Detailed Mechanism Funding and Narrative

Details for Mechanism ID: 4476
Country/Region: South Africa
Year: 2007
Main Partner: FHI 360
Main Partner Program: NA
Organizational Type: NGO
Funding Agency: USAID
Total Funding: $2,970,000

Funding for Biomedical Prevention: Prevention of Mother to Child Transmission (MTCT): $400,000


This PMTCT activity relates to other activities implemented by Family Health International in Basic Care and Support (#7584), Abstinence/Be Faithful (#7585) and ARV Services (#7593) program areas.


Family Health International (FHI) will collaborate with PEPFAR-funded prevention of mother-to-child transmission (PMTCT) partners to strengthen PMTCT services in four provinces. FHI will provide a PMTCT Training of Trainers (TOT) course designed for program implementers. Auxiliary nurses and lay counselors will be equipped with appropriate knowledge and skills of PMTCT. With the provincial departments of health (DOH), FHI will design and provide technical assistance (TA) to PMTCT facilities to improve the quality of those services. This project will provide resources to other PEPFAR partners, including Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) and JHPIEGO. The target populations include adult men and women of reproductive age; family planning clients; pregnant women; people living with HIV and AIDS; HIV-infected pregnant women; policy makers; National AIDS Control staff; nurses; and international counterpart organizations. The major emphasis area is training, with a minor emphasis on development of networks, linkages and referral systems; and information, education and communication.


Since FY 2004, FHI has provided TA to select South Africa provincial DOH PMTCT facilities. The goal of this TA was to improve overall performance of selected PMTCT sites, with an emphasis on promoting best practices including the provision of antiretroviral (ARV) prophylaxis and family planning (FP) counseling and referrals. During FY 2004, FHI supported the provincial DOH in Limpopo and Northern Cape provinces by providing training to over 100 PMTCT service providers and on-site TA to 20 PMTCT facilities. In FY 2005, FHI collaborated with the Northern Cape DOH to select 30 new PMTCT facilities in five districts to participate in the project. FHI conducted trainings for 111 auxiliary nurses and lay counselors in the five districts. In FY 2006 FHI is continuing to work in Limpopo and Northern Cape provinces and has extended TA to Free State and North West provinces. At the request of these provincial Departments of Health, FHI is assisting in the development and adoption of provincial PMTCT protocols.

In FY 2007, FHI will continue to provide TA to Free State, North West, Northern Cape and Limpopo provinces and will expand the program to select facilities in Western Cape province. With FY 2007 funding, the project will build on the lessons learned from the two previous years of PEPFAR funding. FHI will develop and make available on CD-ROM an interactive tutorial that can be used by other PMTCT implementing agencies and the DOH. FHI will also provide TA to improve overall PMTCT performance and on strengthening the systems necessary to support PMTCT programs (e.g., supervision). FHI, in conjunction with clinics, will also design strategies to improve outreach to male partners of women availing themselves of PMTCT services, hence increasing gender equity in HIV programs and addressing male norms and behaviors by providing training on couple counseling, and promoting male attendance at antenatal visits with women (based on women's consent).


ACTIVITY 1: Capacity Building

FHI's activities will build on the FY 2006 program in which FHI developed human capacity by refining the current training course for auxiliary nurses and lay counselors and equipping them with the knowledge and skills necessary to strengthen PMTCT services, including: 1) counseling and testing; 2) provision of ARV prophylaxis; 3) counseling and support for safe infant feeding practices; and 4) counseling on FP. Focusing on transferring skills to trainers to train providers, as well as to providers directly, FHI will:

a) Finalize the curriculum and develop TOT training materials on CD-ROM, which will be a resource for the DOH, all PEPFAR partners, and other PMTCT stakeholders. The CD-ROM

will include the facilitator's guide and participant manual from the refresher course. Interactive in nature, the contents will focus on the main components of a comprehensive PMTCT program and will have an emphasis on increasing counselors' and nurses' knowledge of appropriate FP methods for women with HIV, including those women receiving ARV treatment, strengthening counselors' communication and counseling skills around FP for PMTCT clients, and providing referrals;

b) Provide the TOT course to other agencies supporting or implementing PMTCT programs (e.g., EGPAF, NDOH, JHPIEGO) and work closely with them to provide additional TA to rollout the TOT curriculum through their programs.

