Through its network of community-based volunteers and health care workers working through the 13 ART clinics and 34 OVC sites, SACBC will contribute towards the objectives of the PF and NSP by reducing vulnerability to HIV and TB infection, focusing on the needs of girls and women, through ARV treatment and OVC program activities. Further, SACBC will contribute towards the increase of number of persons who know their HIV and TB status, through intensified case finding, and increasing access to HIV testing, and linking them to appropriate services. SACBC provides treatment, care and support in areas where the government is unable to provide treatment to all who need it. Some form of services (OVC or ART) is provided in more than 30 Districts (10 out of the 15 Districts with the highest rates of HIV) of the country, specifically targeting indigent residents and migrant or mobile populations. SACBC successfully transitioned to become the prime partner after the track 1 transition. Increased partnerships with the DoH were pursued from 2007 with the view of ensuring long term sustainability and cost effectiveness of the program by obtaining financial and in-kind support from DoH at various levels. Most recently, a total of 5 (out of 13) ART sites are receiving ARV drugs (40% of the total) and laboratory tests from DOH, which shows the commitment to ensuring sustainability and cost-effectiveness in the long term. SACBC will also support PHC reengineering in partnership with the districts and provinces M&E systems have been implemented at all the sites. Centralized data quality and verification will continue with monthly reporting to the DOH and the DSD. No vehicles were purchased with the current award, with no vehicles to be purchased in the near future.

All SACBC treatment sites have extensive community based home based care networks that provide care and support to persons with HIV. These community-based projects are used to screen patients for HIV, TB and conduct nutritional assessments, and link them to care providers in their communities. Testing and counseling is provided in non-medical facilities throughout the network of decentralized ART provision points, which increases adherence, uptake and cost-efficiency. Once patients test HIV positive, they are enrolled in the program and registered in the existing M&E system to ensure follow-up and retention in care. Part of standard package of care for patients include prevention and treatment of opportunistic infections, including the provision of Cotrimoxazole, and management of pain and diarrhea as appropriate. All patients are encouraged to join support groups. Nutrition assessment, counselling and support will continue to be provided for all patient on the ART program including patients who are under 18, pregnant women and lactating mothers. patients with a BMI lower than 18 will be provided with nutritional supplements. Where appropriate, patients are assisted to access government disability and other support grants. In an attempt to ensure patient treatment adherence once started, all care patients are included in adherence counseling which focuses on information on ART, HIV prevention and importance of adhering to the prescribed treatment. Patients are also encouraged to identify and make use of a treatment buddy, and to join and attend adherence support groups. Discordant couples and HIV infected persons in particular are given counseling and support to prevent the spread of HIV( PwP). SACBC will work with DOH to roll out care services in line I ACT model. M&E support will be provided and the use of the Pre ART register will be stregthened.The following SACBC ARV treatment sites have residential, in-patient hospices: Holy Cross, Tapologo, Nazareth House, St Francis and Blessed Gerard. At all these facilities palliative care is provided to terminal patients. Patients in these hospices are also initiated on ART most make a full recovery and return to their homes.

SACBC will continue close collaboration with the Department of Social Development (DSD) in the provision of care and support to OVCs in 30 districts. SACBC will become part of District coordination teams tasked to assess the quality and geographic distribution of services so as to prevent duplication. All SACBC sites are members of local child care forums and will maintain linkages with the local police services to address cases of abuse, giving special attention to gender-based violence in HIV prevention education activities. Nationally, the SACBC works with the National Action Committee for Children Affected by AIDS (NACCA) under the DSD. The SACBC has submitted a MOU to National DSD to formalize the partnership. Once signed, the SACBC will then work toward signing agreements at the Provincial level through the Provincial Action Committee for Children Affected by AIDS (PACCA). This is already in process in the Free State and North West. Six SACBC implementing sites provide Early Childhood Development Program targeting 0-6 in cooperation with Provincial DSD. Other sites work with local ECD programs. Currently 90% of children registered in SACBC sites have obtained birth registration and SACBC will continue to make this a priority. All sites will be encouraged to apply for NPO status and to link with provincial structures so the caregivers will be eligible for stipends from government. The SACBC will report to the DSD using the national Monitoring and Evaluation system. Nutritional assessment will continue to be conducted and qualifying children provided with supplements. Child-headed households will be given psychosocial support and training in livelihood skills, such as parenting, budgeting, etc. Support groups for children living with sick and elderly guardians will be established. Through collaboration with government and private sector partnerships, economic strengthening and income generating networks will be established.

