector. The major emphasis area is to provide linkages with other sectors and initiatives and ensuring that
children receive the much-needed care in line with national guidelines. These will include; early diagnosis,
cotrimoxazole prophylaxis, antiretroviral treatment and Integrated Management of Childhood Illnesses
(IMCI) related services. All HIV-exposed children in HIV care and support should be provided with related
supplementation. Minor emphasis areas are household member involvement, nutritional counseling,
community mobilization/participation, development of networks/linkages/referral systems, and human
resources. The main target populations are HIV-exposed children and their families as well as caregivers.
nine countries, including South Africa. Since FY 2005 South Africa COP funding was received to
supplement central funding, with continued funding applied for under FY 2009. The activity is implemented
through two major in-country partners, Southern African Catholic Bishops' Conference (SACBC) and the
Institute for Youth Development South Africa (IYD-SA).
Currently, about eight percent of individuals in Care and Support are children. Many of the rural areas
AIDSRelief serves are resource poor and care and services are scarce due to the remote and rural nature
of these locations. AIDSRelief is trying to address this by identifying HIV exposed children while providing
home-based care, as well as putting increased focus on family-cantered VCT. In addition, AIDSRelief will
involve all cadres of healthcare workers at selected sites to identify pregnant women and HIV-exposed
children's needs. Where the AIDSRelief sites cannot provide the services a functional referral system will be
put into place.
AIDSRelief sites will focus on identifying HIV exposed children in the communities they serve. Early
identification, screening and referral will be emphasized. Every community health care worker will identify
vulnerable children in the household they visit. Children will be identified and registered. Parents will be
counseled and motivated to have children tested. PCR testing will be offered from 6 weeks of the infant's life
for the first year. Thereafter rapid testing will be used.
ACTIVITY 1:
The basic care package to HIV-exposed children includes the following activities:
- Ensure children are fully immunized and refer to primary health care (PHC) where needed;
- Early HIV diagnosis (using serum PCR);
- Cotrimoxazole provision to all HIV exposed children from six weeks until they are confirmed HIV-negative;
- Nutritional support to all children born to HIV-infected parents;
- TB screening for all children;
- TB treatment where necessary,
- IPT if active TB has been excluded (where possible);
- Ensure/refer all children in need of birth registration;
- Assist families with social service applications (child grants etc.) where possible; and
- Integrated Management of Childhood Illnesses (IMCI) and Vitamin A supplementation.
ACTIVITY 2:
Identify all HIV-exposed children of adults in HIV care and support:
-Continue to provide early identification and treatment/referral for opportunistic infections (OIs);
-Continue to provide community support (psychosocial and spiritual);
-Renewed emphasis on family-centered approach through; grouping family visits together; encouraging
partner and HIV-exposed children to join women in care and support activities; and encouraging interactive
family sessions.
ACTIVITY 3:
Strengthen health systems serving patients in HIV care and support:
-Strengthen linkages, coordination and referrals to OVC programs, immunization and well-baby clinics;
primary health care (PHC) facilities, TB clinics, STI clinics, local health and social services; and
-Provide training and technical assistance to staff in the health system.
ACTIVITY 4:
Cotrimoxazole and TB prophylaxis will be provided in line with South African government (SAG) policies.
Activity Narrative: The "Road to Health" card will be used to document interventions according to SAG guidelines. The
National Strategic Plan (NSP) target is to provide an appropriate package of treatment, care and support
services to 80% of people living with HIV and their families by 2011 in order to reduce morbidity and
mortality as well as other impacts of HIV and AIDS. In order to meet this target the AIDSRelief sites will pay
attention to the following key issues: Focusing on specific issues and groups: prevention of mother-to-child
transmission, care of children and HIV-infected pregnant women, and wellness management of people
before they become eligible for ART.
ACTIVITY 5:
The program focus on family centered care and will involve parents and caregivers by involving partners
(through increased partner testing, male support, prevention and interventions in regards to gender-based
violence), including support groups for HIV-infected pregnant women and mothers. Other activities, where
applicable, will include programs targeting partners of pregnant women and providing information to men on
PMTCT, counseling and testing (CT), prevention and other health issues and encouraging couples
counseling and testing in an attempt to increase men's involvement in HIV and AIDS treatment and care
programs and to reduce stigma and violence against women. The approaches will include couple
overcome this challenge, Johannesburg-based Toga Laboratories, another PEPFAR-funded partner, has
virology experts. Toga Laboratories has an on-going quality assurance (QA) program to monitor and
Estimated amount of funding that is planned for Human Capacity Development $660,000
Table 3.3.10:
Activities under the pediatric care and support program activity support the provision of comprehensive HIV
prevention, care and treatment program carried out by Catholic Relief Services (CRS) in 24 field sites in 8
provinces in South Africa. The field sites target those in need of these services, who live in the catchment
area of the site, and who cannot access the services in the public sector. The major emphasis area is to
provide linkages with other sectors and initiatives and ensuring that children receive the much-needed care
and treatment in line with national guidelines. All high-risk HIV-exposed children in HIV care and support
should be provided with related services for wellness, opportunistic infection (OI) and TB treatment and
prevention and nutritional supplementation. The main target populations are HIV-exposed and HIV-infected
children and their families as well as caregivers.
nine countries, including South Africa. Since FY 2005, South Africa PEPFAR funding was received to
supplement central funding, with continued funding applied for under the FY 2009 COP. The activity is
Many of the rural areas AIDSRelief serves are resource poor and antenatal care, PMTCT and HIV care and
treatment services are scarce due to the remote and rural nature of these locations. AIDSRelief is trying to
address this by identifying HIV-exposed children while providing home-based care, as well as putting
increased focus on family-centered voluntary counseling and testing (VCT). In addition, AIDSRelief will
involve all cadres of health-care workers at selected sites to identify pregnant women and HIV-exposed
children' needs. Where the AIDSRelief sites cannot provide the services a functional referral system will be
All AIDSRelief sites provide pediatric care and treatment services in line with the South African Government
pediatric ART guidelines, and in some sites receive pediatric drugs directly from the relevant provincial
health department.