ACTIVITY 2: Technical Assistance

FHI will provide TA to the DOH in PMTCT facilities in four provinces, Free State, North West, Limpopo and Western Cape, to improve program performance. Specifically, the scope of work for the TA is:

a) Conduct training courses for auxiliary nurses and lay counselors to strengthen the four main components of the selected PMTCT programs; and design the TA with the DOH to ensure activities fit into the existing health system to help promote sustainability;

b) Clarify performance expectations of newly trained staff and managers and to strengthen supportive supervision processes;

c) Strengthen referral systems to successfully increase ability to make and track referrals;

d) Improve functional referrals from FP facilities to PMTCT facilities;

e) Conduct training on couple counseling and creating strategies to involve male partners in PMTCT visits, and;

f) Draw on the results of FHI's research on optimal timing for FP counseling to provide TA to facilities that will include the development of FP messages to be incorporated into points in the service delivery system that have shown to increase the likelihood of uptake of FP (e.g., pre-/post-test counseling, post-partum period, infant feeding counseling, infant testing, or child health services).

This project contributes to PEPFAR 2-7-10 goals by reducing the number of new infections infants exposed to HIV and ensuring that HIV-infected pregnant women and infants are appropriately referred to treatment, care and support services. In addition, FHI by strengthening the FP component of PMTCT programs to help prevent future unintended pregnancies in HIV-infected women.

Funding for Sexual Prevention: Abstinence/Be Faithful (HVAB): $200,000


Family Health International (FHI) also implements activities described in the Basic Health Care and Support (#7584), ARV Services (#7586) and PMTCT (#7587) program areas. FHI will work in collaboration with Johns Hopkins University (JHU) (#7632) in this program area.


Family Health International (FHI) will provide technical assistance (TA) to three universities' peer education programs to continue integration of abstinence and be faithful messages (AB) as well as life skills into the ongoing activities of the peer education programs on campus. Using the Rutanang curriculum, the AB life skills training is for a cadre of peer educators (PE) on each of the campuses participating in this project. The PEs will then pass these skills on to other students on campus primarily through interaction in on-going, small behavior change groups. Emphasis areas include information, education and communication; training; and development of linkages/referral systems. Main target populations addressed are men and women of reproductive age, youth (university students), volunteers (PEs) and people living with HIV and AIDS.


Currently, most efforts addressing sexuality and reproductive health needs for young people are focused on out-of-school youth and those in secondary school in South Africa. Youth at institutions of higher learning represent a special group at risk as they are often left unsupervised by both parents and teachers, who are under the assumption that they are mature enough to protect their sexual and reproductive health. Available evidence suggests that these young men and women have high STI and unintended pregnancy rates, an indication that they are not yet equipped with the knowledge and skills required to protect themselves from these adverse outcomes.

In FY 2005, in consultation with the South African Universities Vice Chancellors' Association (SAUVCA) and the Department of Education, FHI implemented a project that took place on three university campuses in South Africa: University of the Western Cape, University of the Free State, Qwa-Qwa campus and University of Limpopo, Medunsa campus. Each campus contributed to the development of the AB/life skills curriculum which was subsequently implemented among 26 PEs from each of the three campuses. After the training, PEs recruited six students each to take part in on-going behavior change communication (BCC) groups on their campus, reaching in total 468 students.