Except for St. Apollinaris Hospital, which is a District public hospital, SACBC does not provide TB treatment to patients. The focus is rather on intensified case finding. All patients, regardless of a setting, are screened for TB through standardized screening tools at every encounter. Three of the site facilities have access to on-site chest x-ray machines for TB diagnosis. All patients with positive TB screening have a clinical workup and are referred to a TB clinic where needed. Infection control plans are in place at all ART facilities, with the dedicated TB point person at each site.TB infection control measures at all sites include open waiting areas, fast-tracking of coughing patients, and mechanical ventilation, as well as patient education which includes recognizing symptoms of TB, the importance of washing hands etc. Several sites support their local TB clinic with DOTS through its community-based outreach.

Identifying and enrolling pediatrics into the care program has been a continuous focus of the program presenting challenges. These included reluctance of guardians to test children, inability of guardians, especially grandparents, to administer medication due to literacy problems, movement of OVCs where the guardians change, as well as the fear of health care workers working on the program to draw blood from children and prescribe treatment. In the coming period, renewed effort will be made to follow the family-centered approach by going out to the communities and testing families, as it has been found that the likelihood of the child being tested is if the entire family gets tested at the same time as the primary caregiver. In the previous program year, the project was able to test 1,181 male and 1,616 female children. Pregnant females in care will continue to be followed-up after giving birth and will be encouraged to bring their babies for testing between 4-6 weeks of age. Programs will consciously form linkages with ANC and PHC facilities in order to ensure better cooperation with these institutions in identifying children in need of care and support. If a child younger than 2 is identified as HIV positive, they will be initiated on treatment immediately. After the age of 24 months, they will be enrolled based on their CD4 percentage. The basic care package for children will include, but not be limited to, provision of prevention and treatment for opportunistic infections, including provision of Cotrimoxazole and treatment of diarrhea. Specific emphasis will be placed on TB screening, nutritional assessment and pain management.

ARV drugs will be procured through a centralized procurement mechanism (SCMS).

Much emphasis is placed on training of staff at treatment sites. In the past year treatment for medical staff has included IMCI and NIMART with staff from all sites participating, enabling task shifting which will relieve human resource shortages in country and improve access to treatment. Nurse mentors have been identified and will receive advanced training to mentor fellow nurses. M&E capacity is utilized to respond to strategic priorities; electronic databases are established at 17 points at all treatment sites, which enable sites to schedule ART patients, track retention, measure progress and provide overall program management to treatment sites. A centralized M&E unit receives weekly data backup from the field treatment sites, and uses the data to conduct data control through quarterly data reviews, and verification of all ARV drug orders with the pharmaceutical supplier. A query module enables the treatment sites and the central unit to collate data and use it for measuring program success, decision-making and improvement of services where applicable. Centralized reporting is conducted on monthly basis through the DHIS. All patients undergo six-monthly CD4, FBC and Viral Load tests. Every patient at every encounter has a TB screen and all eligible patients are put on Cotrimoxazole. Annual program evaluation is conducted by the Desmond Tutu HIV Foundation based at the University of Cape Town. Throughout the program, an overwhelming majority (two thirds) of ART patients have been female. It has been noted that, after the age of 33, males constitute an increasing proportion of ART patients, reflecting an older age of male HIV disease and possible late presentation. In 2004, 80% of the patients had severe immune suppression, which by 2011 was reduced to 20%, demonstrating a marked population benefit of the program. Overall retention through the program (7 years) is 54.8% of patients, with the death rate of 11.6%.Increased partnerships with the DoH were pursued from 2007 with the view of ensuring long term sustainability and cost effectiveness of the program by obtaining financial and in-kind support from DoH at various levels. At present, SAG provides nearly 40% of all ARV drugs to the program.

Once a child younger than 2 years of age is identified as HIV positive, the child will be put on ARV treatment. Children older than 2 will be put on treatment once eligible based on their CD4 percentage. As small children cannot take ARVs on their own, special emphasis will be placed on providing support to caregivers (guardians) in treatment adherence. Advantage will be taken of the available linkages with OVC programs to increase the uptake and retention of children, and the knowledge and experience of staff at these programs will be leveraged to conduct support groups for adolescents and provide HIV prevention education and counseling to older children. Nutritional support is provided to eligible children on ART, with additional support provided through linking them with community-based activities rendered through the program. Capacity building of staff to test and treat children will continue to receive attention, in order to increase uptake of children on ART in the future. Under the program, there were 1,560 children ever enrolled on ART.