ACTIVITY 1: Pediatric Focus
AIDSRelief provides integrated HIV care and treatment services mainly in small, rural non-governmental
organization (NGO) and Church-based settings. This is supplemented by a very strong home-based care
program that provides follow-up care in the home setting. Currently 8% of patients on ART in the AIDSRelief
program are children (with 42% of those under 5). AIDSRelief will put greater emphasis on pediatric
treatment in FY 2009 and increase the pediatric targets to 15% of all patients on treatment. This will be
achieved through forming linkages with PMTCT programs, as this is the entry point into pediatric treatment.
The next challenge is diagnosing children due to difficulties in drawing blood from children, therefore nurses
will be trained or re-trained in this area.
Home-based carers will identify HIV-exposed children and assist families in bringing them to treatment site
for required services, such as cotrimoxazole, opportunistic infection, or ARV treatment. Emphasis will be
placed on community awareness regarding the importance of early diagnosis and treatment of children.
ACTIVITY 2: Community Care
qualify for ART yet), tracking patients in care, using community health care workers to identify household
dependants, renewed emphasis on family-centered care and involvement of men, and increased screening
conducted in community by home-based carers entering homes.
AIDSRelief is supporting community programs involving the local church structures in these rural areas, at
the grassroots level and through active community participation. In doing so, the staffing and infrastructure
challenges are overcome through task shifting by training of community health care workers (by identifying
children in the community in need of care and treatment, cotrimoxazole, TB prophylaxis, vitamin A
supplementation, nutritional support, OVC care and ART, growth monitoring and Integrated Management of
Childhood Illnesses (IMCI) and ART initiation by nurses. This assistance is provided through mentor
programs and training. The lack of infrastructure challenges are overcome by working through the existing
local Church structures and, in special circumstances, provision of limited additional work space through
purchase of parkhomes (movable containers). Additionally, space limitations are overcome through working
directly in the affected communities in order to improve access to services.
ACTIVITY 3: Human Capacity Development
Training will be provided to health care providers from various stakeholders such as the Department of
Health (DOH), municipalities, community-based organizations (CBOs), nurses, doctors,
pharmacists /pharmacist assistants, dieticians where available and data capturers. The outcomes of training
are improved service delivery, role clarification and responsibility, strengthened partnership with
stakeholders, increased pediatric enrolment, quality assurance, integration of services, as well as better
coordination and monitoring of the HIV and AIDS programs, improved compliance of treatment and reduced
HIV prevalence. Quality assurance will be provided through continuous oversight and follow-up by the
AIDSRelief agency members, field trip visits, the annual ART conference, and on-site support to clinical
staff implementing the program.
ACTIVITY 4: Family-Centered Approach
The family-centered testing and care approach will be used where possible. Couple counseling and testing
at counseling and testing (CT) and PMTCT sites will be used to promote testing of men and to build their
support for their female partners. It is also hoped that, through a community-based testing program,
Activity Narrative: employment of women as health care workers to increase the confidentiality and comfort of women and
ACTIVITY 5: Laboratory Support
overcome this challenge, a Johannesburg-based organization, Toga Laboratories, another PEPFAR-funded
partner, has been selected as the laboratory service provider for laboratory tests to be conducted under the
program. The company has been established by Prof. Des Martin and Dr. John Sims, long-time South
African virology experts. Toga Laboratories has an ongoing quality assurance (QA) program to monitor and
ACTIVITY 6: Gender Issues
AIDSRelief will strive to identify child/adolescent-headed households and caregivers, and implementing
targeted programs to meet needs, including programs to keep girls in schools, help them manage
households, address stigma, and compensate for lost of family income.
Some elements of pediatric treatment are also addressed in more details in other linked areas of the COP,
including Pediatric Care and Support, Counseling and Testing, ARV Drugs, and Adult Treatment.
Estimated amount of funding that is planned for Human Capacity Development $642,000
Program Budget Code: 12 - HVTB Care: TB/HIV
Total Planned Funding for Program Budget Code: $37,322,363
Total Planned Funding for Program Budget Code: $0
Program Area Narrative:
South Africa has one of the highest estimated TB rates in the world, ranking fourth among the 22 high burden countries.
According to 2006 National TB Programme (NTP) data, there were more than 341,165 reported cases of TB, at a rate of 628 per
100,000 population. The real prevalence is unknown but the WHO estimates it to be much higher than these statistics.
Of all new and re-treatment cases notified in 2006, only 110,235 or 31% were tested for HIV. Of those, 55% tested positive. Of
the detected HIV-infected TB patients, 98% received cotrimoxazole therapy, and 40% had initiated antiretroviral treatment (ART).
Systematic TB screening among people living with HIV (PLHIV) has been low; 29% of patients screened were infected with TB.
Isoniazid Preventive Therapy (IPT) is not widely implemented.
