To support The Medical Research Council (MRC) in providing the South African Government with the evidence base needed for planning, implementation, monitoring, and evaluation of the priority health outcomes to achieve a long and healthy life for all South Africans and to strengthen its public health system and the national response to HIV, sexually transmitted infections and tuberculosis. PEPFAR South Africa will fund targeted strategic information and capacity building activities with the following objectives: 1) Strengthen and improve the quality of HIV information systems including surveillance, monitoring and evaluation and quality improvement; 2) Inform Make evidence-based contributions and enhance towards enhancing the effectiveness and efficiency of prevention, care and treatment interventions; 3)Improve Implement innovative interventions for improved delivery and monitoring of prevention, care and treatment interventions through targeted capacity building in strategic information, prevention, care and treatment, and laboratory services;

Implementing partners Under this FOA, MRC will act on behalf of the National Department of Health (NDOH) and other relevant South African Government departments as contained in the Negotiated Service Delivery Agreement (NSDA) support SAG to answer questions of national importance that strengthen the national health care systems and to build capacity to implement program recommendations and evaluate program effectiveness. MRC is the entity responsible for biomedical and other forms of research of national importance and is the only agency with this direct governmental mandate in South Africa.

The overall objective is the integration of TB and HIV services and care. It involves activities ranging from counseling and testing, wellness care, antiretroviral treatment (ART), and all aligned TB/HIV activities to ensure that patients have better access to TB and HIV care, resulting in cross-cutting services and budgetary obligations. Several activities will be undertaken under prophylactic treatment. Firstly, TB screening -- which is done at least bi-annually on all patients attending ART and pre-ART clinics -- will be done using TB symptom screening tools as well as sputum analysis of identified TB suspects following a positive symptom screening questionnaire. Secondly, isoniazid preventive therapy (IPT) will be actively implemented using provincial guidelines. Thirdly, co-trimoxazole prophylaxis (CPT) may prevent morbidity in patients infected with HIV. Currently 80% of all eligible patients in Eden district (Western Cape) are on CPT. This activity will be continued with the additional funding. Fourthly, nutritional counseling will be conducted to ensure that all people living with HIV (PLHIV) are enrolled in wellness programs and eat well to boost their immune system. At the same time activities will include nutritional assessments of patients, food counseling, the development of nutritional gardens, nutritional education to all affected people, and support for nutritional security programs that are offered by the Department of Health, and in the relevant thatsit (Tuberculosis HIV and AIDS Treatment Support and Integrated Therapy) supported districts. Lastly, infection control activities will be pursued, specifically through training community health workers in TB symptom screening, basic infection control principles, TB/HIV care, preventing mother-to-chidl HIV transmission. This training will also ensure that mothers enroll in early antenatal care. Patient tracers will continue to visit homes to ensure a diminished defaulter rate and to ensure that HIV positive persons are kept in care. Community outreach activities will continue to increase HIV counseling and testing (HCT) uptake, to decrease stigma and to improve awareness of both HIV and TB in the community. Both HCT and outreach activities will continue with additional funding.

In the comprehensive integrated approach to TB and HIV services, the focus is on regular screening for all HIV-positive patients, offering counseling and testing to all TB patients (where possible provider-initiated), augmented clinical care to all patients, supplementing key personnel where indicated and providing community outreach initiatives to increase awareness of TB and HIV, utilizing community patient tracers to identify pregnant women for PMTCT referrals and to decrease the stigmatization of the dual epidemic. Patients in this activity are those that have been counseled and tested and have received their CD4 count and thus been enrolled in a wellness program. All HIV positive and TB patients receive nutritional support through nutritional assessments and various models on nutrition interventions were explored and are currently implemented. Regular nutritional assessments are done on all patients with a low BMI (<18.5 on initial assessment). Nutrition education and the running of nutrition gardens in the various sites are a priority. A specific objective of this activity is to enrol all HIV-positive patients in wellness programs to ensure that they are educated regarding good nutrition, the disease progress, adverse drug interactions and protection against opportunistic infections as well as infection control to protect those close to them. CPT prophylaxis was endorsed in all supported sites. Human resources support will continue in identified sites. To promote integrated care taking into account infection control principles, minimal refurbishment will take place at identified sites in newly supported sites.

The partner will work with Eden district and the sub-districts (Western Cape), other PEPFAR funded partners and stakeholders to ensure adherance to the DoH policies. Activities will target children and adolescents from newborn to 21 years. Partner will conduct needs assessments and work with the facilities and district health management (DHMT) team to identify gaps in care. Partner will support and strengthen integration of maternal and child health (MCH), integrated management of childhood illness (IMCI), IMAI, nutrition, growth monitoring and HIV services. Identification of HIV-exposed and -infected babies at 6 weeks will be strengthened through optimal use and the recording of the mothers HIV status on the Road-to-health card.

Partner will strengthen referral systems between maternity (labor and delivery) and primary health care clinics to improve follow up and tracking and tracing of mother infant pairs. Partner will support and strengthen the recording and reporting and improve systems to ensure that commodities for dried blood spot (DBS) PCR testing and drugs (antiretrovirals, cotrimozaxole and nevirapine syrup) are available at health facilities.

Partner will strengthen the provision of a minimum package of care for HIV infected children which includes, cotrimoxazole prophylaxis, TB screening at every visit, provision of IPT for children, growth monitoring and nutritional assessment, immunizations, and psychosocial support. Aurum will support the strengthening of adolescent services including PICT, and psychosocial support especially around issues of disclosure, prevention with positives, and adherence.

Partner will assist the district and facilities with the implementation of a quality improvement program that will include the following: improved recording and reporting, and monitoring and evaluation. Moreover, the partner will also support the facility, district and province to develop strategies to improve uptake in PCR testing, cotrimoxazole, retesting post weaning and retesting at 18 months.