Life skills aim to enhance the students' ability to make responsible sexual health decisions and adopt behaviors that will keep them free of STI and HIV infection, as well as avoid unintended pregnancies. The curriculum included sessions on AB, secondary abstinence, values clarification, self-esteem, communication, decision making and negotiation, and utilized participatory learning techniques. Another key component of the AB/life skills training is a session on gender equity. The curriculum complemented the universities' existing peer education curricula, which provides basic information about prevention of HIV and AIDS. The BCC groups provided a safe place to explore strategies for adopting and strengthening the AB life skills in their personal lives. Students were able to support each others' behavior change process, including seeking counseling and testing (CT). Through one-on-one and group interaction, the PEs took advantage of a variety of regularly scheduled campus events-such as orientation week, condom week, and STI awareness week-to reach additional students with basic information on STIs, HIV and unintended pregnancies and how to protect oneself and maintain a healthy lifestyle. The program also promoted referrals between the PEs and student health or community health services for CT as well as family planning (FP).

Major accomplishments to date include development of the AB life skills curricula and successful training of the PEs. The program has gone beyond the university campuses and PE groups to be conducted in high schools in communities near the campuses. A radio series was produced and launched on campus and community stations throughout South Africa, reaching approximately 6,000,000 listeners. The show addressed issues related to risk-reduction behaviors for STIs, HIV and unintended pregnancies that are relevant for

university students. The curriculum was also used by University of Nairobi for a similar intervention.

Although there was no FY 2006 funding, the universities were committed to continue the BCC groups and supervision activities. While the activities are expected to continue with the respective university funding, additional resources are needed to strengthen the longer-term institutionalization of the life skills program.


In collaboration with SAUVCA and the Department of Education, in FY 2007 FHI will continue to work with the three universities: University of the Western Cape, University of the Free State, Qwa-Qwa campus and University of Limpopo, Medunsa campus. FHI will work in collaboration with JHU at the University of Western Cape and the University of Free State, Qwaqwa campus to ensure that all PE programs are harmonized. To align the goals of the program with the government goals, FHI will work closely with the Department of Education staff to further refine the program and improve outreach. Further integrating AB life skills into their peer outreach program work plans, each university will recruit new PEs for the AB life skills project, who will then recruit other students to participate in small, ongoing BCC groups.

FHI will adopt the Rutanang curriculum which is in the process of being accredited. To further develop PEs' gender awareness skills, FHI will promote the University of Western Cape's one-year gender sensitization course to the other two universities in the program. TA will also be provided to strengthen supervision skills to ensure the quality of the peer interactions, modeling problem solving skills, and shaping perceived peer/social norms on sexual behaviors.

Specific activities include:

1) Continue to incorporate AB life skills program into existing peer education workplans in a cost-effective manner;

2) Conduct AB life skills training for all PEs participating in the program;

3) Provide refresher trainings to strengthen basic peer education/facilitation skills;

4) Standardize job aids and tools for PEs to use in small groups;

5) Conduct supervision skills training for and provide TA to supervisors to help support PEs and the BCC group process;

6) Build and strengthen relationships between PEs and student health services, and formalize referral links to health services; and

7) Monitor AB, life skills and BCC group processes.

The project contributes to the prevention of 7 million new infections as per PEPFAR's 2-7-10 goals. The project will help decrease the number of new infections by achieving the expected results which will ultimately lead to a delay in sexual debut, a reduction in sex acts, fewer partners or a reduction in unprotected sex.

Funding for Care: Adult Care and Support (HBHC): $1,520,000

INTEGRATED ACTIVITY FLAG: Family Health International (FHI) also implements activities described in the Counseling and Testing (#7588), ARV Services (#7586) and PMTCT (#7587) program areas. Although Project Support Association-South Africa (PSASA) (#8250) will begin as a prime partner in FY 2007, FHI will continue to have a sub-grant with PSASA for home-based care activities. This partner may benefit from the Partnership for Supply Chain Management ARV Drugs activity (#7935), which will explore current pain and symptom management practices, drug availability and cost, and provide recommendations.

SUMMARY: Family Health International (FHI) will improve access to holistic services for people living with HIV and AIDS (PLHIV) and their families by enhancing palliative care (PC) programs and strengthening links to ARV, counseling and testing (CT), and other essential services. Emphasis areas are network/linkages/referral systems, training, and local organization capacity development. Target populations are men, women, PLHIV, health professionals, faith-based organizations, volunteers, caregivers, children, and families affected by HIV and AIDS.

