WRHIs National Sex Worker and Male Client Programme supports the South African Government to develop, implement and evaluate a package of treatment services for HIV, STI and TB for key populations as referred to in the National Strategic Plan. In 2013, WRHI is targetting implementation of clinical services at 8 different national sites (2 sex workers- and 6 truckers and sex workers- focused). Using WRHIs Hillbrow model, this program will expand services to identified hot spot locations focussing on areas along major trucking routes where services do not exist and where there are large concentrations of brothel- and street-based sex workers. Services will include the Hillbrow package of treatment and prevention for sex workers, and will apply lessons learnt from the inner citys Mens Programme, which draws high-risk men into prevention programmes. The targeted locations include Tshwane, Johannesburg, Ekurhuleni, Cape Town, Zululand, Emakhazeni and eThekwini municipalities. Cost sharing opportunities will be leveraged through this programme at all levels within the DoH and include HIV test kits, condoms, drug supplies and referral support. WRHI and North Star (sub-partner) will involve corporate contribution to the project, based on successful public-private partnership records from both organisations. Corporate partners have already expressed interest in financial support of this program. WRHI has also engaged DoH from the start for transition and to ensure sustainability and local health department ownership. M&E is an integral component of and cross cuts through all of WRHIs programmatic teams. The M&E team will expand WRHIs current Women at Risk programme and Men and HIV programmes comprehensive routine reporting tool for use in this program.

WRHI has over a decades experience developing one of Africas largest sex worker treatment, care and prevention programs in Hillbrow, located in the inner city of Johannesburg, with over 2000 sex workers on their database. This program provides clinic and outreach services to brothel and street-based sex workers and their clients using community and peer educator components. Services include HCT, TB screening, STI diagnosis and treatment, family planning, antiretroviral therapy initiation, condom distribution and pregnancy testing. WRHIs National Sex Worker and Male Client Programme will expand the Hillbrow model of outreach and treatment to also include Pretoria and Ekurhuleni, sites identified by the DoH as having a high concentration of sex workers. This program will also expand services for truck drivers and sex workers nationally, targeting expansion to five satellite sites and one specialist referral site along trucking corridors where services do not currently exist (Ekurhuleni, Cape Town, Northern KwazuluNatal, Emakhazeni and eThekwini municipalities) in 2013. This program will implement clinical and outreach services through identified clinic space or via a clinic container at each site. North Star, which has extensive experience in working with trucking communities, will manage the implementation of these Roadside Wellness Centres. North Star has experience in deploying wellness clinics in SADC Member States. These sites will provide services in basic sexual and reproductive health interventions (contraceptive provision, HIV testing and staging, STI treatment), TB screening, chronic disease screening, treatment of minor ailments, referrals to community structures, and accelerated access to antiretroviral therapy for all HIV-identified patients. The site in southern Johannesburg will act as a specialist site for complex care. WRHI will also work closely with industry wellness programmes in order for cross-linkages regarding referrals and gaps in service. Follow-up of truck drivers will be explored through SMS support, where WRHI has experience using this to support adherence among pregnant women and research participants. Modelled after the Hillbrow program, sex workers who default after being initiated on ARVs are assigned to the community health worker for follow-up. Additionally, Sisonke (sub-partner), a sex worker peer educator and human rights movement, will be establishing branches at selected sites. Through peer educators, Sisonke provides health information, legal support, life skills training, and linkages for clients to community services. WRHI will provide technical support, and ensure smooth relationships between Sisonke, DoH structures, AIDS Councils, and the police.

Finally, to monitor the quality of care, perform programme evaluations and research to identify priority issues, there will be implementation of a clinical data system to allow better characterisation of sex worker and truckers health needs as a component of the monitoring and evaluation system. This data system will be based on the current WRHI sex worker database and North Stars tailored database system developed specifically to track truckers across regions.

Annual audits on clinical services for systems strengthening will be performed and identification of gaps in services and staff training will be planned to improve the quality of services.