Multi- and extensively drug-resistant TB (MDR/XDR-TB) continue to create many challenges for the South African government
(SAG). Between 2004 and early 2007, South Africa reported 898 cases of XDR-TB. Due to lack of culture and drug susceptibility
testing (DST) services in Limpopo and Mpumalanga, these provinces did not report any cases during that period. The total
number of reported drug-resistant cases may represent a small proportion of the actual incidence. Reported case fatality rate
among HIV-infected individuals with MDR/XDR-TB is alarmingly high. In 2006, Ghandi et. al. (2006), reported 95% mortality
among HIV-infected patients with XDR-TB in KwaZulu-Natal. The median survival was 16 days from time of diagnosis, and this
was established among 42 patients with confirmed dates of death. (Gandhi, et al.) This has serious public health consequences,
for South Africa and the African region.
NTP results in 2006 show a case detection rate of sputum positive TB cases at 71%. Nevertheless, there has been little progress
in treatment outcomes; cure rate for new smear positive cases is still low at 58% and the overall treatment success rate is 71%,
lower than the African regional rate of 76%. Default rates at 10% are high. High treatment interruption rates of drug-sensitive TB
and consequent low cure rates, together with the HIV epidemic, have contributed to the emergence of drug-resistant strains,
which require urgent attention.
South Africa adopted the WHO DOTS Strategy in 1996, and since 2006, the DOTS Strategy has been expanded to all districts.
Phased implementation of TB/HIV collaborative activities by sub-districts started in 2002. The aim was to focus on the primary
health care level and build capacity among staff to manage co-infected patients and thus prevent unnecessary hospital
admissions and deaths. By end of 2006/7, 211 sub-districts were implementing TB and HIV activities (87%). In 2005, the SAG
declared TB a national crisis and developed the TB Crisis Management Plan focusing on three provinces Gauteng, KwaZulu-
Natal, and Eastern Cape, with four districts having the highest burden of TB and poor treatment outcomes. The SAG intensified
efforts to reinforce service delivery systems and processes at facility levels and to increase community awareness and
engagement in TB control. Since then, two crisis districts have graduated from the crisis level.
In 2007, the National Department of Health (NDOH) created a separate directorate for NTP and finalized a five-year strategic
plan, the South Africa National TB Strategic Plan for, 2007-2011 (NTP), which highlights TB/HIV. Additionally, the South Africa
National Strategic Plan for HIV & AIDS and STI, 2007-2011 (NSP) espouses integration of TB and HIV services as essential to
ensuring that co-infected patients receive appropriate care and treatment. SAG investment in TB control is significant, but due to
decentralized funding channeled through provincial treasuries, NTP is unable to quantify the resources committed to TB control.
Sixty-eight percent of total central level funding for TB is dedicated to MDR-TB.
Although interaction between TB and HIV has been recognized and collaborative efforts are being scaled-up, TB and HIV
programs continue to be implemented separately. As outlined in NTP's strategic document, collaborative activities between NTP
and HIV & AIDS and STI departments has not been fully realized because of lack of written formal guidelines on collaboration,
and limited integration of services at health facilities. This includes inadequate technical support, guidelines, and registers for
monitoring and evaluating integrated TB and HIV services. Other constraints to effective TB/HIV collaboration include: 1) human
resource constraints at district and facility levels and within laboratory services; 2) lack of decentralization of laboratory networks
(services and systems) resulting in decreased access to sputum smear microscopy, delays in reporting results, scarce and
overburdened culture and DST services, and communication challenges between NTP and laboratories; 3) different program
approaches and cultures of TB and HIV services (i.e., TB services are decentralized into primary health-care clinics, are nurse-
driven, and TB control occurs at facility level, which lacks wide-spread community engagement, while HIV and AIDS care services
are usually hospital-based, physician-driven, and have established linkages with communities); 4)threat of nosocomial
transmission of TB and MDR/XDR-TB, with evidence of facility and community transmission in the context of large-scale HIV care
and treatment programs; 5) little attention to appropriate TB infection control measures in healthcare facilities and congregate
settings, although NTP has recently developed TB infection control policy and guidelines; 6) TB/HIV records not fully integrated at
facility level, especially in HIV clinical and care settings as entry-point to TB management; and 7) referral and counter referral
systems between TB and HIV programs are not yet in place. Improved collaboration between TB and HIV programs is required to
ensure access to integrated quality-assured diagnostic, care, and prevention services for PLHIV and those at risk for TB infection
and disease.
USG activities are consistent with NDOH and WHO TB/HIV policies and guidelines and continue to build on past achievements.
PEPFAR will scale-up efforts that improve effective coordination at all levels; decrease burden of TB among PLHIV; decrease
burden of HIV among TB patients; improve prevention, detection, and management of MDR/XDR TB in HIV-infected patients;
strengthen laboratory services and networks; and strengthen health systems to ensure quality and sustainable care.