BACKGROUND: The FHI-supported Integrated Community Palliative Care (ICPC) model is the first public sector palliative care model at the district level funded by the South African Government with technical assistance from FHI. As requested by the Departments of Health (DOH) and Social Development, FHI provides support to both community- and facility-based PC services at the primary care and hospital level, while strengthening the linkages between PC, CT, ARV and family planning (FP) for comprehensive care and support. FHI's interventions strengthen the physical, spiritual, social, and psychological aspects of PC, and leverage government resources through service networks to meet multiple care needs. Tighter links between PC, CT, ARV and FP services, in particular, afford men and women the opportunity to improve their overall quality of life through integrated services.

Since FY 2005, FHI and partners trained 729 community volunteers and provided services to over 12,000 home-based care (HBC) clients in Mpumalanga and KwaZulu-Natal; trained 50 government HBC volunteers in Limpopo and Northern Cape using the Health/Welfare Sector Education and Training Authority curriculum; trained 158 health care professionals in PC; and provided support to the Johannesburg Hospital Palliative Care Team (HPCT), reaching out to 2,356 clients. In the communities where they are working, FHI is expanding pediatric PC services to ensure HIV-infected children are receiving appropriate care, and setting up a mobile clinic to improve access to integrated services in remote HBC programs. FHI carries out PC activities with government and community-based organizations (CBOs), including PSASA, the South African Council of Churches, South Africa Red Cross, Nightingale Hospice and Evelyn Lekganyane HBC.

ACTIVITIES AND EXPECTED RESULTS: FHI will continue to strengthen access to integrated services as a part of a comprehensive palliative care package for PLHIV and their families in Mpumalanga, KwaZulu-Natal, Limpopo, Northern Cape and Gauteng provinces. This includes the ICPC model in 2 provinces. Effort will be made to ensure equitable access to care services for both males and females and increased participation by men will be encouraged in service delivery (key legislative area). The activities expand existing services that CBOs and government care programs currently provide with an emphasis on promotion of the HIV preventive care package. With FY 2007 funding, FHI will further institutionalize the program within government and CBOs, while also expanding its reach. FHI will emphasize capacity building and local skills transfer, and will also stress gender sensitivity in counseling and community outreach, promote couples counseling, and assist HBC programs to develop strategies to alleviate the care burden on girls.

ACTIVITY 1: Strengthening community-based organizations Benefiting HBC clients, family members and caregivers in Mpumalanga, KwaZulu-Natal, Limpopo, and Northern Cape provinces, FHI will work with community groups to: 1) Provide technical assistance (TA) to HBC volunteers to identify PC, CT, ARV and FP needs in the household and to refer to appropriate services; 2) Leverage government and partner resources by building/strengthening formal referrals between HBC projects and CT sites, nearby ARV providers, and FP clinics;

3) Train HBC volunteers to assist clients with adherence to ARV therapy and care interventions; e.g. referral for cotrimoxazole prophylaxis; 4) Strengthen TB management and nutritional assessment, monitoring and supplements, including and referrals to government/NGO services for food parcels; 5) Support select HBC programs through financial assistance, supportive supervision TA, and reporting; 6) Work with the Hospice Palliative Care Association (HPCA) to provide PC training for health providers and HBC programs using the nationally accredited curriculum, and expand services to include pediatric PC as appropriate, and; 7) Conduct trainings for ARV providers on prevention of positives including FP referral for HIV-infected couples, including those on ARVs.

ACTIVITY 2: Strengthening government programs FHI will provide TA, training and financial support to four districts of Limpopo and Northern Cape. Specifically, FHI will work with government to: 1 )Train district-level PC health providers in pain and symptom assessment and management, TB and other opportunistic infection screening, pediatric PC, psychosocial and spiritual needs of PLHIV and affected families, PMTCT and FP counseling; 2) Implement mechanisms for quality assurance and supervision, as per standard operating procedures; 3) Conduct district-level workshops for family members, traditional healers, and local AIDS councils to promote care, support and treatment services; reduce discrimination and stigma; increase awareness of HIV-infected individuals needs; and support pediatric PC, and; 4) Strengthen referral networks between primary health care and CBO services, including linkages with health and social welfare sectors for grants, legal aid, micro-finance, spiritual support, CT, ARVs, and FP.