The program objectives that this mechanism will focus on include: Strengthen the national PMTCT surveillance system and response in view of contributing towards SAGs PMTCT goal of no child born with HIV by 2015 and improving the survival of HIV-free children; Strengthen programs for linking and retaining of individuals into HIV care and treatment services with a focus on people eligible for, but never in, care; Strengthen programs in the prevention to treatment cascade; Support the development of strategic information, strategies and policies, and stronger national program approaches towards universal access to affordable and good quality HIV prevention, diagnosis, care and treatment interventions; Strengthen the case finding, diagnosis, and treatment of TB in key groups of HIV-infected persons, including pregnant and postpartum women, and infants; Strengthen school-based health programs

To support the roll-out of effective prevention programs targeted at youth in the Western Cape. The programs were developed informed by the baseline assessments. The interventions were developed, piloted and post-tested for effectiveness, supporting prevention programs to expand linkages and integration with HCT

The partner will provide support to thepartner facilities in improving the quality and coverage of the PMTCT services in women from age 15-49 years, to achieve a mother-to-child transmission rate < 2% at 6 weeks and < 5% at 18 months by 2015 in line with National Service Delivery Agreement. The partner will support the national PMTCT program by addressing some of the inherent programmatic gaps through technical assistance, including ongoing support through on-site mentorship of NIMART trained nurses; and health care workers trained in family planning, TB/HIV/STI management, couple counseling, basic antenatal care services (ANC), and infant feeding practices. The partner will ensure that all women seen at ANC will have access to family planning counseling services, safer pregnancy counseling, and nutritional counseling and support services. The partner will work with South African government to improve linkages and integration of services between PMTCT, maternal and child health, sexual and reproductive health, youth and family planning services. Activities will include promotion of provider-initiated counseling and testing, TB screening of all pregnant women irrespective of their HIV status, promotion of early booking and retesting at 32 weeks. The partner will develop effective strategies to follow-up mother-baby pair post delivery. Program will prioritize early infant diagnosis by strengthening the referral systems between hospitals, clinics and community outreach programs. Furthermore, activities addressing cultural attitudes to infant feeding practice, male involvement in PMTCT and ANC, and increased uptake of services will also be supported. Institute for Youth Development of South Africa (IYDSA) will also work with the laboratory department to ensure improved turnaround time for CD4 counts, polymerase chain reaction (PCR) and other laboratory results. Partner will conduct quality improvement activities in order to identify areas of and need and will work with the district to innovate solutions for better program outcomes. Partner will support the District Health Information System to enable tracking of progress by using maternal and PMTCT indicators.

The project will support a comprehensive best-practice approach to integrated TB/HIV care to provide comprehensive, integrated TB/HIV care services and to improve accessibility of HIV care to TB patients. The program will comply with a standard set of objectives to ensure compliance with their mission and vision, which is to provide an integrated service for TB and HIV positive patients. This approach necessitates a strong leadership team that is decentralized and that can manage the program from the rural and resource limited settings in which they operate. Technical advisors in TB supporting and training, data management and monitoring and project coordinators in the various sites, keep the project on course and in line with district strategies.

Staff will be comprised of medical practitioners, nurses, dieticians, administrative staff, data capturers, pharmacists, pharmacist-assistants, clinic-based counsellors, community counsellors, tracers (these are community workers) and regional/area managers. A continued effort will be made to transfer some of these crucial staff members to the National Department of Health (NDoH) for service delivery activities hence ensuring skills transfer and sustainability of the project. The improvement of operational systems and data collection remains one of the focus areas of the program.

TB and HIV technical support will be the main focus of activities. The following activities will be prioritized: the training and mentoring of all NDoH staff in all the requirements of recording and reporting; nurse-initiated managerment of ART (NIMART) as well TB prophylaxis and care;other preventative care support modalities (e.g., PMTCT); and the strengthening of monitoring and evaluation, recording and reporting as well as action research activities in an effort to strengthen current health systems, patient flow and embrace quality improvement in both the TB and HIV program.

The partner will support Eden district (Western Cape) and the South African government's overarching goals to scale up the number of pediatric patients on ART to 15% of the total on ART for the sub-district or district, and increase service delivery to HIV-infected infants, children and adolescents. This will be achieved with the district and the Regional Training centers, and other stake holders. Capacity will be built in the following manner:

1. Provide continuous training to clinicians (physicians, nurses and clinical associates) on the diagnosis, treatment and management of HIV-infected infants and children.

2. Provide support to the district and facilities to ensure scale up of provider-initiated counseling and testing of HIV. Sensitize provider to offer HIV tests to infants, children and adolescents that are encountered at all levels of care with an unknown HIV status.

3. Provide ongoing support for NIMART. The partner will provide onsite mentorship and regular onsite follow up to ensure that nurses are capacitated to initiate and provide care and treatment services to HIV-infected infants and children.

4. Support and ensure linkages to programs providing nutritional support, adherence, and psychosocial support.

5. Support and ensure that pediatric ART services are integrated with maternal and child health, Expanded Programme for Immunisations, and IMCI.

6. Support the district to ensure that all HIV-infected children have access to CD4% and viral load testing. Work with the National Health Laboratory Service (NHLS) and District to ensure that results are returned to facilities at a timely manner. Work with District to ensure that staff at facility reports and records results.

7. Support the District and sites in ensuring that there is a quality improvement plan in place. Ensure that District and sites use data to affect change at the site and District levels.

8. Support District and Regional Training Centres in providing training and onsite support for improving data collection, recording and reporting.

9. Support the District to ensure that there are adolescent friendly spaces to address the unique issues and challenges that HIV-infected adolescents encounter, particularly issues related to disclosure, and sexual and reproductive health.