USG resources and technical assistance complement NDOH efforts in a broad range of TB/HIV activities at organizational and
service delivery levels. At an organizational level, USG supports the strengthening of mechanisms for collaboration at all levels,
and developing and implementing strategies to address TB/HIV, and MDR/XDR TB. PEPFAR will continue to support NDOH's
efforts to improve linkages for joint policy development, planning, implementing, and monitoring TB/HIV integrated activities. Other
activities include improved surveillance of TB/HIV and MDR-TB and enhanced human resource development that respond to
needs posed by integrated TB/HIV programs. Activities at service delivery level include those that streamline continuity of care for
co-infected patients by ensuring effective referral linkages between TB and HIV services as well as between these services and
community and home-based care. To decrease burden of TB in PLHIV, USG-supported activities will include scaling up the three
Is. This includes: a) intensified TB case finding in HIV services (e.g., VCT, PMTCT, and OVC, strengthening referrals to TB
program for diagnosis and treatment, or provide TB treatment in settings where appropriate); b) IPT for clients in whom TB has
been ruled out; and c) infection control (IC). TB IC (aligned with the WHO-10 point plan) will include training, developing policy,
assessing facilities, and purchasing equipment. In addition, nutritional support (e.g., food gardens), health education, and
empowerment programs are supported. To decrease the burden of HIV in TB patients, activities will include scaling-up provider-
initiated HIV counseling and testing in TB clinics, prompt referral to HIV treatment and care services for those dually infected,
cotrimoxazole for co-infected patients and in some instances, initiation of ART within TB clinics, including facilities that provide
MDR treatment.
Activities to prevent, detect, and manage MDR/XDR TB patients build on current efforts outlined in NTP's Strategic Plan and will
feature scaling-up TB IC practices in health care and congregate settings and community-based DOT (CB-DOT) through USG-
supported initiatives, such as home-based care. In addition, systems will be strengthened to improve timely access to quality
assured culture and DST and to improve coordination with provincial health departments to ensure appropriate case management
of all suspected and confirmed MDR/XDR TB patients. Social mobilization efforts that inform and engage communities to reduce
stigma, improve early access to diagnosis and care of TB and HIV, and enhance CB-DOT will also be supported. TB/HIV and
MDR surveillance efforts include enhancement of the electronic TB register (ETR.Net) software that renders measurement of TB
treatment outcomes by HIV status. TB/HIV and MDR data collection tools have been revised, and the new tools should help
encourage widespread TB/HIV and MDR surveillance.
The USG, in collaboration with NDOH and National Health Laboratory Services (NHLS), supports strengthening laboratory
services to ensure effective health systems response to appropriate and timely referral and counter referral. This includes
activities that enhance good practices in sputum collection, improve turn-around-times for test results for sputum smear
microscopy and culture; ensure availability of HIV test kits, and enhance quality assurance programs. New initiatives to improve
information systems to enhance program and clinical management include the design, development, and pilot test of an integrated
electronic TB/HIV Patient Management System. Features of this system are automation of routine TB registers, suspect TB-
Register, pre-ART and ART-registers, electronic interfaces between laboratory and program registers for uploading laboratory
requests and downloading laboratory results, which can also produce reports at facility, districts, provincial and national levels.
The USG supports NHLS by leveraging resources for accelerating implementation of rapid PCR assay that allows for typing of TB
strains in a short time.
Emerging concerns about interaction between TB, HIV, and drug resistance came to the forefront in 2006. Efforts to understand
and control these threats have begun and will be accelerated through 2009. The USG also supports several public health
evaluations to identify improved methods for rapid screening and diagnosis of TB in co-infected patients and to improve referral
networks between HIV and TB services.
With regards to sustainability, the USG works closely with NDOH to enhance collaboration, develop policies and tools, and build
capacity of service providers. The USG will work closely with public and private sector partners to capture best practices and to
ensure that these support policy development. Increased emphasis on strengthening management systems, such as human
capacity development, planning, supportive supervision, monitoring, and evaluation will also help to sustain gains.
The USG TB/HIV program is complemented with non-PEPFAR funds through USAID's Operational Plan (OP) for TB. USAID
provides extensive support to implementing NTP's TB Strategic Plan at all levels. This includes development, implementation. and
scale-up of service delivery models to address challenges from increasing TB/HIV and MDR/XDR TB incidences, as well as
strategies to improve linkages with communities. These efforts are reinforced at community level through implementation of
culturally sensitive social mobilization activities. USAID's OP provides extensive assistance to crisis districts and continues to
support expansion of strong public-private partnerships. USAID is also supporting the development of training materials for
management of TB in children. Mechanisms, such as TB/HIV Task Force, are well established to enhance coordination within and
among the PEPFAR team.
The PEPFAR TB/HIV team continues to liaise with international donors and complement activities with agency-specific non-
PEPFAR funded activities to ensure collaboration. Several international donors support TB/HIV activities, including Belgian
Technical Corporation, UK Department for International Development, Italian Institute of Health, Japanese International
Cooperation Agency, Bill and Melinda Gates Foundation, The Global Fund, and the European Union. Recent information indicates
that there is some donor overlap. In 2008/2009, PEPFAR will increase coordination efforts to reduce duplication of efforts and
resources. Collection and review of up-to-date information on donor supported TB/HIV activities will feed into PEPFAR's efforts to
develop a country-specific TB/HIV strategic plan in collaboration with the NDOH by March 2009. The plan will be driven by the
NTP and NSP, as well as by OGAC and WHO TB/HIV guidelines. A task force, with representation from SAG, USG and
implementing partners, will meet regularly to influence the development of USG's TB/HIV strategic plan. In addition, a two-day
workshop with TB/HIV implementing partners will be held in early 2009 to provide a venue for sharing best practices, discuss
common issues and gaps in TB/HIV, and make recommendations that will feed into the plan. This plan will inform PEPFAR II
planning as a South Africa inter-agency team and will establish networking mechanisms among partners to support sharing of
best practices.
PEPFAR will ensure regular monitoring and supervision of OGAC program indicators, through regular site visits by
multidisciplinary teams (TB and HIV) and development and implementation of a standard checklist for these site visits. These
activities will be enhanced through the South African PEFPAR Partner Assessment Contract in FY 2009. In addition, all Activity
Managers will ensure that all assessment and/or training modules include appropriate components of TB/HIV integration and
management.