ACTIVITY 3: Technical assistance to Johannesburg HPCT FHI will continue to support the Johannesburg HPCT and other government-accredited ART sites by increasing access to pediatric PC and reinforcing the integration of HIV and FP services. Through TA to nurse managers, nurses, midwives, medical officers, coordinators and other providers in ART sites, FHI will improve the capacity of Johannesburg HPCT and promote similar models for replication.

ACTIVITY 4: Support to the NDOH To guide the HIV/FP integration efforts described above, and in response to specific requests from the DOH, FHI will support National DOH (NDOH) and provincial staff in Mpumalanga, KwaZulu-Natal, Northern Cape, Limpopo and Gauteng provinces. With separate funding, FHI will help the NDOH to revise the current sexual and reproductive health curriculum to include guidelines for HIV-infected couples, including those on ARVs. In FY 2007 FHI will provide TA to the NDOH on implementing the new curriculum and integrating HIV and FP services, particularly in PC service sites.

ACTIVITY 5: Plus-Up funds will be used to strengthen existing community based organizations and add new community based organizations by support for the expansion of home-based care activities in Mpumalanga Province including the provision of elements of the preventive care package and caring for caregivers.

These activities contribute to the PEPFAR goal of providing care services to 10 million. The activities also support the USG strategy for South Africa by collaborating closely with the DOH to improve access to and quality of basic care and support.

Funding for Testing: HIV Testing and Counseling (HVCT): $0

This activity was approved in the FY 2006 COP, is funded with FY 2006 PEPFAR funds, and is included here to provide complete information for reviewers. No FY 2007 funding is requested for this activity.

In FY 2006, PEPFAR funds allocated to VCT ($150,000) are for FHI to expand counseling and testing (CT) to HBC settings, and to use a mobile support unit to provide HIV/FP services, including CT, in underserved areas in Mpumalanga province. In FY 2007, these activities are now being integrated to the ARV Services Program Area. FHI will continue to create functional referral mechanisms between HBC/FP/ARV and CT service programs in the two provinces to holistically meet the health care and treatment needs of HBC caregivers, clients and their families. Through the Mobile Support Unit, FHI will identify individuals eligible for ART through CT. As these activities are being integrated with ARV Services, there is no need to continue funding this activity with FY 2007 COP funds.

Funding for Treatment: Adult Treatment (HTXS): $850,000


Family Health International (FHI) also implements activities described in the Counseling and Testing (#7588), Basic Health Care and Support (#7584) and PMTCT (#7587) program areas. This FHI activity is closely linked to Right to Care (#7545) and BroadReach (#7510) ARV Services activities.


Family Health International will use FY 2007 funding to expand access to integrated services for HIV-infected and affected individuals in home-based care (HBC) programs by strengthening the linkages between HBC and counseling and testing (CT) through establishing additional mobile clinics in underserved areas in Mpumalanga and KwaZulu-Natal provinces. FHI will work with PEPFAR partners, Project Support Association of Southern Africa (PSASA), Right to Care (RTC), and BroadReach, and will refer patients in need of antiretroviral treatment (ART) to RTC and BroadReach for ART initiation. The emphasis areas for the following activities are the development of network/linkages/referral systems, training and local capacity development. Target populations addressed are people living with HIV (PLHIV) and their families, men and women of reproductive age, family planning (FP) clients, faith-based organizations, health professionals, and caregivers.