Prior COP activity was focused on the Hillbrow site, where the program has been very successful in partnership with the local municipality. A database provides outcomes of the program, which has provided extensive operational data. The project has excellent relations with the surrounding brothel owners & attached sex workers, as well as with the street-based sex workers. Referral into services is relatively simple, as other WRHI programmes focus on health systems strengthening in the inner city, & hence sophisticated understandings of the local referral networks strengths & weaknesses. WRHIs National Sex Worker & Male Client Programme addresses the South African Governments goal of a long & healthy life for all South Africans through expansion of targeted sex worker & trucking wellness services. Within the NSP there is specific reference to a package of treatment services for HIV, STI & TB for key populations which WRHIs program aims to develop & deliver. At the SANAC Project Implementation Committee meeting in March 2012, it was agreed that there would be 1000 additional service points targeting key populations in response to implementing the NSP. WRHIs program will contribute to the addition of these national service points through clinical & outreach programme delivery.

To coordinate activity across partners, WRHI is a member of a new DoH steering committee which brings together stakeholders from government, civil society & academic institutions, working in the field for sex work. Initiatives of this committee include the development of sex worker guidelines for health service provision. WRHI is also working with local partners to develop a national surveillance tool for sex workers allowing for regular activity mapping to guide where interventions should be introduced & monitor the impact of existing interventions.

Sufficiently trained personnel are essential to delivering programmes to these key populations. Truckers & sex workers face additional barriers in accessing HIV & TB care. WRHIs training department has developed an advanced HIV & TB course to support doctors & nurses based in public referral sites. WRHI also provides specialized modular sexual & reproductive health courses for nurses & other core service delivery staff at facility level & provide evaluated curricula in basic SRH, TB & HIV for community members appropriate for the empowerment of community sex worker advisory boards & outreach workers. All training will be reviewed & adapted for this COP & will help ensure that there is sufficiently trained staff to carry out the proposed activities in satellite communities.

WRHIs Monitoring & Evaluation teams support is cross cutting through providing support for program monitoring, reporting, data quality, operations research, data use, Health Management Information Systems & others. This project focuses on providing health services to two underserved & under-represented populations. Currently there are no program monitoring indicators available for these populations thus project input, process, outcome indicators will be developed with the intention that some of the indicators will be integrated in the national databases. Program outcomes will be regularly reported for the indicators listed in the M&E plan. As detailed in the SI section of the COP, this project will undertake formative research to gain a better understanding of the needs of these populations.

Support for adult treatment will focus on technical assistance at the national, provincial, district, facility and community level of care. Technical assistance includes training, mentoring, monitoring, evaluation, quality improvement (QI), problem identification with formulation of solutions and ensuring systems are implemented to provide routine quality clinical service. HIV infected adults in this population including those with TB will be targeted in this program.

Support is offered to all cadres of health care workers. WRHI district team members work together, with one clinician providing clinical support to release DoH clinical staff, whilst colleagues provide onsite supportive training, mentorship and facilitation of NIMART accreditation, and supermentorship for DoH NIMART mentors together with QI support. Quality of care with a focus on retention in care and referral systems is strengthened through institutionalizing continuous QI methodologies, process mapping and the use of National Core Standards. Use of routine available data will identify the facility and sub-district-specific priority areas where targets are not being met. QI interventions will target these specific issues with measurable outcomes, and empower facility managers to implement improvements.

Retention in care and adequate referral will be supported using PHC re-engineering staff to ensure tracing and follow-up occurs. WRHI will ensure referral of complex HIV cases occurs efficiently, and that loss to pre-ART and ART programs is minimized. Novel mechanisms to improve retention in care will be developed and implemented, including the use of mHealth technologies. Within the referral service, non-adherent patients will be identified. WRHI will develop a model of support for patients failing ART and TB treatment, who require specialized support, to prevent unnecessary morbidity. Continued training and skills transfer will enable the system to become self-sustaining in the future.