TB/HIV programming will be prioritized in FY 2009. Since FY 2006, USG efforts to address TB/HIV services have been expanded.
In FY 2008, over $30 million was invested in TB/HIV, approximately 5% of the PEPFAR budget in South Africa. In keeping with
OGAC guidance to expand TB/HIV programming, close to $31 million is requested in FY 2009 by 34 mostly indigenous, partners.
Table 3.3.12:
Catholic Relief Services (CRS) FY 2008 activities will be continued in FY 2009, with the following
modifications:
There will be increased focus on tracking and screening patients requiring tuberculosis (TB) treatment.
Where TB treatment is not provided at the AIDSRelief facility, referrals to South African Government (SAG)
clinics will be made and conscious efforts to followup on the outcome of TB treatment and subsequent
inclusion on antiretroviral treatment (ART) where necessary. Discussions are currently in place with the
SAG to provide TB drugs for several AIDSRelief sites. At the moment, however, the majority of AIDSRelief
sites are not providing TB treatment. AIDSRelief staff will undertake to screen all patients in the community
and at the facility; if TB symptoms are detected the patients will be tested for TB, and all patients with TB
symptoms and/or new patients will be asked to provide sputum for Acid-Fast Bacilli (AFB) testing and
culture in accordance with South African TB guidelines. Because of the well-known fact that severely
immuno-compromised patients have a high prevalence of sputum-negative TB, AIDSRelief is trying to work
within the SAG guidelines and increasing its efforts for early diagnosis within the home-based care network;
however this still presents a challenge in terms of diagnosing patients requiring ART.
In cases where active TB is diagnosed, patients will receive TB medication at a public facility, with
AIDSRelief staff, in conjunction with the SAG TB clinic, providing directly observed treatment short-course
(DOTS) in the community.
AIDSRelief recognizes the high number of co-infections and high immortality due to TB. Community care
workers will be trained to conduct home-based care screening of basic TB symptoms and refer for testing
where necessary. Professional healthcare workers will be trained to treat and appropriately transfer or refer
patients in need of TB treatment. Activities will include training for nurses, doctors, and counselors with
specific TB diagnosis and treatment issues as a primary focus. The plan includes training for lay and
community healthcare workers to provide TB identification and to encourage early identification of TB
patients in need of ART as part of the provision of holistic health care service, in line with SAG National
Department of Health guidelines. Salaries will include those for lay and community healthcare workers and
a limited number of clinical staff (primarily nurses and doctors) to implement the program activities, as well
as increased focus on INH prophylaxis.
and to build their support for their female partners. It is also hoped that, through a community based testing,
increased outreach will be made to women and children in villages in identifying patients in need of TB
treatment. Where possible, training and employment of women as health care workers to increase the
confidentiality and comfort of women and girls seeking treatment will be emphasized .
The community-based screening and referral has already been piloted at two AIDSRelief sites (Winterveldt
Hope for Life and Orange Farm) in conjunction with CDC, and in FY 2009, AIDSRelief aims to roll out this
innovative approach to several other treatment sites.
overcome this challenge, a Johannesburg-based PEPFAR partner, Toga Laboratories, has been selected
as the laboratory service provider for laboratory tests to be conducted under the program. The company has
been established by Prof. Des Martin and Dr. John Sims, long-time South African virology experts. Toga
Laboratories has an on-going quality assurance program to monitor and evaluate, objectively and
systematically, the reliability of the laboratory data. There is an in-house laboratory quality unit that
coordinates external quality assurance. For every test performed in the laboratory, there is a quality control
plan stated in standard operating procedures. Internal quality controls are performed daily on all instruments
as well as for manual tests and recorded. External quality assessments include the UK National External
Quality Assessment Scheme as well as National Health Laboratory Services assessment programs, among
others.
Isoniazid (INH) prophylaxis for TB will be provided to HIV-positive adults with latent TB according to SA
Government guidelines, as well as to children exposed to the disease where possible.
In cooperation with Dr. Norbert Ndjeka of an AIDSRelief treatment site at Bela Bela (Limpopo Province) and
advisor to the National Department of Health (NDOH) on multiple drug-resistant TB AIDSRelief sites will be
assisted to draw up their infection control plans in line with NDoH guidelines to minimize the spread of TB in
healthcare settings and curb mortality due to TB-HIV coinfection.
-----------------------------------
Activities are implemented to support provision of TB diagnosis under the comprehensive antiretroviral
treatment (ART) program carried out by Catholic Relief Services (CRS) in 25 field sites in 8 provinces in
South Africa. The focus of the activity is on diagnosing patients with TB so that they can be referred to the
South African Government TB program for treatment, and commence with ART while on TB treatment as
soon as the doctor at the site sees this as being medically feasible. The field sites target those in need of
these services, who live in the catchment area of the site, and who lack the financial means to access
services elsewhere.
AIDSRelief (the Consortium led by Catholic Relief Services) received Track 1 funding in FY 2004 to rapidly
Activity Narrative: scale-up antiretroviral therapy in nine countries, including South Africa. In FY 2005, FY 2006 and FY 2007,
South Africa COP funding was received to supplement central funding, with continued funding applied for in
FY 2008. The activity is implemented through two major in-country partners, Southern African Catholic
Bishops' Conference (SACBC) and the Institute for Youth Development South Africa (IYD-SA).
of Health (DOH) in which they operate, observing the national and provincial health protocols. There is a
sustainability by diagnosing TB in potential ART patients, referring them to nearby SAG TB treatment
facilities, and commencing ART once the patients are ready.