In response to requests from the National and provincial Departments of Health and Social Development, FHI has been strengthening the linkages between HBC, CT, ARV and FP services for comprehensive treatment, care and support. This project addresses the need to establish formal referral and follow-up mechanisms for CT and antiretroviral therapy and other essential healthcare services, such as FP, in HBC programs where clients are often in need of ARV treatment. Experience suggests that improved access to ARV services in South Africa is improving the health status of many HIV-infected individuals, leading to a return of libido and sexual activity, and this also requires careful decisions about their sexual and reproductive health. Tighter links between palliative care (PC), CT, ARV and FP services, in particular, afford men and women the opportunity to improve their overall quality of life through integrated services.

FHI is creating and strengthening functional referral mechanisms between CT, HBC, ARV and FP service programs in Mpumalanga and KwaZulu-Natal in collaboration with PSASA and the South African Council of Churches (SACC) HBC programs. To date, over 500 new clients have initiated ARVs through the program referral network. Access to ART is still a major constraint in these rural programs. PSASA's and SACC's HBC programs typically reach out to low-resource, isolated communities where HIV service needs are high and transport to services is prohibitively expensive.

In FY 2006 FHI and its partners are establishing a mobile clinic to provide better access to CT, diagnosis/treatment of sexually transmitted infections (STI), ARV services, and FP. These integrated mobile services target HBC caregivers, clients and their families, as well as the surrounding communities. Additional units are needed to reach those who reside in remote, underserved areas in Mpumalanga and KwaZulu-Natal. This will enable project partners to cover a larger geographical area and meet the needs of more HBC clients and family members.


In close collaboration with the Mpumalanga and KwaZulu-Natal Departments of Health (DOH), PSASA, SACC, RTC and BroadReach, FHI will expand access to quality integrated services for infected and affected individuals in HBC programs through a continuation of the FY 2006 project and through the set-up of additional mobile service units to provide CT, ARV services, STI screening and FP services in rural, underserved areas. PSASA and SACC will provide basic care and support services and refer clients for services offered by the mobile clinics and provide follow-up and ART adherence at the HBC level. RTC and BroadReach will process lab work for CD4 counts and place clients on ARVs according to clinical protocols. Specifically FHI will:

1) Continue to support the mobile clinics initiated in FY 2006 which serves 10 HBC projects;

2) Purchase and set up three additional mobile clinics, one based in Mpumalanga and two in KwaZulu-Natal;

3) Select new remote HBC sites in Mpumalanga and KwaZulu-Natal of which the program participants and immediate community will have access to the mobile clinics;

4) Hire and supervise local mobile clinic staff (professional nurse and one counselor in each mobile clinic) to provide CT, STI and FP services and ARV referrals. It is anticipated that patients treatment by the mobile clinic staff will be transferred to public sector sites as soon as these sites have the necessary capacity.;

5) Train four professional nurses and four counselors to oversee the quality of CT, ARV screening, STI testing and treatment, and FP services and counseling;

6) Train four professional nurses and four counselors on couple counseling and gender awareness, and ensure it is staffed by qualified health professionals;

7) Work with HBC volunteers in mobile clinic service sites to provide referrals for CT, STI, FP and ARV referrals services;

8) Conduct outreach to HBC projects and communities through IEC materials and household visits, and;

9) When necessary, use the mobile clinics to transport clients to doctors or facilities for urgent care.

FHI will leverage resources from partners and the DOH for all commodities. FHI will support a Management Information System to collect service and referral data relating to all patients. A monitoring and evaluation specialist will be hired to spearhead this effort. All activities will be implemented closely with local partners with an aim towards bolstering capacity to take ownership of the mobile clinics by September 2009.

These activities will contribute to the PEPFAR 2-7-10 goals by increasing the number of people receiving ARV treatment.

Subpartners Total: $725,000
Project Support Association: $250,000
South African Council of Churches: $100,000
University of Limpopo: $50,000
Hospice and Palliative Care Association of South Africa: NA
Makuduthamakaga Home Based Care Umbrella Organisation: $75,000
Nightingale Hospice: $75,000
International Federation of Red Cross and Red Crescent Societies: $75,000
Free State University: $50,000
University of the Western Cape: $50,000