With funding provided in FY 2008 AIDSRelief will continue implementing the activities in support of the
South African national ARV rollout. Of the 25 existing field sites, activated in program year 1 (Mar '04 - Mar
'05), two have transferred all their ART patients to SAG rollout facilities in FY 2006, and have ceased
providing treatment. Two new field sites have been activated in FY 2007 to replace these sites and to enroll
additional ART patients in support of the SAG rollout plan.
All TB treatment in South Africa is provided for free by the SAG. Screening of TB patients is problematic in
NGO sites, but this programmatic area is strengthened with CDC-Atlanta technical assistance and
increased focus in FY 2008. AIDSRelief will screen all patients who present themselves to field sites for TB,
and will perform laboratory smear microscopy and culture (if indicated according to NDOH algorithms) on
those suspected of having TB. If laboratory tests are positive, they will be referred to the SAG TB program
for treatment, as per the agreement with the government. This activity includes additional training and
commodities for the vast network of home-based carers to implement a single TB screening algorithm within
the home setting, which improves referrals.
As part of the home-based care training, all home-based carers have to complete a module in TB DOTS.
Most of them were selected as ART adherence monitors in the first place because of the considerable
experience they have gained over the years in implementing the TB DOTS program.
AIDS (in itself and its relation to TB/HIV) is stigmatized in many South African communities because of the
association with death. This is because the perception exists that AIDS inevitably leads to death. As the
number of patients on treatment has grown, and as communities see that those on treatment are living
normal, healthy lives, stigma is decreasing visibly and more and more patients are presenting themselves to
be tested, either in VCT, or if they know that they are positive, to have their CD4 counts tested and see
whether they qualify for treatment. This process has been accelerated by the way in which patients on
treatment at each site are used as community peer educators and counselors.
As described earlier, all activities will be implemented in close collaboration with the South African
Government's health authorities to ensure coordination and information sharing, thus directly contributing to
the success of the SAG rollout and the goals of PEPFAR. These activities are also aimed at successful
integration of AIDSRelief activities into those implemented by the SAG, thus ensuring long-term
sustainability.
Continuing Activity: 13711
13711 7953.08 HHS/Health Catholic Relief 6580 2790.08 $630,500
7953 7953.07 HHS/Health Catholic Relief 4438 2790.07 $300,000
Health-related Wraparound Programs
* TB
Estimated amount of funding that is planned for Human Capacity Development $346,000
There will be an increased emphasis on monitoring and evaluation (M&E) to keep track of all patients
tested. HIV-infected patient should be offered care at diagnosis and followed up, regardless of their CD4
count. Household dependants should be identified and screened after help with disclosure.
Field-based medical nurses will be specifically trained in community-based counseling and testing (CT)
identification of household dependants and encouraging family-centered support, including pre- and post-
test counseling, as well the clinical aspects of testing. Adherence monitors across the program will be
trained (or re-trained) in CT, including pre- and post-test counseling, as well the application of rapid tests on
adults and children, of a non blood nature, such as oral rapid testing which has been used across the
country, and has proven to be extremely cost-efficient and effective in conducting rapid tests. Other support
includes salaries for implementing staff at the sites, such as salaries and benefits.
A family centered testing and care approach will be used where possible. Couples counseling and testing at
CT and prevention of mother-to-child transmission (PMTCT) sites will be used to promote testing of men
Different models of counseling and testing are used, among which are voluntary counseling and testing
(VCT) and provider-initiated counseling and testing (PICT). Counseling and testing algorithms used at
AIDSRelief sites involve rapid HIV test (finger prick and oral) which is used in both facility-level and
community settings in patients older than 12 months. Patients who test negative are counseled and asked
to return after three months for retesting. Patients who test positive receive a confirmation test with another
rapid test of a different type. In a tie-breaker situation, an Enzyme-Linked Immunoadsorbent Assay (ELISA)
serum test is performed. ELISA tests are also done for every 10th positive test as a quality assurance
measure. Polymerase chain reaction (PCR) serum tests are performed for children between 6 weeks and
12 months of age.
---------------------
Catholic Relief Services (CRS) activities are implemented to support provision of counseling and testing
(CT) under the comprehensive antiretroviral treatment (ART) program carried out by Catholic Relief
Services (CRS) in 25 field sites in 8 provinces in South Africa. The program aims to establish the HIV status
of as many residents of the catchments area of each site as possible, with a view to determine their CD4
counts, so that they can be placed on ART as soon as necessary. Major emphasis is placed on community
mobilization/participation, with minor emphasis given to the development of network/linkages/referral
systems, development of human resources and training. Specific target populations include the general
population, people affected by HIV and AIDS, nurses and other healthcare workers.
AIDS Relief (the Consortium led by Catholic Relief Services) received Track 1 funding in 2004 to rapidly
scale-up ART in nine countries, including South Africa. In FY 2005, FY 2006 and FY 2007, PEPFAR funding
was received to support central funding, with continued funding applied for under COP 2008. The activity is
of Health (DOH) in which they operate, observing the national and provincial protocols. Many patients
present themselves for CD4 tests and/or ART after having undergone CT at the South African Government
(SAG) clinic.
Contrary to initial expectations, the most difficult issue has been ensuring that men benefit from the CT
activities offered. It is mostly women who undergo CT at the field sites. At each field site, home-based
caregivers, who are based in their communities, are vigorously recruiting men to undergo CT. A problem
experienced by all treatment programs in South Africa is the reluctance of males to present themselves for
treatment. CRS sites attempt to overcome this by encouraging females to attend adherence sessions with
their partners. Once the participation of males has been secured in this way, they are encouraged to
undergo CT and/or CD4 testing.
With funding provided in FY 2008 AIDSRelief will continue implementing the activities in support of South
African national ARV rollout. Of the 25 existing field sites, activated in program year 1 (March 2004 - March
2005), two have transferred all their ART patients into the SAG rollout, and have ceased providing
treatment, and two new field sites have been activated in the same period of FY 2007 to replace them..
ACTIVITY 1: Support for SAG Rollout
Two new field sites have been activated in FY 2007 period to enroll additional ART patients in support of the
SAG rollout plan. Utilizing technical assistance from AIDSRelief staff members and South African experts,
ongoing support and guidance will be provided to sites in the form of appropriate refresher medical training
courses, patient tracking and reporting, monitoring and evaluation mechanisms and other necessary
support.
Activity Narrative: At each field site, staff are trained in counseling techniques, including the provider-initiated testing and
counseling (PITC) in support of the HIV & AIDS and STI National Strategic Plan, 2007-2011. Trained nurses
are employed at each site, and they are able to perform rapid tests. Those patients who are identified as
HIV-infected undergo CD4 and viral load tests. If their CD4 count is below 200, they commence with ART.
The home-based caregivers provide care to large numbers of patients, many of them not necessarily people
living with HIV. The caregivers are trained to be aware of possible symptoms that might be AIDS-related (for
example, weight loss or persistent diarrhea). Where a caregiver suspects that illness might be AIDS-related
they give the patients appropriate counseling and advise them to be tested.
In sites with onsite medical services, counseling and testing will be provided by trained nurses and
counselors, though the majority of patients in the AIDSRelief program receive free counseling and testing in
public sector facilities. Commodity procurement (test kits) is provided for by Department of Health.
All activities will continue to be implemented in close collaboration with the South African Government's HIV
and AIDS Unit and the respective provincial authorities to ensure coordination and information sharing, thus
directly contributing to the success of the South African Government's own rollout and the goals of
PEPFAR. These activities are also aimed at successful integration of AIDSRelief activities into those
implemented by the South African Government, thus ensuring long-term sustainability.
FY 2008 COP activities include the provision of PITC for all patients visiting the partner treatment sites, as
well as family-oriented CT which will try to include all members of a family of the person currently on ART.
These activities are in line with the efforts to encourage testing for HIV for increased number of people,
while leaving them the option of refusing the testing if they feel they should not have it. Application of rapid
tests of a non-blood nature, are being considered as one of the tools in the implementation of the program,
along with PCR testing for children younger than 12 months. It is hoped that the increased rate of voluntary
testing for HIV and AIDS will assist additional people who are in need of treatment across the program.
Continuing Activity: 13712
13712 3308.08 HHS/Health Catholic Relief 6580 2790.08 $291,000
7488 3308.07 HHS/Health Catholic Relief 4438 2790.07 $150,000
3308 3308.06 HHS/Health Catholic Relief 2790 2790.06 $0
Estimated amount of funding that is planned for Human Capacity Development $110,000
Table 3.3.14:
Monitoring and Evaluation
In order to improve data collection, analysis and reporting, AIDSRelief plans to introduce an appropriate
upgrade to the existing monitoring and evaluation system, in the form of an electronic database to be
utilized at the site level (for data collection) and central level (for data consolidation and reporting purposes).
The system is based on the system developed by the sub-grantee of the program, the Institute for Youth
Development South Africa (IYD-SA). The draft database has been presented to CDC team members and
development is continuing based on initial feedback provided. The final product will be technically
appropriate to the level of skills available at the site level as well as able to report on PEPFAR and South
African government (SAG) indicators under the program.
Laboratory Services
The company has been established by Prof. Des Martin and Dr. John Sims, both long-time South African
Collaboration with SAG
Due to increased access of quality services provided by the SAG, patients from two AIDSRelief sites
(Sinosizo clinic in Groutville near Durban in KwaZulu-Natal and the Sisters of Mercy home-based care
program at the Bethal District Hospital in Mpumalanga Province) have been fully absorbed into the public
health care system and the AIDSRelief non-governmental organization activities became redundant, with
funding reallocated to other resource-poor sites. At the same time, significant progress is being made
collaborating more closely with SAG in other geographic areas. These include the Masibambisane
treatment center in Eastern Cape Province, which moved into the Stutterheim District Hospital and
subsequently have been successfully accredited as the SAG roll-out site. In this instance, AIDSRelief is
providing staff and technical assistance while the SAG is providing laboratory tests and ARV drugs.
---------------------------------------------------
Activities support procurement of antiretroviral (ARV) drugs under the comprehensive ART program carried
out by Catholic Relief Services (CRS) in 25 sites. Coverage extends to eight provinces in South Africa
(excluding the Western Cape). The emphasis areas are human capacity development and local
higher risk populations such as migrant workers and refugees.
scale-up antiretroviral therapy (ART) in nine countries, including South Africa. Since FY 2005, in-country
funding has supplemented Track 1 funding, and this will continue in FY 2008. The activity is implemented
With funding provided in FY 2008, AIDSRelief will continue implementing the activities in support of the
South African Government (SAG) national ART rollout. In the interest of maximizing available funds the
focus will be placed on strengthening the existing sites' provision of services rather than on assessing and
activating new sites. Utilizing technical assistance from AIDSRelief staff members and South African
experts, ongoing support and guidance will be provided to sites in the form of appropriate refresher medical
training courses, patient tracking and reporting, monitoring and evaluation mechanisms and other
necessary support.
ARV drugs are provided to all qualifying HIV patients who present at the sites, irrespective of their age,
gender, nationality, religious or political beliefs. The access to non-South Africans is particularly significant,
as the public sector rollout program is restricted to South African and legal refugees and asylum seekers.
However, South Africa has a large displaced population, including economic migrants who do not have
South African identity documentation. Historically, about 90% of adults and 10% of children with HIV have
been receiving ARV drugs through the 25 partner sites.
ARV drugs purchased will be used by the 25 sites to treat ARV patients through clinic-based and home-
based activities aimed at optimizing quality of life for HIV-infected clients and their families. For most of the
25 sites, ARV drugs are currently being purchased centrally through a Johannesburg-based pharmaceutical
company, and delivered via courier to the field sites monthly on a patient-named basis. CRS is billed once a
month for all site deliveries after verification of drugs delivered to each site. The opportunity of accessing
preferential cost drugs is being utilized through cooperation with GlaxoSmithKline where available. Although
the AIDSRelief sites have not experienced stock-outs in significant volume, they have been experienced on
a limited number of occasions. Efforts to address or prevent such occurrences in the future include
substitution by a more expensive drug on stock (all approved by the appropriate regulatory authorities of the
Activity Narrative: host country and the donor). Generic medications purchased comply with the USG PEPFAR Task Force
requirement of FDA approval as well as approval from the Medicines Control Council of South Africa.
All activities will continue to be implemented in close collaboration with the SAG's HIV and AIDS Unit and
the respective provincial authorities to ensure coordination and information sharing, directly contributing to
the success of the SAG's own rollout and the goals of PEPFAR. These activities are also aimed at
successful integration of AIDSRelief activities into those implemented by the government, thus ensuring
long-term sustainability.All sites operate in terms of a Memorandum of Understanding with the provincial
Department of Health in which they operate, observing the national and provincial treatment protocols.
There is a concerted effort at each site to ensure sustainability by either having the SAG provide
antiretroviral drugs, or by down referring stable patients in to the public primary healthcare clinics after
numbers, has already been accredited as a SAG rollout site. Sinosizo is receiving drugs from Department of
Health due to its status as a down referral clinic for Stanger Hospital. At Centocow and Bethal, all patients
are already receiving drugs through the SAG rollout.
In terms of the actual drug procurement, AIDSRelief in South Africa has a centralized procurement system
of ARV drugs, which already provides the economies of scale in terms of drug pricing to the extent possible
(outside of the SAG-mandated single exit price). This centralized procurement system buys drugs in
volume, and keeps sufficient stock levels to supply the AIDSRelief sites with drugs and ensure no stock-
outs occur. The centralized procurement system also manages losses due to expiry of the drugs, and
ensures compliance with FDA and MCC (Medicines Control Council of South Africa) requirements. Each
patient has their 6-month repeat prescription originally assigned by the doctor and then dispensed by the
pharmaceutical supplier, which is revised where necessary (in line with SAG guidelines).In terms of
monitoring of the program, the majority of the AIDSRelief sites are utilizing the centrally-based laboratory
services provider Toga (a PEPFAR prime partner) that conducts blood tests (CD4, viral load etc.) for the
sits, using the courier service available in country to deliver the blood samples, and reporting back to the
sites on the results through either e-mail or an online electronic reporting system setup by the Laboratory
services provider. Due to good existing infrastructure in South Africa, AIDSRelief sites are able to perform
viral load and CD4 tests once every six weeks, to monitor the treatment progress and possible failure on the
individual patient level. These analyses are conducted by each of the AIDSRelief sites, using the data
provided by the Laboratory services provider, as part of the clinical management of the patients. The
majority of the AIDSRelief sites also use hand-held lactate meters (provided for free by the laboratory
services provider) to screen for hyperlactatemia, which is the most common severe side effect of patients
who have been on treatment for prolonged periods of time. Feedback on program level of the progress and
viral suppression is regularly provided by a clinical expert at the Desmond Tutu HIV Foundation, using the
laboratory data provided by Toga Labs on patients whose blood was tested through their facilities.
FY 2008 COP activities will be expanded to include increased collaboration with the SAG to ensure long-
term sustainability of the program, through different arrangements that vary from one province to another.
These include the transfer of "stable" patients (on ART for 6 months or longer) to public sector health
facilities, and then enrolling additional patients at the AIDSRelief partner site. Other options include
provision of free ARV and opportunistic infections drugs and laboratory tests for SAG-accredited facilities
run by AIDSRelief, or those that are physically located on SAG-owned premises, thus allowing them to
receive free drugs or services. As in the case above, this allows the AIDSRelief sites to enroll additional
patients on ART. Other examples include provision of ARV drugs by the SAG, and home-based care and
support and adherence follow-up by the AIDSRelief-run partner site. All the different models of collaboration
are individually discussed with the provinces where the partner sites operate, and largely depend on
specific needs and operating environment of each treatment site and SAG authorities, but are designed to
ultimately allow long-term sustainability and success of the program.
Continuing Activity: 13713
13713 3309.08 HHS/Health Catholic Relief 6580 2790.08 $7,760,000
7489 3309.07 HHS/Health Catholic Relief 4438 2790.07 $6,068,370
3309 3309.06 HHS/Health Catholic Relief 2790 2790.06 $4,572,000
Table 3.3.15:
